Information Notice 1991-14, Recent Safety-Related Incidents at Large Irradiators
4
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS
WASHINGTON, D.C.
20555
March 5, 1991
NRC INFORMATION NOTICE NO. 91-14:
RECENT SAFETY-RELATED INCIDENTS AT
LARGE IRRADIATORS
Addressees
All Nuclear Regulatory Commission (NRC) licensees authorized to possess
and use sealed sources at large irradiators.
Background
This issue was previously addressed in NRC Information Notice No. 89-82,
"Recent Safety-Related Incidents at Large Irradiators" (attached). Because
of the significance and frequency of recurrence of these incidents, NRC
believes this issue should be reiterated.
Purpose
This information notice is intended to remind recipients of the potential
for large irradiators to deliver life-threatening radiation doses when safety
and security systems are bypassed or preventive maintenance programs are
ignored.
It Is expected that licensees will review this information, distribute and review it with all facility workers and radiation staff to
prevent similar incidents from occurring at their facility.
Licensees are
also expected to consider actions, if appropriate, to ensure that adequate
preventative maintenance and proper safety training programs with periodic
retraining exists.
However, suggestions contained in this notice do not
constitute any new NRC requirements; therefore, no specific action or written
response is required.
Description of Circumstances
Several incidents of overexposure, resulting in loss of life, occurred outside
of the United States as a result of bypassing safety and security systems and
not following safety and operating procedures.
However, at the facility of an
Agreement State licensee, a worker avoided overexposure by following proper
safety and operating instructions and procedures.
In another instance, during
an inspection of an NRC licensee, violations noted, including the bypassing
of safety systems and the willful misleading of NRC during the subsequent
investigations, resulted in proposed civil penalties. A more detailed
description of these incidents is provided in Attachment 1.
K
102701588gF
I
IN 91-14 March 5, 1991 Discussion:
As shown in Attachment 1, beliefs such as "no risk because the machine is
turned off" and actions such as using numerous ways to bypass safety and
security systems demonstrate a lack of knowledge of the nature of radiation, as well as its danger.
All supervisory personnel, particularly the radiation
safety officer, are reminded of their responsibility to ensure safe operation
at their facilities.
The incidents described in the attachment demonstrate the
importance of:
1. Not bypassing interlocks and other safety systems
2. Following all authorized operating procedures
3. Training all involved personnel in safety and operational procedures, with periodic retraining, stressing the need for operators to promptly
notify their supervisors when unusual or conflicting signals arise on
control systems
4. Maintaining all equipment in good working condition and promptly
repairing or replacing any defective or nonfunctional equipment
5. Complying with all regulatory requirements and license conditions
This information notice requires no specific action or written response.
If you have any questions about the information in this notice, please
contact the technical contact listed below or the appropriate NRR project
manager.
Richard E. Cunningham, Director
Division of Industrial and
Medical Nuclear Safety, NMSS
Technical Contact:
Susan L. Greene, NMSS
(301) 492-0686 Attachments:
1. NRC Information Notice 89-82
2. Attachment 1
3. List of Recently Issued NMSS Information Notices
4. List of Recently Issued NRC Information Notices
Attachment 1
IN 91-14 March 5, 1991 DESCRIPTION OF INCIDENTS AT LARGE IRRADIATOR FACILITIES
Case 1. (340,000 Ci Co-60 Irradiator in Israel) A transport jam occurred,
.causing the transport mechanism to stop, the "source-down" signal to come
on, and the gamma alarm to sound.
The sounding of the gamma alarm was
considered unusual.
Acting against operating and safety instructions, the
operator did not notify his supervisor and instead handled the situation on
his own.
He turned the alarm system off by disconnecting the console cables, defeated the door interlock by cycling the power switch, unlocked the door, and entered the radiation room.
He did not check the Geiger counter he carried
before entering the radiation room, and consequently was unaware that the
instrument was not operational.
Seeing torn cartons, but unable to see that the source rack remained up
because it was resting on the edge of a carton, the operator got a cart and
began removing the damaged cartons.
After about a minute, he began to feel
a burning sensation in his eyes and left the room.
