IR 05000131/2005201

NRC Inspection Report No. 50-131/2005-201 and Notice of Violation, Veterans Administration Medical Center Triga Reactor Facility, June 7-9, 2005

ML051710507
Person / Time
Site:	05000131
Issue date:	06/23/2005
From:	Beckner W NRC/NRR/DRIP/RNRP
To:	Washko A US Dept of Veterans Affairs, Nebraska-Western Iowa Health Care System
Bassett C, NRR/DRIP/RNRP, 404-562-4712
References
50-131/2005-201 50-131/2005-201
Download: ML051710507 (23)

Text

June 23, 2005

SUBJECT:

NRC INSPECTION REPORT NO. 50-131/2005-201 AND NOTICE OF VIOLATION

Dear Mr. Washko:

This letter refers to the inspection conducted on June 7-9, 2005, at the Veterans Administration Medical Center TRIGA Reactor Facility. The inspection included a review of activities authorized for your facility. The enclosed report presents the results of that inspection.

Areas examined during the inspection are identified in the report. Within these areas, the inspection consisted of selective examinations of procedures and representative records, interviews with personnel, and observations of activities in progress. Based on the results of this inspection, the NRC has identified three violations of NRC requirements. These violations are cited in the enclosed Notice of Violation (Notice). The circumstances surrounding them are described in detail in the subject inspection report. The violations are of concern because:

1) they apparently demonstrate a lack of attention to the reactor program, and, 2) they were identified by the NRC and not as a result of your own audit program.

You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. The NRC will use your response in accordance with its policies to determine whether further enforcement action is necessary to ensure compliance with regulatory requirements.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRCs document system (ADAMS). ADAMS is accessible from the NRC Web site at (the Public Electronic Reading Room) http://www.nrc.gov/reading-rm/adams.html.

Mr. Al Washko-2-June 23, 2005 Should you have any questions concerning this inspection, please contact Craig Bassett at (404) 562-4712.

Sincerely,

/RA/

William D. Beckner, Program Director New, Research and Test Reactors Program Division of Regulatory Improvement Programs Office of Nuclear Reactor Regulation Docket No. 50-131 License No. R-57 Enclosures: 1. Notice of Violation 2. NRC Inspection Report No. 50-131/2005-201 cc w/enclosure: Please see next page

Veterans Administration Docket No. 50-131 Medical Center cc:

Mayor City of Omaha Omaha, NE 68102 Dr. Lynell Klassen Associate Chief of Staff for Research Omaha Veterans Administration Medical Center 4101 Woolworth Avenue Omaha, NE 68105 Test, Research, and Training Reactor Newsletter University of Florida 202 Nuclear Sciences Center Gainesville, FL 32611 Julia Schmitt, Program Manager Department of Health and Human Services P.O. Box 95007 Lincoln, NE 68509-5007 M. Brenda Hebert (12C1)

Department of Veterans Affairs 810 Vermont Avenue, N.W.

Washington, DC 20420

Mr. Al Washko-2-June 23, 2005 Should you have any questions concerning this inspection, please contact Craig Bassett at (404) 562-4712.

Sincerely,

/RA/

William D. Beckner, Program Director New, Research and Test Reactors Program Division of Regulatory Improvement Programs Office of Nuclear Reactor Regulation Docket No. 50-131 License No. R-57 Enclosures: 1. Notice of Violation 2. NRC Inspection Report No. 50-131/2005-201 cc w/enclosure: Please see next page DISTRIBUTION:

PUBLIC RNRP/R&TR r/f AAdams CBassett WBeckner PDoyle TDragoun WEresian FGillespie DHughes EHylton PIsaac PMadden MMendonca CNagel KWitt PYoung DBarss (MS O6-H2)

BDavis (Ltr only O5-A4)

NRR enforcement coordinator (Only for IRs with NOVs, O10-H14)

ACCESSION NO.: ML051710507 TEMPLATE #: NRR-106 OFFICE RNRP:RI RNRP:LA RNRP:SC RNRP:PD NAME PMM for CBassett EHylton PMadden WBeckner DATE 6/22/2005 6/22/2005 6/22/2005 6/23/2005 C = COVER E = COVER & ENCLOSURE N = NO COPY OFFICIAL RECORD COPY

NOTICE OF VIOLATION Omaha Department of Veterans Affairs Docket No.: 50-131 A. J. Blotcky Reactor Facility License No.: R-57 During an NRC inspection conducted on June 7-9, 2005, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the violations are listed below:

A.

