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EA-97-192 - Calvert Cliffs 1 & 2 (Baltimore Gas & Electric Company)August 11, 1997 EA 97-192 Mr. Charles H. Cruse
SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL
PENALTIES - $176,000
(NRC Inspection Reports Nos. 50-317/97-02 & 50-318/97-02;
50-317/97-03 & 50-318/97-03)
Dear Mr. Cruse: This letter refers to the NRC inspection conducted at the Calvert Cliffs Nuclear Power Plant from March 2, 1997 to April 12, 1997 and on April 24, 1997, the findings of which were provided to you during an exit meeting on May 7, 1997. The inspection report was sent to you on May 29, 1997. During the inspection, several apparent violations were identified, including a number of violations related to the failure to effectively control activities conducted by a contractor diver in the Unit 2 spent fuel pool. Other apparent violations, related to inadequate radiation protection controls, as well as inadequate fuel handling operations, were also identified. On June 12, 1997, a Predecisional Enforcement Conference was conducted with you and members of your staff to discuss the violations, their causes, and your corrective actions. During the conference, two examples of an additional apparent violation of radiological protection program requirements were also discussed. Those additional apparent violations, which were identified by your staff, were reviewed by the NRC during an inspection conducted between April 13, 1997 to May 31, 1997, for which an exit meeting was held on June 19, 1997. That inspection report was sent to you on July 1, 1997. Based on the information developed during the inspections, and the information provided during the enforcement conference, thirteen violations of NRC requirements are being cited and are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (Notice). The three most significant violations relate to the failure to implement appropriate radiological controls during the diving operations in the Unit 2 spent fuel pool, resulting in the potential for a diver to gain unauthorized or inadvertent access to very high radiation areas that could have resulted in significant radiological exposure to the individual. Specifically, due to insufficient controls, inadequate pre-job planning and communication, ineffective surveillance of the diver, and deficient supervisory oversight of the activity, the individual was inadvertently able to gain access to areas in which radiation levels could be encountered at 500 rads or more in an hour due to the proximity of spent fuel. The specific violations associated with the diving activity involve (1) failure to ensure that the diver would not be able to gain unauthorized or inadvertent access to areas where radiation levels could be 500 rads or more in an hour; (2) failure to provide adequate instructions to the diver as to the nature and location of very high radiation fields and the authorized work tasks; and (3) failure to perform adequate surveys during and after the diver entered an area of the spent fuel pool that had not been previously surveyed. Your radiological control staff, responsible for planning and monitoring this activity, failed to provide control of this activity sufficient to assure that the diver would not be unexpectedly exposed to, or inadvertently enter, very high radiation fields within the spent fuel storage pool. This event occurred during the fourth of five dives into the Unit 2 refueling cavity and spent fuel pool in April 1997 to inspect and repair malfunctioning fuel transfer equipment. During the fourth dive, the diver left the previously surveyed and approved dive location at the south end of the Unit 2 spent fuel pool, and moved into an unapproved, unsurveyed area in the north end of the pool. In doing so, the diver entered areas exhibiting significantly higher radiation fields, where he received an unplanned radiation exposure, and could have been occupationally exposed in excess of regulatory limits. The fundamental controls provided to ensure that the diver could not gain unauthorized or inadvertent access to very high radiation fields were inadequate. Even though the diver was equipped with a tether, the individual monitoring the tether did not question the excessive amount of restraint that was let out as the diver traversed to the unsurveyed north end of the pool. While the diver was provided with multiple personal dosimetry devices that were remotely monitored by the radiation protection technicians, he was not continuously monitored by a television camera, as he had been during previous dives. Instead, the radiation protection personnel were expected to provide continuous coverage via a viewing glass placed on the surface of the pool. However, such coverage was flawed in that bubbles from the divers breathing air and to some degree, the refueling bridge, obscured direct observation. Also, the individual responsible for maintaining direct visual contact, by your own admission at the enforcement conference, became distracted from his responsibilities. As a result, the radiation protection personnel failed to observe the diver move away from the approved location. Further, when the dosimetry readouts indicated that the diver was being exposed to higher than expected fields, rather than confirming his whereabouts, the diver was inappropriately directed to reenter the area to locate the source of the radiation. In addition, the prejob briefing with the diver and dive support personnel was ineffective in that a late change in the scope of the work directly resulted in the diver's misunderstanding of the work scope. Also, the radiation survey briefing at the job site did not identify to the diver the radiological hazard associated with the fresh irradiated fuel in the north end of the pool in that the diver was provided with a survey map of the south end of the pool, which he interpreted as representing the entire pool. Moreover, the diver was unaware that he was restricted from performing any activities at the north end of the spent fuel pool since the area was not