Since the operator was
not wearing his film badge, the whole body dose for the 1 1/2 to 2 minutes
he was in the radiation room was estimated to be about 1,000 to 1,500 rads.
The source rack was later released and lowered to the pool under the direction
of the supplier, and no further overexposures were reported. The operator
died from radiation exposure due to acute radiation syndrome effects 36 days
after the accident.
Case 2. (18,000 Ci Co-60 Irradiator in El Salvador) The sounding of the
source transit alarm alerted the night shift operator (Worker A) that the
source was neither fully up nor fully down as a result of a fault condition, which should have caused the source rack to be automatically lowered to the
pool.
He followed the reset procedure at the control panel, however had no
success in stopping the alarm and releasing the door. He tried to free the
source rack by detaching the normal regulated air supply and applying
overpressure to force the source rack into the fully raised position (a
procedure not recommended by the supplier). This attempt also failed. The
worker was eventually able to stop the alarm, but the general failure light and
the "source-up" light remained on.
He then manipulated the microswitch system
to produce a "source-down" light.
Worker A disabled the door interlock system by rapidly cycling the buttons on
the radiation monitor panel, while turning the key in the door switch (another
procedure not recommended by the supplier), thus simulating the detection of
normal background radiation in the radiation room by the fixed monitor and
succeeded in opening the door.
He then shut off the power supply to the
facility and entered the radiation room believing that, as with unpowered X-ray
equipment, there would be no continuing radiation.
Without first checking the
radiation levels with a portable radiation instrument, he began to remove the
deformed product boxes that had jammed.
At this point he noticed that the
---
Attachment 1
IN 91-14 March 5, 1991 descent of the source rack was prevented by the slack cable of the hoist
mechanism.
Unable to free the rack by himself, he left the radiation room
and turned the power back on, noticing that the failure light was "on" and
the "source-down" light was intermittent, but that no alarm was sounding.
Worker A then enlisted Workers 8 and C to help free the source rack.
They
had no experience or knowledge of the irradiation facility.
After assuring
Workers B and C that there was no risk as the machine was turned off, the
three men entered the radiation room and began removing the jammed product
boxes, while standing directly in front of the source rack.
As the product
boxes were removed and the source rack was lowered to the surface of the
water, the workers noticed the blue glow in the pool from Cerenkov radiation.
Worker A was surprised at this and after fully lowering the source rack, he
told the others to exit quickly.
When leaving the radiation room, Worker A
was questioned by Worker B as to the use of the portable radiation monitor
that was located some distance from the irradiator.
He explained that the
instrument was for radiation detection and measurement, but that it had not
been necessary to use it.
Worker A became ill minutes after leaving the radiation room and was taken to
the hospital. Workers B and C later became ill and also went to the hospital.
The company was unaware of the accident for several days because the workers
were incorrectly diagnosed as having food poisoning.
It was later discovered
that some of the source pencils had fallen from the source rack into the pool
and that one of the pencils had fallen into the radiation room.
At least four
more persons were overexposed before the circumstances of the accident were
fully realized.
Worker A was hospitalized for extensive radiation burns to his legs and feet
and gastrointestinal and hematopoietic radiation syndrome.
His right leg was
amputated and, 197 days after the accident, Worker A died as a result of his
radiation exposure.
Worker B was treated for symptoms of acute radiation exposure and severe
burns.
After the amputation of both legs, he was transferred to a
rehabilitation facility 221 days after the accident.
Worker C suffered less severe symptoms of radiation exposure and remained
on sick leave from work for 199 days after the accident.
Long term effects
to these workers may include eye damage from radiation exposure. A more
detailed description of the incident can be found in IAEA, Vienna, 1990
STI/PUB/847.1
1STI/PUB/847, IAEA Vienna, 1990.
Copies can be obtained for reference and
training tools from UNIPUB, 4611-F Assembly Drive, Lanham, MD 20706-4391
Attachment 1
IN 91-14 March 5, 1991 Case 3. (3.5 million Ci Co-60 Irradiator in an Agreement State) The
operator noticed that the product had received an unacceptably low dose.
He shut down cell operations and, with the source position monitor indicating
that the sources were down and the in-cell radiation monitor showing radiation
levels at zero, he entered the cell with a portable radiation survey instrument.