TS Section 6.7.1 requires that routine operating reports covering the operation of the facility during the previous calendar year shall be submitted before March 31 to the Nuclear Regulatory Commission.

Contrary to the above, as of June 9, 2005, no annual operating report covering facility operations had been submitted to the Nuclear Regulatory Commission for the calendar year 2004.

This is a Severity Level IV violation (Supplement VII).

B.

TS Section 6.2.4 requires that, among other issues, the Reactor Safeguards Committee audit facility operations for compliance to the Technical Specifications and applicable license conditions annually.

Contrary to the above, no annual audits of facility operations had been conducted since an audit that was completed on February 28, 2003, for the period from September 1, 2001 through December 31, 2002.

This is a Severity Level IV violation (Supplement VII).

C.

TS Section 4.0 stipulates that the surveillances specified in Sections 4.3, 4.5, and 4.6(1)

may not be deferred during shutdown.

TS Section 4.3.1 requires that the reactor pool water be sampled for gross activity on an average monthly and for isotope identification on an average quarterly.

TS Section 4.3.3 requires that a monthly channel test shall be performed to ensure that the alarm float switch specified in TS Section 3.1.4 is operable.

TS Section 4.5(2) requires that the automatic absolute damper and alarm shall be tested on an average monthly and following repair or maintenance.

TS Section 4.6(1) requires that all radiation monitors listed TS Section 3.6.1 shall be calibrated annually and after maintenance. (TS Section 3.6.1 lists the radiation monitoring channels as the area radiation monitor - pool level and the continuous air monitor.)

ENCLOSURE 1

-2-Contrary to the above, 1.

No analyses of the reactor pool water had been performed to determine gross activity or isotope identification since June 2002; 2.

No monthly channel tests to verify operation of the alarm float switch had been conducted since June 2002; 3.

The automatic absolute damper and alarm in the ventilation system of the reactor facility had not been tested on a monthly basis since June 2002; and, 4.

The continuous air monitor had not been calibrated since August 27, 2001. The area radiation monitor - pool level could not be located.

This is a Severity Level IV violation (Supplement I).

Pursuant to the provisions of 10 CFR 2.201, the Omaha Department of Veterans Affairs is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the responsible inspector, within 30 days of the date of the letter transmitting this Notice of Violation (Notice). This reply should be clearly marked as a "Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation, or, if contested, the basis for disputing the violation or severity level, (2) the corrective steps that have been taken and the results achieved, (3) the corrective steps that will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Your response may reference or include previous docketed correspondence, if the correspondence adequately addresses the required response. If an adequate reply is not received within the time specified in this Notice, an order or Demand for Information may be issued as to why the license should not be modified, suspended, or revoked, or why such other action as may be proper should not be taken.

Where good cause is shown, consideration will be given to extending the response time.

If you contest this enforcement action, you should also provide a copy of your response, with the basis for your denial, to the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, D.C. 20555-0001.

Because your response will be made available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of the NRCs document system (ADAMS), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be made available to the public without redaction. ADAMS is accessible from the NRC Web site at (the Public Electronic Reading Room) http://www.nrc.gov/reading-rm/adams.html. If personal privacy or proprietary information is necessary to provide an acceptable response, then please provide a bracketed copy of your response that identifies the information that should be protected and a redacted copy of your response that deletes such information. If you request withholding of such material, you must specifically identify the portions of your response that you seek to have withheld and provide in detail the bases for your claim of withholding (e.g., explain why the

-3-disclosure of information will create an unwarranted invasion of personal privacy or provide the information required by 10 CFR 2.390(b) to support a request for withholding confidential commercial or financial information). If safeguards information is necessary to provide an acceptable response, please provide the level of protection described in 10 CFR 73.21.

In accordance with 10 CFR 19.11, you may be required to post this Notice within two working days.

Dated at Rockville, Maryland this 23rd day of June 2005.

