1 Bruce Power Radiological Event November-December, 2009 Overview of the 2009 Radiological Event and Lessons Learned for the Bruce Power Units 1 & 2 Restart Leadership Team Presented to: The Connecticut Local Section of the American Nuclear Society East Windsor, CT by Michael D. Quinn April 9, 2014 1
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Bruce Power Radiological Event November-December, 2009 · 09.04.2014 · 1 Bruce Power Radiological Event November-December, 2009 Overview of the 2009 Radiological Event and Lessons
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Bruce PowerRadiological Event
November-December, 2009
Overview of the 2009 Radiological Eventand
Lessons Learnedfor the
Bruce Power Units 1 & 2 Restart Leadership TeamPresented to:
The Connecticut Local Section of the American Nuclear SocietyEast Windsor, CT
byMichael D. Quinn
April 9, 2014
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2
Discussion Overview
• Site and Project Overview
• What Happened
• Event Causes, Consequences, and Significance
• Effective Lessons to be Learned Review
• Takeaways
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Bruce A Units 1-4
• Had been shut down in the 1990s
• Decision to restart/ refurb in 2002
• Units 3&4 patched and running by 2004
• Units 1&2 need complete refurb starting~2007
• Schedule: four years
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Bruce PowerBruce County, Ontario
New York State
.
LakeHuron
Lake Erie
Lake Ontario
Toronto
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Bruce B Units 5-8
Bruce A Units 1-4
Bruce Power Site
Douglas Point(Decommissioned) 5
The Setup in Late 2009
• Reactor rebuilds at Bruce U1 and U2 in Year 3
• Feeder tube preparation for tie-in to pressuretubes
• Flapper wheeling/ grinding of the 480 inletand 480 outlet tubes
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Feeder Tube Views
Calandria Face
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Feeder Tube Configuration
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Feeder Tube Orientation
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Figure 1.1.1
Top: section of feederpipe with J shaped bevel;
Bottom left:grinding of inner surfaceof feeder tube;
Bottom right: grinding ofouter surface of feeder tube.
The Job at the Local Level
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RM-14
Air Sampler
Prior to and During the Event:Rad Protection Layout
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The Issue wasnoted in a CR
Over The Holiday Break~December 27, 2009
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Consequences• 557 workers more or less internally exposed to transuranics
between 11/24 and 12/21, 2009; Extent of Condition: >900
• Very unsettled workforce
• Vault closed both Units 1&2 for 42 days (early February 2010)
• Regulatory scrutiny by Canadian Nuclear Safety Commission
• About 10 exposed to alpha radiation received radiation dosesgreater than 500 mrem; all were less than 1,000 mrem;
• Extensive urine and fecal sampling regime
• Dose data handling regime
• Recovery team of 24 established for 11 months (6 Countries)
• $$
• Many more
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Significance
– Over-dose potential if we do not effectively address
– Protection model improvements
– Nuclear workers taking more ownership in theirRP practices and their dose
– An agreed-upon approach with OPG
– Turn-key projects at risk unless Licensee ownershipimproves
– Increased regulatory interest and impact
– Increased costs of doing business
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Dosimetry Options
1. Measure in Urine
2. Measure in Feces
3. Lung counting
• Selected #1 – measure urine
• # 3 under evaluation
• Urine preferred to feces – samples easier toprovide and easier to handle
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Present and Future Extent
Three phases:• Potential exposure before building tents
for feeder work (from 24 November to 28 November)
• Potential exposures after 28 Novemberuntil the end of feeder work(21 December 2009)
• Extent of condition assessment goingback several years through all units
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The Isotopes . . . .
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Nuclide
Half Life
years
Alpha Activity % Dose % Alpha energy (yield)
Pu238 87 38 16 5.5(72) 5.4(28)
Pu239
Pu240
24,000
6560
14 7 5.2(88) 5.1(11)
5.2(76) 5.1(24)
Pu241 14 Beta only small None
Am241 432 30 33 5.5(85) 5.4(13)
Cm242 0.5 0 0
Cm243
Cm244
28
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18 12 5.8(73) 5.7(11)
5.8(100)
- Courtesy of Canberra
The Actions• Recovery Team plan developed with over 200 programmatic
and tactical actions
• Third Party Oversight (RSIC) brought in
• Dose modeling
• Designed and built two state of the art counting rooms: fieldlab and a spectroscopy lab
• Alpha Training by RSIC to over 1000 crafts
• Developed and delivered Rad Tech training to109 Green Men
• Action Plan became focal to the Restart Project
• Lessons to be Learned presentation to >500
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Figure 2.6.4RADOS Whole Body Monitor
Post-Event
Figure 2.6.3Left: ICAM with Trolley Mount;
Right: Portable Air Sampler ("Gooseneck")
Figure 2.6.2 - Ludlum Model 12 Ratemeterwith Model 43-5 Alpha Detector
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Post-Event
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Field Count Room(rendition)
Spectroscopy Lab(Alpha and Gamma Spec
(rendition)
Sample Excerpt from Over 900 . . . .