He noticed elevated radiation levels between 1-2 mR/hr on the survey instrument
and aborted his attempt to enter the cell.
The operator restricted the area
and notified supervisory personnel.
Investigation into the cause of the
elevated radiation readings revealed that one of the source racks was not
fully down and that the top of the rack was about 1A feet from the top of the
pool.
An inspection of the winch mechanism indicated that the cable brake had
failed to stop the winch allowing the cable to completely unwind.
As a result, the source rack was raised instead of lowered with the continuing rotation of
the winch mechanism.
The source rack was then manually lowered into the pool.
It was determined that deterioration of the wiring in the Geiger-Muller tube of
the cell monitor due to radiation exposure was the cause of this system failing
to warn of the elevated radiation levels in the radiation room.
The necessary
repairs were made to the control panel and the cell monitor and procedures
instituted to upgrade the safety systems of the facility.
The operator followed
safety and operating procedures during the incident and avoided overexposure by
correctly using the portable survey instrument.
Case 4. (1.3 million Ci Co-60 Irradiator in NRC Jurisdiction) During an
inspection and subsequent investigation at an irradiator facility, NRC
identified the following violations, including but not limited to: (1) failing
to promptly and effectively repair the lock on the personnel-access door to
the irradiator cell; (2) modifying a procedure without first obtaining NRC
approval (i.e., replacing a safety component in the irradiator start-up
system), as was required in the license; and (3) the deliberate bypassing of
administrative procedures and safety interlock and physical barriers to gain
entry to the irradiator cell by climbing over the irradiator cell access door.
An NRC investigation also determined that senior licensee management knew of
the violations and made incomplete and inaccurate statements to the NRC during
an enforcement conference and the subsequent investigations involving the
circumstances of these violations. The potential for extremely high radiation
exposures and the licensee's lack of candor with NRC raised questions about the
ability and willingness of the licensee to comply with NRC requirements.
NRC
considered these violations of the safety requirements to be serious and
proposed a civil penalty of $13,000 be assessed against the licensee. Senior
management involved in this incident are no longer associated with the facility.
The licensee has instituted a Quality Assurance program and additional training
requirements.
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
All U.S. Nuclear Regulatory Commission (NRC)
licensees authorized to possess
and use sealed sources at large irradiators.
Purpose
This notice is intended to inform recipients of recent safety-related incidents
at large irradiators and emphasizes the need for proper management actions and
attention to preventive maintenance programs.
This notice also serves to remind
licensees of other safety-related incidents at irradiators covered in Infor- mation Notice 87-29.
It is expected that licensees will review this information, distribute the notice to responsible radiation safety staff, and consider actions, if appropriate, to ensure both proper preventive maintenance programs and proper
management actions to preclude similar situations from occurring at their faci- lities.
However, suggestions contained in this notice do not constitute any new
NRC requirements, and no written response is required.
Description of Circumstances
A description of each of the following events is provided in Attachment 1. In
summary, these events included:
O
Deliberate bypass of the radiation monitor interlock system and another
safety system designed to protect individuals from radiation-produced
noxious gases.
o
Significant contamination of pool water remaining unnoticed, which could
have been detected sooner, had the pool water been continuously circulated
and monitored through the demineralizer.
O
An uncontrolled descent of a shipping cask into an irradiator pool, due
to brake malfunction on a lifting crane.
O
Leaks in the irradiator pool caused by localized caustic stress corrosion
in pool liner welds.
3911 OGGC50
Sep
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
Technical Contact:
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)().
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 t 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 gan 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.
Attachment 2
December 7, 1989 UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, D. C. 20555
June 26, 1987
NRC INFORMATION NOTICE NO. 87-29: RECENT SAFETY-RELATED INCIDENTS AT
LARGE IRRADIATORS
Addressees
All NRC licensees authorized to possess and use sealed sources in large
irradiators.
Purpose
This notice is being issued to inform recipients of recent safety-related
incidents at large irradiators, which could have been prevented by proper
management actions and attention to preventative maintenance programs. It
is suggested that recipients review this information and their procedures
and consider actions, if appropriate, to ensure both proper preventative
maintenance programs and proper management actions at their facilities.
