ML18289A463
| ML18289A463 | |
| Person / Time | |
|---|---|
| Site: | 03002278 |
| Issue date: | 10/15/2018 |
| From: | Beckfield F Univ of Missouri |
| To: | Lipa C A NRC/RGN-III |
| References | |
| EA-18-095 IR 2018001 | |
| Download: ML18289A463 (12) | |
Text
Ei) University of Missouri Environmental Health & Safety 180 General Services Building Columbia, MO 65211 October 15, 2018 Christine Lipa PHONE 573-882-7018 FAX 573-882-7940 EMAIL ehs@missouri.edu WEB ehs.missouri.edu Acting Director, Division of Nuclear Materials Safety US Nuclear Regulatory Commission
-Region III 2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352 Re: Response to the Apparent Violation in NRC Inspection Report No. 03002278/2018001(DNMS);
Dear Ms. Lipa:
Please see the responses below to the apparent violation of 10 CFR 20.1801 per NRC's request in the September 6, 2018 Routine Inspection Report: Question 1: What was the reason for the apparent violation, or, if contested, the basis for disputing the apparent violation?
University ofMissouri response:
The reason for the apparent violation observed on May 14, 2018 in the University Hospital 2"d Floor Nuclear Medicine Department was an individual's error in failing to follow procedure for securing and/or keeping radioactive material within line of sight upon leaving the hot lab. The hot lab door was propped open using installed hardware thus preventing the automatic door closer from closing, latching, and locking the hot lab door. Question 2: The reason for the apparent violation that occurred on May 11, 2017 associated with the waste storage room was due to human factors associated with a poorly designed locking mechanism.
This event was documented in an event report and was reported to the Radiation Safety Committee Medical Quorum on August 3, 2017. What were the corrective steps that have been taken and the results achieved?
Page 1 of 12 University ofMissouri response:
As oudined in the inspection report dated September 6, 2018, the steps taken to mitigate the apparent violation observed on Allay 14, 2018 were the following:
Que s tion 3: 1. Secure and inventory the radioactive material in the hot lab. 2. Retraining of staff on the apparent violation and its causes including discussion of the requirements in 10 CFR 20.1801 and 20.1802. 3. Removal of the hardware to prop open the door preventing the door closer from closing, latching, and locking the hot lab door. Please refer to the Figures 1 through 3 in Appendix B for photographic evidence of this step. As oudined in the inspection report dated September 6, 2018, the steps taken to mitigate the apparent violation documented on May 11, 2017 were the following:
- 1. Secure and invento1y the radioactive material in the room. 2. Replacement of the door lock and installation of an automatic door closer such that the door shuts automatically, locks on its own , and unlocks with the use of a key. Please refer to Figures 4 through 7 for photographic evidence of this step. What are the corrective steps that will be taken to avoid further violations?
University ofMissouri response:
In addition to the aforementioned steps oudined in the response to Question 2 , as oudined in the inspection report dated September 6, 2018, the University of Missowi is committed to continue enforcing the policies set forth as part of the radiation safety program and emphasizing the importance of securing radioactive material from unauthorized removal or access. Please refer to Tables 1 and 2 in Appendix A for evidence of continued surveillance in these areas. Page 2 of 12 Question 4: The date when full compliance was or will be achieved?
