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, 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:	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

and manufacturers

All U.S. Nuclear Regulatory Commission radiography licensees

of radiography equipment.

Purpose

to alert thein. to, and

NRC is issuing this Information notice to addressees 10 CFR 34.30. It is expected

inform them of, the reporting requirements under to their

that recipients will review the information for applicability

as appropriate. This includes

facilities and activities and consider actions, radiography licensees or

manufacturers of radiography equipment who advise

10 CFR Part 34. However, potential licensees on the requirements of are not NRC requirements;

suggestions contained in this information notice

response is required.

therefore, no specific action nor written

Description of Circumstances

requirement, under

On January 10, 1990, Part 34 was amended to add a reportinglicensees to report to

10 CFR 34.30, that made it necessary for radiography or the failure of any

NRC, occurrences of source disconnects, source hangups, perform its

safety related radiography equipment component to properlyare not being reported

intended function. NRC is concerned that incidents of this section

either because licensees have not understood the requirements

or because they do not know that such requirements exist.

under this section.

As of January 1995, NRC has received only about 65 reports

audits of radiography

Based on other sources of information -- including in accordance with 10 CFR

equipment manufacturers' records, reports filed radiography licensees and

Part 21 requirements, and unofficial reports from reports of incidents should

equipment suppliers -- NRC believes that manyofmorea radiography equipment

have been received. Specifically, an audit had been a

manufacturer's customer complaint file showed that there the failure of a

substantial number of complaints from radiographers aabout few reports of this type.

locking mechanism. However, NRC has received only reports that NRC has

of failure. In addition, a substantial number of the of NRC radiography

received have been submitted by only a small percentage likely be more evenly

licensees. Such incidences of reportable events would

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 were indicated to

device outlet fitting. The majority of the hangups reported indicating human

be caused by human error or wear in the equipment. Reports set-up the

error have included incidents where the radiographer did not the guide tube

exposure jigs properly, which then toppled onto and crushed

radiographer bent the

sufficiently to prevent source retraction, and where the and preventing proper

guide tube around too sharp an angle, crimping the tube have included

source movement. Reports indicating wear in the equipment depleted uranium, causes such as extensive wear in the S-tube and surrounding the resulting

sufficient to cause the source capsule to become stuck in

indention.

reported, the

In the cases where manual-locking-mechanism failures werecaused by an inherent

manufacturer determined that the reported failures were

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

or caused the lock to partially malfunction. The manufacturer

of these types of failures have been

design flaw, and no additional reports

received.

guidance on, and

The failures discussed above are intended to provide general incidents that

familiarize radiography licensees with, the typical types ofthis guidance, and

have been reported. Radiography licensees should consider if an

the additional guidance contained in Attachment 1, when determining radiography

that

incident should be reported. It is extremely importantin a timely manner, licensees make the required reports to the Commission that have the

since the reports are used to detect trends or generic issues NRC uses the

potential to cause a significant safety hazard. In addition, course of

information gleaned from the reports to determine the appropriate and to protect

action to reduce or eliminate similar incidents in the future, licensees and the public.

the health and safety of both the radiography

(see Question 3 of

In addition to the information specified in 10 CFR 34.30 contain a contact's

Attachment 1), we strongly suggest that submitted reports

on the report, if

name and phone number, so that NRC personnel may follow upsuch as facsimile

necessary. Information on other means of communication, 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),(a) describe the types of events

that must be reported. These include: source disconnects involving

assembly from the drive

a separation of the source capsule or sourceassembly from being retracted

cable; (b)hangups that prevent the source in this position, as

to the fully shielded position, and to be secured

of any other component of the

designed and intended; and (c)the failure equipment to operate in an

radiography equipment that could cause the not separation of the

unsafe manner. Disconnects would include also only loss of radioactive

source assembly from the drive cable, but of the source capsule from

material from the source capsule, separation

the drive cable along its length.

the source assembly, and separation of. intended travel of the source, Hangups may occur at any point along the

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

components to operate

stops, etc.). Examples of the failure ofinother

an unsafe manner, include:

properly, causing the device to operate adequately secure the

(a)failure of the lock or securing mechanism to thereby allowing

source assembly in the fully shielded position,(b) failure of the guide

unintended movement of the source assembly; device as intended, or

tube or controls to connect to the exposure position indicators to show

operate properly; and (c) failure of source for evaluating

actual source position. The licensee is responsible and use appropriate

events that may be reportable under 10 CFR 34.30 If, after evaluation, judgment as to whether the event is reportable.

the event, we recommended

the licensee is not sure whether to reportCommission, according to

that the licensee make the report to the the licensee is unsure whether

10 CFR 34.30, and include the reasons why

the event is reportable.

