ML20078G524
| ML20078G524 | |
| Person / Time | |
|---|---|
| Site: | 07000572 |
| Issue date: | 05/06/1983 |
| From: | Hoadley S MONSANTO RESEARCH CORP. |
| To: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML20078G503 | List: |
| References | |
| NUDOCS 8310120292 | |
| Download: ML20078G524 (3) | |
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)ll0rEBrit0 ENowEERED PRODUCTS MONSANTO RESE ARCH CORPORADON Dayton Laboratory 1515 Nicholas Poad P. O.. B o n 8. S t a t io r. B Dayton.Chio 45407 Phones + f513) 2SB-67ES (513) 26 6 -3 411 Telegrap h: TWX 810-459 1681 6 May 1983 U. S. fluclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, Illinois 60137
Dear Sir:
Enclosed contamination report is submitted in compliance with 10CFR20.404(a)(5).
The report is a copy of our log entry with the names separated. An individual left the controlled area with contamination on his right forearm.
Spread of contamination was limited to his personal clothing.
See the attached for details.
Sincerely,
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Stephen D. Hoadley Radiation Safety Officer SDH/bo
Enclosure:
H.P. Log Engry cc:
Director of Inspection and Enforcement U.S. fiuclear Regulatory Commission Washington, D. C. 20555 8310120292 831007 PDR ADOCK 07000572 9
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HEALTH PHYSICL LOG UNUSUAL EVENT
no DESCRIPTION OF EVENT:
At a ppro::i matc l y 1345 hrs. on 4/25/83 health physics was informed that c worker had a contaminated right forearm.
Surveys. showed 2OOOOpCi direct and 1750 pCi wipe on his forearm.His work clothing wac found to be contaminated and was d i c.p o c e d. o i in the hot trash. He was decontaminated at tht - E>D decontamination facility.
Inv.
'wtion revealed that he had failed to properly survey himselt
'or to leaving the plant for lunch. A survey was then made t
's personal clothing. The inside of the right sleeve on hi--
- was f ound to be contaminated (500pCi direct). in addis
- the right upper leg of his trousers had a direct readi ng at Ci.
Health Physics with tas
,curence of the operations manager decided that a survey shos he made of the places that he
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visited during the time he L
'ut of the plant. These areas were his car and house. After completing decontamination of the man, he and a second technician (trained and qualified to perform surveys) left the plant at 143Ohrs. with a direct alpha survey meter and wipes. Surveys were made in the guard house, the man'c car and house. The results were all negative, no contamination was detected. A total of 53 wipes were taken during the survey off site.
Surveys of room 8 where the man had been working showed that a glove was leaking. Wipes showed 12730pCi on the glove with lesser levels on other gloves used (500-800pCi). Air samples in the room showed less then one NPC-HR airborne. Wipes on the floor were 2OOOpCi under the leaking glove and less then 225pCi for the balance of the room. The glove was replaced 4/26/93 and decontami nati on, compl eted.
on CAUSE OF EVENT:
The primary cause for this event was the man's failure to follow the required operating procedure. The procedure person completely survey them self prior to requiree, that a leaving the wort area. He passed three operating survey meters durinn m:i tina the work area at lunch time. If tha survny had been properly performed the contamination would have boen detected prior to going to lunch.
ACTION TAREN TO TERMIN41E EVENT The man was d6 contaminated and his worL clothina disposed of in the hot tr&ch. His personal clothing was decontaminated (pante) or disposed of in the hot trash (coat). Work in room 8 was stopped until the clove was replaced and the area deconteminated.
Page 2 ACTION TD 1: RF i'E N T REOCCLiRRENCE A eneeti nci of the Radi al i on Saf et y Committee was called. The fol1owino steps were taken. Additianal signs wi11 be installed t o remi nd personnel that a body survey is required. Management will meet with the involved employee to insure that he understands the severity of the event (completed 5/4/83). A special trai ning meeti na will be held (c cmp 1 eted 5/5/82.) to en.phasize the importance of seli survey and the consequences at failing to follow procedures.
(ie contami nati on could have been spread outside the controled area.I ASSISTANCE REQUESTED none PERSONS NOTIFIED The laboratory assistant director was contacted initially at 142.Oh r s and at several times thereaf ter to assure that he was I:ept up to date on the event.
ENTRY BY: S.Hoadley
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Monsan:o Ch3ACERCD PRODUCT 5 MONSANTO RESE AROH CORPORATION Dayton Laboratory 1515 Nicholas Roa d P. O. S o m 8. St a tio n B Dayton.ONo 45407 Phones: (513) 268-6759 (513) 2EB-3411 Telegraph: TWX 810-459-1881
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Dear Sir:
Enclosed report is submitted for information. The report is a copy of
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our log entry with the names separated.