surveyed. After the fourth dive was completed, but prior to processing the diver's dosimetry, a decision was made to initiate a fifth dive, using another diver to complete the repair/inspection. Without his dosimetry first being processed to determine the exposure obtained during the fourth dive, the diver from the fourth dive was allowed to re-enter the spent fuel storage pool work area to support the other diver. Although he re-entered the radiological controlled area and worked in areas with low radiation dose rates, a comprehensive dose assessment had not been performed to determine whether the unauthorized entry into the unsurveyed area resulted in the diver receiving a dose in excess of the limits of 10 CFR Part 20. Preliminary calculations performed by your staff, indicated that the diver's right extremity (right knuckles) may have entered radiation fields of 155 to 310 rem/hr and the whole body (right arm) may have entered radiation fields ranging from 45 to 90 rem/hr. Although subsequent detailed dose assessments for the diver indicated that no apparent radiation exposure in excess of NRC limits likely occurred, this was nonetheless a significant event given the serious consequences that could result from the diver being in close proximity to irradiated fuel. Weaknesses in the establishment and implementation of the type of radiological controls necessary to assure safety in the vicinity of very high radiation areas resulted in a substantial potential for an exposure in excess of regulatory limits at the facility. In summary, the NRC considers that the event resulted from a serious lack of attention toward licensed responsibilities. The event involved a serious breakdown in controls that were to be provided for the diving evolutions. Significant deficiencies in communications, coordination, and management oversight and decision-making, also existed. As a result, a substantial and unnecessary occupational exposure nearly occurred. Therefore, the violations in Section I, which involve a very significant regulatory concern, have been classified in the aggregate as a Severity Level II problem in accordance with Section IV of the "General Statement of Policy and Procedure for NRC Enforcement Actions " (Enforcement Policy), NUREG-1600. In accordance with the Enforcement Policy, a base civil penalty in the amount of $88,000 is considered for a Severity Level II violation or problem. Also, since this is a Severity Level II problem, the NRC considered whether credit was warranted for Identification and Corrective Action in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. Credit for identification is not warranted because there were several missed opportunities during the dive to identify these problems, particularly when dosimetry first alarmed, when the technician lost visual contact of the diver because of the bubbling, and when the diver asked a technician for more line and was not questioned. Credit for corrective actions is also not warranted because the immediate corrective actions after the fourth dive were deficient in that another diver was allowed to enter the pool without having obtained a thorough understanding of the cause of the earlier "near miss". Given the potential for substantial personnel exposures that could result from being in such close proximity to the irradiated fuel, a root cause analysis should have been performed before commencing the fifth dive, as you acknowledged at the enforcement conference. Additionally, even though you took action to change your radiological controlled area dive operations and formalize your job coverage standard into a radiation safety procedure, you did not adequately assess the full scope and root causes of the breakdown that occurred. For example, you did not determine the extent to which production pressure was a factor in causing the event. Further, during the enforcement conference, you did not appear to understand all potential contributors to the event, such as the cause of the inattentiveness of the individual assigned to observe the diver. Therefore, to emphasize the seriousness of this event, and the importance of appropriate management control and oversight of such activities, I have been authorized, after consultation with the Director, Office of Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) in the amount of $176,000 for the violations in Section I. The remaining violations being cited are described in Sections II and III of the enclosed Notice and are classified at Severity Level IV. A number of these violations were identified by your staff and while a civil penalty is not being proposed for these violations, they are indicative of further programmatic weaknesses in radiological controls and protection, maintenance of refueling equipment, and conduct of refueling activities. Two other apparent violations listed in Inspection Report 97-02, which you identified, involving (1) the failure to verify that each exhaust fan maintains the spent fuel storage pool at a measurable negative pressure relative to the outside atmosphere during system operation, and (2) the refueling machine's main hoist 3,000 pound overload limit being bypassed during portions of fuel movement within the reactor pressure vessel, are not being cited because they meet the criteria in Section VII.B.1 of the enforcement policy regarding the exercise of discretion. Further, another apparent violation in Inspection Report 97-02, involving drawings not being used to prepare either the troubleshooting form or contingency plans during assessment and repair of the stuck refueling transfer carriage, is being withdrawn because of information you provided at the conference where it was stated that drawings were used in a parallel assessment of the event. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. The NRC will use your response, in part, to determine whether further enforcement action is necessary to ensure compliance with regulatory requirements. In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response will be placed in the NRC Public Document Room (PDR).