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NAME Union Contractor
CategoryA= <100,
B= 100-499,C= > 500
24Nov-21Dec-TotalAlpha
DAChrs(based on
0.26Bq/m3 for
a DAC)
Totalexposure(DAChrs)
Trade
1 A #233 A 22 Carpenter
2 B #244 A 81 Labourer
3 C #255 B 141 Labourer
4 A #266 B 98 Millwright
5 B #277 B 135 Electrician
6 C #288 C 522 Carpenter
7 A #299 C 650 Labourer
8 B #310 B 181 Labourer
9 C #321 B 442 Millwright
10 A #332 A 70 Boilermaker
11 B #343 A 15 Carpenter
12 C #354 A 18 Millwright
13 A #365 B 178 Boilermaker
14 B #376 B 231 Boilermaker
15 C #387 A 88 Boilermaker
16 A #398 A 4 Less than 10 Boilermaker
17 B #409 A 3 Less than 10 Electrician
18 C #420 A 35 Pipefitter
19 A #431 B 113 Millwright
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Bruce PowerRadiological Event
November-December, 2009
Overview of the 2009 Radiological Eventand
Lessons Learnedfor the
Units 1 & 2 Restart Leadership Team
Michael D. QuinnJune 10, 2009 This LL
Workshopwas 2-3hours inlength
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Objectives
• ‘Lessons Learned’ to be communicated withemphasis on their role in this event toenhance future conduct of RestartManagement and identified workgroups.
• The Challenger video will be used to facilitatediscussion and communicate the need toutilize lessons learned.
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Effective Lessons to be Learned Review
is Critical to Two Specific Objectives:
• Not repeating the same or similar behaviors/mistakes in the Radiation Protection Program
• Not repeating the same or similar behaviors/mistakes in all Restart Programs
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We Avoid Repeats By:
Improving the methods and processes thatidentify problems earlier
in a safer, better, higher quality,
schedule congruent, and
more cost-effective manner
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The Occurrence Pyramid
Infractions/ Deviations ~1000
- adapted W.R. Corcoran 2001
Compromises ~100
Near-misses ~10
High Consequence Event
Less serious issues indicateprocess and
implementation challenges
High consequence events result fromcommand accountability issuesthat lead to program failures in:
• Human Performance• PI&R
• Safety Culture
Levels of Precursors
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The Lessons are Learned by:
– Comprehensively enacting the event’s Corrective Actions– Leadership providing clear expectations and accountability– Decreasing the problem identification threshold to below the
‘near miss’ level (preferably lower), which encourages staff toreport problems
– And . . . . . . by fully engaging:
• The Restart Human Performance Program
• Problem Identification & Resolution (PI&R)(Corrective Action Program)
• Nuclear Safety Culture Concepts
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Barriers to Effective Lessons Learned
There’s no leadershipinvolvement or commitment
We don’t have timefor this stuff - I havea milestone to meet
Everyone is personally responsiblefor nuclear safety.
Leaders demonstrate commitment tonuclear safety.
Trust permeates the organization.
Decision-making reflects safety first.
Nuclear technology is recognized asspecial and unique.
A questioning attitude is cultivated.
Organizational learning is embraced.
Nuclear safety undergoes constantexamination.
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10. Ignorance -- “I didn’t know this was a hazard."
9. Lack of skill -- "I didn’t know what to do about it."
8. Mistrust of authority -- "They lied to us before about safety, so how do I
know they're telling the truth now?"
7. Personal experiences -- “Risk taking; Nothing bad ever happened to me
before by doing it this way, so why worry now?"
6. Lack of incentives -- "What's in it for me? Why should I follow this much
harder procedure?” (I’ll use my skills)
5. Mixed incentives -- "My boss tells me to report unsafe conditions but still expects me toget the job done on time and with less help.”
4. Inconsistent Accountability - "Nothing bad will happen to me if I ignore the hazard
or do things my own way."
3. Group norms -- "If I point out the hazard, my buddies will think I'm ratting on them;or if I insist on following some procedure, they'll think I'm a wimp"
2. Macho self-image -- "I can do this job in spite of the hazards, thrill of risk taking, I can be ahero, and others will respect me for it."
1. Personality factors -- "I know better - who needs to work that hard?”