IR 05000054/1988002

Insp Repts 50-054/88-02 & 70-0687/88-06 on 880809-11.No Violations Noted.Major Areas Inspected:Emergency Preparedness Program Including:Changes to Program,Emergency Action Levels,Training,Facilities & Procedures

ML20154S340
Person / Time
Site:	05000054, 07000687
Issue date:	09/22/1988
From:	Fox E, Lazarus W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20154S334	List: IR 05000054/1988002 ML20154S330
References
50-054-88-02, 50-54-88-2, 70-0687-88-06, 70-687-88-6, NUDOCS 8810050046
Download: ML20154S340 (10)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Report No /88-02 70-687/88-06 Docket No License No R-81 Priority - Category -

SNM-639 Licensee: Cintichem, In P. O. Box 324 Tuxedo New York Facility Name: Hot Laboratory and Reactor Inspection At: Tuxedo, New York Inspection Conduct - Augusta-ll/j988 Inspectors: -

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/ bMd7 date E. M en g y y PreparddHEss Spe K. Christopher, Emergency Preparedness Spe R. Nimitz, Senior Radiation Specialist Approved by: Mw  %#' 9 ,70 / [

W. Lazarus, [hir , Emergency Preparedness dats Section Inspection Summary: Inspection conducted on August 9-11,1988 (Combined Report hos. 50-54/8 W-; 70-68T/88 06)

Areas Inspected: Routine announced inspection of the licensee's emergency preparedness program includin changes to the program; Emergency Action Levels; off-site interface; training;g:facilitios and procedures; follow-up of previously identified inspection item Results: No violations were identified. One unresolved item concerning the g f the licensee's criticality accident monitoring system setpoi ts was 0810050046 880927 4 ADOCK 0500 gDR

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DETAILS 1.0 Individuals Contacted

• J. McGovern, Plant Manager

• L. Thelin, Staff Health Physicist

• J. Stewart, Radiation Protection Supervisor

• Ruzicka, Manager, Nuclear Operations

• T. Vaughn, Manager, Radiological Health, Safety, and Environment K. Sanford, Chief, Tuxedo Fire District J. Radar, President, Greenwood Lakes Ambulance Service J. Kelley, Tuxedo N.Y. Police Dep D. Fitzpatrick, Adm. Supervisor, Emergency Dept. Good Samaritan Hos *The above individuals attended the exit meeting on August 11, 1988.

The inspectors also contacted other licensee personnel during the course of this inspectio .0 Purpose and Scope of Inspection This inspection was a routine announced Emergency Preparedness inspection of the following areas:

- Emergency kits, facilities and procedures

- Licensee implementaticn of the June 30, 1988 Confirmatory Action Letter

- Criticality safety

- Respiratory protection

- Changes to the Radiological Contingency Plan (RCP)

- Training

- Off-stte interfaces

- Emergency Action Levels 3.0 Licensee Action on Previous Findings During this inspection, the inspectors reviewed records and interviewed licensee personnel regarding the status of items identified during previous inspections (Inspection Reports 50-54/84 03 and 70 687/87-04). The status of these items are as follows:

- (Violation) IR 7n-687/87-04 (a) The Emergency Planning Coordinator did not review and update the emergency plan and implementing procedures biennially since 1983 (b) Agreements with off-site support groups were either not initiated or were not updated biennially since 1976; and (c) The Emergency Planning Coordinator did not review the emergency roster and telephone listings and verify each individual's or organizations phone number annually since 198 .

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The inspectors reviewed plans and procedures and conducted interviews of licensee personnel to determine the status of the licensee's response to the violation. It was determined that the Radiological Contingency Plan (RCP) is undergoing significant revision and will be submitted to the NRC for review in the near future. As part of the revision, the EPC is conducting an ongoing review of the plan and implementing procedures. The EPC is documenting all completed reviews. The inspectors noted that the Nuclear Safety Committee has recommended that an independent review of the plan be conducted by the Corporate Safety Review Committe The inspectors confirmed that the licensee has updated letters of agreement with the appropriate off-site support groups including police, fire, ambulance and medical services effective as of Dec. 15, 198 The inspectors confirmed through documentation review that the licensee has completed and documented a review and update of the emergency roster and telephone listings including a verification of each individuali or organizations telephone numbe (CLOSED) 84-03-01: Identify responsibilities of the emergency director (E.D.) that cannot be delegate Sec. 3.1 of the RCP specifies those responsibilitter that cannot be delegated and must be performed by the Emergency Directo (CLOSED) 84-03-02: Provide written guidance to the Public Information Officer (P10).