Sincerely,
Hubert J. Miller
Regional Administrator
Docket Nos. 50-317, 50-318 Enclosure: Notice of Violation and Proposed Imposition of Civil Penalties cc w/encl:
NOTICE OF VIOLATION
Baltimore Gas & Electric Company Docket
Nos. 50-317; 50-318
Calvert Cliffs License
Nos. DPR-53; DPR-69
EA 97-192
During an NRC inspection conducted between March 2, 1997 to April 12, 1997 and on April 24, 1997, and an inspection conducted between April 13, 1997 and May 31, 1997, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: I. VIOLATIONS RELATED TO INADEQUATE RADIOLOGICAL CONTROL OF DIVING ACTIVITIES IN THE SPENT FUEL POOL A. 10 CFR 20.1602 requires that in addition to the requirements in 10 CFR 20.1601, the licensee shall institute additional measures to ensure that an individual is not able to gain unauthorized or inadvertent access to areas in which radiation levels could be encountered at 500 rads or more in an hour at one meter from a radiation source or any surface through which the radiation penetrates. Contrary to the above, on April 3, 1997, adequate measures were not provided to ensure that an individual working as a diver in the Unit 2 spent fuel pool was not able to gain unauthorized or inadvertent access to areas in which radiation levels could be encountered at 500 rads or more per hour. Specifically, while working in the Unit 2 spent fuel pool, a diver inadvertently accessed and worked in areas in which radiation levels could be encountered at 500 rads or more in an hour. (01012) B. 10 CFR 19.12 requires, in part, that all individuals working in or frequenting any portion of a restricted area be kept informed of the storage, transfer, or use of radioactive materials or of radiation in such portions of the restricted area. Contrary to the above, on the morning of April 3, 1997, the licensee did not adequately inform a diver, diving in the Unit 2 spent fuel storage pool, a restricted area, of the storage of radioactive materials or of radiation in the spent fuel pool that the diver might encounter. Specifically, the instructions provided to the worker did not adequately provide the location of radiation surveys made to support the diver's work in the south end of the spent fuel pool, did not adequately limit the scope of work performed by the diver commensurate with those radiation surveys, and did not instruct the diver as to the location of irradiated fuel assemblies. As a result, the diver moved from the dive area at the south end of the Unit 2 spent fuel pool (that had been comprehensively surveyed and had been approved for work), traversed an unsurveyed portion of the spent fuel pool, travelled to the north end of the spent fuel storage pool which had not been approved for entry, and entered high radiation fields caused by radiation emanating from irradiated spent fuel elements. (01022) C. 10 CFR 20.1501 requires, in part, that licensees make or cause to be made surveys that may be necessary to comply with the regulations in 10 CFR Part 20 and are reasonable under the circumstances to evaluate the extent of radiation levels and the potential radiological hazards that could be present. 10 CFR 20.1201 provides limits for occupational exposures, including exposure limits of 50 rems (shallow dose) to the skin or any extremity and 5 rems to the whole body (total effective dose). Contrary to the above, on April 3, 1997, while the diver was supplied with radiation surveying instruments and multiple personal dosimetry devices capable of real-time indication, surveys performed with these devices were inadequate to assure compliance with occupational dose limits in that: (1) the diver was not trained in the use and limitations of the radiation survey instruments; (2) the diver failed to carry and use the survey instruments at all times when he was in the unsurveyed portion of the spent fuel pool; (3) no personal radiation dosimetry real-time measuring devices were sufficiently located to monitor exposure to the diver's lower extremities as he traversed the unsurveyed portion of the spent fuel pool; (4) the diver was directed to re-enter an area having unknown radiation levels without any verification or evaluation of the potential for personnel exposure in excess of regulatory limits; and (5) upon discovery that the diver had been in an unsurveyed area in which there was high potential for personnel exposure in excess of regulatory limits, the individual was permitted to re-enter radiologically controlled areas prior to evaluating personnel dosimetry devices for exposure assessment. (01032) These violations have been categorized in the aggregate as a Severity
