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Offline S T I G

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Worst screw up you have ever witnessed?
« on: Jan 10, 2014, 05:53 »
1) What is the worst radiological screw up you have ever witnessed on the job?
2) What did you learn, if anything?

(try and keep it fairly short if you can)
« Last Edit: Jan 10, 2014, 06:47 by The Stig »

Offline RDTroja

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Re: Worst screw up you have ever witnessed?
« Reply #1 on: Jan 10, 2014, 05:57 »
death,...

Damn... beat me by a minute
"I won't eat anything that has intelligent life, but I'd gladly eat a network executive or a politician."

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Offline S T I G

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Re: Worst screw up you have ever witnessed?
« Reply #2 on: Jan 10, 2014, 06:46 »
I slightly altered the question..

Online Marlin

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Re: Worst screw up you have ever witnessed?
« Reply #3 on: Jan 10, 2014, 07:34 »
   I think that would be a bent control rod. The rod was not properly disconnected and when the upper internals were lifted and movement to the storage stand started it bent not allowing the upper internals to be moved. This was a CE plant where the Internal Core Instrumentation stored position is in the upper internals. RDTroja I believe you were also at that outage. If you have not been in the containment it is hard to relate dose in the R/hr range on the polar crane catwalk during the lift and movement of the internals to it's storage stand. I went in with one of the early crews trying to unlatch it but it was just the crane operator and another Rad tech on the walkway during the lift and movement.

   Lessons learned were primarily for operations on control rod unlatching. Not much choice on how to handle the move after additional attempts to unlatch the rod as is.
« Last Edit: Jan 11, 2014, 01:52 by Marlin »

Offline S T I G

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Re: Worst screw up you have ever witnessed?
« Reply #4 on: Jan 10, 2014, 07:39 »
That's a good one! Thanks Marlin!

Offline UncaBuffalo

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Re: Worst screw up you have ever witnessed?
« Reply #5 on: Jan 10, 2014, 07:49 »
What are the rules...did we have to actually be at the scene?  Or was on site good enough?

The worst that comes to mind that I was actually there for was pipe-end decon during an SGRP.  They lost their blast head ventilation (which they had assured us would immediately stop the shot-blast machine)...and then didn't even bother telling us they were having problems.  We found out quickly enough...when our CAM alarmed...and the CAM on the refuel floor alarmed...and the CAM in the AUX bldg hallway alarmed...and...

As far as just being on site?  During a S/G sleeving outage they dropped the >50 R/hr 'honing' (think vacuum filter that has been catching the fine dust generated by running a bottle brush up a generator tube) filter from the refuel floor to the basement.  I was outside containment both (yes, BOTH - they didn't learn very fast) times this happened.  The first time it wasn't TOO bad because the bag around the filter maintained some integrity...although the tech who was standing right there got the largest body burden I'd seen up to that point.  The second time, the bag exploded, too, and we had minus eighth air all the way out in the access trailer.  It was 'interesting' to do D&D in that quadrent when we tore the place down.

There's another 'war stories' thread in here somewhere, but...
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Re: Worst screw up you have ever witnessed?
« Reply #6 on: Jan 10, 2014, 08:11 »
   If it is one that I witnessed from start to stop it would have to be a reactor head movement. I was standing on the refuel floor of containment (minding my own business) when I suddenly felt a high wind that started at my feet that moved up to my waist. I looked around to see what the heck it could be then looked up, the reactor head was being moved from the head stand and had passed over one of the ventilation units that exhausted straight up into the underside of the reactor head. I visualized massive ingestion and huge airborne but as it turned out the containment only hit 0.25 mpc (before DAC) and I showed no ingestion later on the body counter. Apparently dilution is the solution for pollution.

