Information Notice 1996-04, Incident Reporting Requirements for Radiography Licensees

Incident Reporting Requirements for Radiography Licensees
	ML031060309
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, 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, Crane
Issue date:	01/10/1996
From:	Cool D; NRC/NMSS/IMNS
To:	;
References
	IN-96-004, NUDOCS 9601040335
	Download: ML031060309 (13)
	v • d • e

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C.

20555

January 10, 1996

NRC INFORMATION NOTICE 96-04:

INCIDENT REPORTING REQUIREMENTS FOR

RADIOGRAPHY LICENSEES

Addressees

All U.S. Nuclear Regulatory Commission radiography licensees and manufacturers

of radiography equipment.

Purpose

NRC is issuing this Information notice to addressees to alert thein. to, and

inform them of, the reporting requirements under 10 CFR 34.30.

It is expected

that recipients will review the information for applicability to their

facilities and activities and consider actions, as appropriate. This includes

manufacturers of radiography equipment who advise radiography licensees or

potential licensees on the requirements of 10 CFR Part 34.

However, suggestions contained in this information notice are not NRC requirements;

therefore, no specific action nor written response is required.

Description of Circumstances

On January 10, 1990, Part 34 was amended to add a reporting requirement, under

10 CFR 34.30, that made it necessary for radiography licensees to report to

NRC, occurrences of source disconnects, source hangups, or the failure of any

safety related radiography equipment component to properly perform its

intended function. NRC is concerned that incidents are not being reported

either because licensees have not understood the requirements of this section

or because they do not know that such requirements exist.

As of January 1995, NRC has received only about 65 reports under this section.

Based on other sources of information -- including audits of radiography

equipment manufacturers' records, reports filed in accordance with 10 CFR

Part 21 requirements, and unofficial reports from radiography licensees and

equipment suppliers -- NRC believes that many more reports of incidents should

have been received. Specifically, an audit of a radiography equipment

manufacturer's customer complaint file showed that there had been a

substantial number of complaints from radiographers about the failure of a

locking mechanism. However, NRC has received only a few reports of this type.

of failure. In addition, a substantial number of the reports that NRC has

received have been submitted by only a small percentage of NRC radiography

licensees. Such incidences of reportable events would likely be more evenly

distributed.

960,1040335a t,

IN 96-04 January 10, 1996 This information notice is intended to alert radiography licensees to the

requirement to report incidents under 10 CFR 34.30, to describe and provide

examples of the types of incidents that must be reported, and to clarify the

information that must be included in a report to satisfy the requirements of

this section. Attachment 1 to this notice lists frequently asked questions

and answers that provide additional guidance on the types of incidents that

must be reported under 10 CFR 34.30, and how and where the reports are to be

made.

Licensees may use the attachment and this notice as a guide when

preparing reports in accordance with 10 CFR 34.30. This notice (and

attachment) will also serve to inform manufacturers of radiography equipment

(who advise and assist radiography licensees) of this requirement.

This

notice describes only the minimum information that must be reported. However, licensees may include additional information in a report, as necessary, or

appropriate.

NRC uses information from these reports to detect trends or identify generic

issues associated with the construction or use of radiography equipment, and

to take appropriate actions to reduce or eliminate similar incidents in the

future.

Licensee failure to make the required reports hampers this effort and

violates NRC regulations.

Discussion

There are about 169 NRC specific licensees authorized to perform radiographic

operations under NRC jurisdiction.

The majority of the reports received

during a 5-year period concerned source disconnects or source hangups. In

addition, several reports were received, early in the period, about manual- locking-mechanism failures that were determined to be caused by a

manufacturing defect. The following paragraphs illustrate examples of reports

received, in accordance with 10 CFR 34.30, on these types of incidents. A

number of other reports, on a variety of other failures, were also received.

A disconnect occurs when the source capsule or source assembly becomes

separated from the drive cable and cannot be normally retracted to the fully

shielded position. Approximately half of all the reports received involved

disconnects.

The primary causes of the disconnects were reported to have

resulted from wear in the connector, human error, design flaws, or equipment

malfunction or defect caused during manufacture. For example, disconnects

have occurred when the end of the male connector broke off, when the crimp

holding the female connector on the drive cable failed, and when the pigtail

frayed and broke.

A hangup occurs when the entire source assembly remains connected to the drive

cable, but the source cannot be retracted to the fully shielded position

because of resistance in the equipment or an obstruction.

All the reported

hangups have occurred either in the guide tube, the S-tube, or at the exposure

S

/

IN 96-04 January 10, 1996 device outlet fitting.