However, suggestions contained in this Information Notice do not constitute
NRC requirements; therefore, no specific action or written response is required.
Description of Circumstances
A description of each of six events is provided in Attachment 1. In summary, these events included:
o
hose failure resulting in a leak, failure to report the incident to NRC,
and deliberate cover-up of this incident when NRC tried to investigate, leading to company fines and personnel probation;
o
intentional bypass of safety interlocks, resulting in license suspension
and other enforcement actions by NRC;
o
improper pipe routing and inadequate piping material, which broke and
caused partial loss of pool water;
o
source unable to retract to its fully shielded position, due to a frozen
o
a stuck source plaque, due to failure to promptly replace a frayed lift
cable; and
o
a stuck source plaque, due to interference from the product carriers and
shroud.
Q7O62Z0O33-
rN 87-29 june 26, 1987 Discussion:
These incidents illustrate a failure by management to assure that proper
safety and maintenance procedures are followed. It is suggested that super- visory personnel, particularly the Radiation Protection Officer and maintenance
personnel, be reminded of their responsibilities'to assure safe operation at
their facilities. The incidents discussed in Attachment 1 demonstrate the
importance of:
1. prompt reporting of incidents to the NRC, as required by regulations or
license conditions
2.
safety training and periodic retraining of personnel
3. not bypassing interlock systems or other safety systems
4. attention to proper plumbing installation and use of appropriate piping
material
5. proper maintenance of cables, carrier systems, and other components that
could prevent radioactive sources from being retracted to a shielded
position.
No specific actions or written response is required by this Information
Notice. If you have any questions about this matter, please contact the
Regional Administrator of the appropriate NRC regional office or this office. -
Richard E. Cunningham, Director
Division of Fuel Cycle, Medical,
Academic, and Commercial Use Safety
Office of Nuclear Material Safety
and Safeguards
Technical Contact:
Bruce Carrico, NMSS
(301) 427-4280
Attachments:
1. Events That Occurred at Large Irradiator Facilities
2. List of Recently Issued NRC Information Notices
Attachment 2
December 7, 1989 Attachment I
June 26, 1987
EVENTS THAT OCCURRED AT LARGE IRRADIATOR FACILITIES
1. While the licensee was attempting to decontaminate pool water because of
a leaking source, a hose on a filtration system ruptured. Contaminated
pool water was then pumped onto the facility floor and leaked outside into
the surrounding soil. the licensee failed to report the incident to NRC,
and made deliberate efforts to prevent KRC's discovery of this incident.
"Subsequently, the licensee was indicted by a Federal Court. A conviction
resulted in a $35,000 fine for the company and two years probation for a
management employee.
Licensee failure to make required reports prevents
the NRC from performing its radiological health and safety function and
from making a timely assessment of the nature and severity of an incident.
2. A licensee deliberately bypassed the safety interlock systems.
The KRC
subsequently learned that licensee personnel had willfully violated
requirements, and that senior licensee management knew, or should have
known, of these violations. When NRC attempted to inspect and investigate
these suspected violations, senior licensee management knowingly provided
false information to the NRC. Subsequent enforcement action included
suspension of the license.
3. A water line fractured in the pool circulation system which resulted in
the loss of 5 feet of pool water.
The line break led to a loss of
shielding water because the intake and outlet pipes were misaligned
during maintenance. The pipe break appears to have occurred because
the pipe was made of polyvinyl chloride, designed for cold water, rather
than for the heated water temperatures typical for the irradiator. The
piping was replaced with polypropylene pipe.
4. A night shift operator noticed that the travel time for the source to
reach the fully unshielded position was excessive. After completing
the next phase of irradiation, the source would not retract to the fully
shielded position, even using emergency equipment. The operator discovered
that the solenoid valve, that was supposed to retract the source to a
shielded position, was frozen due to weather conditions. The valve was
in a room above the irradiator facility. The operator went there and
turned on a room heater to thaw out the valve so that it would operate.
The operator violated license requirements to (1) notify the Radiation
Safety Officer (RSO) that the source had not returned to its shielded
position because of the frozen valve, and (2) obtain RSO permission to
enter and heat the room housing the valve.
