ML052130139

Omaha Department of Veterans Affairs Reply to Notice of Violation

ML052130139
Person / Time
Site:	05000131
Issue date:	07/22/2005
From:	Klassen L, Washko A US Dept of Veterans Affairs, Nebraska-Western Iowa Health Care System, US Dept of Veterans Affairs, Omaha, NE
To:	Document Control Desk, NRC/FSME
References
IR-05-201
Download: ML052130139 (16)

Text

- .

Omaha 4101 Woolworth Avenue DEPARTMENT OF VETERANS AFFAIRS Omaha NE 68105-1873 NEBRASKA-WESTERN IOWA HEALTH CARE SYSTEM Lincoln 600 S 70h Street Lincoln NE 68510-2493 Grand Island 2201 N Broadwell Avenue Grand Island NE 68803-2196 In Reply Refer To: 636/151 July 22, 2005 U.S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555 RE: Reply to Notice of Violation The following is the response by the Omaha Department of Veterans Affairs A.J. Blotcky Reactor Facilities to the NRC inspection report #50-131/2005-201 and notice of violation.

Violation A TS section 6.7.1 requires that routine operating reports covering the operation of the facility during the previous calendar year shall be submitted before March 31 to the Nuclear Regulatory Commission.

1. Reason for violation:

Contrary to the above as of June 9, 2005 no annual operating report covering facility operations has been submitted to the Nuclear Regulatory Commission for the calendar year 2004.

2. Corrective steps taken:

The A.J. Blotcky Reactor Facility sincerely regrets not complying with this technical specification during 2004. The reactor facility has not been operational since the transfer of all of the fuel to the USGS TRIGA Facility during June of 2002, the removal of the fission chambers in December 2002, and the removal of all neutron sources in July 2003. The reactor has been maintained in a scheduled secured permanently shutdown condition since November 5, 2001.

A 2004 operating report for the Alan J. Blotcky Reactor Facility, license R-57, docket #50-131 has been sent on June 9, 2005. A copy of this report is attached.

3. Corrective steps taken to avoid further violations:

The Research Service of the Omaha VA Medical Center has taken appropriate administrative action to make sure that all annual reports will be completed and sent prior to the technical specifications deadline of March 31 of that calendar year. All reporting requirements for the AJBR facility have been added to the Education and Compliance Log.

em DI 1

4. Date when full compliance will be achieved:

June 9, 2005 Violation B TS section 6.2.4 requires that the Reactor Safeguards Committee audit faculty operations for compliance to technical specifications and applicable license conditions annually.

1. Reason for Violation:

Contrary to the above no annual audits of faculty operations have been conducted since an audit that was completed on February 28, 2003 for the report period from September 1, 2001 to December 31, 2002.

2. Corrective steps taken:

The Reactor Safeguards Committee has met and authorized a complete audit of the operations of the Department of Veterans Affairs A.J. Blotcky Reactor Facility by the Midwest Environmental Radiation Services, Inc.. 812 Elmhurst Drive, Papillion, Nebraska, 68046. This activity will include a review of the previous audit conducted by the same organization on February 28, 2003 as well as reviewing all aspects of the technical specifications and applicable license conditions.

3. Corrective steps taken to avoid future violations The Reactor Safeguards Committee has directed the Research Service Administrative Office to provide the appropriate initiation of all annual operational audits via the Education and Compliance Log system of compliance and certification used for all other aspects of the Research Service compliance and certification activities.

4. Date that full compliance will be achieved:

August 31, 2005 Violation C TS section 4.0 stipulates that the surveillance specified in sections 4.3, 4.5, and 4.6 (1) may not be deferred during shutdown.

TS section 4.3.1 requires that reactor pool water be sampled for gross activity on an average monthly, and for isotope identification on an average quarterly.

TS section 4.3.3 requires that monthly channel tests will be performed to ensure that the alarm float switch specified in TS section 3.1.4 is operable.

TS section 4.5(2) requires that the automatic absolute damper and alarm shall be tested on an average monthly and finally following repair or maintenance.

