ML20056F243
| ML20056F243 | |
| Person / Time | |
|---|---|
| Site: | 07000734 |
| Issue date: | 08/24/1993 |
| From: | Asmussen K GENERAL ATOMICS (FORMERLY GA TECHNOLOGIES, INC./GENER |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| Shared Package | |
| ML20056F244 | List: |
| References | |
| NUDOCS 9308260221 | |
| Download: ML20056F243 (12) | |
Text
I ' l' 9 CENERAL ATOMICS August 24, 1993 696-2118 VIA OVERNIGHT EXPRESS MAX.
ATfN: Document Control Desk U.S. Nuclear Regulatory Commiss:on Washington, D.C. 20555
Subject:
Docket No.70-734; License No. SNM-696: Reply to a Notice of Violat and Notice of Deviation Dated July 26,1993 n
Reference:
Reese, James 11., Letter to General Atomics, ATTN: Mr. R N Radem
" Notice of Violation / Notice of Deviation /NRC Inspection Report N er, 93-03," dated July 26, 1993 The enclosed Attachments 1 & 2 are General Atomics' (GA's) resp Violation and Notice of Deviation, respectively issued on July 26 1993 onses to the Notice of responses were prepared following the directions provided in the refere (Reference). Both nced letter.
should have any questions concerning this response p a e and satisfactory. Ifyou me at (619) 455-2823.
Very truly yours, WA*=
Keith E. Asmussen, Director Licensing, Safety, and Nuclear Compliance KEA:shs Enclosures - as above Mr. Michael Cillis, U.S. NRC Region V ce:
Mr. James II. Reese, U.S. NRC Region VMr. Bobby Faulken Mr. Robert E. Wilson, U.S. NRC Headquarters
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3%O GE NE RAL ATOMICS COURT. SAN DIEGO. CA 921711194 y
l PO BOX 0%OR. SAfd DIEGO. CA 92186 9784 161914 % 3000
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i
- to General Atomics' l
Letter No. 696-2118 Dated July 26,1993 Page 1 of 2 t
General Atomics' Reply to the Notice of Violation l
NRC Inspection Report No. 70-734/93-03 During an inspection conducted on June 21-25, 1993, a violation of NRC requirements was identified. The violation and GA's response are provided below-Violation:
l Condition 9 of License No. SNM-696 authorizes in part, the use of licensed materials in f
accordance with the statements, representations, and conditions, contained in Part 11, " License Specifications," dated July 24,1981, and supplements to the license application dated March 16, l
1992 through June 18,1992.
l
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Section 4.1.6.3.c of Part 11 of the License Specifications requires the licensee, as part of I
the respiratory protection program, to develop and implement " procedures to assure the adequate fitting of respirators and the testing of equipment for operability".
l l
Emergency Services' - Fire Department Procedures For Self-Contained Breathing Apparatus (SCUBA) requires testing and inspection of SCBA's for operability and states in part: "The Monthly test and inspection shall be performed as follows..."
Contrary to the above, two emergency use Self-Contained Breathing Apparatus' at f
Building 37 were not tested and inspected for the month of May,1993.
i This is a Severity Level IV violation (Supplement IV).
l t
GA's Repiv to the Violation.
1)
The reason for the violation:
l l
The two emergency use Self-Contained Breathing Apparatuses at the guard station near i
Building 37 were not tested for the month of May,1993 because they were missed by the i
Emergency Services Technician doing the inspection. The main contributing factor was j
the format of the inspection checklist.
l The inspection checklist was not devoted exclusively to inspection of SCBA's but included other inspections for fire safety equipment; i.e., safety showers, fire extinguishers,.
j emergency lights, exit signs, hazardous material spill kits, and protective clothing. Some l
of these items are inspected at frequencies other than monthly. Because the two SCBA's were recently placed in this location they'were entered into the computer listing under a e
quarterly inspection rather than a monthly inspection which contributed to their being
l to General Atomics' Letter No. 696-2118 i
Dated July 26,1993 Page 2 of 2 missed. These two SCBA's (along with all the other SCBA's at GA) were inspected in April and June 1993.
