ML20058H751
| ML20058H751 | |
| Person / Time | |
|---|---|
| Site: | 03015266 |
| Issue date: | 11/05/1993 |
| From: | Yuhas G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | Menge M ALASKA, STATE OF |
| References | |
| NUDOCS 9312130213 | |
| Download: ML20058H751 (8) | |
See also: IR 05000148/1958002
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UNITED STATES
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NUCLEAR REGULATORY ~ COMMISSION
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1450 MARIA 1.ANE
WALNUTCREEK CAUFORNIA94596-5368
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Docket No. 030-15266
License No. 50-14858-02
State of Alaska
Division of Environmental Quality
410 Willoughby Avenue
Suite 105
Juneau, Alaska 99801-1795
Attention: Michael Menge, Director
Division of Environmental Quality
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27, 1993, prepared by~ Dr. Alan Love,
Thank you for the letter dated 0ctober
informing us of the steps that have been taken to correct the items which we
22, 1993. Your
brought to your attention in our letter dated September
corrective actions will be verified during our next inspection.
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Sincerely,
M
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Gregory P.
has, Chief
Radioactive Materials Safety Branch
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cc:
Dr. Mary J. Freeman
Acting Laboratory Director
State of Alaska
Department of Environmental Conservation
EQM&LO, Juneau laboratory
10107 Bentwood Place
Juneau, Alaska 99801-8552
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9312130213 931105
ADOCK 03015266
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MEMORANDUM
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te of Alaska
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TO:
Mike Menge
DATE:
October 27,1993
Environmental Quality
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FILE NO.:
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TELEPHONE NO.:'
790 2169
THRU:
MJ Pilgrim, Acting Chief
EOMLO
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FROM:
Alan L Love, Supervisor
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Nuclear Regulatory
SUBJECT;
Juneau Laboratory
Commission
Corrective Action Report
Attached please find a copy of the corrective action report prepared in response to the
NRC on-site audit conducted by David Skov of the NRC on August 13-17,1993, and to
the internal audit conducted by M.J. Freeman-Wittig on December 30,1992. NRC
audit report 030-15266-02/93-01, and a portion of the internal audit report are included.
Jim Powell
David Skov
Bob Reick
George Dilbeck
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RADIOCHEMISTRY CORRECTIVE ACTION REPORT
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Prepared: October 27,1993
Prepared by: Dr. Alan L. Love
This was an
This report is a response to NRC Inspection Report # 030-15266-02/93-01.
unannounced inspection conducted by Mr. David D. Skov of the US Nuclear Regulatory
Commission, Region V. This report will also address concerns raised in the internal audit
report of December 30,1992.
RECEIPT, USE AND DISPOSAL OF MATERIAL
The inspection found the inventonf control to be inadequate, with records being incomplete
and not well organized.
A new inventory control has been designed and implemented. This system clearly identifies
radionuclides, dates of changes in inventory, balances on hand, and cross-references
laboratory notebooks so that there is a clear audit trail. This is now in place. Further actions
include:
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1. Rewrite the Standard Operating Procedure (SOP) for receiving samples to include
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inventory control.
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2. Prepare an inventory control SOP.
3. Prepare a standard quarterly inventory summary report using a spreadsheet or database
which will be maintained in a 3 ring binder filed with the RSO.
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4. Prepare a radioactive / mixed waste control system linked to the inventory control.
5. Rewrite the waste disposal SOP to account for the change in 10 CFR Part 20. This will
require use of a DEC facility connected to the municipal wastewater treatment system as of
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Jan.1,1994.
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The estimated completion date for steps 1 through 5 is Dec.1,1993
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RADIATION SURVEYS
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Deficiencies noted with this procedure include failure to maintain frequency, incorrect
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reporting units, incorrect calculation of activity, no record of area wiped, and no map showing
location of areas wiped.
The supervisor revised the formula for calculation of activity to include the efficiency factor -
A map has been prepared showing the locations of the wipe areas. JEAL
based on Pb210
adopted a standard wipe area of 10cm X 10cm. A wipe test of the Radiochemistry lab has
been carried out and the results entered into the survey log book. Actions yet to be carried
out include:
1. Include the new waste disposal site which will be used after Jan 1,1994, in the survey.
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2. Rewrite the radiation survey SOP to reflect the changes in calculation of activity, standard _
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wipe area, and location map.
3. Establish a reminder so that the required frequency of wipe tests is maintained.
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The estimated completion date for the above corrective actions is Dec.15,1993
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POSTING AND LABELING
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Deficiencies included an incorrect caution sign on the laboratory door, and incomplete
labelling of radioactive materials, that is, the EPA performance evaluation samples.
A " Caution - Radiation Materials" sign replaced the " Caution - Radioactive Area" sign per 10 CFR 20.203(b). JEAL purchased individual" Radioactive Material" labels and placed them in
the sample receiving laboratory and in the Radiochemistry Laboratory.
The SOP for sample receiving will be rewritten to include appropriate' labelling of all samples.
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The estimated completion date for this is November 25,1993.
OTHER
The audit revealed that the principal analyst was deficient in his knowledge of radiochemistry.
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The inorganic chemistry supervisor assumed the duties of principle analyst until such time as
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a qualified radiochemist can be retained.