Offline Old HP

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Re: Worst screw up you have ever witnessed?
« Reply #7 on: Jan 10, 2014, 11:58 »
1.   Three Mile Island   (first 4 months after the accident)

2.  Lesson learned, "Do Not Volunteer" to work a plant with ruptured fuel and 6" of primary water in the aux. building.

Offline gerald.rood

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Re: Worst screw up you have ever witnessed?
« Reply #8 on: Jan 11, 2014, 09:37 »
Pressurizer relief tank (PRT) had been drained and the valve left open to the reactor coolant drain tank. (RCDT)
Hydrogen migrated upward from the RCDT into the PRT.
HPT ascended a scaffold to reach the manhole at the top of the PRT, and raised an air sampler by rope.
HPT lowered the running air sampler into the PRT to obtain a sample.
“Rapid hydrogen burn” occurred within the PRT, shredding the HPT’s raingear coat, and nearly occurred knocking him 30 feet to the concrete.
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1.    Your instrumentation is not intrinsically safe.
2.   Communication, communication, communication.
3.   There is a God.

Offline UncaBuffalo

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Re: Worst screw up you have ever witnessed?
« Reply #9 on: Jan 11, 2014, 11:37 »
What are the rules...did we have to actually be at the scene?  Or was on site good enough?

The worst that comes to mind that I was actually there for was pipe-end decon during an SGRP.  They lost their blast head ventilation (which they had assured us would immediately stop the shot-blast machine)...and then didn't even bother telling us they were having problems.  We found out quickly enough...when our CAM alarmed...and the CAM on the refuel floor alarmed...and the CAM in the AUX bldg hallway alarmed...and...

As far as just being on site?  During a S/G sleeving outage they dropped the >50 R/hr 'honing' (think vacuum filter that has been catching the fine dust generated by running a bottle brush up a generator tube) filter from the refuel floor to the basement.  I was outside containment both (yes, BOTH - they didn't learn very fast) times this happened.  The first time it wasn't TOO bad because the bag around the filter maintained some integrity...although the tech who was standing right there got the largest body burden I'd seen up to that point.  The second time, the bag exploded, too, and we had minus eighth air all the way out in the access trailer.  It was 'interesting' to do D&D in that quadrent when we tore the place down.

There's another 'war stories' thread in here somewhere, but...

I missed the lesson-learned part of the question, so...

On the first:  Fail-Safes sometimes don't.

& second:  Don't get so focused on one aspect of the job that you do something stupid on another part.  A hook on a rope & pulley system was our standard way of moving waste from the basement to the refuel floor.  The focus was on dose reduction, so a 'shepherd's hook' was made to lift the bagged filter from the rope hook.  Long-handled tools...your standard ALARA friend, right?  Unfortunately, on two occasions this led to HUGE contamination & airborne issues when filters were dropped and broken.
We are plain quiet folk and have no use for adventures. Nasty disturbing uncomfortable things! Make you late for dinner! I can’t think what anybody sees in them.      - B. Baggins

Offline x6655

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Re: Worst screw up you have ever witnessed?
« Reply #10 on: Jan 11, 2014, 07:52 »
Duane Arnold Recirc pipe replacement in 1978/79.  They welded in the pipe, when they tried to start up found that they had left a 10 lead plugs in the line.

Offline S T I G

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Re: Worst screw up you have ever witnessed?
« Reply #11 on: Jan 11, 2014, 08:42 »
this is all good stuff guys thank you