5. A licensee had identified a frayed lift cable a few days previously, but
instead of imediately replacing the cable, the licensee decided to wait
for scheduled maintenance. The cable jammed and froze the source plaque
in a less than fully shielded position. Employees cut the cables and let
the source plaque free-fall into the pool. The incident could have been
prevented by replacing the frayed cable limed lately, and selecting cable
material with fray-resistant qualities.
Attachment 2
IN 89-82 December 7, 1989 A. A source plaque became stuck in the exposed position. Conveyors stopped,
-oarcu vows Visit came on, but cell radiation levels remained high.
Cable slack data indicated that the plaque was stuck about five and a half
feet down from its full-up position. The RSO attempted some raising and
lowering maneuvers, but the plaque then stuck in a full-up position. The
RSO, able to run the product containers out of the cell, saw some were
misaligned on the carrier. The RSO notified a State Inspector, who arrived
in the afternoon. It was determined that the plaque cable was off its pulley.
The bottom of a splice in the cable was resting on the lip of the tube
leading to the cell. After the cable was set on its pulley, the cable was
guided through the tube, and the plaque was lowered, until it caught again.
-.A borrowed radiation-resistant camera arrived the next morning. An adequate
view of the plaque was obtained by midnight. Apparently the stationary
aluminum shroud between product containers and plaque had been deflected
and caught on the plaque frame. The plaque was carefully raised and dropped
to break the jam. On the second try, the plaque broke free and dropped
into the pool. Analysis revealed that a product container had probably
tipped onto the shroud, causing interference with the plaque.
This incident was apparently caused by inadequate design of the shroud.
This led to the shroud deforming, which interfered with plaque motion.
Inadequate maintenance contributed to the problem. The cable should
have been replaced instead of spliced. A few months later, the entire
source hoist mechanism failed and had to be replaced. This failure oc-
- curred when the source plaque was submerged.
Attachment 2
IN 89-82 December 7, 1989 - 2 -
I
Attachment 3
December 7, 1989
Page I of I
LIST OF RECENTLY ISSUED
hMSS IMFORMATIOM NOTICES
informtion
Date of
Notice No.
Subject
Issuance
Issued to
Attachrent 4
Decoiber 7, 1989
Page I of 1
LIST OF RECENTLY ISSUED
NRC INFORMATIOt
NOTICES
inTormat1on
vate OT
Notice No.
Subject
Issuance
Issued to
89-59.
Suppliers of Potentially
12/6/89
All holders of OLs
89-78
89-60
89-47
89-46
89-37
89-35
89-34
89-25 Failure of Packing
Nuts on
11/22/89 One-Inch Uranium Hexafluoride
Cylinder Valves.
Maintenance of Teletherapy
08/18/89 Units
Potential Problems with
05/18/89
Worn or Distorted Hose
Clamps on Self-Contained
Breathing Apparatus
Confidentiality of
05/11/89
Exercise Scenarios
Proposed Amendments to 40
04/04/89
CFR Part 61. Air Emission
Standards for Radionuclides
Loss and Theft of Unsecured
03/30/89
Licensed Material
Disposal of Americium
03/30/89 Wel -Logging Sources
Unauthorized Transfer of
03/07/89
Ownership or Control of
Licensed Activities
All U.S. NRC licensees
authorized to possess
and use source material
and/or special nuclear
material for the heating.
emptying, filling, or
shipping of uranium
hexafluoride in 30- and
48-inch diameter cylinders.
All U.SI
NRC Medical
Teletherepy Licensees.
All holders of operating
licenses or construction
permits for nuclear power
reactors and fuel
facilities.
All holders of licenses
for fuel cycle facilities
and byproduct material
licensees having an
approved emergency
response plan.
All U.S. NRC licensees.