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RECOMMENDATIONS OF INTERNAL AUDIT REPORT
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(page 8 attached)
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1. Water quality checks shall be immediately instituted and the SOP shall be revised to
include monthly samples of tap water and distilled water,
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2. Beginning in the fourth quarter,1993, all Performance Evaluation and Inter-comparison
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samples will be analyzed and reported.
3. A data review system shall be implemented immediately to reduce risk of transcription
errors and ensure quality assurance criteria are met. A minimum data package will be
specified in the SOP.
4. A new inventory system has been implemented and the SOP shall be rewritten to reflect
the changes. (See above under RECEIPT, USE AND DISPOSAi_ OF MATERIAL)
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5. JEAL has initiated separation of the sample preparation and inshiment areas as a long-
term project. The anticipated completion date is Dec.1998.
6. A portable, hand held radiation survey instrument has been located. This will detect alpha
and beta radiation. A gamma detector needs to be purchased.
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7. JEAL has purchased an alpha / beta gas proportional flow counter and is purchasing a
liquid scintillation counter.
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8. Two infrared lamps have been purchased for evaporating the samples in the planchets.
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Method development is in progress and this will be reflected in the revised SOP. The
targeted completion date is Feb. 28,1994.
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9. JEAL has implemented strict inventory control.
10.The revised SOP, approximately Feb.,1994, will contain more specific instructions
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regarding spills, handling, hazardous waste, and clean-up levels.
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11. A program has been instituted for annual training by the Radiation Safety Officer.
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12. Currently, the radiocheniistry can only be accessed with a key. However, a number of.
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different keys in possession of analysts can open this door. A new lock needs to be
installed with a separate key that will be made available only to properly trained persons.
This will be incorporated into the scheduled upgrading of building security.
13. Labels have been purchased for labelling radioactive materials and containers.
14. Copies of the NRC Licensing egreement documents will be posted in the radiochemistry
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laboratory. Reference to these docurr.9nts along with 10 CFR 20 is posted on the
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laboratory door.
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Radchem Quafity Assurance Audit and Safety inspection
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30 December 1992
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page 8
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Although most posters and other NRC required "right to know" materials were properly
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displayed, no copy of the NRC license approving this location for the storage and use
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of hazardous (radioactive) materials was apparent.
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Recommendations
in summary, the following recommendations are made in order to bring the Juneau
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Laboratory Facility into compliance with requirements from both NRC licensing and
EPA drinking water programs. Most of these recommendations have been made
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previously, some as long ago as 1988:
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Water quality should be checked and recorded on a routine basis.
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Increase participation in the EMSL-LV Intercomparison and Performance
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studies program
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The Supervisor should compare data in final reports and on disk file with bench
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sheets to ensure that no transcription errors have been made, and to assure
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that the quality assurance parameters are within control limits.
4)
Although top priority was assigned by EPA to the items in the Sample
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Collection, Handling, Preservation, Records and Data Reporting Section, little
progress has been made in that area. These violations are considered serious,
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and need to be addressed immediately.
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5)
The sample preparation area and the radiation instrument counting area need
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to be separated and placed in different rooms.
6)
A portable, hand held, radiation suntey instrument needs to be purchased for
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use by the Radiation Safety Officer, for reasons outlined in the August EPA site
visit report, item 4, Recommendations.
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7)
Laboratcrf equipment updates need to be made to the radiochemistry section,
as outlined in the EPA report, item 5, Recommendations.
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An infrared heat lamp should be obtained and used to dry the water from the
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planchets instead of using a hot plate.
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9)
Strict inventory control of all radioactive materials needs to be maintained at all
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times. To not do so is a severe violation of our NRC licensing agreement, and
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could result in suspension or revocation of our license with attendant fines.
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Radchem Quality Assurance Audit and Safety Inspection
30 December 1992
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page 9
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When wipe tests indicate that spills have occurred which result in total counts
exceeding background, the area should be decontaminated and wipe tests
repeated until activity shows that cleanup is sufficient. Acceptable levels'of
cleanup should appear in an SOP.
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11)
All chemists working in the radiochemistry program should have radiation safety
training on an annual basis.
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The radiochemistry room must remain locked at all times, with access limited to
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trained, badge personnel.
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All containers and materials used in the radiochemistry program must be clearly
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labeled as " radioactive" with the international symbol.
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A ccpy of the NRC licensing agreement should be posted in the radiochemistry
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area,
Summarv
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Although some small progress has been made since the NRC visit in 1991 and the
EPA visit in 1992, it is not nearly sufficient for us to maintain full licensing and
certification, according to the deficiencies outlined in reports from these two agencies
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and additional deficiencies uncovered during this internal audit.
Lack of attention to the method requirements, inventory control and previous
recommendations made by federal personnel have led to a poor showing during this
internal audit. All deficiencies noted in both federalinspections must be addressed
thoroughly and in writing to the Certifying Authorities at the Region X Environmental
Protection Agency Offices in Seattle, Washington and the Licensing Authorities at the
Region V Nuclear Regulatory Commission Offices in Walnut Creek, Califomia in order
to regain full certification status in the radiochemistry program from EPA and to
maintain NRC licensing.
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This document will be forwarded to the State Drinking Water Certification Officer for
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review, comment and corrective actions he feels are necessary for certification
reinstatement. All Safety violations must be corrected immediately, and a corrective
action report filed to the Radiation Safety Officer. Failure to do so may result in
removal of the NRC license, or fines, or both (since violations have to be reported
within 30 days to NRC, they will receive a copy of this report, with corrective actions
attached, in February).
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