Level II problem. (Supplement IV). II. OTHER VIOLATIONS RELATED TO INADEQUATE RADIOLOGICAL CONTROLS A. Technical Specification 6.4.1, "Procedures", requires, in part, that the licensee establish, implement, and maintain the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33 recommends, in Section 7.e., "Radiation Protection Procedures", that procedures be established for access control to radiation areas.1. Licensee radiation protection procedure RSP 1-104, "Area Posting and Barricading", Revision 10, requires in Section 6.5, "Locked High Radiation Area", that areas exhibiting radiation levels in excess of 1000 millirem at 30 centimeters from the radiation source be provided with a locked barrier or ensure that the area is provided with continuous direct or electronic surveillance capable of preventing unauthorized entry.Contrary to the above, on February 16, 1997, areas inside the Unit 2 Containment exhibited radiation levels greater than 1000 millirem at 30 centimeters, and at the time, the access door (Unit 2 Emergency Airlock door) was not locked, and the area was not provided with continuous direct or electronic surveillance capable of preventing unauthorized entry. (02014) This is a Severity Level IV Violation (Supplement IV) 2. Licensee procedure RP-1-100, "Radiation Protection," states that a high radiation area shall be posted with a sign stating "Caution: High Radiation Area," and that entry into the area includes a requirement for dosimetry. Procedure RP-1-100 also defines a high radiation area as any area accessible to personnel in which radiation levels could result in an individual receiving a dose in excess of 100 millirem in one hour.a. Contrary to the above, on May 1, 1997, a plant worker entered and worked in the Unit 2 reactor coolant pump bay, which is posted as a high radiation area, with no dosimetry. (03014)b. Contrary to the above, on May 4, 1997, plant workers erected scaffolding into an area of approximately 300 millirem per hour that was not posted as a high radiation area. (04014)These are each a Severity Level IV Violation (Supplement IV).B. 10 CFR Part 50, Appendix B, Criterion V, "Instruction, Procedures, Drawings," states that activities affecting quality shall be prescribed by procedures and shall be accomplished in accordance with the procedures.10 CFR Part 50, Appendix B, Criterion II, "Quality Assurance Program," states that applicants shall identify the major organizations subject to the requirements of Appendix B through the Quality Assurance Program. Baltimore Gas and Electric Quality Assurance Policy, Revision 47, dated October 18, 1996, states the Plant General Manager is responsible for the radiation safety and also for directing investigations of significant events to determine the root cause and for recommending corrective actions. The Policy states the Issues Assessment Unit reviews issue reports, and assigns follow-up actions, under the direction of the Plant General Manager.Procedure No. QL-2-100, Revision 5, "Issue Reporting and Assessment", provides that an issue report be used to document an actual or suspected condition adverse to quality or a significant condition adverse to quality and provides a method for notifying affected groups and initiating corrective actions. Further, Section 4.7, specifies that reviewing supervisors ensure issue reports are received by the issues assessment unit group within three working days of being initiated.Contrary to the above, in February 1997, issue reports were written for a high radiation area access control concern and a safety concern associated with locking and control of Unit 2 containment emergency airlocks. The reviewing supervisor was aware of the issue reports; however, neither report was provided to the Issues Assessment Group for cause and corrective action determination. (05014)This is a Severity Level IV Violation (Supplement IV).III. VIOLATIONS RELATED TO INADEQUATE CONTROL OF REFUELING ACTIVITIES A. 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, deficiencies, defective equipment, and nonconformances are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to appropriate levels of management. 10 CFR Part 50, Appendix B, Criterion II, "Quality Assurance Program," requires that applicants establish in their Quality Assurance Programs those structures, systems, and components which are to be subject to the requirements of Appendix B. Baltimore Gas and Electric Quality Assurance Policy, Revision 47, dated October 18, 1996, states that systems and components subject to the requirements of the Quality Assurance Policy are specified on a Quality List (Q-List). All refueling equipment is specified on the Q-List. Contrary to the above, as of March 30, 1997, the licensee's actions to identify and correct certain conditions adverse to quality were inadequate to preclude the numerous and repeated problems with refueling equipment during defueling of Calvert Cliffs Unit 2 in March 1997, as evidenced by the following examples, each of which is a separate violation: 1. On March 28, 1997, a missing capscrew for a limit switch