Information Notice 1989-82, Recent Safety-Related Incidents at Large Irradiators

Recent Safety-Related Incidents at Large Irradiators

ML031190109
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant
Issue date:	12/07/1989
From:	Cunningham R NRC/NMSS/IMNS
To:
References
IN-89-082, NUDOCS 8911300050
Download: ML031190109 (5)

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555 December 7, 1989 NRC INFORMATION NOTICE NO. 89-82: RECENT SAFETY-RELATED INCIDENTS AT

LARGE IRRADIATORS

Addressees

licensees authorized to possess

All U.S. Nuclear Regulatory Commission (NRC)

and use sealed sources at large irradiators.

Purpose

of recent safety-related incidents

This notice is intended to inform recipients for proper management actions and

at large irradiators and emphasizes the need This notice also serves to remind

attention to preventive maintenance programs. irradiators covered in Infor- licensees of other safety-related incidents at will review this information, mation Notice 87-29. It is expected that licenseessafety staff, and consider actions, distribute the notice to responsible radiation maintenance programs and proper

if appropriate, to ensure both proper preventive from occurring at their faci- management actions to preclude similar situations notice do not constitute any new

lities. However, suggestions contained in this required.

NRC requirements, and no written response is

Description of Circumstances

is provided in Attachment 1. In

A description of each of the following events

summary, these events included:

system and another

° Deliberate bypass of the radiation monitor interlock radiation-produced

from

safety system designed to protect individuals

noxious gases.

unnoticed, which could

o Significant contamination of pool water remaining continuously circulated

been

have been detected sooner, had the pool water

and monitored through the demineralizer.

an irradiator pool, due

o An uncontrolled descent of a shipping cask into

to brake malfunction on a lifting crane.

caustic stress corrosion

° Leaks in the irradiator pool caused by localized

in pool liner welds.

8911300050

A I

IN 89-82 December 7, 1989 Discussion:

Licensees are reminded of the importance of ensuring the safe performance of

licensed activities in accordance with NRC regulations and the requirements

of their licenses. Irradiators with high activity sealed sources are capable

of delivering life-threatening exposures in a short period of time. Therefore, compliance with regulatory requirements and proper equipment maintenance Is

critical to safe operation.

Event Nos. 1, 2 and 3 on Attachment 1 illustrate a failure by management to

assure that proper safety and maintenance procedures are followed. In June

1987, NRC brought to the attention of irradiator licensees other incidents

that were caused by similar management practices. (See Attachment 2). Event

No. 4 on Attachment 1 is included in this notice to remind licensees of the

possibility of pool leakage, the need to investigate the causes of such oc- currences, and their responsibility to take appropriate corrective action.

In view of the current and past incidents at irradiator facilities, it is

strongly recommended that supervisory personnel be reminded of their

responsibilities to evaluate potential safety hazards and assure safe

operation at their facilities. The incidents described in Attachment 1 demonstrate the importance of:

1. Not bypassing interlock systems and other safety systems.

2. Adhering to regulatory requirements, license conditions and authorized

operating procedures.

3. Continuously using demineralizers equipped with radiation monitors, or alternatively, frequently monitoring pool water conductivity and

radioactivity concentration.

4. Properly maintaining equipment used with or incident to handling licensed

materials.

5. Taking appropriate and effective action when operational abnormalities

are observed.

Licensees are reminded that NRC must review and approve operating and emergency

procedures prior to implementation at irradiator facilities. Licensees are also

reminded that operating procedures approved by NRC during the licensing process

are incorporated by reference into the license as requirements. Such operating

procedures cannot be modified without prior approval. If you have developed

alternate procedures that could be used temporarily to keep your facility

operating during maintenance intervals, you must file an amendment with NRC

regional offices, for review and approval, before such procedures can be used

at your facility.

IN 89-82 December 7, 1989 No written response is required by this information notice. If you have any

questions about this matter, please contact the appropriate regional office

or this office.

Richard E. Cunningham, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Tony Huffert, NMSS

(301) 492-0529 Attachments:

1. Events That Occurred at Large Irradiator Facilities

2. Information Notice No. 87-29

3. List of Recently Issued NMSS Information Notices

4. List of Recently Issued NRC Information Notices

RECORD NOTE:

Event No. 1 occurred at Isomedix, Inc. (Docket Nos. 030-08985 and 030-19752)

at their Parsippany, NJ and Northboro, MA plants in August 1987.