Implementing procedure, EP 15, provides written guidance to the designated PI (CLOSED) 84-03-03: Provide additional on-site trainin The inspectors reviewed documentation and interviewed licensee personnel relative to the status of training as to the content of the RCP and the interactions of the various entities of the response organization. The licensee has completed and documented training pursuant to Sec. 1 (Training) of the RCP and EP16 for all emergency directors radiological assessmentteammembers,publicinformationofficersandfIrstaidteam members. The training consists primarily of "read and sign" as set forth in Sec. 10.2 of the RC (CLOSED) 84 03-04/84-03-05: Update letters of agreement with off-site support agencies.

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l , RCP letters of agreement have been updated i

As notedthe between in paragraph 2(b)do Fire and Police, two local ambulance services licensee, Tuxe and Good Samaritan Hospita .

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(OPEN 84-03-06:

provid)e for periodic retraining and participation in emergency drills. Complete trainin The inspectors determined through interviews of off-site support group representatives that the licensee has conducted updated training for relevant support groups such as ambulance, fire and police services, as well as having in place written procedures for the handling of a contaminated injured person at Good Samaritan Hospital. This training consisted chiefly of plant tours followed by discussions of various aspects of the RCP. It was noted that the Tuxedo Fire District was in possession of a copy of the RCP and was supportive of the licensee's efforts in this area. However, a provision for periodic retraining has not been developed and not all off-site support organizations have participated in emergency drills (i.e. Police).

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84-03-07:

Tu(CLOSED)d xedo an State Police in the event of a civil disturbance.The emergency call list should The inspectors determined that EP-01-03 of the RCP lists the Tuxedo Police and the N.Y. State Police as response agencies in the event of a civil disturbanc (CLOSED) 84-03-08: Provide reliable backup communication means for notifying off-site emergency support organization The inspectors determined that reliable backup communications for on-site and off-site is in place and available. Back up power supplies are provide :

-(CLOSED)tation instrumen and data back up. Provide a means for obtaining meteorological The inspectors reviewed a letter of agreement between the licansce and the Power Authority of the State of New York PASNY at the Indian Point 3 Nuclear Power Station dated Jan. 15, 1988(, where)by PASNY has agreed to provide the licensee with the required back up meteorological data in the event of an emergenc (CLOSED 84-03-10: Eliminate Sec. 7.2.3 of the RCP which discusses methodolo)gy for calculating whole body dose rates at the site boundary

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The inspectors determined this section of the RCP was deleted in October

1984 and documented by letter to the NRC in March 1985.

l -(CLOSED) 84 03-11: Provide EAls in procedures for the stack monitor which j will trigger notification of the radiological assessment team (RAT)

The inspectors reviewed EP 02 02 and determined that EALs are provided with the referenced procedures to trigger notification of the RAT team leader.

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-(CLOSED) 84-03-12: Provide a statement in each emergency procedure as appropriate which would require the Emergency Director to classify the emergency using guidance in Tables 5.1 thru 5.3 of the RC The inspectors determined that EP-02-02, and Sec. 2.5 of the RCP requires that the ED use tables 5.1 thru 5.3 of the RCP to assist in the classification of an emergency. This requirement is also reflected in EP-05-01. Sec. 3.7, EP-04-02, Sec. 2.7, EP-05 01, Sec. 2.6 and EP-06-02,

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Sec. 2.1 (0 PEN) 84-03-14: Develop a formal training / retraining progra While the initial on-site emergency response training is completed per EP 26, there is no planning establishing time tables and criteria for the periodic retraining of the plant staf Provisions for scheduling such refresher training cycles should be included in EP 16 and tracked to ensure a timely cycle of retraining of the emergency response personne This item will be reviewed in a subsequent inspectio .0 Operational Status of the Emergency Prepredness Program and Procedures 4.1 Changes to the Radiological Contingency Plan (RCP) and_ Proc;edures The RCP and implementing procedures are currently unjergoing significant revision by the licensee to upgrade the RCD in response to recommendations from previous NRC inspections, It is planned that the revised RCP will be subjected to an external independent review by the Corporate Safety Review Committee and will then be submitted to the NRC for review. Based on a i preliminary review of the draft revision and the existing plan, the following observations were noted and should be evaluatec by the licensee:

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- The licensee maintains supplies of potassium iodide on site and the ED is charged with making the decision as to its distribution. There is no guidance in the RCP as to the criteria and/or considerations that should be utilized by the E. D. in making a determination as to it's use. Such guidance should be incorporated into the pla Sec. 3.1 of the RCP provides for the designation of the ED but does not provide for a )lanned turnover of the position to an alternate and l does not address t1e role of corporate involvement above the plant

manager in the event of a senior corporate officer arrivins on-site during an emergency. The licensee has indicated they woulc revise the ED turnover mechanism to ensure a controlled turnover and would also clearly set forth the role of any on-site corporate official during an

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emergenc I i

- Table 5.11, item 7 of the RCP sets forth actions to be taken by licensee personnel during an unusual event declaration. The table

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directs that the NRC be notified only "if the situation warrants."

This should be revised to require NRC notification and eliminating the phrase "if the situation warrants".

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The EALs do not provide for protective actions based on projected exposures. The plant instrumentation goes off scale at the alert level and there are no procedures or back u in quantifying or estimating ongoing releases.p means to use initiated The licensee action to improve this are These items will be an inspector follow up item and will be reviewed in a subsequent inspection (88-02-01).

Based on the above review and except as noted above, this portion of the licensee's emergency preparedness program is adequat .2 Coordination of Emergency Planning with Off-site Support Agencies L

The inspectors reviewed updated letters of agreement between the licensee and police fire with the llcensee, ambulance and hospital and representative of the services off-site and held discussionsThe organization agreements have been updated in accordance with Sec. 10.5 of the RC Trainin , in the form of plant tours, discussions, procedure re/iews and partici ation in drill activities have been offered to the off-site organiz tions. Fire fighting personnel have toured the facility to l ascertain its layout and location of hazardous materials and both ambulance services and hospital personnel have been fully briefed on the transport and handling of an injured victim who has been contaminate Based on the above review, this portion of the licensee's emergency preparedness program is adequat .3 Knowledge and Performance of Duties (Training)

The inspectors reviewed training documentation and established that emergency response personnel have received "read and sign" training in the basic emergency response functions. There are no formal training outlines or established retraining cycles through which it is ensured that on-site response personnel receive refresher training as to their emergency response duties and responsibilities It was noted that the licensee has committed to the guidelines of Reg. Guide 2.6 (Emergency Planning for Research Reactors which recommends that the training program for the emergency organ)ization be documented in the form of

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schedules and outlines.

The inspectors conducted walk throughs with two senior licensed personnel from the operations department. Scenarios were presented that would test the ability of the operators to classify events using the EAls and their overall knowledge of the RC The operators' responses were adequate and sufficiently conservative to protect the public health and safety; however they exhibited some difficulty and unfamiliarit with the RCP in terms of their ability to classify events and in identif ing the required actions to be taken in response to the event classificat o '

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It was apparent that the annual "read and sign" training for operators on the RCP is insufficient to provide the desired level of knowledge required for effective implementation of the RCP during an emergenc This issue will be evaluated in a subsequent inspection and will be included in the evaluation of 0! 84-03-14 referenced in Sec. Based on the above review and except as noted above, this portion of the '

licensee's emergency preparedness program is adequat .4 Tests and Orills

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The inspectors examined records and scenarios of emergency preparedness tests and drills as well as licensee critiques of those exercises for 1985, 1986, and 1987. The exercises tested areas such as activation of the Radiological Assessment Team, transportation and handling of a contaminated injury victim with offsite support personnel, and full dress !

out in protective clothing and SCBA's in response to the dropping of a high integrity container behind a hot cell. The scenarios appeared generally adequate to test the various aspects of the emergency response organization. However the exercise critiques reflected the identification of problems with the adequacy of various emergency team response actions and there is nothing to indicate that the licensee has undertaken any actions in the way of changes to the RCP or enhanced

. training to address the issues identified in the critique This is an inspector follow up item and will be addrested in a subsequent inspection (88 02-02).