Supp.1I
misrepresented Fasteners
89-S1
89-80
89-79
89-56, Su". 1
Inadequate Control of
Teponrawy Modifications
to Safety-Related Systems
Potential for Water HMamer,
Therwel Stratification, and
Stem Binding In High-
Pressure Coolant Injection
Piping
Degraded Coatings and
Corrosion of Steel
Containment Vessels
Questionable Certification
of Material Supplied to
the Defense Department
by Nuclear Suppliers
Failure of Packing Nuts
on One-Inch Uranium
Mexafluoride Cylinder
Valves
Debris in Containment
Emergency Sums and
Incorrect Screen
Configurations
81ofouling Agent: Zebra
Nussel
12/6/89
12/1/89
12/1/69
All holders of OLs
11/22/89
All holders of OLs
or CPs for nuclear
power reactors.
or CPs for nuclear
power reactors.
All holders of OLs
or CPs for nuclear
power reactors.
All holders of OLs
or CPs for nuclear
power reactors.
All U.S. NRC
byproduct, source and special
nuclear material licensees.
All holders of U.S. NRC
specific licenses
authorizing well-logging
activities.
All NRC source, byproduct, and special nuclear
material licensees.
89-78
89-77
89-76
11/22/89 All NRC
licensees
uthorized to possess
and use source material
and/or special
ulear
material for the heating, emptying, filling, or
shipping of uranium
hexafluoride In 30-
and 48-inch diuieter
Y
cylinders.
11/21/89
All holden of OLS
11/21/89
All holders of OLs
or CPs for nuclear
power reactors.
- Operating LiCense
CP = Construction Permit
..; J ' "
.1 I
Attachment 3
March 5. 1991 Attachment 4
March 5. 1911
Pop 1 of 1
LIST OF RECENTLY ISSUED
WSS INFORNATION WtICES
Dat of_
LIST OF RECENTLY ISSUED
NRC
INFORPATION MOTICES
Information
notice No.
Subject
95-03 management of Wastes Conter-
1neted with Radioactive
materials (,Red Bg
Waste
and Ordinary Trash)
91-02
Brachytherapy Source Management
90-82
Requirements for Use of
Nuclear Regulatory Coe
Ission-(&RC-)Approved
Transport Packages for
Shipment of Type A Quanti- ties of Radioactive Materials.
90-S.
Fitness for Duty
90-75
Denial of Access to
- Current Low-Lel Radio- active waste Disposal
Facilities
90-n
Effective Use of Radiation
Safety Comaittees to
Exercise Central Over
MediCal Use Prras
90-70
Pump Explosions Involving
Amnilm Nitrate
90-38, License and Fee Require- Supp. 1 ments for Processing Fin- ancial Assurance Submittals
for Decoemissioning
Date of
Issuance
02107/91 Issued to
All medical licensees.
01/07/91
All Nuclear Regulatory
Coimission (NRC) medi- cal licensees author- ized to use byproduct
material for medical
purposes.
1231/90
All registered users
of NRC-approved
Packages.
Information
Notice No.
91-13
91-12
91-11
86-99.
Supp. 1
89-32, Supp. 1
91-10
Date of
Subject
Inadequate Testing of Emergency
Diesel Generators (EDOs)
Potential Less of Net Positive
Suction Need (MMSN)
of Standby
Liquid Control System Pimps
Inadequate Physical Separation
and Electrical Isolation of
Nonrsefety-related Circuits
from Reactor Protection System
Circuits
Degradation of Steel Con- teaiments
Surveillance Testing of Low-
T qerature Overpressure
Protection Systees
Suary of Semiannual Progre
Pe.rfomance Reports on Fitness- for-Duty (FFD) In the Nuclear
Industry
Ceunterfaiting of Cran Valves
Medical Exzminations for
Licensed Operators
Inadvertent Removal of Fuel
Asseablies free the Reactor Core
- Istuance
Issued to
03/04/91
All holders of OLs
or CPs for nuclear
poer reactors.
0215/91
All holders of OLs
or CPs for boiling
water reactors (MA1s).
02/20/91
All holders of OLs
or CPs fto
U-designed
nuclear power reactors.
02/1491
All holders of OLS or
CPs for nuclear prer
reactors.
02/12/91
All holders of OLs or
CPs for nuclear powr
reactors.
02/91
All holders of OLs or
Cps for nuclear power
reactors.
02/0SM
All holders of OLS or
Cps for nuclear power
reactors.
02/05/91
All holders of OLs or
Cfs for nuclear power, test and research
reactors.
o24/91
All holdars of OLs or
Ch for pressurized- water reactors (PUft).