U.S. NUCLEAR REGULATORY COMMISSION OFFICE OF NUCLEAR REACTOR REGULATION Docket No:

50-131 License No:

R-57 Report No:

50-131/2005-201 Licensee:

Omaha Department of Veterans Affairs Facility:

A. J. Blotcky Reactor Facility Location:

Omaha, Nebraska Dates:

June 7-9, 2005 Inspector:

Craig Bassett Approved by:

William D. Beckner, Program Director New, Research and Test Reactors Program Division of Regulatory Improvement Programs Office of Nuclear Reactor Regulation ENCLOSURE 2

EXECUTIVE SUMMARY Omaha Department of Veterans Affairs A. J. Blotcky Reactor Facility Report No. 50-131/2005-201 The primary focus of this routine, announced inspection was the on-site review of selected aspects of the licensees Class III research reactor safety programs including: organizational structure and staffing and operating reports, review and audit functions, radiation protection, operator requalification and active license status, maintenance and surveillance, emergency preparedness, security, and material control and accounting since the last NRC inspection of these areas. Although the licensees programs were generally directed toward the protection of public health and safety, various violations of NRC requirements were identified.

Organizational Structure and Staffing and Operating Reports

!

The organizational structure and functions were consistent with Technical Specification requirements.

!

One violation was noted for failure to submit an operating report covering the operation of the facility during 2004.

Review and Audit Functions

!

The review program conducted by the Reactor Safeguards Committee satisfied Technical Specification requirements.

!

A violation for failure to conduct annual audits of facility operations was identified.

Radiation Protection

!

The radiation protection program satisfied some NRC requirements but various issues needed to be addressed.

!

Signs met regulatory requirements but one Non-Cited Violation was noted for failure to post the current version of NRC Form 3 as required.

!

Periodic surveys of the reactor facility were not being conducted.

!

The Radiation Protection and ALARA Programs satisfied regulatory requirements.

!

A Radiation Safety Officer would need to be hired before any active decommissioning could begin.

Operator Requalification and Active License Status

!

There were no qualified operators at the facility and the Requalification Program was not being implemented.

-2-Maintenance and Surveillance

!

Only one of five required surveillance activities was being completed.

!

One violation was noted for failure to comply with the requirements of Technical Specification Section 4.0 which stipulates that the surveillances specified in Technical Specification Section 4.3, 4.5, and 4.6(1) may not be deferred during shutdown. The licensee failed to sample the reactor pool water for gross activity on an average monthly and for isotope identification on an average quarterly as required by Technical Specification Section 4.3.1.

!

Another example of the violation was identified for failure to perform a monthly channel test to ensure that the alarm float switch in the reactor pool is operable as required by Technical Specification Section 4.3.3.

!

Another example of the violation was noted for failure to test the automatic absolute damper and alarm on an average monthly and following repair or maintenance as required by Technical Specification Section 4.5(2).

!

Another example of the violation was identified for failure to calibrate all radiation monitors listed Technical Specification Section 3.6.1 annually and after maintenance as required by Technical Specification Section 4.6(1).

Emergency Preparedness

!

The emergency preparedness program was not being implemented at the facility.

Material Control and Accounting

!

There was no Special Nuclear Material maintained under the reactor license at the facility because it had been shipped off-site to other facilities.

Security

!

The current physical security for the facility was acceptable.

Report Details Summary of Plant Status The Omaha Veterans Administration Medical Center reactor, located in the Alan J. Blotcky Reactor Facility, was a 20-kilowatt TRIGA Mark I open pool type reactor primarily used for medical research. It ceased operation and was permanently shut down on November 5, 2001.

Records indicated that the reactor fuel had been shipped off-site in June 2002. On September 21, 2004, the licensee submitted a Request for License Termination and a Decommissioning and Decontamination Plan to the NRC. The NRC is currently considering the Request and Plan. During this inspection, the inspector verified that the reactor remained in a shut down status and that no active decommissioning efforts were underway.

1.

Organizational Structure and Staffing and Operating Reports a.

Inspection Scope (Inspection Procedure [IP] 69001)

The inspector reviewed the following regarding the licensees organizational structure and functions to ensure that the requirements of Technical Specifications (TS),

Sections 6.1 and 6.7, Amendment No. 11, dated August 24, 2002, were being met:

current organization and staffing for the Alan J. Blotcky Reactor Facility (AJBRF)

administrative controls and management responsibilities specified in TS Section 6

NRC Inspection Report No. 50-131/2002-201 dated March 13, 2003

Reactor Safeguards Committee meeting minutes from September 2002 through the present

AJBRF Annual Report for January 1 - December 31, 2003, issued March 23, 2004 b.