2)
The corrective steps that have been taken and the results achieved:
1.
The Emergency Services Supervisor has re-emphasized the importance of ensuring that all safety equipment is tested and inspected as required by the applicable procedure.
2.
The Emergency Services Suporvisor has implemented an audit program to assure that all inspections have been completed as required and in a timely manner.
3.
Administrative support has been provided to the Emergency Services Group to assist in setting up and maintaining improved records, documents and files. This has allowed more time for the Emergency Services Supervisor to oversee the workload and audit the files.
4.
The six remaining Scott Air Pak SCBAS's were replaced with Survivair SCBA's including the two which were located at the guardhouse near Building 07.
5.
The Emergency Services procedure for SCBA's has been re-written and approved by the Emergency Services Supervisor, the Health Physics Manager and the Licensing, Safety and Nuclear Compliance Director. The procedure includes requirements for testing, inspecting, storage, use and maintenance required for Survivair SCBA's. The procedure was approved on July 21,1993. A new inspection checklist is included in the procedure and is exclusive for the monthly SCBA inspections. GA began using the new checklist in August 1993. A copy of the j
procedure is enclosed.
(3)
The corrective actions that will be taken to avoid further violations:
GA believes that further violations will be avoided as a result of the actions taken and described in item 2 above.
(4)
The date when full compliance will be achieved:
GA is currently in full compliance. Monthly inspections on all SCBA equipment are bemg I
completed as required.
i l
i i to General Atomics' Letter No. 696-2118 l
Dated July 26,1993 i
Page 1 of 9 i
General Atomics' Reply to the Notice of Deviation l
NRC Inspection Report No. 70-734/93-03 l
During an inspection conducted on June 21-25, 1993, a deviation to i
commitments described in GA's response to inspection report 92-07, l
dated November 20, 1992, was identified.
The deviation and GA's i
l response to the deviation is listed below:
Deviation:
General Atomics' letter dated November 20, 1992, lists the following actions to be taken to strengthen the licensee's respiratory protection program.
All the actions below were to be i
in place by December 23, 1992, except the database (i.e.,
Item 4, l
l below) which was to be operational by February 1, 1993.
l 1.
GA's Health Physics procedure HP-182, " General Atomics l
Respiratory Protection Program" was to be issued to become l
the " Top Level" procedure for the site respiratory protection program.
2.
Procedure HP-182 will require that Emergency Services l
procedures that deal with respiratory protection be reviewed i
and approved by the Manager, Health Physics (HPM) or designee.
i 3.
With the restructuring of the respiratory protection program and closer contact with the groups involved, GA will shift all groups to a quantitative fit test method.
4.
The training, medical examination, fit test, and i
l qualification records for the three groups involved (i.e.
Health Physics, Industrial Safety / Industrial Hygiene, and l
Emergency Services) will be integrated into a database set up and maintained by Health Physics.
The database will be set up such that each group will have their own entry forms and i
reports which will have password access control required for data modification.
Contrary to the above, the actions committed to by the licensee to strengthen their respiratory protection program were either late being completed or still incomplete as of-June 25, 1993, as evidenced by the following examples:
1.
GA's procedure HP-182 was issued four months late'on March 23, 1993.
2.
Procedure HP-182 required Emergency Services procedures
l
, to General Atomics' LeMer No. 696 2118 Dated July 26,1993 Page 2 of 9 involving respiratory protection to be reviewed and approved by the HPM or designee.
However, as of June 25, 1993, l
Emergency Services' respiratory protection related procedures l
had not been reviewed or approved by the HPM or designee.
+
t 3.
Procedure HP-182, allowed for both qualitative and l
quantitative fit testing methods to be used without providing l
any specific guidance as to the circumstances under which.
each fit test method was appropriate.
4.