TS section 4.6(1) requires that all radiation monitors listed in TS section 3.6.1 shall be calibrated annually and after maintenance.

2

1. Reason for violation:

a. No analysis of the reactor pool water had been performed to determine gross activity, isotope identification since June 2002.

b. No monthly channel test to verify operation of the alarm float switch had been conducted since June 2002

c. The automatic absolute damper and alarm in the ventilation system of the reactor facility had not been tested on a monthly basis since June 2002

d. The continuous air monitor had not been calibrated since August 27, 2001

e. The area radiation monitor-pool level could not be located

2. Corrective steps:

The A.J. Blotcky Reactor Facility acknowledges that the surveillance specified in the above sections was not completed. The initial rationale was that all of these elements were related to the operational aspects of the nuclear reactor. With removal of the fuel, fission chambers, and neutron sources; the functional aspects of the surveillance was non-operational. For example, the radiation monitors listed in TS section 3.6.1 were to be active during reactor operations (TC section 3.6.1). Since the removal of the fuel, the reactor could not be operational, thus the radiation monitors were essentially not operational based upon these technical specifications.

Nonetheless, variation from TS section 4.6(1) is acknowledged and corrected.

A similar situation existed for regular su rveillance of the reactor pool water for gross radioactivity. The complete site characterization that had occurred as part of developing the decontamination and decommissioning plan indicated that the reactor pool water had no detectable radioactive material. Since no fuel remained in the reactor pool, additional radioactivity was not generated.

The specific corrective steps that have been taken to address these violations are as follows:

a. Reactor pool water has been sampled and analyzed by the Radiation Health Center, Division of Nuclear Medicine, University of Nebraska Medical Center. The Nuclide MDA Report and the Gamma Spectrum Analysis indicates that all radioactivity was below the minimal detectable activity (MDA) levels. A copy of the analysis report is attached.

b. A channel test has been performed and the alarm float switch worked as specified in TS section 3.1.4.

c. The automatic absolute damper and alarm has been tested and performs as required in TS section 4.5(2).

d. Both the continuous air monitor and the air radiation monitor have been reassembled, and made operational. A contract has been made with the Midwest Environmental Radiation Services, Inc., 812 Elmhurst Drive, Papillion, Nebraska, 68046 to calibrate both of these units prior to August 31, 2005.

3

3. Corrective steps taken to avoid further violations:

A formalized monthly surveillance program has been developed by the Omaha VA Research Service to follow the appropriate monitoring as defined in the above technical specifications. It will be the responsibility of the Reactor Facility Supervisor (Ed Fennel) and the Omaha VA Radiation Officer (Mike Christensen) to complete the appropriate monitoring at weekly and monthly intervals as detailed in the technical specifications. A monthly surveillance report will be completed and sent to the Associate Chief of Staff for Research for supervisory signature.

These completed surveillance reports will be reviewed by the Reactor Safeguards Committee on a quarterly basis. Monitoring of these surveillance events will be done by the Omaha VA Research Service via the Education and Compliance Log. A copy of the monthly surveillance report is attached. This will ensure that the monitoring reports are completed on a monthly basis.

4. Date when full compliance will be achieved:

August 31, 2005 Additional Actions The Omaha VA Research Service has contracted with Midwest Environmental Radiation Services Inc. at 812 Elmhurst Drive, Papillion, Nebraska, 68046 to provide the following areas of expertise:

1. A quarterly review of the surveillance and licensing issues pertinent to the NRC licensing requirement. This will be done in conjunction with regularly held meetings of the Radiation Safeguards Committee.

2. Expertise in submitting a written request for exemption from the NRC concerning termination of the reactor operational requalification program

3. Expertise in submitting a written proposal to the NRC concerning termination of the emergency preparedness program and requesting an exemption from the program requirements

4. Aid in the preparation of a request to the NRC concerning approval for variation from TS section 4.6(1) and the quarterly isotope identification identified in TS 4.3.1.

We trust that this information responds appropriately to the concerns raised by the recent NRC inspection that led to the issuing of 3 specific violations. It is the intent of this facility to remain in full compli ce with NRC regulations.