Observations and Findings (1) Organizational Structure and Staffing The licensees current operational organization structure and assignment of responsibilities were consistent with that specified in TS Section 6.1.1. Through discussions with licensee representatives, the inspector determined that no functional changes had occurred in the organization since the last NRC inspection in June of 2002 (documented in NRC Inspection Report No. 50-131/2002-201, dated March 13, 2003).

After reviewing various licensee records and through interviews with licensee representatives, the inspector determined that no reactor operations had been conducted since the Omaha Veterans Administration Medical Center (OVAMC)

formally notified the NRC of their decision, by letter dated December 6, 2001, to permanently shut down the reactor.

The inspector noted that the former Reactor Supervisor, who had been the only remaining licensed reactor operator at the facility, had found another job and was no longer employed by the OVAMC. Another individual in the licensees

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organization had been designated as the Reactor Facility Manager. This individual was a Research Electronics Technician and had worked at the facility for many years during past reactor operations. The OVAMC Radiation Safety Officer (RSO) served on the AJBRF Reactor Safety Committee but did not currently function as the reactor facility RSO. A Medical Doctor/Researcher, who was the Associate Chief of Staff for Research, also functioned as the Chairman of the Reactor Safeguards Committee.

The inspector noted that, with the aforementioned individuals functioning in the respective positions, the management structure was as described in TS 6.1.

(2) Operating Reports TS Section 6.7.1 requires that routine operating reports covering the operation of the facility during the previous calendar year shall be submitted before March 31 to the Nuclear Regulatory Commission.

The inspector reviewed the licensees last annual report, AJBRF Annual Report for January 1 - December 31, 2003, issued March 23, 2004. The licensee acknowledged that, as of the date of this inspection (June 2005), no annual operating report covering facility operations had been submitted to the Nuclear Regulatory Commission for the calendar year 2004.

The licensee was informed that failure to submit an operating report covering the operation of the facility during 2004 was a violation (VIO) of TS Section 6.7.1 (VIO 50-131/2005-201-01).

c.

Conclusions The organizational structure and staffing were consistent with Technical Specification requirements. One violation was noted for failure to submit an operating report covering the operation of the facility during 2004.

2.

Review and Audit Functions a.

Inspection Scope (IP 69001)

To verify that the licensee had established a Reactor Safeguards Committee and had conducted reviews and audits as required in TS Section 6.2, the inspector reviewed:

Reactor Safeguards Committee (RSC) Charter C

RSC membership and qualifications

RSC meeting minutes from September 2002 through the present C

safety reviews and reactor operations audit reports

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b.

Observations and Findings (1) Reactor Safeguards Committee Composition and Reviews The inspector reviewed minutes documenting the RSC meetings since the last inspection. The records showed that the RSC membership and personnel qualifications satisfied the TS 6.2.1 requirements. The meeting minutes also showed that the committee met at the frequency required by TS Section 6.2.2 and that a quorum was present at each meeting. The topics considered and the reviews conducted during the meetings were appropriate and as stipulated in TS Sections 6.2.3.

(2) RSC Audits TS Section 6.2.4 requires that, among other issues, the Reactor Safeguards Committee audit facility operations for compliance to the Technical Specifications and applicable license conditions annually.

While reviewing the RSC meeting minutes and related documents, the inspector noted that an audit of facility operations had been conducted for the period from September 1, 2001 through December 31, 2002. The audit was conducted by a Certified Health Physicist and the report, documenting the audit findings, was issued February 28, 2003. Three issues were noted in the audit findings. An issue concerning the failure to conduct control rod inspections was noted but was subsequently resolved when all the fuel was shipped off-site in June 2002.

Another issue concerning failure to conduct reactor pool water conductivity measurements weekly was corrected. The third issue involving failure to conduct analysis of the pool water for radioactivity was not resolved but a letter was to be written to the NRC requesting relief from this requirement, i.e., a change to the TS requirement. (This issue will be addressed further in Paragraph 5 of this report.)

The inspector verified that no audits of facility operations had been conducted since the one for the period from September 2001 through December 2002.

Consequently, no facility operations audits had been conducted for the calendar years 2003 and 2004 to date. The licensee was informed that failure to conduct annual audits of facility operations was a violation of TS Section 6.2.4 (VIO 50-131/2005-201-02).

c.

Conclusions The review program satisfied Technical Specification requirements. One violation for failure to conduct annual audits of facility operations was identified.

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3.

Radiation Protection Program a.