The qualified respirator user integrated database was
{
l incomplete. Specifically, each. group did not have their own i
entry form and reports, immediate access was not available l
l for the groups that required the information, and access control to prevent inadvertent data modification had not been established.
L L
l GA's ReDiv to the Deviations i
t GA's reply is provided for each example listed in the notice of deviation.
In addition, other actions taken or to be taken by GA are provided after the examples.
In general, the~ reason for the deviation was due to commitments made which were to optimistic and dates provided in the response chich were unrealistic for the scope of work to be performed.
l Exannle #1 of Deviation:
GA's Health Physics procedure HP-182, " General Atomics Respiratory
[
l Protection Program" was to be issued to-become the " Top Level" I
procedure for the site respiratory protection program, i
GA's procedure HP-182 was issued four months late on March 23, l
1993.
1.
Reason for the Deviation:
3 Although it was GA's intention to give the procedure revision " top priority", we failed to do this.
-l I
2.
The corrective steps that have been taken and the results achieved-:
As noted above, the procedure was approved on March 23, 1993 as the_" top level" respiratory protection procedure for GA.
3.
The corrective _ actions that will be taken to avoid further f
I
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+ -,. ~.
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i to General Atomics' Letter No. 696-2118 l
Dated July 26,1993 f
Page 3 of 9 i
i violations:
l l
The procedure is being kept up-to-date and is being l
reviewed and approved by all groups involved in a timely l
manner.
4.
The date when full compliance will be achieved:
i GA is currently in compliance.
l
' I My== ale #2 of Deviations t
Procedure HP-182 will require that Emergency Services procedures that deal with respiratory protection be reviewed and approved i
by the Manager, Health Physics (HPM) or designee.
j i
l However, as of June 25, 1993, Emergency Services' respiratory i
l protection related procedures had not been reviewed or approved l
by the HPM or designee.
[
l 1.
Reason for the Deviation:
l
[
HP-182 which included the requirement for approval by the HPM i
I of Emergency Services procedures dealing with respiratory protection was approved March 23, 1993.
It was recognized that the procedure needed updating but it was not completed i
until July 1993.
i
. i 2.
The corrective steps that have been taken and the results
{
achieved:
t The Emergency Services procedure for SCBA's has been re-l l
written and approved by the Emergency Services Supervisor, i
the Health Physics Manager and the Licensing, Safety and l
Nuclear Compliance Director.
The procedure includes requirements for testing,_ inspecting, storage, use'and maintenance required for Survivair SCBA's The: procedure was approved on July 21, 1993. A new-inspection checklist is
~
included in the procedure and is exclusively for the monthly l
SCBA inspections.
GA-began using the new checklist in August i
1993.
A copy of.the procedure is enclosed.
3.
The corrective actions that will be taken to avoid.further violations:
t The procedure is being kept up-to-date and is being reviewed and approved by all~ groups involved in~a timely. manner.
I Y
.,r
-m n
l
! to General Atomics' Leuer No. 696-2118 i
Dated July 26,1993 j
Page 4 of 9
)
l 4.
The date when full compliance will be achieved:
)
i GA is currently in compliance.
Ex==nle #3 of deviation:
With the restructuring of the respiratory protection program and l
closer contact with the groups involved, GA will shift all groups j
to a quantitative fit test method.
i l
Procedure HP-182, allowed for both qualitative and quantitative l
methods to be used without providing any specific guidance as to
{
the circumstances under which each fit test method was l
appropriate.
1.
Reason for the Deviation:
l The procedure allowed for both qualitative and quantitative fit testing because only qualitative fit testing on SCBA's i
was being done and GA was still investigating the need for quantitative fit testing of SCBA's.
After it was determined that we would do a quantitative fit test, we then had to l
evaluate the feasibility of doing such tests.
For instance, could we do the tests using the existing PORTACOUNT unit.
i l
2.
The corrective steps that have been taken and the results achieved:
i 1.
The six remaining-Scott Air Pak SCBAS's were replaced with Survivair SCBA's including the two which were located at the guardhouse near Building 37.
2.