Event No. 2 occurred at Radiation Sterilizers, Inc. (State of GA licensee)

at the Decatur, GA plant in June 1988.

Event No. 3 occurred at Radiation Sterilizers, Inc. (State of GA licensee)

at the Decatur, GA plant in July 1989.

Event No. 4 occurred at the Defense Nuclear Agency's Armed Forces Radiobiology

Research Institute (Docket No. 030-06931) in Bethesda, MD in April 1989.

Attachment 1 IN 89-82 December 7, 1989 EVENTS THAT OCCURRED AT LARGE IRRADIATOR FACILITIES

1. A licensee deliberately bypassed the radiation monitor interlock systems

and substituted an administrative procedure for the engineered safeguard

provided by the radiation monitor interlock. The substituted cell entry

procedure was implemented without NRC review, approval and incorporation

in the license. The alternate procedures did not constitute an entry con- trol device that functioned automatically to prevent inadvertent entry and

did'not comply with the requirements of 10 CFR Subsection 20.203(c)(6)1(i).

In addition, the licensee installed Jumper cables to bypass ventilation

system interlock which were designed to automatically protect individuals

from noxious gases produced as a result of irradiation.

Because of the extremely high radiation exposures that could result if

interlock are not operational, NRC concluded this incident was a very

serious violation of safety requirements. The licensee was not allowed

to operate the irradiator until all safety systems were fully operational.

This violation of NRC requirements, along with other safety-related

violations, resulted in NRC proposing a substantial civil penalty.

2. Leaking cesium-137 source capsules contaminated pool water at Radiation

Sterilizers, Inc.'s (RSI's) Decatur, GA plant and remained undetected

for an extended period of time,-because the licensee did not use the

pool water monitoring system associated with the demineralizer. The

contamination problem was finally discovered when the licensee took

discrete samples and performed radiation surveys of the pool water, after activation of the radiation-level monitoring system, which had

automatically locked the sources in the safe storage position., due to

excessive radiation levels while the sources were in the stored position.

Failure to continuously use the demineralizer/pool-water monitoring system

was contrary to the licensing Agency's understanding of the operations.

Had the demineralizer been operated continuously, pool water contamination

possibly could have been detected earlier and enabled the licensee to begin

mitigating the contamination.

The facility has been shut down since June 1988. The U.S. Department of

Energy (DOE), its contractors, and the State of Georgia are managing

decontamination efforts at the site, which have been estimated to cost

several million dollars so far. The DOE and RSI are also in the process

of removing all the Waste Encapsultion Storage Facility sources from the

RSI facilities at Decatur, Georgia and Westerville, Ohio and shipping

them to DOE.

Attachment 1 IN 89-82 December 7, 1989 EVENTS THAT OCCURRED AT LARGE IRRADIATOR FACILITIES

(continued)

The State of Georgia and DOE are conducting investigations of other

aspects and lessons learned as a result of this event. NRC has been

periodically providing information in the NMSS Licensee Newsletter on

the status of the DOE investigation into the cause of the source leakage.

Licensees will be sent further information when it becomes available.

3. A contractor providing lifting crane services at a licensed facility was

moving a shipping cask from the source storage pool to a mezzanine area, when the cask made an uncontrolled descent of approximately 19 feet. The

cask stopped its descent approximately five feet below the surface, only

after an operator activated a manual brake. No personnel were injured

and there was no damage to, or contamination of, the licensee's facility

or equipment as a result of this event. However, had the cask not been

secured quickly, it could have damaged the radioactive sources in the

pool or the pool itself.

This incident was a result of improper brake adjustment of the crane

hoist. The crane brake was subsequently repaired and recertified for

normal operations in accordance with current Occupational Safety and

Health Administration regulations. Braking system inspection and

adjustment, as well as functional load testing, are now established

daily procedures before crane operation.

4. A licensee experienced a loss of pool water for several weeks that was

approximately three times higher than expected from evaporative losses;

The licensee performed tests to characterize the nature and quantity

of the water loss and be an daily assays of the pool water to determine

compliance with release limits for unrestricted areas. Suspecting a leak

in the irradiator pool, the licensee inspected the stainless steel liner

and found localized caustic stress corrosion in many welds.

Apparently, welds made during construction of the facility in 1968 were

not in accordance with industry standards. Thus, these faulty welds were

subject to caustic stress corrosion which resulted in the recent pool

water losses.

The facility has been shut down pending completion of repairs.