HPT001.024 Rev. 1 Page 1 of 22 Radiological Control Current Concerns and Industry Events TP-1 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 2 of 22 Enabling Objectives • Apply Error Prevention tools. • Identify Two Types of NRC Notifications • Identify Two Organizations Promoting Excellence in the Nuclear Power Industry • Identify Three Types of Event Reports • Evaluate Events on Summary Worksheet • Identify Major RADCON Concern • Name Four Other Areas of Concern TP-2 TVAN Technical Training Health Physics (RADCON) Initial Training Program SAFER • • • • HPT001.024 Rev. 1 Page 3 of 22 Summarize Critical Steps Anticipate Errors at Critical Steps Foresee Consequences of Errors Evaluate Defenses, Barriers & Contingencies • Review Experience TP-3 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 4 of 22 TVAN Human Performance Initiative Protect People and the Plant From Human Error through: • Aggressive Control of Defense-in-Depth • Rigorous Use of Error-Prevention Techniques TP-4 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 5 of 22 Error Prevention Tools - 1 Two-Minute Rule Procedure Use & Adherence Independent Verification Second Party Verification Effective Communication Three-Way communication Phonetic Alphabet TP-5 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 6 of 22 Error Prevention Tools - 2 Self-Checking STAR – Stop, Think, Act, Review Flagging Peer-Checking Questioning Attitude QV&V – Qualify, Validate, & Verify Stop When Unsure TP-6 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 7 of 22 NRC Concerns Notices • Licensee Event Reports (LERs) 10 CFR 50.73 • Information Notices (INs) TP-7 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 8 of 22 Nuclear Industry Improvement Organizations • Institute of Nuclear Power Operations (INPO) Promote Safety, Reliability and Excellence • World Association of Nuclear Operators (WANO) Maximize Safety & Reliability by Exchanging Information and Encouraging Communications TP-8 TVAN Technical Training Health Physics (RADCON) Initial Training Program Event Reports HPT001.024 Rev. 1 Page 9 of 22 • INPO/WANO Operating Experience Report (OE) • INPO/WANO Significant Event Notification (SEN) • INPO/WANO Significant Event Report (SER) • INPO/WANO Significant Operating Experience Report (SOER) • INPO/WANO Operations and Maintenance Report (O&MR) TP-9 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 10 of 22 Unplanned Exposures Weaknesses in Defenses • SOER 2001-01 1. Complying with Administrative Controls 2. Human Performance 3. Insufficient Training 4. Incorporation of Operating Experience 5. Inadequate Management Participation TP-10 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 11 of 22 Radiological Concerns • Unplanned Radiation Exposures (Major Concern) • Contamination/DRPs • Intakes/Internal Exposures • High Radiation Areas • Radiography TP-11 TVAN Technical Training Health Physics (RADCON) Initial Training Program Common Causes of Radiography Events • • • • HPT001.024 Rev. 1 Page 12 of 22 Postings not Understood Assumptions rather than Verification Inadequate Surveys Inadequate Evaluation of Adjacent Dose Rates • Radiological Personnel Unfamiliar with Radiography Posting Requirements TP-12 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 13 of 22 Adverse Trends in Radiological Protection Events • 1. 2. 3. 4. 5. Common Causes: Insufficient Radiological Controls Insufficient Line Management Oversight Knowledge of New Equipment Limits Inadequate Dose Monitoring Over Reliance on Knowledge & Skills of Contract & RadCon Workers 6. Lack of Questioning Attitude TP-13 TVAN Technical Training Health Physics (RADCON) Initial Training Program TP-14 O er ro l th on t C n at io W P ls ry tro R en t rc e So u ru m st In on C qu at e g gs et im e ig n Po st in ed os er in Ad e in e En g /T el ls yt im es St a D tro e ag ur e f ak in g M on C n A H R ov er C D ec is io ED iv e rv at se on TVAN Technical Training Health Physics (RADCON) Initial Training Program C R P Br ie ce d Pr o -jo b ht ni ng rs ig Pl an O ve Pr e qu at e Ad e er vi so r A ve y Su r 20 Su p AL AR qu at e Ad e Barrier Analysis HPT001.024 Rev. 1 Page 14 of 22 25 Barriers Associated with Events/Barriers Failed 15 10 5 0 Barrier Analysis Report Highest Five Categories • • • • • HPT001.024 Rev. 1 Page 15 of 22 Unplanned Dose (28%) Uptakes (Internal Exposures) (19%) Personnel Contamination (15%) High Radiation Areas (9.5%) Radiography & ALARA Planning (8% each) TP-15 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 16 of 22 Barrier Analysis Report Important Recommendations • • • • • More Use of Staytimes Workers Self-Monitor Dose Improve ALARA Planning Survey After Removing Shielding Monitor Dose Rates Approaching Limits • Compare As-Found Radiological Conditions with Forecast TP-16 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 17 of 22 Barrier Analysis Report Important Recommendations • Clarify Radiology Responsibilities • ALARA Planning Identify Airborne Risks • Use CAMs During Refuel Floor Work • Strengthen Controls for DRPs • Evaluate Equipment Release Practices • Thorough Evaluation of Whole Body Monitor Alarms TP-17 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 18 of 22 Performance Indicators • Provide Quantitative Indication of Plant Performance • Trend Performance & Progress • Set Challenging Goals for Improvement • Compare Performance with Others • Adjust Priorities & Resources TP-18 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 19 of 22 NRC Performance Indicators • Zero Unplanned Exposures • Zero Overexposures • Zero High Radiation Area Violations TP-19 TVAN Technical Training Health Physics (RADCON) Initial Training Program HPT001.024 Rev. 1 Page 20 of 22 INPO Performance Indicators • BWRs – Industry Average Cumulative Radiation Exposure (CRE): 120 man-rem/unit/year • PWRs – Industry Average Cumulative Radiation Exposure (CRE): 65 man-rem/unit/year TP-20 TVAN Technical Training Health Physics (RADCON) Initial Training Program Summary - 1 HPT001.024 Rev. 1 Page 21 of 22 • Review of Industry Events Important Tool in Preventing Recurrence • Event Notices Issued by NRC: LER & IN • Event Notices Issued by INPO/WANO: OE, SEN, SER, & SOER • Recurrence of Events may lead to Increased Severity of Penalties TP-21 TVAN Technical Training Health Physics (RADCON) Initial Training Program Summary - 2 HPT001.024 Rev. 1 Page 22 of 22 • Use of TVA Human Performance Tools • Major Concern: Unplanned Exposures • Other Concerns: Intakes or Internal Exposures Personnel Contamination High Radiation Areas Radiography • Performance Indicators TP-22 TVAN Technical Training Health Physics (RADCON) Initial Training Program