Offline thenukeman

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Re: Worst screw up you have ever witnessed?
« Reply #12 on: Jan 11, 2014, 09:05 »
1. Person  burned  to  death.  I  was  on  the emergency response team.        2.  I  told  management  we  need  to come  in early  to  set  up  a pump of a tank  full  of  strontium.  The  management  would  be  useless  watchers as we  set up. Management  said  no  come  in regular time in July in TN  and  we  would  be  pumping  in a containment  hut.  Well  since it  was  so hot for  safety  we  had to do  the  final  hook up  with  4  different  people  doing  15  minute   jumps.  Would  you  know  that  it  did  not  get  hooked   up right(  should  have  been  a one  person job  done  in  the  morning) The   line  broke off  the  flange  and  sprayed  strontium 90   all  around  the  containment.  Fortunately no  one  was  in there.   (  I was  also  scolded  about  the containment but  w as  grudgingly  allowed  to  put it  up.)
3.  A  company  I was  checking I told  to  change  their  RWP  because  it was  poorly  written  and should  have at  least  3  things, Current  conditions,  hold  points  and   a  final  survey.  Well I  get  called later.  They  tell me  a employee  walked  into  their  office  and  set  off  a  frisker. (  He  is  now  in TN  but  has  shipped waste  from SC)  I  was  told  that  there  was  a 100  mr an  hr  hot  spot  in SC  in  a  hospital.  Old  Cesium  sources were  crushed ( did  not  fit  the  right  pig  so  they  just  smashed  them  in another  pig, Unfortunately  (Old)  they  disintegrated.  Crapping  up  the  hospital,  the  person (yes  internally  also)  and  container,  Then  crap  up the  vehicle while   driving  then   crap up  his  house,  then  crap  up his  facility,  This   cost them  in  fines  and  clean up. They  said  from  now  on  they  will  survey a  facility   they  leave  and  have  a person  watch  them  survey  to  insure  it   was   not  crapped  up.  Also state  conditions  and  hold  points,  Nice.
4.  Numerous  incidents,  a  boat  trailer  was crapped  up  with cesium  found at a scrap  yard, 20  mr/hr contact.  Brass at  a  scrap  yard  with  radioactive zinc  and  cobalt.  Copper  with  Radioactive cobalt  and    silver.  100   R  an  hour contact radium source  found at  a bridal  shop  that  was  put  in  backwards  in  the  pig, (  Fully exposed  not  shielded) (Nasopharyngeal  source) doctor died  years  ago  and  no  one  knew  what it  was,   Funny  a  spit  bottle  reading  200  mr/hr contact from I-131 thyroid  ablation, Last  2  found  by  a  fellow  HP.      
« Last Edit: Jan 11, 2014, 09:08 by thenukeman »

Offline RDTroja

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Re: Worst screw up you have ever witnessed?
« Reply #13 on: Jan 11, 2014, 09:57 »
Setting off a stick of dynamite in the bottom of a Steam Generator Channel Head after a cycle with fuel problems.
"I won't eat anything that has intelligent life, but I'd gladly eat a network executive or a politician."

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"Politics is supposed to be the second-oldest profession. I have come to understand that it bears a very close resemblance to the first."
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I have never made but one prayer to God, a very short one: 'O Lord, make my enemies ridiculous.' And God granted it.

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Offline UncaBuffalo

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Re: Worst screw up you have ever witnessed?
« Reply #14 on: Jan 11, 2014, 10:05 »
Setting off a stick of dynamite in the bottom of a Steam Generator Channel Head after a cycle with fuel problems.

Explosive sleeving?  ...or...?
We are plain quiet folk and have no use for adventures. Nasty disturbing uncomfortable things! Make you late for dinner! I can’t think what anybody sees in them.      - B. Baggins

Offline RDTroja

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Re: Worst screw up you have ever witnessed?
« Reply #15 on: Jan 11, 2014, 10:10 »
Explosive sleeving?  ...or...?

Explosive plugging... bad Boilermaker.
"I won't eat anything that has intelligent life, but I'd gladly eat a network executive or a politician."

                                  -Marty Feldman

"Politics is supposed to be the second-oldest profession. I have come to understand that it bears a very close resemblance to the first."
                                  -Ronald Reagan

I have never made but one prayer to God, a very short one: 'O Lord, make my enemies ridiculous.' And God granted it.

                                  - Voltaire

Offline thenukeman

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Re: Worst screw up you have ever witnessed?
« Reply #16 on: Jan 11, 2014, 10:36 »
Does  a nuke  simulator count? I  call  this a  almost  screw up.
Well  the  Army  made  nuke  simulators  by  digging a  50  foot  ditch putting  2  sticks  in the  ends  of  the  ditch  and  wrapping detonation cord  20 times  around the sticks.  A  600 gallon  fuel  truck  would  fill up  55  gallon drums  with   gas.  We  would put  2.5  tubs  of  thickener  in each  drum  and then  we  would pour this  into  the  ditch. Flares  would  be  wrapped  with the  det  cord. at  the end  of the  ditch.    The time  fuse would  be cut  for  10 minutes.  After  several  these  went of  I felt comfortable and let  my   Sergeants  cut  and  measure this.  They usually   went off   within  10  seconds  of  the  10 minutes.  Well  one  time it  did not  go off.  I waited  20 minutes still no  boom.  Being  the safety officer I  was  responsible  to go  down range  to see  why there   was  no  mushroom  cloud.   We  discussed  this and  then  there  was  a boom  at  about  25  minutes.  I decided  then  I would  always  watch the  det  cord end  being  cut  off  to  insure  no moisture  build up  and I would watch  it be  measured after  the end cut off for each  shot.  No  more  problems.

