Information Notice 1994-16, Recent Incidents Resulting in Offsite Contamination

Recent Incidents Resulting in Offsite Contamination

ML031060616
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, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant
Issue date:	03/03/1994
From:	Paperiello C NRC/NMSS/IMNS
To:
References
IN-94-016, NUDOCS 9402240318
Download: ML031060616 (9)

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555 March 3, 1994 NRC INFORMATION NOTICE 94-16: RECENT INCIDENTS RESULTING IN OFFSITE

CONTAMINATION

Addressees

All U.S. Nuclear Regulatory Commission material and fuel cycle licensees.

PurDose

NRC is issuing this information notice to alert licensees of recent

contamination incidents and their root causes. It is expected that recipients

will review the information for applicability to their facilities and consider

actions, as appropriate, to avoid similar problems. However, information

contained in this notice does not constitute a new requirement, and no

specific action nor written response is required.

Description of Circumstances

Recently, NRC responded to three radioactive material contamination incidents, which resulted in contamination of both individuals and personal property, both on and off the licensees' property, and which required access to the

contaminated areas to be restricted for more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. Two of the cases

summarized below occurred at large universities and one occurred at a large

medical facility. All have resulted in escalated enforcement actions

involving fines.

Case 1: The licensee notified NRC that a contamination event involving

phosphorus-32 (P-32) had occurred at the facility, contaminating

several floors of a research building.' A graduate student, working

on the weekend, using P-32, accidentally and unknowingly

contaminated the floor of the laboratory with 3.7 to 18.5 megabecquerels (100 to 500 microcuries) of the material. He failed

to survey himself or the laboratory before leaving, as required by

the licensee's procedures. His actions resulted in the widespread

contamination of the laboratory building and of private residences, clothing, and vehicles. The licensee reported the event after it

was clear that the research building decontamination work was going

to extend beyond 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, and that the facility would have to

remain restricted. In the licensee's verbal report, it assured NRC

that the contamination was confined to the research building. NRC

dispatched a special inspection team to the site, and in the process

of conducting confirmatory surveys, off-site contamination was

identified. The licensee focused its efforts on the decontamination

of the laboratory, and failed to perform an adequate assessment of

possible offsite contamination. Contributing causes of this

9402240318 ?D h4 - e go-cge-

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S.-' IN 94-16 March 3, 1994 contamination event were: 1) failure of a student researcher to

exercise appropriate precautions in the handling of licensed

materials; 2) failure to conduct personnel surveys; 3) inadequate

training or supervision by the authorized user; 4) failure to

conduct performance-oriented audits of the licensee's authorized

users; and 5) failure of the Radiation Safety Staff to properly

analyze and respond to the event.

Case 2: NRC became aware of a potential contamination problem and called the

licensee to determine if a problem did exist. The licensee

confirmed that a contamination event had occurred involving carbon-

14 (C-14) in a research building, but that it was confident that no

contamination had left the building. NRC dispatched a special

inspection team to the site. While the team was traveling to the

site, the licensee discovered that the contamination occurred

because a researcher, looking for materials for an experiment, unknowingly contaminated himself and some personal effects with

C-14. The individual was not aware that he had handled radioactive

material because the material was improperly stored in an

unrestricted area, in an unmarked container. Surveys conducted by

the licensee, NRC, three States, other universities, and a U.S.

Department of Energy laboratory, identified that the individual

unknowingly spread the contamination throughout the facility, to

residences he visited, to automobiles, and to his private residence.

In addition, other personnel who had entered the facility

contaminated their shoes. Contributing causes of this contamination

event were: 1) the improper storage of the material which was

caused, in part, by 2) an inadequate inventory system that did not

identify the presence of long-lived licensed material in an

unrestricted area; 3) improper labelling; and 4) inadequate training

for staff responsible for storage.

Case 3: A contamination event occurred when a post-graduate student came

into a laboratory to do some work involving P-32, on the weekend.