GA contacted TSI Incorporated (Portacount manufacturers) and obtained information on how to use the Portacount s
unit to fit test SCBA's.
New facepieces were needed.
l 3.
The facepieces were purchased and received by-Emergency I
Services.
4.
HP-182 was revised to include fit testing for SCBA's.
1 5.
Training has been provided to four (4) main site HP i
Technicians and one (1) EMERGENCY SERVICES Technician on August 12 and 13, 1993 on how to do the fit-tests.
6.
Fit-tests for all "SCBA Required" personnel have now I
been scheduled and will be completed by November 12, 1993.
i
^
i t
! to General Atomics' LeMer No. 696-2118 Dated July 26,1993 Page 5 of 9 i
3.
The corrective actions that will be taken to avoid further violations:
GA believes that further violations will be avoided as a j
result of the actions taken and described in item 2 above.
4.
The date when full compliance will be achieved:
GA will be in full compliance November 12, 1993.
Examnle #4 to Deviation
- The training, medical examination, fit test, and qualification records for the three groups involved (i.e. Health Physics, Industrial Safety / Industrial Hygiene, and Emergency Services) will be integrated into a database set up and maintained by Health Physics.
The database will be set up such that each group will have their own entry forms and reports which will have password access control required for data modification.
l l
The qualified respirator user integrated database was incomplete.
Specifically, each group did not have their own entry form and reports, immediate access was not available for the groups that required the information, and access control to prevent
(
inadvertent data modification had not been established.
1.
Reasons for the Deviation:
{
i l
1.
The commitments made were to optimistic and the dates l
provided in the response were unrealistic considering
)
l the scope of work to be performed.
I 2.
The database we planned to use (Paradox) was too complex l
and time-consuming to set up.
l l
2.
The corrective steps that have been taken and.the results i
achieved:
1.
Decided to use a spreadsheet (Quattro Pro) instead ofL setting up'a database using Paradox because of the problems we encountered when trying to manipulate a large amount of data with a new, unfamiliar database.
(Quattro Pro is similar to Lotus).
2.
The qualified respirator user integrated database has been completed.
The listing is maintained by Health Physics.
1 i
a
, to General Atomics' i
Letter No. 696-2118 Dated July 26,1993 l
Page 6 of 9 3.
As a result of using a spreadsheet instead of the i
database, GA will have only one group enter the data.
l Therefore, each group will not have their own entry 1
forms or password access control for data modification.
F Information will not be scanned into the computer program as previously committed to.
4.
The listing of emergency personnel has been completed and a new Work Authorization was approved on July 26, i
1993.
The new work authorization lists ALL emergency personnel at General Atomics (by facility, by position and responsibility and in alphabetical order by individual), describes the training needed for each individual, and documents the dates of training.
The' Emergency Coordinator at General Atomics is Jon. Brock, l
Supervisor, Emergency Services and is responsible for requesting and coordinating the activities of all the 4
various emergency support groups.
List "A"
in the WA is sorted by facility and shows each response team member assigned to a facility.
The emergency response and recovery directors (ERRD's) are noted as Directors "D".
Alternate emergency response and recovery directors, noted as alternate directors
+
"AD" and emergency response team members, noted as i
responders "R".
l l
l Individuals who may. assist in the-event.of an emergency, including both the Primary Support Groups l(Health Physics, Emergency Services, Security and Media l
Coordinator)are referred to as Assistants "A".
l i
List "B"
is sorted by position of response in alphabetical order; Assistants, Alternate Directors, Directors and Responders.
List "C" is sorted in-alphabetical order (by last name of the individual).
I Training and/or qualification (and-frequency) in one or more of the following has been determined for each position (directors, alternate directors, responders and l
assistants):
)
Radiation safety training Radiological contingency plan training Medical Respirator Physical SCBA Procedure Training SCBA User Training Respirator Fit Tests (as required)
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i l
r i to General Atomics' Leuer No. 696-2118 j
Dated July 26,1993 l
Page 7 of 9
{
Fire Safety /First Aid CPR i
5.
