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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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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

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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

This is a lot of workfor something that doesn’t

apply to my work group

These lessons learnedare too general

to make a difference

Management just payslip service to

this stuff - nothing will change

Yeah . . . butmy project is different

I don’t know how to do this,and if I ask,

it’ll make me look stupid.

What’s the point -we’re almost done !

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Factors of theNovember - December 2009

Radiological Event

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30Reference: RCA Alpha Event Report March 2010 30

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Radiological Event November-December 2009:Event Causes/ Contributors

(nearly all have important underlying factors)

1. Turn-Key Approach

2. ‘Unknown’ MaterialCondition

3. LTA Radiation workplanning procedure

4. Deficient source termdetermination

5. LTA Performance testingof tool

6. LTA RP knowledge

7. Tent installation . . . . . . .

8. NE Radiation workplacemonitoring

9. EPRI Guidelines (OPEXMissed)

10. LTA REPs

11. Unmonitored loosecontamination

12. LTA Bruce Poweroversight

Reference: RCA Alpha Event Report March 2010 31

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How Safety Culture Should Showin Lessons Learned

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Principles for aStrong Safety Culture

WANO/ INPOThe 8 Principles:

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?”

“Who cares - it's not my problem.”

One More: Lack of clear expectations

Top 10 ReasonsNuclear Managers and Workers

Don't Comply withSafety Culture Expectations

- Adapted from Dr. Edgar Schein and INPO 34

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Technical and StructuralCorrective Actions

Programs, Procedures, ProcessesAugmented Staff/ Recovery Team

Equipment Hardware/ Infrastructure

Lessons to be Learned:Engage existing organizational processes and tools, e.g.,

Human PerformanceProblem Identification and Resolution (PI&R)

(Blue Card reporting system/ Corrective Action Program)Nuclear and Radiological Safety Culture

Effective Self-Assessment/ OPEXKey Performance Indicators

Configuration Control/ Conduct of Operations

Behavioral and Cultural Actions

Provide clear expectations and accountabilityEstablish consistent roles, responsibilities, and authority

Role model and establish an open climate and cultureEffectively plan, organize, lead, and control processes

Provide timely information to LeadershipMake informed decisions

Effectively manage organizational interfaces- Picture by Ralph Clevenger

RP Event Corrective Actions and Lessons to be Learned

© 2010 Michael Quinn

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Recapping

• People will make Skill, Rule and Knowledge-Based Errors

• Systems that make such errors less consequential (e.g., HumanPerformance, PI&R, Safety Culture) find and address the precursors

• High Reliability Organizations encourage the reporting of errors andconstantly seek ways to reduce errors and improve safety andreliability

• Serious consequences are preceded by missed patterns, manyprecursor opportunities, smaller incidents, and ‘near-miss’ events

• Interactions between organizations do contribute to events

• Most events have multiple causes (technical, structural, cultural,behavioural) that need to be carefully identified and addressed

• Enacted lessons Learned from event analysis can improveSafety Culture

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Take-Away Lessons LearnedProgrammatic Areas

• Human Performance Program

• Incident reporting threshold levelas low as practical

• Corrective Action Program

• Nuclear Safety Culture

• Radiological Safety Culture

• Industrial Safety Culture

• Quality Programs

• Effective Self-Assessment/ OPEX

• Conduct of Operations

• Configuration Management

• Configuration Control

• Others ?

Leadership Practices

• Establish consistent roles,responsibilities, and authority

• Provide clear expectations andaccountability

• Enact and role model the tenetsof Safety Culture

• Effectively plan, organize, lead,and control processes

• Provide timely information to theRestart Leadership Team

• Make informed decisions

• Effectively manage organizationalinterfaces

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“Lessons aren’t learned untilthey are institutionalized”

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Close-out Discussionand

Going Forward Expectationsof All Restart Leadership

and Workgroups

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Questions ?

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References

• WANO GL 2006-02:“Principles for a Strong Nuclear Safety Culture”

• Root Cause Report: Alpha Contamination Event (November - December, 2009)

• Ishikawa Fishbone - 2009 Radiological Event by the Root Cause Team

• RP Recovery Plan dated April 28, 2010

• Event Contributors May 17, 2010 (Romanowich, Widmeyer, Quinn)

• Irving Janis, Victims of Groupthink, 1972

• Michael D. Quinn (various references)

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