Inspection Scope (IP 69001)

To verify that the licensee had written procedures concerning radiation protection as required in TS Section 6.4 and to verify compliance with 10 CFR Part 20, the inspector reviewed:

C radiological signs and posting C

routine surveys and monitoring C

maintenance and calibration of radiation monitoring equipment C

AJBRF Radiation Protection Program as defined in the various facility radiation protection procedures (some of which are noted below)

C AJBRF Procedure Number (No.) RP-01, Radiation Safety Manual, RSC approval dated March 20, 2003 C

AJBRF Procedure No. RP-02, Organization and Qualifications, RSC approval dated March 20, 2003 C

AJBRF Procedure No. RP-03, Radiation and Safety Training and Re-Training Program, RSC approval dated March 20, 2003 C

AJBRF Procedure No. RP-10, Maintaining Exposures to Radiation As Low As Reasonably Achievable (ALARA), RSC approval dated March 20, 2003 C

AJBRF Procedure No. RP-11, Control of Access to Restricted Areas, RSC approval dated March 20, 2003 C

AJBRF Procedure No. RP-12, Internal and External Radiation Protection Exposure Controls, RSC approval dated March 20, 2003 C

AJBRF Procedure No. RP-13, Radiological Postings and Labels, RSC approval dated March 20, 2003 C

AJBRF Procedure No. RP-21, Conduct of Radiation, Contamination, and Airborne Radioactivity Surveys, RSC approval dated March 20, 2003 C

AJBRF Procedure No. RP-30, Use and Control of Personnel Monitoring Devices, RSC approval dated March 20, 2003 b.

Observations and Findings (1) Periodic Surveys The inspector reviewed the current monitoring and survey program for the facility.

No radiation monitoring or survey activities were being completed at the facility at the time of the inspection. The licensee indicated that none had been conducted since the shipment of the reactor fuel in 2002. However, two portable survey meters had been acquired by the licensee and they were being maintained and calibrated annually as required.

The licensee was informed that they should consider conducting at least an annual survey of the reactor facility to verify that no radioactivity was present and that none was being released to uncontrolled areas. This issue was identified as an Inspector Follow-up Item (IFI) and will be tracked by the NRC and reviewed during a future inspection (IFI 50-131/2005-201-03).

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(2) Postings and Notices 10 CFR 19.11(c)(1) stipulates that each licensee shall prominently post NRC Form 3, Notice to Employees, dated August 1997. Later versions of NRC Form 3 that supersede the August 1997 version shall replace the previously posted version within 30 days of receiving the revised NRC Form 3 from the Commission.

The inspector observed the NRC Form 3, Notice to Employees, that was posted on entrance to the AJBRF. It was noted that the copy posted at the entrance to the reactor room was not in accordance with 10 CFR 19.11 in that it was dated August 1999 and was not the current version issued by the NRC dated March 2005. This issue was brought to the attention of the licensee and the current NRC Form 3 was posted on the reactor room door the next day. The licensee was informed that this failure (to post the current copy of NRC Form 3)

constituted a violation of minor significance and was being treated as a Non-Cited Violation (NCV), consistent with section IV of the NRC Enforcement Policy (NCV 50-131/2005-201-04).

(3) Caution Signs and Controls Caution signs and controls established for radiation areas and other restricted areas within the facility were as required in 10 CFR 20, Subpart J. The doors to the reactor room were maintained locked and the only keys to the doors were issued to the Reactor Facility Manager, the Associate Chief of Staff for Research, and the OVAMC RSO. At the time of the inspection, security personnel did not have a key to the doors.

(4) Radiation Safety Officer As noted above, as of this inspection, there was no RSO for the facility. The OVAMC did employ an individual as the RSO for the hospital but he was a contractor and his contract currently did not cover any support of the reactor facility with the exception noted above, i.e., the OVAMC RSO was serving as the facility RSC. The licensee acknowledged this fact and noted that a new contract with the OVAMC RSO would need to be signed or a separate person would need to be hired when actual decommissioning of the reactor began. This issue was identified as an IFI and will be tracked by the NRC and reviewed during a future inspection (IFI 50-131/2005-201-05).

(5) Radiation Protection Program A documented radiation protection program was available as required by 10 CFR 20.1101. It was fully outlined in the licensees AJBRF Procedure No. RP-01, Radiation Safety Manual, RSC approval dated March 20, 2003, and the other radiation protection procedures.