Al ashko ne I W. Klassen, M.D.

Director ACOS/Research Attachments

1. 2004 Annual Operating Report by A.J. Blotcky Facility, license #R-57, docket #50-13B

2. Results of Gamma Spectrum Analysis of the Reactor Pool Water completed July 13, 2005

3. Monthly surveillance report for July 2005

4. Reactor Safeguards Committee minutes, June 9, 2005 Cc: Craig Bassett 4

Omaha 4101 Woolworth Avenue Gil,, DEPARTMENT OF VETERANS AFFAIRS Omaha NE 681051873 NEBRASKA-WESTERN IOWA HEALTH CARE SYSTEM Uncoln 600 S 70t Street Uncoln NE 68510-2493 2201 N Broadwell Avenue Grand Island NE 68803-219 June 9, 2005 In Reply Refer To: 636/151 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555 Re: 2004 Annual Operating Report for the Alan J. Blotcky Reactor Facility, License R-57, Docket # 50-131 This annual operating report is being submitted in compliance with technical specification 6.7.1, "Annual Operating Report".

Summary of Reactor Operating Experience durina 2004.

The reactor remained shutdown with no fuel onsite throughout 2004. The reactor was permanently shutdown on 11/5/2001. All fuel was transferred to the USGS TRIGA facility during June of 2002. The fission chambers used in the reactor's nuclear instrumentation system were transferred to USGS during December 2002. The reactor's Am-Be neutron sources were removed from the reactor facility and transferred to the Department of Energy's Off-Site Source Recovery Program on 7/24/2003 Unscheduled Shutdowns The reactor was maintained in a scheduled secured shutdown condition throughout 2004 Maior preventative and corrective maintenance No major safety related maintenance was performed during 2004 Changes, Tests and Experiments There were no changes, tests or experiments conducted during 2004 Radioactive Effluents No radioactive effluents were associated with the AJBRF were released or discharged beyond the effective control of the Medical Center during 2004 Environmental Survevs No additional environmental surveys were conducted during 2004

Radiation Exposures There were no radiation exposures received by AJBRF personnel or visitors exceeding 25% of allowable limits during 2004.

AL WASHKO YNELL W. KLASSEN Director Associate Chief of Staff/Research ASBRF.On Site Manager Cc: Alexander Adams, Jr.

Department Veterans of Affairs Memorandum Date: 18 July 2005 From: Michael B. Christensen Radiation Safety Officer Subj: Reactor Pool Water To: Lynell WV. Klassen, M.D.

Attached are Gamma Spectrum Analysis results for the reactor pool water. This shows there is nothing in the water.

If there are any questions, please feel free to contact me.

VA FORM MAR 1989 2105

G A M M A S P E C T R U M A N A L Y S I S Filename: GEl Report Generated On  : 7/13/2005 11:33:01 AM Sample Title  : VA POOL WATER Spectrum Description Sample Identification  : VA POOL WATER Sample Type  : ANALYSIS Sample Geometry  : SCINT VIAL Peak Locate Threshold 5.00 Peak Locate Range (in channels) : 1 - 4096 Peak Area Range (in channels)  : 1 - 4096 Identification Energy Tolerance 3.000 keV Sample Size 1.OOOE+000 Sample Taken On  : 7/11/2005 1:00:00 PM Acquisition Started  : 7/13/2005 11:16:18 AM Live Time  : 1000.0 seconds Real Time  : 1000.6 seconds Dead Time 0.05 %

Energy Calibration Used Done On  : 11/22/2004 Efficiency Calibration Used Done On  : 4/7/2004 Efficiency ID

Nuclide Identification Report 7/13/2005 11:33:02 AM Page 2

• N U C L I D E I D E N T I F I C A T IO N R EPORT *****

Sample

Title:

VA POOL WATER Nuclide Library Used: C:\GENIE2K\CAMFILES\RHCRa226.nlb

.................... . IDENTIFIED

.. NUCLIDES ....................