Based on the above review and except as noted above, this portion of the licensee's emergency preparedness program is adequat .5 Facilities, Equipment and Procedures The inspector equipment andreviewed the adequacy procedure of licensee The evaluation emergency of licensee facilities, performance in this area was based on review of equipment including review of off-site

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monitoring equipment, discussion with cognizant personnel and review of .'

documentatio The following was reviewed:

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- Emergency kits including supplies, operability of equipment and  ;

frequency of inventory,

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- Respiratory protective equipment, t

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Protective clothin and supplies, i

- Operability of acic showers and acid eye wash stations, i

- On-site and off-site rendezvous facilities, l

- Off-site monitoring equi

- On site medical faciliti,nment e and capabilities, and

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The following matters were discussed with licensee representatives as areas for potential improvement:

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The licensee could not provide a basis for the equipment selected to be in the kits or the numbers of supplies included in the kits. A review should be performed to evaluate the adequacy of the equipment selected and supplies include Some kits (e.g. decontamination kits } did not include an inventor The inventories for some Emergency Kits did not reflect all equipment that was contained in the kits. Also some equipment was stored without an inventor Also, methods for There were no off-site monitoring kits. infield analysis of off-site air samples we

- The licensee did not have pre-identified off-site rendezvous locations where personnel would go in the event the site was evacuate Licensee personnel indicated the above items would be reviewed. These items are an inspection follow up item (88-02-03) and will be reviewed in a subsequent inspectio Based on the above review, except as noted this portion of the licensee'semergencypreparednessprogramIsadequat .0 Confirmatory Action Letter implementation The inspector reviewed the implementation of the June 30, 1988, Confirmatory Action Letter (CAL) issued to the licensee. This CAL dealt with licensee commitments to secure unmonitored effluent releases from the facility via the Hot Cell Emergency Ventilation Syste Inspector review indicated the licensee was implementing the commitments documented in the CAL. Licensee implementation of long term actions described in the CAL and scheduled for completion by December 31, 1988, will be reviewed during a subsequent inspectio .0 Criticality Monitoring / Safety The inspector reviewed selected aspects of the licensee's criticality monitoring and safety. The review was with respect to criteria contained in applicable regulator following was reviewed:y requirements and industry standards. The

- Criticality alarm monitoring system and periodic system operability checking,

- Response procedures, and Personnel monitoring provision O

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Within the scope of this review, no violations were identified. The licensee has an installed alarm system which is periodically verified to be operable. The following matters were discussed with licensee personnel as l areas needing attention:

- The licensee's criticality accident monitoring system alarm setpoints and detector locations were based on an assumed criticality event involving a sustained event with a power level of about 300 watts. The inspector questioned the adequacy of the alarm set points (1000 mR/hr.) and detector response times assuming a criticality event of short duration at a higher power level. The licensee was unable to provide data to demonstrate that the current alarm setpoints were adequate for this type of event. Licensee personnel indicated the cognizant individual was not available but this matter would be reviewed. This matter is considered unresolved (70-687/88-06 01).

- The licensee has established post-criticality accident emergency procedures. However, the procedures provided limited guidance as to

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the actions to be taken by radiological controls personnel when responding to the accident. For example, the licensee did not have well defined procedures for use by the staff which describe a means j to quickly identify which individuals had received 10 rads or mor The licensee did have published documentation but it was not distributed to the staff. The licensee indicated this would be reviewe Review the adequacy for monitoring of personnel exposure monitoringevent during criticality devices (he T

licenseei.e. TLD badges)

initiated a review of this matte .0 Respiratory Protection l The licensee does not have an approved Respiratory Protection Program, j Consequently, the licensee is not permitted to make allowance for the use of such equipment when assessing exposur On July 18, 1988 the licensee notified the NRC of his intent to implement anapprovedRespIratoryProtectionProgram.Theinspectorreviewedthe

information presented in the July 18, 1988 letter with respect to criteria contained in 10CFR 20.103.

Within the scope of this review, no violations were identified. Inspector

review indicated a number of a) parent procedural and program weaknessus.

! The following weaknesses were arought to the licensee s attention:

- A policy statement required by 10CFR20.103 was not in plac A training program for all devices was not in plac No procedures for inspection, repair and maintenance of the equipment was in place.

- A program for medical certification of potential respirator users was not in place.

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The inspector noted that a number of the program required criteria the specified inspector in 10CFR 20.103 concluded that protection did not appear factorstoauthorized be satisfie forConsequentlylory the respira protection equipment could not be used because of the above program inadequacies. Licensee personnel indicated additional effort would be  !

directed to the program such that protection factors could be use .0 Exit Meeting The inspectors met with the licensee personnel denoted in Sec. I at the conclusion of the inspection. The licensee was informed of the status of all open Areas for improvement in the licensee's program were als/o closed items.The licensee acknowledged the findings and agreed discusse to institute corrective actions as appropriate. No written materials were provided to the licensee by the inspectors during the inspection.

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