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(6) Dosimetry The licensee had three Pocket Ion Chamber dosimeters for use at the facility.

There were no permanently assigned personnel dosimeters currently in use. The dosimeters had not been calibrated since July 2003.

c.

Conclusions The radiation protection program satisfied some NRC requirements but various issues needed to be addressed. Periodic surveys of the reactor facility were not being conducted. An RSO would need to be hired before any active decommissioning could begin. One NCV was noted for failure to post the current copy of NRC Form 3 as required by 10 CFR 19.11.

4.

Operator Requalification and Active License Status a.

Inspection Scope (IP 69001)

The inspector reviewed selected aspects of:

C OVAMC TRIGA Requalification Plan dated January 4, 2000, with approval by the NRC dated February 7, 2002 C

operator active duty status b.

Observations and Findings There were no licensed reactor operators at the facility. As noted above, the former Reactor Supervisor, who was the only remaining licensed reactor operator at the facility, had found another job and was no longer employed by the OVAMC. As a result, the OVAMC TRIGA Reactor Operator Requalification Program approved for the facility was not being implemented and no operator requalification training was being conducted. However, the inspector determined that the licensee had not requested exemption from the NRC before they discontinued the requalification program.

The licensee was informed that a written proposal should be submitted to the NRC concerning termination of the requalification program and requesting an exemption from the program requirements. This issue was identified as an IFI and will be tracked by the NRC and reviewed during a future inspection (IFI 50-131/2005-201-06).

c.

Conclusions There were no qualified operators at the facility and no Requalification Program was being implemented.

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5.

Maintenance and Surveillance a.

Inspection Scope (IP 69001)

The inspector reviewed selected aspects of the following to verify compliance with TS Sections 4.3, 4.5, and 4.6(1):

C maintenance and surveillance records

RSC meeting minutes from September 2002 through the present b.

Observations and Findings (1) Analysis of Coolant for Radioactivity TS Section 4.0 stipulates that the surveillances specified in Sections 4.3, 4.5, and 4.6(1) may not be deferred during shutdown.

TS Section 4.3.1 requires that the reactor pool water be sampled for gross activity on an average monthly and for isotope identification on an average quarterly.

During an audit conducted in 2003, a deficiency was noted involving failure to conduct analysis of the pool water for radioactivity. Following this finding, no program was established to conduct the required analysis. However, because of the audit finding, the licensee had decided to write a letter to the NRC requesting relief from this requirement, i.e., requesting a change to the TS. During this inspection, no copy of the letter could be found. The NRC Project Manager for the facility was also contacted and he was not aware of any letter requesting a TS change concerning this requirement and no record was found to exist on the NRC Docket File for the facility.

The licensee was informed that, before this analysis could be discontinued, a request needed to be submitted to the NRC and a TS change approved. The licensee indicated that a program to analyze the pool water for gross activity and for isotope identification would be initiated.

Although this issue was identified by the licensee, it could not be verified that any corrective actions had been taken since no letter was on file with the NRC concerning this issue and no analyses were being performed. This issue was identified as a violation of TS Section 4.0 (VIO 50-131/2005-201-07).

(2) Conductivity and pH TS Section 4.0 stipulates that the surveillances specified in Sections 4.3, 4.5, and 4.6(1) may not be deferred during shutdown.

TS Section 4.3.2 requires that the conductivity of the reactor pool water be measured weekly and that the pH of the water be measured at least once every month.

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The inspector verified that the licensee was completing these measurements as required. Surveillances involving both conductivity and pH measurements were completed weekly and in accordance with licensee procedures. All the recorded results were within the procedurally prescribed parameters.

(3) Pool Water Level TS Section 4.0 stipulates that the surveillances specified in Sections 4.3, 4.5, and 4.6(1) may not be deferred during shutdown.

TS Section 4.3.3 requires that a monthly channel test shall be performed to ensure that the alarm float switch specified in TS Section 3.1.4 is operable.

(TS Section 3.1.4 indicates that one of the objectives of maintaining a minimum height of water above the reactor core was to provide necessary shielding.)

The inspector reviewed this issue with the licensee. The licensee indicated that a channel test to verify operation of the alarm float switch was not being conducted.

None had been conducted since the reactor fuel had been shipped off-site in June 2002. The licensee assumed that this requirement only applied when the reactor had fuel in it, notwithstanding the requirement specified in TS Section 4.0.