Nuclide Id Energy Yield Activity Activity Name Confidence (keV) (%) (uCi/ ) Uncertainty

• = Energy line found in the spectrum.

Energy Tolerance : 3.000 keV Nuclide confidence index threshold 0.30 Errors quoted at 1.000 sigma No peak search results available for nuclide analysis.

Nuclide MDA Report 7/13/2005 11:33:02 AM Page 3

• • • • • N U CL I DE M DA R EPO R T***

Detector Name: GE1 Sample Geometry: SCINT VIAL Sample

Title:

VA POOL WATER Nuclide Library Used: C:\GENIE2K\CAMFILES\RHCRa226.nlb Nuclide Energy Yield Line MDA Nuclide MDA Activity Name (keV) (%) (uCi/ ) (uCi/ (uCi/

K-40 1460.81 10.67 1.9487E-004 1. 95E-004 O.OOOOE+000 SC-46 889.25 99.98 1.3015E-005 1. 30E-005 O.OOOOE+000 1120.51 99.99 5.5566E-005 1.1968E-005 MN-54 834.83 99.97 4.1675E-005 4. 17E-005 8.9759E-006 MN-56 846.75 98.90 1.1129E+001 1.11E+001 2.3969E+000 1810.69 27.20 6.8355E+001 9.2889E+000 2113.05 14.30 0.OOOOE+000 O.OOOOE+000 CO-57 122.06 85.51 2.4777E-005 2.48E-005 -1.0952E-005 136.48 10.60 2.1927E-004 -1.3738E-005 CO-58 810.76 99.40 3.2831E-005 3.28E-005 4.4614E-006 CO-60 1173.22 100.00 1.6678E-005 1. 67E-005 O.OOOOE+000 1332.49 100.00 1.8938E-005 O.OOOOE+000 SE-75 96.73 3.41 5.1555E-004 4.09E-005 4.6710E-005 121.11 16.70 1.4690E-004 6.9377E-005 136.00 59.20 4.0933E-005 1.1960E-005 198.60 1.45 2.4303E-003 -8.2107E-004 264. 65 59.80 4.0912E-005 -6.5534E-005 279.53 25.20 7.1224E-005 1.5340E-005 303.91 1.32 1.6654E-003 -5.4149E-004 400.65 11.40 3.7865E-004 4.8547E-005 KR-85 513.99 0.43 1.0934E-002 1.09E-002 3.9626E-003 KR-SM 151.18 75.30 3.5133E-002 3.51E-002 -3.8437E-003 304.87 14.00 2.2809E-001 7.5958E-002 SR-85 513.99 99.27 4.8335E-005 4. 83E-005 1.7517E-005 Y-88 898.02 93.40 3.8098E-005 2.70E-005 5.1773E-006 1836.01 99.38 2.7003E-005 O.OOOOE+000 CD-109 88.03 3.72 4.9602E-004 4. 96E-004 -4.6984E-005 SN-113 255.12 1.93 1.5752E-003 5.30E-005 4.8837E-004 391.69 64.90 5.2992E-005 -1.5030E-005 I-129 39.58 7.52 1.5772E-004 1.58E-004 -7.6421E-005 I-131 80.18 2.62 9.2571E-004 4.70E-005 2.7284E-004 284.30 6.05 3.5042E-004 7.5473E-005 364.48 81.20 4.6965E-005 3.3301E-006 636.97 7.26 7.5280E-004 -7.6563E-005 722.89 1.80 2.3965E-003 5.1616E-004 CS-134 475.35 1.46 2.6967E-003 3.22E-005 -5.0991E-004 563.23 8.38 4.9956E-004 5.3348E-005 569.32 15.43 2.2474E-004 4.4073E-005 604.70 97. 60 3.2205E-005 6.9362E-006 795.84 85.40 6.0302E-005 2.0081E-005 801.93 8.73 4.5916E-004 9.8893E-005 1038.57 1.00 5.0911E-003 1.0965E-003

Nu~clidq MDA Report 7/13/2005 11:33:02 AM Page 4 Nuclide Energy Yield Line MDA Nuclide MDA Activity Name (keV) (%) (uci/ ) (uci/ (uci/