The majority of the hangups reported were indicated to

be caused by human error or wear in the equipment. Reports indicating human

error have included incidents where the radiographer did not set-up the

exposure jigs properly, which then toppled onto and crushed the guide tube

sufficiently to prevent source retraction, and where the radiographer bent the

guide tube around too sharp an angle, crimping the tube and preventing proper

source movement. Reports indicating wear in the equipment have included

causes such as extensive wear in the S-tube and surrounding depleted uranium, sufficient to cause the source capsule to become stuck in the resulting

indention.

In the cases where manual-locking-mechanism failures were reported, the

manufacturer determined that the reported failures were caused by an inherent

design flaw that allowed the key to be removed when in the unlocked position, or caused the lock to partially malfunction.

The manufacturer corrected the

design flaw, and no additional reports of these types of failures have been

received.

The failures discussed above are intended to provide general guidance on, and

familiarize radiography licensees with, the typical types of incidents that

have been reported.

Radiography licensees should consider this guidance, and

the additional guidance contained in Attachment 1, when determining if an

incident should be reported. It is extremely important that radiography

licensees make the required reports to the Commission in a timely manner, since the reports are used to detect trends or generic issues that have the

potential to cause a significant safety hazard. In addition, NRC uses the

information gleaned from the reports to determine the appropriate course of

action to reduce or eliminate similar incidents in the future, and to protect

the health and safety of both the radiography licensees and the public.

In addition to the information specified in 10 CFR 34.30 (see Question 3 of

Attachment 1), we strongly suggest that submitted reports contain a contact's

name and phone number, so that NRC personnel may follow up on the report, if

necessary.

Information on other means of communication, such as facsimile

phone numbers and Internet E-mail addresses, is also helpful.

IN 96-04 January 10, 1996 This information notice requires no specific action nor written response.

If

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

the technical contact listed below or the appropriate regional office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical contact:

Douglas Broaddus, NMSS

301-415-5847 Internet:dab@nrc.gov

Attachments:

1. Questions and Answers for Reporting Requirements in 10 CFR 34.30

2. List of Recently issued NMSS Information Notices

3. List of Recently issued NRC Information Notices

Attachment 1

IN 96-04

January 10, 1996 FREQUENTLY ASKED

QUESTIONS AND ANSWERS FOR REPORTING

REQUIREMENTS IN 10 CFR 34.30

1.

WHAT INCIDENTS MUST BE REPORTED?

Section 34.30(a), paragraphs (1)

to (3), describe the types of events

that must be reported. These include: (a) source disconnects involving

a separation of the source capsule or source assembly from the drive

cable; (b) hangups that prevent the source assembly from being retracted

to the fully shielded position, and to be secured in this position, as

designed and intended; and (c) the failure of any other component of the

radiography equipment that could cause the equipment to operate in an

unsafe manner. Disconnects would include not only separation of the

source assembly from the drive cable, but also loss of radioactive

material from the source capsule, separation of the source capsule from

the source assembly, and separation of. the drive cable along its length.

Hangups may occur at any point along the intended travel of the source, including the S-tube, the outlet fittings, the guide tube, and any

fittings connected to the end of the guide tube (e.g., collimator, end

stops, etc.).

Examples of the failure of other components to operate

properly, causing the device to operate in an unsafe manner, include:

(a) failure of the lock or securing mechanism to adequately secure the

source assembly in the fully shielded position, thereby allowing

unintended movement of the source assembly; (b) failure of the guide

tube or controls to connect to the exposure device as intended, or

operate properly; and (c) failure of source position indicators to show

actual source position. The licensee is responsible for evaluating

events that may be reportable under 10 CFR 34.30 and use appropriate

judgment as to whether the event is reportable. If, after evaluation, the licensee is not sure whether to report the event, we recommended

that the licensee make the report to the Commission, according to

10 CFR 34.30, and include the reasons why the licensee is unsure whether

the event is reportable.

2.

WHEN AND WHERE SHOULD THE REPORTS BE SENT?

Within 30 days of an event that is determined to be reportable under

10 CFR 34.30, two copies of the report must be submitted to NRC, to the

addressees listed in 10 CFR 34.30, paragraph (a).

The addressees are:

Branch Chief

Director

Medical, Academic, and

Office for Analysis and Evaluation

Commercial Use Safety Branch

of Operational Data

U.S. Nuclear Regulatory Commission

Washington, D.C.

20555 Washington, D.C.

20555

Attachment 1

IN 96-04 January 10, 1996 3.

WHAT MUST THE REPORTS INCLUDE?