Annual refresher training for radiation safety, i
contingency plan and SCBA is being coordinated by Health Physics.
Health Physics will ensure that medical respirator physicals are current for all emergency personnel listed as "SCBA required" on.the Work l
Authorization.
NOTE:
Current training / qualification deficiencies are being noted and training is being scheduled in the various areas.
The listing will be updated on a quarterly basis and will identify any training overdue as "due" in the proper column.
3.
The corrective actions that will be taken to avoid further l
violations:
GA believes that further violations will be avoided as a.
l result of the actions taken and described in item 2 above.
4.
The date when full compliance will be achieved:
{
GA is currently in full compliance.
j l
i l
l l
, to General Atomics' Letter No. 696-2118 Dated July 26,1993 Page 8 of 9 Below is a brief summary of additional corrective actions already taken plus those planned or in progress with regard to improving our respiratory protection program at General Atomics (GA).
1.
Re: " Degraded" SCBA Equipment GA has purchased six (6) SURVIVAIR Mark 2 SCBA units to replace i
the Scott units.
The SURVIVAIR units have non-rubber components which are not subject to ozone induced degradation as were the hoses on the Scott units.
The SURVIVAIR units are the same type of units as are used at other GA locations.
i l
2.
Re: The 15-20 Respirators Which Were in One Bag (Bldg. 37) i They have all been individually bagged.
Note:
There were, and are, 45 cleaned, inspected and individually wrapped units in the dress-out trailer of which the inspector (s) was unaware and not informed.
l 3.
Re: Respirators & Cartridges Stored Away From Each Other (Bldg.
37)
The cartridges have been moved to an empty bin alongside the protective clothing in the dress-out trailer and stored with the respirators.
4.
Re: " Dirty" Respirators in a 55-gal Drum Stored Outside (Bldg.41)
The drum of respirators, which were waiting to be decontaminated, have been moved inside the building.
5.
Re: Respirators Not Readily Accessible (Bldg.41) l The subject respirators and the cartridges have been moved to the shelves in the High-Bay area of Bldg. 41 where they are in full l
view and readily available for use.
6.
Re:
Issuance of Respirators A respirator was issued to an individual by an HP technician I
without the technician verifying that the individual was qualified to wear one.
(The individual was, in fact, qualified and on the authorized users' list.)
The technician had been previously trained on the necessary requirements prior to issuing a respirator to an individual.
1 i
. to General Atomics' Leuer No. 696-2118 Dated July 26,1993 Page 9 of 9 (This was a test question on an exam given to HP technicians working on the D&D project.)
Retraining has been provided to the technician.
Additionally, all other SVA HP technicians have been given refresher training on the qualifications for respirator use.
They have been tested on this as well.
The latest copy of the Respiratory Qualifications. listing is now available at Bldg. 41 and updates are being provided.
7.
Re:
Proper Storage of Respirators Health Physics Procedure HP-182 has been revised to address proper storage of respirators.
8.
Emergency Services procedures have been formalized to include issue number (or letter), date of issue, approvals, and responsibility.
9.
Prepared an Emergency Services procedure for the 5 minute emergency escape resnirator entitled "LIFEAIR5 Emergency Escape Breathing Apparatus' In addition to the above described actions that have already been taken, the following items to improve the respiratory protection program are planned or are in progress:
1.
The Industrial Safety procedure on respiratory protection has been reviewed by Health Physics.
The suggested. changes will be discussed with Industrial Safety and a schedule for any resulting revisions will be established.
We anticipate that the revision will be completed by November 12, 1993.
2.
Complete training deficiencies identified in the emergency personnel listing.
To be completed by end of 1993.
3.
Formalize company policy on respiratory protection program (put into company policy manual).
To be completed by November 12, 1993.
4.
Finalize draft procedure on "Survivair SAC PAC Emergency-Escape Breathing Apparatus" (the 15 minute. emergency escape respirator).
To be completed by August 31, 1993.
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