It covers the miss-marking of ten 1000 Mci sources as 1000 uci. As required by 10CFR21 a radiation safety comittee meeting was held.
It was concluded that in this case no significant safety hazard violation occurred.
See the attached report for details.
If there are any questions please call.
Sincerely,
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Stephen D. Hoadley Radiation Safety Officer SDH:bo
Enclosure:
HP Log Entry Letter to customer b
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Director of Inspection and Enforcement U.S. Nuclear Regulatory Comission Washington, D. C. 20555
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l HEALTH RHYSICS LOG UNUSUAL EVENT?
no DESCRIPTION OF EVENT:
At 1340 hrs en May 26,1983 the OA manager reported that 8 Ohmart i
1000 mci Am-241 sources that had been. shipped to Ohmart on 4/1/83 (MRC-AM-1574.1575,1577,1579) and 4/28/83 (MRC-AM-1580,1581,1582,1533) 7 were probably miss marked uCi instead of mci. The likelihood of miss-marking was discovered by MRC O.C.
during final inspection of two additional sources from the same lot, but which had not yet left MRC.
As required by 10CFR21 and NPD-STD-043 a meeting of the Radiation Safety Committee and other knowledgeable individuals was called by the Operations Manager.
The committee came to the following conclusions:
- 1. eight sources had been shipped with "1000uCi" marking instead of "1000 mci" marking.
2.
The sources would only be handled by Ohmart's licensed personnel. The source's go to Ohmart's customers in fixtures which only Ohmart can open and which are marked with the proper information.
3.
All other documentation has the proper information.
4.
Ohmart should be notified of the miss-marking in writing and that MRC recommends the return of the sources to MRC for correction at no cost to Ohmart.
5.
There is not a loss of safety function to the extent that there is a maj or reduction in the degree of protection provided to public health and safety. No person is expected to exceed those limits specified in 10CFR20. There is no deviation as defined in 10CFR21.
6.
A copy of this report should be sent to the NRC for information.
7.
Laboratory management should be notified of the occurrence.
Several days after the meeting the RSO found that the subject sources i
had two sets of markings; one set contains the uCi marking and the other has the correct mci marking. The marking with the correct information is on the side of the source and the incorrect marking is on the back of the source.
CAUSE OF EVENT:
The work order for the engraved markings was not clearly marked that
" mci" was to be used. OC inspection failed to catch the error.
ACTION TAKEN TO TERMINATE EVENT The customer was notified by phone at about 143Ohrs on 5/26/83 (i. e.
prior to the end of the RSC meeting). The customer indicated that they preferred not to return the sources.The MRC-Dayton assistant laboratory director was notified of the situation at about 1500 hrs on 5/26/83. Written notification to Ohmart as outlined in item 4 above was made on 6/1/83 (copy attached). The markings on the two sources that had not been shipped were corrected.
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Page 2 ACTION TO PREVENT REOCCURRENCE The DC inspection procedure used was changed, approximately two weeks prior to the discovery of the miss-marked sources, to require that the markings on a sources be recorded on the inspection form instead of using a check mark to indicate that the markings had been i nspected.
The inspection form itself will be revised to include a note that the actual label markings on the sources are to be copied on to the form.
ASSISTANCE REQUESTED none t
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i Monsan:o DtGt4EERtv PRODUCTS MONSANTO RESEARCH CORPORATION 151 Ncoes cad P. O. E c s 8. St ation 8
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Dayton.Chio 45407 Phones: (513) 268-6769 (513) 26 8 -3 411 Tele greg h: TWX 810-d59 1681
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1 1 June 1983 3
fj Mr. Ben Foster
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The Ohmart Corporation 4241 Allendorf Cincinnati, Ohio
Dear Ben:
As I informed you on 26 May, eight Am-241 gamma sources, serial numbers as listed, were incorrectly labeled. The labels on each source indicates 1000 uti when they should indicate 1000 mci.
1.
MRC-Am-1574 2.
MRC-Am-1575 3.
MRC-Am-1577 4.
MRC-Am-1579 5.
MRC-AM-1580 h
6.
MRC-Am-1581 7.
MRC-Am-1582 8.
MRC-Am-1583 We strongly recommend returning eallect the above sources so that they may be corrected. T,his will be dor,e at no expense to Ohmart.
Please let me have your comments prior to 14 June as to your decision on this matter.
Sincerely,
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' Kathy Flayler
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