The requirements for what must be included in a report are contained in

10 CFR 34.30, paragraph (b), and are detailed below:

Section 34.30(b)(1) requires that the report contain "A description of

the equipment problem." The description should include the type of

incident (disconnect, hangup, lock failure, etc.) along with an

explanation of how the event occurred. This explanation could include

the number of exposures taken before the incident happened, the

arrangement of the equipment at the time of the incident, and the

environment in which the incident occurred (a roadside trench, an

exposure cell, excessively hot, cold, or humid conditions, etc.). The

report should always include how the incident was noticed. For example, a disconnect may be noticed by a sudden release in tension on the cable

or a high survey meter reading approaching the exposure device.

Section 34.30(b)(2) requires that the report contain the "Cause of each

incident, if known." The licensee should attempt to determine the root

cause of the incident to the best of its ability and describe it in the

report. We are especially interested in why a licensee believes a part

has failed, whether caused by a manufacturing problem, a design flaw, improper use, or insufficient maintenance.

Section 34.30(b)(3) requires that the report contain the "Manufacturer

and model number of equipment involved in the incident."

This would

include the source assembly, exposure device, guide tube, control

assembly, and any fittings, placed on the end of the guide tube, that

were involved in the incident. in all cases, information on the camera

and source assembly involved in the incident should be provided.

This

section does not require serial numbers of equipment, although a

licensee may include serial number(s) in the report, and in some cases, this information is helpful.

Section 34.30(b)(4) requires that the report contain the "Place, time, and date of the incident."

The place should be a complete street

address, if possible.

If the site has no address, the licensee should

describe the site to the best of its ability, including the name of the

site, the nearest road to the site, the nearest town or city, and any

other descriptive information that would be useful in identifying the

location of the incident. The time (including a.m. or p.m.) the

incident occurred and the date(s) it occurred on must also be included

in the report.

If the description of the incident includes events that

occurred over several days, the date each event occurred should be

clear.

Section 34.30(b)(5) requires that the report contain a description of

the 'Actions taken to establish normal operations." This includes any

1_

Attachment 1

IN 96-04 January 10, 1996 action taken by the licensee or other persons following the incident to

return to a normal and safe situation. It would include actions like

attempting to get the equipment to operate properly, posting barriers

and maintaining surveillance of the area while a source is exposed, and

source-retrieval procedures. It does not include investigation into the

cause of the incident or corrective actions following the investigation

(see next section).

Section 34.30(b)(6) requires that the report contain a description of

the "Corrective actions taken or planned to prevent recurrence." This

includes training given to personnel to better detect and respond during

an incident. It also includes investigation into the cause of the

equipmeut, failure, any repairs made on the equipment, whether the

equipment was removed from service, and whether the equipment was sent

for testing. If testing was performed, the results from such testing

should be provided.

Section 34.30(b)(7) requires that the report contain a description of

the Qualifications of personnel involved in the incident." This

section does not need to be extensive. All that is needed is a

description of the types of personnel involved.

For instance, was the

radiographer or the radiographer's assistant operating the equipment

when the incident was noticed? Who was operating the equipment before

that time? Was the radiation safety officer involved at any time?

Specific names are not required, only the positions of the people

involved. However, the field experience of the personnel involved may

be useful information to include.

4.

WHAT IF DETAILS OF THE INCIDENT ARE REPORTABLE UNDER ANOTHER REGULATION?

Unless a specific exclusion is contained in the regulations, all reports

required in the regulations must be submitted, regardless of whether the

information has been provided in accordance with the regulations in

another separate report. However, in some situations, one report can be

submitted to multiple addressees to satisfy several requirements. For

example, section 34.30, paragraph (c) requires "Reports of overexposure

submitted under section 20.405 [new Part 20, section 20.2203] which

Involve failure of safety components of radiography equipment must also

include the information specified in paragraph (b) of [10 CFR 34.30]."

Therefore, the report submitted under section 34.30 may also be

submitted to meet part or all of the requirements contained in

section 20.2203.

Reports submitted under regulations other than

10 CFR 34.30 should contain a statement that the incident is also

reportable under 10 CFR 34.30 so that the reports can be properly

cataloged by the Commission.

-

N

Attachment 2

IN 96-04

January 10, 1996 LIST OF RECENTLY ISSUED

NMSS INFORMATION NOTICES

Information

Date of

Notice No.

Subject

Issuance

Issued to

95-58

95-55

95-51

95-50

95-44

10 CFR 34.20; Final

Effective Date

Handling Uncontained

Yellowcake Outside of a

Facility Processing Circuit

Recent Incidents Involving

Potential Loss of Control

of Licensed Material

Safety Defect in Gammamed

12i Bronchial Catheter

Clamping Adapters

Ensuring Combatible Use of

Drive Cables Incorporating

Industrial Nuclear Company

Ball-type Male Connectors

Brachytherapy Incidents

Involving Treatment

Planning Errors

Oversight of Design and

and Fabrication Activities

for Metal Components Used

in Spent Fuel Dry Storage

Systems

Emplacement of Support

Pads for Spent Fuel Dry

Storage Installations at

Reactor Sites

12/18/95

12/6/95

10/27/95

10/30/95

09/26/95

09/19/95

06/07/95

06/05/95

Industrial Radiography

Licensees.