The licensee was informed that failure to conduct a monthly channel test of the alarm float switch was a second example of a violation of TS Section 4.0 (VIO 50-131/2005-201-07).

(3) Ventilation Systems TS Section 4.0 stipulates that the surveillances specified in Sections 4.3, 4.5, and 4.6(1) may not be deferred during shutdown.

TS Section 4.5(2) requires that the automatic absolute damper and alarm shall be tested on an average monthly and following repair or maintenance.

The licensee indicated that the ventilation system was operating in the reactor facility but that the damper and alarm had not been checked monthly as required.

The inspector verified that the ventilation system was operating in the reactor facility. However, through licensee interviews with maintenance personnel, the inspector determined that the ventilation system was being checked and maintained but the automatic absolute damper and alarm had not been tested on a monthly basis. The tests had not been completed since the reactor fuel was shipped off-site in June 2002. The licensee was informed that failure to test the automatic absolute damper and alarm was another example of a violation of TS Section 4.0 (VIO 50-131/2005-201-07).

(4) Radiation Monitoring Systems TS Section 4.0 stipulates that the surveillances specified in Sections 4.3, 4.5, and 4.6(1) may not be deferred during shutdown.

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TS Section 4.6(1) requires that all radiation monitors listed TS Section 3.6.1 shall be calibrated annually and after maintenance. (TS Section 3.6.1 lists the radiation monitoring channels as the area radiation monitor - pool level and the continuous air monitor.)

The licensee indicated that the radiation monitors had not been operating since the removal of the reactor fuel from the reactor facility in June 2002. The inspector verified that the radiation monitors were not operating in the reactor facility. Consequently, the constant air monitor had not been calibrated since August 27, 2001. The area radiation monitor - pool level could not be located.

The licensee was informed that failure to calibrate the monitors annually was yet another example of a violation of TS Section 4.0 (VIO 50-131/2005-201-07).

c.

Conclusions The surveillance program was generally not being complete as required by the Technical Specification. A violation of TS Section 4.0 was noted with four examples for failure to sample the pool water for gross activity and isotope identification, for failure to conduct a channel test to ensure the operability of the alarm float switch, for failure to test the automatic absolute damper and alarm in the ventilation system, and for failure to calibrate the radiation monitors annually and check them monthly as required.

6.

Emergency Preparedness a.

Inspection Scope (IP 69001)

The inspector reviewed selected aspects of:

C Emergency Plan for the Omaha Veterans Administration Medical Center TRIGA Mark I Reactor, last revision dated April 7, 2000 C

implementing procedures C

emergency response supplies, equipment and instrumentation C

emergency drills and exercises b.

Observations and Findings The inspector discussed the subject of emergency preparedness with a licensee representative. The licensee indicated that the Emergency Plan was not currently being implemented. The provisions for training, annual emergency drills, plan reviews, and equipment inventories were not being done. However, the inspector determined that the licensee had not requested exemption from the NRC before they discontinued the emergency preparedness program.

The licensee was informed that a written proposal needed to be submitted to the NRC concerning termination of the emergency preparedness program and requesting an exemption from the program requirements. This issue was identified as an IFI and will be tracked by the NRC and reviewed during a future inspection (IFI 50-131/2005-201-08).

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c.

Conclusions The emergency preparedness program was not being implemented at the facility.

7.

Material Control and Accounting a.

Inspection Scope (85102)

The inspector reviewed selected aspects of:

C nuclear material inventory and locations C

accountability records b.

Observations and Findings (1) General Material Control and Accounting Records indicated that all radioactive material and/or Special Nuclear Material had been shipped off-site on various dates in the past. The reactor fuel was shipped off-site on June 24, 2002. The facility fission chambers were transferred off-site in December 2002. On July 24, 2003, the reactor start-up sources (Am-Be neutron sources) were removed from site and transferred to the Department of Energys Off-Site Source Recovery Program. The appropriate Material Balance Reports (DOE/NRC Form-742 and 742c) for these transactions had been submitted by the licensee as required by the requirements specified in 10 CFR 70.53.

The inspector verified that there appeared to be no other radioactive material in the reactor facility except for the activated core support structure and the residual radioactive material in some laboratories and drains. This would be dealt with during decommissioning.