Univer s ity ofMissouri response: Full compliance for the apparent violation obsen r ed on May 14, 2018 was achieved immediately and corrective actions addressing the route cause were completed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> on May 15, 2018 as oudined in the inspection report dated September 6, 2018. Full compliance for the apparent violation documented on May 11, 2017 was achieved immediately and corrective actions addressing the route cause were completed on May 23, 2017 as oudined in the inspection report dated September 6, 2018. During your review of the apparent violation, we ask that you consider our recent NRC inspection history and account for self-identifying and internally reporting the May 11, 2017 incident, the expedience in which we have achieved compliance, and our swift completion of the associated corrective actions. If you have any further questions, please feel free to contact me at (573) 882-7018. Felicity Beckfield, MS, CHP Radiation Safety Officer cc: Todd Houts, Director, Environmental Health & Safety, University of Missouri encl.: Appendix A: Table of Visits Documenting Compliance Appendix B: Photographs Documenting Changes Page 3 of 12 Appendix A: Table of Visits Documenting Compliance Page 4 of 12 Table 1: Visits to 2nd Floor Nuclear Medicine University Hospital since the observed apparent . I . secunty VlO atrnn Date of Visit Type ofVisit 5/20/2018 Impromptu verification 6/6/2018 Contamination survey 6/11/2018 Radiation Safety inspection 6/13/2018 Contamination survey 6/20/2018 Contamination survey 6/28/2018 Contamination survey 7/11/2018 Impromptu verification 7/12/2018 Contamination survey 7/19/2018 Radiation Safety inspection 8/1/2018 Impromptu verification 8/8/2018 Impromptu verification 8/9/2018 Contamination survey 8/15/2018 Contamination survey 8/17/2018 Radiation Safety inspection 8/23/2018 Contamination survey 8/30/2018 Contamination survey 8/31/2018 Impromptu verification 9/6/2018 Contamination survey 9/13/2018 Contamination survey 9/14/2018 Radiation Safety inspection 9/21/2018 Impromptu verification T bl 2 V. a e : lSltS to w aste s torage R oom (GL 29) -Date ofVisit Type ofVisit 5/12/2017 Radiation Safety inspection 5/18/2017 Waste collection 5/25/2017 Waste collection 6/1/2017 Waste collection 6/8/2017 ,vaste collection 6/15/2017 Waste collection 6/20/2017 Radiation Safety inspection 6/21/2017 Prostate seed implant packal{e delivery 6/22/2017 Waste collection 6/23/2017 Prostate seed implant packal{e delivery 6/29/2017 ,vaste collection 7/6/2017 ,vaste collection 7/13/2017 Waste collection Page 5 of 12 7/14/2017 Radiation Safety inspection 7/20/2017 Waste collection 7/27/2017 Waste collection 8/3/2017 Waste collection 8/10/2017 Waste collection 8/11/2017 Prostate seed implant package delivery 8/17/2017 Waste collection 8/23/2017 Waste collection 8/23/2017 Prostate seed implant package delivery 8/30/2017 Waste collection 9/7/2017 Waste collection 9/14/2017 Waste collection 9/20/2017 Waste collection 9/28/2017 Waste collection 10/7/2017 ,vaste collection 10/11/2017 Waste collection 10/17/2017 Radiation Safety inspection 10/18/2017 Waste collection 10/25/2017 Waste collection 11/2/2017 Waste collection 11/6/2017 Waste collection 11/16/2017 Waste collection 11/22/2017 Waste collection 11/28/2017 Radiation Safety inspection 12/6/2017 Waste collection 12/13/2017 Waste collection 12/15/2017 Prostate seed implant package delivery 12/20/2017 Radiation Safety i~spection 12/21/2017 Waste collection 1/11/2018 Waste collection 1/18/2018 Waste collection 1/19/2018 Prostate seed implant package delivery 1/24/2018 Radiation Safety inspection 1/25/2018 Waste collection 2/1/2018 Waste collection 2/7/2018 Waste collection 2/9/2018 Prostate seed implant package delivery 2/15/2018 Waste collection Page 6 of 12 2/22/2018 Waste collection 3/1/2018 Waste collection 3/8/2018 Waste collection 3/15/2018 Waste collection 3/16/2018 Prostate seed implant package delivery 3/22/2018 Waste collection 3/29/2018 Waste collection 4/5/2018 Waste collection 4/9/2018 Radiation Safety inspection 4/11/2018 Waste collection 4/19/2018 Waste collection 4/26/2018 Waste collection 4/27/2018 Prostate seed implant package delivery 5/3/2018 Waste collection 5/10/2018 ,vaste collection 5/11/2018 Radiation Safety inspection 5/11/2018 Prostate seed implant package delivery Room closed out for renovation 8/9/2018 Waste collection 8/15/2018 Waste collection 8/22/2018 Radiation Safety inspection 8/24/2018 Prostate seed implant package delivery 8/30/2018 Waste collection 8/30/2018 Prostate seed implant package delivery 9/6/2018 Waste collection 9/13/2018 Waste collection 9/14/2018 Prostate seed implant package delivery 9/17/2018 Radiation Safety inspection 9/23/2018 ,vaste collection Page 7 of 12 Appendix B: Photographs Documenting Changes Page 8 of 12 I Figure 1. 2nd Floor Nuclear Medicine University Hospital hot lab door Figure 2. 2nd Floor Nuclear Medicine University Hospital hot lab door's automatic closure mechanism Page 9 of 12 Figure 3. Latch on 2"d Floor Nuclear Medicine University Hospital hot lab door latch removed Figure 4. University Hospital waste storage room door Page 10 of 12 Figure 5. University Hospital waste storage room door's new exterior door handle Figure 6. University Hospital waste storage room door's new interior door handle Page 11 of 12 Figure 7. University Hospital waste storage room door's new door closure mechanism Page 12 of 12