I also  learned  my  Colonel  was  inaccurate when  he told me  it  would  always be  a good  nuclear  day  with  a  Nuclear  Fusion  star (The  Sun)  and  no  Mushroom  clouds in  the  sky.  I wanted  to  see  the  mushroom  so I did  not  have  to see  why  there  was  no  mushroom.   So   No  mushroom  equals not  a  good day for  me.
« Last Edit: Jan 11, 2014, 10:42 by thenukeman »

Offline GLW

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Re: Worst screw up you have ever witnessed?
« Reply #17 on: Jan 12, 2014, 08:38 »
Quote

from: GLW on Jan 10, 2014, 05:54
death,...


Damn... beat me by a minute

OBE

Overcome By Edit

been there, dun that,... the doormat to hell does not read "welcome", the doormat to hell reads "it's just business"

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Re: Worst screw up you have ever witnessed?
« Reply #18 on: Jan 13, 2014, 08:08 »
A real staff on-shifter 1979, 3-Mile and the few months following.

Offline GLW

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Re: Worst screw up you have ever witnessed?
« Reply #19 on: Jan 13, 2014, 09:08 »
Does TMI count as radiological or operational?

A person could postulate it is both.

Yet, in our line of work, most operational SNAFU's have a high potential for prompting radiological challenges.

I would contend the root SNAFU is operational, the radiological challenges are collateral damages and do not distinctly qualify as radiological screw ups.

I'm just saying,...as I see it,... TMI is no Mr. Chips (yes I know Mr. Chips was set up for failure),... [coffee]


been there, dun that,... the doormat to hell does not read "welcome", the doormat to hell reads "it's just business"

Online Marlin

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Re: Worst screw up you have ever witnessed?
« Reply #20 on: Jan 13, 2014, 11:30 »
(yes I know Mr. Chips was set up for failure),... [coffee]

   Not so much set up as it was a sign of the times. There was a shortage of techs at the time and inexperienced techs with little technical training was normal at many plants. "Mr Chips" was trying to be very conscientious and failed to recognize the difference in actual to indicated contact dose rate. He went farther than some of the techs would have to take care of his work crew and inadvertently received elevated exposure to his extremities. I was a lead tech on that project and had the opportunity to talk to him while he was going through all the critiques, I did and do think highly of him I suspect if he is still swinging a meter he is doing an exceptional job.

Offline spentfuel

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Re: Worst screw up you have ever witnessed?
« Reply #21 on: Jan 13, 2014, 12:26 »
Watching a couple house tech sent to survey a "vent duct" to try and determine why QA's PD was offscale during fuel movement observations in the SFP.  Turns out the vent duct was the transfer tube and seems when they built the plant they forgot to install any shielding around it.

lesson learned don't mess with spent fuel and just cause your told something don't blindly believe it

sf

Offline Old HP

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Re: Worst screw up you have ever witnessed?
« Reply #22 on: Jan 13, 2014, 11:43 »
The "vent duct"  story sounds like a later version of the Trojan OE of 1978 when an HP and an Operator each received @ 25R while monitoring dose rates near the transfer canal. The HP from that day forward called Teletectors  fence posts.  All you new generation HPs will never experience off scale pencil dosimeters.

Offline S T I G

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Re: Worst screw up you have ever witnessed?
« Reply #23 on: Jan 14, 2014, 02:05 »
The "vent duct"  story sounds like a later version of the Trojan OE of 1978 when an HP and an Operator each received @ 25R while monitoring dose rates near the transfer canal. The HP from that day forward called Teletectors  fence posts.  All you new generation HPs will never experience off scale pencil dosimeters.

That's one experience I don't mind not having.  ;)

Offline RadRooster

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Re: Worst screw up you have ever witnessed?
« Reply #24 on: Jan 14, 2014, 06:22 »
Cavity decon with pressure washers while the equipment hatch and personnel door were both open causing a "cyclone" type wind. Didn't witness it but relieved the crew that was there and dealt with the aftermath.

 


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