(2) Task 8 Inspection Prior to the inspection, the inspector requested and received a Task 8 Inspection package from the Nuclear Materials Management and Safeguards System (NMMSS) group in Georgia. The material supplied by NMMSS showed that the licensee had no material on site. These data were checked against the records and documentation maintained by the licensee. No discrepancies were noted.

c.

Conclusions All Special Nuclear Materials had been shipped off-site to other facilities.

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8.

Security a.

Inspection Scope (IP 81431)

The inspector reviewed selected aspects of:

C Physical Protection Plan for the Protection of Special Nuclear Material of Low Strategic Significance at the Omaha Veterans Administration TRIGA Reactor, Revision 5, dated August 17, 1998 C

key control C

physical barriers b.

Observations and Findings The Physical Protection Plan (PPP) was the same as the latest revision approved by the NRC. Physical protection barriers were in place and keys were being controlled as noted above. Access control was appropriate for the current condition of the facility.

The licensee was informed that, due to the current status of the facility, a PPP was no longer needed. However, written procedures were required to be in effect that stipulated the physical protection for the facility. Since the procedures would be reviewed and approved by the licensee, any changes to them could be accomplished by a 10 CFR 50.59 review and approval from the RSC.

c.

Conclusions The current physical security for the facility was acceptable.

9.

Exit Interview The inspector reviewed the results of the inspection with members of licensee management at the conclusion of the inspection on June 9, 2005. The licensee acknowledged the findings presented with no dissenting comments.

PARTIAL LIST OF PERSONS CONTACTED Licensee E. Fennel, Research Electronics Technician and Acting Reactor Facility Manager L. Klassen, Associate Chief of Staff for Research and Chairman of the Reactor Safeguards Committee A. Washko, Chief Executive Officer, Department of Veterans Affairs, Omaha Other Personnel M. Christensen, OVAMC Radiation Safety Officer (contractor)

F. Hamel, Deputy Associate Chief of Staff for Research S. Nowling, Administrative Officer for Research INSPECTION PROCEDURES USED IP 69001 Class II Research and Test Reactors IP 81431 Fixed Site Physical Protection of Special Nuclear Material Of Low Strategic Significance IP 85102 Material Control and Accounting ITEMS OPENED, CLOSED, AND DISCUSSED OPENED:

50-131/2005-201-01 VIO Failure to submit an operating report covering the operation of the facility during 2004 by March 31, 2005, as required by TS Section 6.7.1.

50-131/2005-201-02 VIO Failure to conduct annual audits of the facility operations as required by TS Section 6.2.4.

50-131/2005-201-03 IFI Follow-up to determine the status of the initiation of a survey program for the reactor facility.

50-131/2005-201-04 NCV Failure to post the current copy of NRC Form 3 at the entrance to the reactor room as required by 10 CFR 19.11.

50-131/2005-201-05 IFI Follow-up to ensure that a new contract with the current OVAMC RSO is written or a separate person is hired when actual decommissioning of the reactor begins.

50-131/2005-201-06 IFI Follow-up to ensure that the licensee submits a written request for an exemption from the NRC concerning termination of the Reactor Operator Requalification Program requirements.

-2-50-131/2005-201-07 VIO Failure to comply with TS Section 4.0 including: 1) failure to analyze the pool water for gross activity and for isotope identification as required by TS Section 4.3.1; 2) failure to conduct a monthly channel test of the alarm float switch as required by TS Section 4.3.3; 3) failure to test the automatic absolute damper and alarm as required by TS Section 4.5(2); and 4) failure to calibrate the reactor facility monitors annually as required by TS Section 4.6(1).

50-131/2005-201-08 IFI Follow-up to ensure that the licensee submits a written proposal to the NRC concerning termination of the emergency preparedness program and requesting an exemption from the program requirements.

CLOSED:

None LIST OF ACRONYMS USED ADAMS Agencywide Documents Access and Management System AJBRF Alan J. Blotcky Reactor Facility CFR Code of Federal Regulations HP Health Physics IFI Inspector Follow-up Item IP Inspection Procedure NCV Non-Cited Violation NMMSS Nuclear Materials Management and Safeguards System No.

Number NRC Nuclear Regulatory Commission OVAMC Omaha Veterans Administration Medical Center PPP Physical Protection Plan RS Reactor Supervisor RSC Reactor Safeguards Committee RSO Radiation Safety Officer SNM Special nuclear material SRO Senior Reactor Operator TS Technical Specifications VA Veterans Administration VIO Violation