CS-134 1167.94 1.80 2.5113E-003 3.22E-005 3.4126E-004 1365.15 3.04 1.7381E-003 2.3620E-004 CS-136 66.91 12.50 1.4820E-004 3. 59E-005 -2.4672E-005 86.29 6.30 3.2094E-004 -6.7248E-005 153.22 7.46 3.3395E-004 5.0100E-005 163.89 4. 61 6.3200E-004 -1.1332E-004 176.55 13.56 2.4613E-004 -9.5005E-006 273. 65 12.66 1.7749E-004 -5.7709E-005 340.57 48.50 6.5315E-005 O.OOOOE+000 818.50 99.70 3.5866E-005 -1.6247E-006 1048.07 79.60 7.1308E-005 -1.4078E-005 1235.34 19.70 9.8578E-005 O.OOOOE+000 CS-137 661.65 85.12 8.8736E-005 8.87E-005 6.4221E-005 CS-138 138.10 1.49 1.OOOOE+020 1.OOE+020 1.OOOOE+020 227.76 1.51 1.OOOOE+020 1.OOOOE+020 408.98 4.66 1.OOOOE+020 1.OOOOE+020 462.79 30.70 1.OOOOE+020 1.OOOOE+020 546.94 10.80 1.OOOOE+020 1.OOOOE+020 871.80 5.11 1.OOOOE+020 1.OOOOE+020 1009.78 29.80 1.OOOOE+020 1.OOOOE+020 1147.22 1.24 1.OOOOE+020 1.OOOOE+020 1343.59 1.14 1.OOOOE+020 1.OOOOE+020 1435.86 76.30 1.OOOOE+020 1.OOOOE+020 CE-139 165.85 80.35 3.0794E-005 3.08E-005 -5.3034E-006 HG-203 279.19 77.30 2.3612E-005 2.36E-005 5.0855E-006 BI-214 609.31 46.30 5.4042E-005 5.40E-005 7.3439E-006 768.36 5.04 8.8600E-004 -9.1450E-006 806.17 1.23 3.2685E-003 -3.5198E-004 934.06 3.21 4.1747E-004 O.OOOOE+000 1120.29 15.10 3.6204E-004 7.7976E-005 1155.19 1.69 2.6414E-003 -1.7050E-003 1238.11 5.94 2.9593E-004 O.OOOOE+000 1280.96 1.47 3.3644E-003 4.5720E-004 1377. 67 4.11 1.6346E-003 3.5205E-004 1385.31 0.78 6.8641E-003 -4.8971E-003 1401.50 1.39 4.9187E-003 1.0594E-003 1407.98 2.48 8.0718E-004 O.OOOOE+000 1509.19 2.19 2.6707E-003 -1.9054E-003 1661.28 1.15 5.6272E-003 7.6469E-004 1729.60 3.05 8.1457E-004 O.OOOOE+000 1764.49 15.80 4.3690E-004 5.9371E-005 1847.44 2.12 3.4224E-003 4.6507E-004 2118.54 1.21 O.OOOOE+000 O.OOOOE+000 PB-214 74.81 6.33 2.0633E-004 9.52E-005 -9.2855E-005 77.11 10.70 1.7064E-004 -5.4737E-005 87.20 3.70 4.9549E-004 -1.6498E-004 89.80 1.03 1.9450E-003 5.0802E-004 241.98 7.49 3.6963E-004 -5.9699E-005 295.21 19.20 1.7193E-004 5.3878E-005 351.92 37.20 9.5233E-005 4.8019E-005 785.91 1.10 4.1417E-003 1.1542E-003

Nuclide MDA Report 7/13/2005 11:33:02 AM Page 5 Nuclide Energy Yield Line MDA Nuclide MDA Activity Name (keV) (%) (uCi/ ) (uCi/ (uCi/