He failed to survey, because of an inoperative survey meter, and

left the laboratory, having contaminated himself with P-32. When

the contamination was discovered, the licensee focused on the

contaminated individual and the laboratory. The licensee called to

inform NRC that it was sending a report documenting a P-32 contamination event that had occurred at the facility approximately

10 days earlier. The licensee indicated that there had been

personnel contamination, but that no offsite contamination had

occurred. NRC dispatched a special inspection team to the facility.

Confirmatory surveys conducted by the licensee and this team

identified offsite contamination in a church, several residences, and in automobiles. Contributing causes of this event were: 1) the

licensee failed to respond properly to a recognized spill; 2) the

licensee failed to perform an adequate survey of all the possible

locations where the individual had been during the interim period

IN 94-16 March 3, 1994 after the contamination event; 3) the licensee failed to follow

proper, established survey procedures; 4) there was inoperative

equipment; and 5) Inadequate training of staff.

Discussion

In the cases described above, the root cause was one or a combination of the

following: (1)inadequate training of the employee in the handling and use of

radioactive material; (2)inadequate monitoring of persons and facilities

where material was used; and (3)inadequate management oversight of licensed

activities.

Training had been provided to the user of the material, in most cases, but it

was either inadequate or Ignored. Site-specific training should include

proper survey techniques and correct response to contamination events, and

should be strongly emphasized through retraining programs.

General requirements for monitoring are contained In 10 CFR 20.1501. In

specific cases, licensees have not discovered the spread of contamination, because of inadequate surveys, until days, or sometimes weeks, after the

original Incident occurred. The person using the material did not check for

personal contamination before leaving the laboratory, and routine surveys of

the area were not conducted in time to prevent widespread contamination.

Regulations also require licensed materials to be properly stored and labeled;

proper labeling could have prevented some of the above, by alerting personnel

to the existence of radioactive material and to the necessity of following

radiation safety procedures and survey requirements.

When a spill does occur, it is important that the licensee respond properly to

the event. A rush to resume normal activities should be avoided. The lack of

sufficient technical personnel for proper offsite assessment may complicate an

already undesirable situation. The possibility of offsite contamination

should be considered in the evaluation of a spill or contamination, and in a

subsequent decontamination plan.

In two of the cases detailed above, licensees failed to notify the NRC

Operations Center within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, as required by 10 CFR 30.50, after the

discovery of an unplanned contamination event that required access to the

contaminated area to be restricted for more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. The notification

requirements of 10 CFR 30.50, 40.60, and 70.50, are in addition to 10 CFR

20.2202, Involving personnel exposure and releases of radioactive material.

The NRC Operations Center telephone number is (301) 951-0550; it is available

24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> a day.

Each licensee is responsible for protecting the public health and safety by

ensuring that all NRC requirements are met, and any potential hazards are

promptly identified, corrected, and, if necessary, reported. This

responsibility can only be fulfilled if there is persistent and adequate

management oversight of licensed activities.

IN 94-16 March 3, 1994 This information notice requires no specific action nor written response. If

you have questions about the information in this notice, please contact the

technical contact listed below, or the appropriate regional office.

Car aperiello, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical contacts: Roy Caniano, RIII

(708) 829-9804 Joseph E. DeCicco, NMSS

(301) 504-2067 Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

Attachment 1 IN 94-16 March 3, 1994 LIST OF RECENTLY ISSUED

NMSS INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

94-15 Radiation Exposures during 03/02/94 All U.S. Nuclear Regulatory

an Event Involving a Fixed Commission licensees author- Nuclear Gauge ized to possess, use, manu- facture, or distribute

industrial nuclear gauges.

94-09 Release of Patients with 02/03/94 All U.S. Nuclear Regulatory

Residual Radioactivity Commission medical

from Medical Treatment and licensees.

Control of Areas due to

Presence of Patients Con- taining Radioactivity

Following Implementation

of Revised 10 CFR Part 20

94-07 Solubility Criteria for 01/28/94 All byproduct material and

Liquid Effluent Releases fuel cycle licensees with

to Sanitary Sewerage under the exception of licensees

the Revised 10 CFR Part 20 authorized solely for

sealed sources.93-100 Reporting Requirements 12/22/93 All U.S. Nuclear Regulatory

for Bankruptcy Commission licensees.