12/24/90
All U.S. Nuclear
Regulatory Comission
(NRC) and non-pwmr
reactor licensees.
22/5/90
All Michigan holders
of NR licensee.
91-09 C
1V6/90
All NRC
licenses
authorized to use
byproduct psterial
for medical purposes.
S6/90
All urania. fuel
fabrication and
conversion facilities.
12/6/90
All fuel facility and
materials licensees.
91-OS
90-77.
Supp. I
- Operating License
CP - Construction Permit
OL - Operating License
CP - Construction Permit
IN 91- February
, 1991
\\o Xiscussion:
As hown in Attachment 1, beliefs such as "no risk because the machine is
turn d off" and actions such as using numerous ways to bypass safety and
secur ty systems demonstrate a lack of knowledge of the nature of radiation, as wel as its danger. All supervisory personnel, particularly the radiation
safety oficer, are reminded of their responsibility to ensure safe operation
at their
cilities. The incidents described in the attachment demonstrate the
importance f:
1. Not bypas ng interlocks and other safety systems
2. Following al
authorized operating procedures
3. Training all iv lved personnel in safety and operational procedures, with periodic ret ining, stressing the need for operators to promptly
notify their superv ors when unusual or conflicting signals arise on
control systems
4. Maintaining all equipmen in good working condition and promptly
repairing or replacing any efective or nonfunctional equipment
5. Complying with all regulatory equirements and license conditions
This information notice requires no secific action or written response.
If you have any questions about the in rmation in this notice, please
contact the technical contact listed be w or the appropriate regional
office.
Richard E. unningham, Director
Division of ndustrial and
Medical Nuc ear Safety, NMSS
Technical Contact:
Susan L. Greene, NMSS
(301) 492-0686 Attachments:
1. NRC Information Notice 89-82
2. Attachment 1
3. List of Recently Issued NMSS
Information Notices
4. List of Recently Issued NRC
Information Notices
- See Previous Concurrence
IMAB*
- Tech Editor*
PRathbun
- EKraus
02/11/91
- 12/13/90
OFC: IMAB
- IMAB*
- 1MOB*
- IMAB*
zD
_:D/IMNk
e
NAME:SGreene:sg/ht
- MLamastra :CTrottier :JEGLenn
- GS
Xblom
atop- DATE:02/06/91
- 02/06/91 :02/06/91
- 02/21/91 :02/ 91 :02/ 191
OFFICIAL RECORD COPY
IN-IRRADIATORS
IN 91- February
, 1991 Discussion:
As hown in Attachment 1, beliefs such as "no risk because the machine is
turn d off" and actions such as using numerous ways to bypass safety and
secur ty systems demonstrate a lack of knowledge of the nature of radiation, as wel as its danger. All supervisory personnel, particularly the radiation
safety o ficer, are reminded of their responsibility to ensure safe operation
at their
cilities. The incidents described in the attachment demonstrate the
importance f:
1. Not bypas ng interlocks and other safety systems
2. Following al authorized operating procedures
3. Training all in lved personnel in safety and operational procedures, with periodic ret ining, stressing the need for operators to promptly
notify their superv sors when unusual or conflicting signals arise on
control systems
4. Maintaining all equipme
in good working condition and promptly
repairing or replacing an defective or nonfunctional equipment
5. Complying with all regulator requirements and license conditions.
This information notice requires no pecific action or written response.
If you have any questions about the i formation in this notice, please
contact the technical contact listed b ow or the appropriate regional
office.
Richard E. nningham, Director
Division of Industrial and
Medical Nucl r Safety, NMSS
Technical Contact:
Susan L. Greene, NMSS
(301) 492-0686 Attachments:
1. NRC Information Notice 89-82
2. List of Recently Issued NMSS
Information Notices
3. List of Recently Issued NRC
Information Notices
- See Previous Concurrence
IMAB*
- Tech Editor*
PRathbun :EKraus
02/11/91
- 12/13/90
1 OFC: IMAB
- ItIAB*
- IMOB*
IMAB
- DD/IMNS
- D/IMNS
--------------------------
A--lbtv-------------
NAME:SGree
/ht
- MLamastra :CTrottie3 :JEGLenn :GSjoblom :RECunningham
- 02/06/91
- 02/06/91
- 027 /91 :02/
/91 :02/ /91
OFFICIAL RECORD COPY
IN-IRRADIATORS
IN 91- February
, 1991 Discussion:
As shown in Attachment 1, beliefs such as "no risk because the machine is
turned off' an using numerous ways to bypass safety and security systems
demonstrate a la
of knowledge of the nature of radiation, as well as its
danger. All supe isory personnel, particularly the radiation safety officer, are reminded of the
responsibility to ensure safe operation at their
facilities.