RA-226 186.21 3.28 9.9933E-004 9. 99E-004 3.5448E-004

+ = Nuclide identified during the nuclide identification

• = Energy line found in the spectrum

> = MDA value not calculated

@ = Half-life too short to be able to perform the decay correction

I . . %

Spectral Data Plot le+00 -6I

-I le+00 le+00 4 C

0 U 100 0o n

s It oi 1A 10 1

0 500 1000 1500 2000 Energy (keV)

Datasource: GE1 Live Time: 1000 sec Real Time: 1001 sec Acq. Start: 7/13/2005 11:16:18 AM Start: 1  : 0.45 (keV)

Stop: 4096  : 1999.87 (keV)

Alan J. Blotcky Reactor Facility Monthly Surveillance Report

Reference:

TS 4.3,TS 4.4,TS 4.5,TS 4.6 Month: -,:1 J  %

U Pool Water:I Wk1 Wk2 uk3 wk4 signature Conductivity (<5pmhos/cm 2 h.}L 3'.6 pH (5.0-7.5) _ 5.6 s P S. Y -i Water level (from top) _ _ _

6LI 9.5 ta-e Radioactivity (<0.1p C:/rnl) PJrL- ort 41 1 fz 1&/

%44, 6 aSf-Pool water channel test:

Date: 7//q 1q5 Operational: ( DsNo Signature: Z eA -

Confinement:

Reactor facility doors locked and secured daily sloQ, Signature:

Automatic ventilation damper and alarm test:

Date: 7111/ 1/0'5 Operational:(g No Signature: _

Actions taken:

Approval

/F . 15 Date: Signatu F fig _

Associate Chie of Staff for Research

Reactor Safeguards Committee Veterans Administration Medical Center Minutes of RSC Meeting - June 9, 2005 Meetinq Date and Location:

June 9, 2005 at 4:00 P.M. in the 12th floor Research Conference Room Committee Members Attending:

Lynell W. Klassen, M.D.

Ed Fennel, Reactor Facility Manager Mike Christensen, RSO Fred Hamel, Ph.D.

Topics Discussed:

NRC Inspection Dr. Klassen reported that the preliminary NRC report suggests that we are in violation of three aspects of our technical specifications:

A. Failure to submit an annual operating report by March 31 B. Failure to have a facility operational audit C. Failure to complete certain aspects of surveillance including

1. Sampling the reactor pool for radioactivity

2. Performing a monthly channel test

3. Monitor the damper and alarm

4. Calibrate the area radiation monitor and the continuous air monitor Other suggestions were to obtain additional expertise in NRC regulation and licensing issues to help us review our technical specifications and license requirements.

AJBRF Operational Issues A. The 2005 Annual Operator Report was reviewed Committee Decisions of Record A. The minutes from the December 17, 2004 meeting were approved B. The 2005 Annual Operating Report was approved for submission to.

the Medical Director for signature and transmission to the Nuclear Regulatory Commission C. Decision was made to contact Midwest Environmental Radiation Services, Inc. of Papillion, Nebraska to help us with the licensing and compliance issues.

D. A system for ensuring appropriate surveillance that would comply with the technical specifications were outlined.

Action Items A. Dr. Klassen will submit the 2005 Annual Operating Report to the Director for signature and then transmit it to the NRC.

B. Dr. Klassen will contact Midwest Environmental Radiation Services to perform the facility operational audit as required by the technical specifications C. Ed Fennel will evaluate the requirements for performing a monthly channel test to ensure that the alarm float switch is operational as well as determining the steps required to monthly test the automatic ventilation damper and alarm D. Mike Christensen will arrange for conducting a monthly radioisotope gross activity to determination on a reactor pool water sample and for isotope identification on a quarterly basis E. Dr. Klassen will develop a monthly surveillance report that will be completed by the appropriate individuals and will be signed on a monthly basis by the Associate Chief of Staff for Research (Dr.

Klassen). The Reactor Safeguards Committee will then meet quarterly to review the surveillance reports.

Attachments 2005 Annual Operating Report for the Alan J. Blotcky Reactor Facility, license #

R-57, docket# 50-131 Lyn . Klassen, M.D.

Chair