All Uranium Recovery

Licensees.

All material and fuel cycle

licensees.

All High Dose Rate

Afterloader (HDR) Licensees.

All Radiography Licensees.

All U.S. Nuclear Regulatory

Commission Medical

Licensees.

All holders of OLs or CPs

for nuclear power reactors.

Independent spent fuel

storage installation

designers and fabricators.

All holders of OLs or CPs

for nuclear power reactors

95-39

95-29

95-28

It

K-

.

Attachment 3

IN 96-04

January 10, 1996 LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information

Date of

Notice No.

Subject

Issuance

Issued to

96-03

Main Steam Safety Valve

Setpoint Variation as a

Result of Thermal Effects

01/05/96

All holders of OLs or CPs

for nuclear power reactors

96-02

96-01 Inoperability of Power-

Operated Relief Valves

Masked by Downstream

Indications During Testing

Potential for High Post- Accident Closed-Cycle

Cooling Water Temperatures

to Disable Equipment

Important to Safety

01/05/96

01/03/96 All holders

for PWRs

All holders

for PWRs

of OLs or CPs

95-58

95-57

95-56

95-55

10 CFR 34.20; Final

Effective Date

Risk Impact Study Regarding

Maintenance During Low-Power

Operation and Shutdown

Shielding Deficiency in

Spent Fuel Transfer Canal

at a Boiling-Water Reactor

Handling Uncontalned

Yellowcake Outside of a

Facility Processing

Circuit

12/18/95

12/11/95

12/06/95

Industrial Radiography

Licensees

All holders of OLs or CPs

for nuclear power reactors.

All holders of OLs or CPs

for nuclear power reactors.

All Uranium Recovery

Licensees.

OL - Operating License

CP - Construction Permit

I~

K11 IN 96-04 January 10, 1996 This information notice requires no specific action nor written response. If

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

the technical contact listed below or the appropriate regional office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical contact:

Douglas Broaddus, NMSS

301-415-5847 Internet:dab@nrc.gov

Attachments:

1. Questions and Answers for Reporting Requirements in 10 CFI

2. List of Recently issued NMSS Information Notices

3. List of Recently issued NRC Information Notices

Coordinated with IMAB (Pat Santiago) and AEOD (Sam Pettijohn)

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IN 95- December

, 1995 In the cases where manual-locking-mechanism failures were reported, the

manufacturer determined that the reported failures were caused by an inherent

design flaw that allowed the key to be removed when in the unlocked position, or

caused the lock to partially malfunction. The manufacturer corrected the design

flaw, and no additional reports of these types of failures have been received.

The failures discussed above are intended to provide general guidance on, and

familiarize radiography licensees with, the typical types of incidents that have

been reported.

Radiography licensees should consider this guidance, and the

additional guidance contained in Attachment 1, when determining if an incident

should be reported. It is extremely important that radiography licensees make

the required reports to the Commission in a timely manner, since the reports are

used to detect trends or generic issues that have the potential to cause a

significant safety hazard. In addition, NRC uses the information gleaned from

the reports to determine the appropriate course of action to reduce or eliminate

similar incidents in the future, and to protect the health and safety of both the

radiography licensees and the public.

In addition to the information specified in 10 CFR 34.30 (see question 3 of

Attachment 1), we strongly suggest that submitted reports contain a contact's

name and phone number, so that NRC personnel may follow up on the report, if

necessary.

Information on other means of communication, such as facsimile phone

numbers and Internet E-mail addresses, is also helpful.

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

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

technical contact listed below or the appropriate regional office.

Donald A. Cool, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety and

Safeguards

Technical contact:

Douglas Broaddus, NMSS

301-415-5847 Attachments:

1.

Questions and Answers for Reporting Requirements in 10 CFR 34.30

2.

List of Recently issued NMSS Information Notices

3.

List of Recently issued NRC Information Notices

DOCUMENT NAME: IMNS988.DB2 Coordinated with IMAB (Pat Santiago) and AEOD (Sam Pettijohn)

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IN 95- December

, 1995 The manufacturer determined that the reported Caowa4- eck4fng-meehran+sm failures

were caused by an inherent design flaw that allowed the key to be removed when

in the unlocked position, or caused the lock to partially malfunction.

The

manufacturer corrected the design flaw, and no additional reports of these types

of failures have been received.