The inci
nts described in the attachment demonstrate the
importance of:
1. Not bypassing interloc
and other safety systems
2. Following all authorized
erating procedures
3. Training all involved perso el in safety and operational procedures, with periodic retraining, str sing the need for operators to promptly
notify their supervisors when
usual or conflicting signals arise on
control systems
4. Maintaining all equipment in good wqking condition and promptly
repairing or replacing any defective-tr nonfunctional equipment
5. Complying with all regulatory requirem ts and license conditions.
This information notice requires no specific a ion or written response.
If you have any questions about the information n this notice, please
contact the technical contact listed below or the\\appropriate regional
office.
4
Richard E. Cunningham, brector
Division of Industrial an4
Medical Nuclear Safety, UMSS
Technical Contact:
Susan L. Greene, NMSS
(301) 492-0686 Attachments:
1. NRC Information Notice 89-82
2. List of Recently Issued NMSS
Information Notices
3. List of Recently Issued NRC
Information Notices
!Sae.Previous Concurrence
LM0S? 9:Tech Editor*
- EKraus
02////91
- 12/13/90
OFC: IMAB
- IMAB*
- IMOB
- IMAB
- DD/IMNS
- D/IMNS
-
---
-
NAME:SGr 4i:ht
- MLamastra :CTr tier :JEGLenn
- GSjoblom :RECunningham
__
__ __
_-
__
__
__
__
_ __
__
__
__
__
__
__
__
_ __
__
__
__
__
__
__
__
_
DATE:02/f /91
- 02/ b/91
- 02/1
/91
- 02?
/91 :02/ /91
- 02/ /91
OFFICIAL RECORD COPY
IN-IRRADIATORS
'
IN 91-14 March 5, 1991 Discussion:
As shown in Attachment 1, beliefs such as "no risk because the machine is
turned off" and actions such as using numerous ways to bypass safety and
security systems demonstrate a lack of knowledge of the nature of radiation, as well as its danger.
All supervisory personnel, particularly the radiation
safety officer, are reminded of their responsibility to ensure safe operation
at their facilities.
The incidents described in the attachment demonstrate the
importance of:
1. Not bypassing interlocks and other safety systems
2. Following all authorized operating procedures
3. Training all involved personnel in safety and operational procedures, with periodic retraining, stressing the need for operators to promptly
notify their supervisors when unusual or conflicting signals arise on
control systems
4. Maintaining all equipment in good working condition and promptly
repairing or replacing any defective or nonfunctional equipment
5. Complying with all regulatory requirements and license conditions
This information notice requires no specific action or written response.
If you have any questions about the information in this notice, please
contact the technical contact listed below or the appropriate NRR project
manager.
Richard E. Cunningham, Director
Division of Industrial and
Medical Nuclear Safety, NMSS
Technical Contact:
Susan L. Greene, NMSS
(301) 492-0686 Attachments:
1. NRC Information Notice 89-82
2.
Attachment 1
3. List of Recently Issued NMSS Information Notices
4. List of Recently Issued NRC Information Notices
- See Previous Concurrence
IMAB*
- Tech Editor*
PRathbun :EKraus
02/11/91
- 12/13/90
OFC: IMAB
- IMAB*
- IMOB*
- IMAB*
- DD/IMNS
- D/IMNS
D
NAME:SGreene:sg/ht
- MLamastra :CTrottier :JEGLenn :GSjblom :}Runnt g am
DATE: 02/06/91
- 02/06/91
- 02/06/91
- 02/21/91 :02/ \\91 :02/12f91 OFFICIAL RECORD COPY