2. WHEN AND WHERE SHOULD THE REPORTS BE SENT?

be reportable under

Within 30 days of an event that is determinedbe tosubmitted to NRC, to the

10 CFR 34.30, two copies of the report must (a). The addressees are:

addressees listed in 10 CFR 34.30, paragraph

Branch Chief Director

Medical, Academic, and Office for Analysis and Evaluation

Commercial Use Safety Branch of Operational Data

U.S. Nuclear Regulatory Commission 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 following the incident to

action taken by the licensee or other persons include actions like

return to a normal and safe situation. It would posting barriers

attempting to get the equipment to operate properly,source is exposed, and

and maintaining surveillance of the area while a investigation into the

source-retrieval procedures. It does not include the investigation

cause of the incident or corrective actions following

(see next section).

contain a description of

Section 34.30(b)(6) requires that the report prevent recurrence." This

the "Corrective actions taken or planned to detect and respond during

includes training given to personnel to betterinto the cause of the

an incident. It also includes investigation whether the

equipmeut, failure, any repairs made on the equipment, the equipment was sent

equipment was removed from service, and whether

the results from such testing

for testing. If testing was performed, should be provided.

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

incident." This

the Qualifications of personnel involved in the is needed is a

section does not need to be extensive. All that For instance, was the

description of the types of personnel involved. the equipment

radiographer or the radiographer's assistant operatingthe equipment before

when the incident was noticed? Who was operating at any time?

that time? Was the radiation safety officer involved

of the people

Specific names are not required, only the positionspersonnel involved may

involved. However, the field experience of the

be useful information to include.

ANOTHER REGULATION?

4. WHAT IF DETAILS OF THE INCIDENT ARE REPORTABLE UNDER

regulations, all reports

Unless a specific exclusion is contained in the of whether the

regardless

required in the regulations must be submitted, the regulations in

information has been provided in accordance with

situations, one report can be

another separate report. However, in some requirements. For

submitted to multiple addressees to satisfy several

"Reports of overexposure

example, section 34.30, paragraph (c) requiressection 20.2203] which

submitted under section 20.405 [new Part 20, equipment must also

Involve failure of safety components of radiography

(b) of [10 CFR 34.30]."

include the information specified in paragraph may also be

Therefore, the report submitted under section 34.30

contained in

submitted to meet part or all of the requirements other than

section 20.2203. Reports submitted under regulations incident is also

10 CFR 34.30 should contain a statement that the can be properly

reportable under 10 CFR 34.30 so that the reports

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 10 CFR 34.20; Final 12/18/95 Industrial Radiography

Effective Date Licensees.

95-55 Handling Uncontained 12/6/95 All Uranium Recovery

Yellowcake Outside of a Licensees.

Facility Processing Circuit

95-51 Recent Incidents Involving 10/27/95 All material and fuel cycle

Potential Loss of Control licensees.

of Licensed Material

95-50 Safety Defect in Gammamed 10/30/95 All High Dose Rate

12i Bronchial Catheter Afterloader (HDR) Licensees.

Clamping Adapters

95-44 Ensuring Combatible Use of 09/26/95 All Radiography Licensees.

Drive Cables Incorporating

Industrial Nuclear Company

Ball-type Male Connectors

95-39 Brachytherapy Incidents 09/19/95 All U.S. Nuclear Regulatory

Involving Treatment Commission Medical

Planning Errors Licensees.

95-29 Oversight of Design and 06/07/95 All holders of OLs or CPs

and Fabrication Activities for nuclear power reactors.

for Metal Components Used

in Spent Fuel Dry Storage Independent spent fuel

Systems storage installation

designers and fabricators.

95-28 Emplacement of Support 06/05/95 All holders of OLs or CPs

Pads for Spent Fuel Dry for nuclear power reactors

Storage Installations at

Reactor Sites

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 01/05/96 All holders of OLs or CPs

Setpoint Variation as a for nuclear power reactors

Result of Thermal Effects

96-02 Inoperability of Power- 01/05/96 All holders of OLs or CPs

Operated Relief Valves for PWRs

Masked by Downstream

Indications During Testing

96-01 Potential for High Post- 01/03/96 All holders of OLs or CPs

Accident Closed-Cycle for PWRs

Cooling Water Temperatures

to Disable Equipment

Important to Safety

95-58 10 CFR 34.20; Final 12/18/95 Industrial Radiography

Effective Date Licensees

95-57 Risk Impact Study Regarding 12/18/95 All holders of OLs or CPs

Maintenance During Low-Power for nuclear power reactors.

Operation and Shutdown

95-56 Shielding Deficiency in 12/11/95 All holders of OLs or CPs

Spent Fuel Transfer Canal for nuclear power reactors.

at a Boiling-Water Reactor

95-55 Handling Uncontalned 12/06/95 All Uranium Recovery

Yellowcake Outside of a Licensees.

Facility Processing

Circuit

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 CFIR 34.30

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)

qa nrovinuc concuirrener

I N IMOB* lEl Dll

I

vF SCDB* I ElSCDB* I E N SS*

iAME DBroaddus/tk/ll RBaer EKraus KRamsey

DATE 12/21/95 12/22/95 12/20/95 10/10/95 1/L /96 OFFICIAL RECORD COPY

DOCUMENT NAME: 96-04.IN

/

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)

See previous concurrence 'E' - Copy with attachment/enclosure N'

No copy

To receive a copy of this document, Indicate In the box: TC = Copy without attachment/anclosur

OFC SCDB* E SCDB* El PMDA* N IMOB* E D: l

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__l ___

NAME DBroaddus RBaer EKraus KRamsey

l DATE l12/21/95_ 12/22/95 12/20/95 10/10/95 l1/3 /96 OFFICIAL RECORD COPY

-1i

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.