actuating magnet had not been identified during preparations for spent fuel handling activities. Subsequently, the loose magnet became dislodged and caused the fuel transfer carriage carrying a spent fuel assembly to become stuck in the fuel transfer tube. (06014)2. On March 28, 1997, after the stuck fuel assembly was removed from the fuel transfer carriage, but prior to completing defueling, metallic debris was identified in the carriage and noted in the refueling log; however, an evaluation of the debris was not done, and the problem was not reported to management. (07014)3. On March 28, 1997, during initial fuel moves in the spent fuel pool, a grapple closed light remained lit when the grapple open light was lit; however, fuel movement continued without an evaluation of the cause or the corrective actions. (080104)4. On March 31, 1997, a relief valve stuck open on the refueling upender, preventing lowering the upender; the cause of the valve being stuck open was sludge and other debris in the upender hydraulic system. Although the sludge had been identified in previous inspections, corrective actions to prevent recurring problems were not taken. (09014)5. During fuel handling activities on March 27, 1997, a control element drive mechanism cable was caught by the moving refueling machine and damaged. Corrective action, including determining the cause of the problem to preclude recurrence, was not taken. (10014) These are each a Severity Level IV Violation (Supplement IV). B. 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," requires that activities affecting quality be prescribed by documented procedures, of a type appropriate to the circumstances and be accomplished in accordance with these procedures. Operation of the spent fuel handling machine is accomplished in accordance with Operating Instruction OI-25A, "Spent Fuel Handling Machine," and OI-22D, "Fuel Handling Area Ventilation System", which states that spent fuel ventilation must be in service with charcoal filters when spent fuel handling will occur. Calvert Cliffs Updated Safety Analysis Report, Section 9.8, Revision 20, states, in part, that the limitations placed on the spent fuel pool area ventilation system were to ensure that in the event of a fuel handling accident, all of the radioactive material released would be filtered through the HEPA filters and charcoal absorbers prior to discharge to the atmosphere. OI-25A, Step 6.1.B.2.a requires that the charcoal filters be placed in operation prior to any fuel movement. Contrary to the above, on April 23, 1997, activities were not accomplished in accordance with procedures when Unit 2 refueling commenced without properly aligning the spent fuel pool area ventilation system charcoal filters for operation in accordance with Step 6.1.B.2a of OI-25A. This condition existed until the following day, April 24, 1997, when it was identified during a shift change. (11014) This is a Severity Level IV Violation (Supplement IV). Pursuant to the provisions of 10 CFR 2.201, Baltimore Gas & Electric Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the receipt of this Notice of Violation and Proposed Imposition of Civil Penalty (Notice). This reply should be clearly marked as a "Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, and if denied, the reasons why, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an Order or a Demand for Information may be issued as to why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, money order, or electronic transfer payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty, in whole or in part, by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an "Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice, in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the factors addressed in Section VI.B.2 of the Enforcement Policy should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due that subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c. The response noted above (Reply to Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: James Lieberman, Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, One White Flint North, 11555 Rockville Pike, Rockville, MD 20852-2738, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, and a copy to the NRC Senior Resident Inspector at the facility that is the subject of this Notice. Because your response will be placed in the NRC Public Document Room (PDR), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR. If redactions are required, a proprietary version containing brackets placed around the proprietary, privacy, and/or safeguards information should be submitted. In addition, a non-proprietary version with the information in the brackets redacted should be submitted to be placed in the PDR. Dated at King of Prussia, Pennsylvania
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