93-80 Implementation of the 10/08/93 All byproduct, source, and

Revised 10 CFR Part 20 special nuclear material

licensees.

93-77 Human Errors that Result 10/04/93 All nuclear fuel cycle

in Inadvertent Transfers licensees.

of Special Nuclear Material

at Fuel Cycle Facilities

93-69 Radiography Events at 09/02/93 All holders of OLs or CPs

Operating Power Reactors for nuclear power reactors

and all radiography

licensees.

Attachment 2 IN 94-16 March 3, 1994 LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

94-15 Radiation Exposures during 03/02/94 All U.S. Nuclear Regulatory

an Event Involving a Fixed Commission licensees author- Nuclear Gauge ized to possess, use, manu- facture, or distribute

industrial nuclear gauges.

94-14 Failure to Implement 02/24/94 All holders of OLs or CPs

Requirements for Biennial for nuclear power and non- Medical Examinations and power reactors and all

Notification to the NRC licensed reactor operators

of Changes in Licensed and senior reactor

Operator Medical Conditions operators.

92-36, Intersystem LOCA 02/22/94 All holders of OLs or CPs

Supp. 1 Outside Containment for nuclear power reactors.

94-13 Unanticipated and Un- 02/22/94 All holders of OLs or CPs

intended Movement of for nuclear power reactors.

Fuel Assemblies and

Other Components due to

Improper Operation of

Refueling Equipment

94-12 Insights Gained from 02/09/94 All holders of OLs or CPs

Resolving Generic for nuclear power reactors.

Issue 57: Effects of

Fire Protection System

Actuation on Safety- Related Equipment

94-11 Turbine Overspeed and 02/08/94 All holders of OLs or CPs

Reactor Cooldown during for nuclear power reactors.

Shutdown Evolution

94-10 Failure of Motor-Operated 02/04/94 All holders of OLs or CPs

Valve Electric Power for nuclear power reactors.

Train due to Sheared or

Dislodged Motor Pinion

Gear Key

OL = Operating License

CP = Construction Permit

IN 94-16 March 3, 1994 This information notice requires no specific action nor written response. If you have

questions about the information in this notice, please contact the technical contact listed

below, or the appropriate regional office.

olrg II F

Carl J. Paperiello, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical contacts: Roy Caniano, RIII

(708) 829-9804 Joseph E. DeCicco, NMSS

(301) 504-2067 Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

OFC IMOB I IMOBIl I MAB I IMO I RII Il IMNS I FCSS l lIMNS I

NAME JDeCicco CJones JGIenn FCombs RCanlano WBrach RBurnett CPaperiel

DATE 01/09/94 01/12/94 02/01/94 2/01/94 01/07/94 02/04/94 02/07/94 02/18/94 DOC NAME: IN94-16.JED

OFFICIAL RECORD COPY

IN 94-XX

January X, 1994 This information notice requires no specific action nor written response. If

you have questions about the information in this notice, please contact the

technical contact listed below, or the appropriate regional office.

Carl J. Paperiello, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical Contacts: Roy Caniano, Region III

(708) 829-9804 Joseph E. DeCicco, NMSS

(301) 504-2067 Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

• See previous concurrence

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NAME JDeCicco CJones * JGlenn * FCombs * RCaniano

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DATE 1/09/94 - 1/12/94 - 1/14/94 - 2/01/94 l 1/07/94 2/ /4-1-94

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OFFICIAL RECORD COPY G:CONTAMIN.IN

IN 94-XX

January X, 1994 promptly identified, corrected, and, if necessary, reported. This

responsibility can only be fulfilled if there is persistent and adequate

management oversight of licensed activities.

This information notice requires no specific action nor written response. If

you have questions about the information in this notice, please contact the

technical contact listed below, or the appropriate regional office.

Carl J. Paperiello, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical Contacts: Roy Caniano, Region III

(708) 829-9804 Joseph E. DeCicco, NMSS

(301) 504-2067 Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices.

DISTRIBUTION:

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NAME JDeC n EWBrach CPaperiello

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