ML20086F176

Responds to Violations Noted in Insp Rept 50-186/91-04 & Proposed Imposition of Civil Penalty in Amount of $1,875. Corrective Actions:Shipping Procedure Revised to Include independent,dual-recorded Verification of Capsule

ML20086F176
Person / Time
Site:	University of Missouri-Columbia
Issue date:	11/27/1991
From:	Mckibben J, Reilly W MISSOURI, UNIV. OF, ROLLA, MO
To:	NRC OFFICE OF ENFORCEMENT (OE), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9112030137
Download: ML20086F176 (5)

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A i Research Reactor Facility II Ree,eurch Ibik Cotumtna. Muoan M211 i

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% Q3y?Q UNIVERSITY OF MISSOURl-COLUMBIA November 27,1991 i

Director, Office of Enforcement US Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555

REFERENCE:

Docket 50-186 University of Missouri Research Reactor License R-103 SUIMECT: Reply to a Notice of Violation in Accordance with 10 CPR 2.201

Dear Sir:

This is the written statemen. required by the provisions of 10 CFR 2.201 in response to the Octob,tr 29,1991 U.S. NRC Region III NMJee of Violation and Proposed Imposition of Civil Penalty $1,875 (NRC Inspection Repsrt No. 50-JC/91004) concerning events at the University of Missouri Research Reactor (MURR).

Each violation is listed below followed by the c.. ociated reply. Replies follow the five step format given in the Notice of Violation, i.e. (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, and if denied, the reasons why,(3) the corrective steps that have been taken and the results achieved,(4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. Violations 1.A.1, and I.A.2.

are grouped together because the reply for both is the same.

I, A.1. On August 5,1991, the licensee delivered il curies of rhenium-186 to a carrier for transport to the NASAlJohnson Space Center with the description on the shipping papers ar.d the radioactice label stating that the shipment contained 16 millicuries <

• sodium 21, and the package was not excepted from labeling.

l- 1.A.2. On August 5,1991, the licensee delivered 16 millicuries of sodium 24 to a carrier l for transport to Mallinckrodt Medical with the description on the shipping papers and the radioactive label stating that the shipment contained 11 curies of rhenium 186, and the package was not excepted from labeling.

(1) The:.e violations are admitted. MURR voluntarily reported them to the NRC Office of Nnclear Reactor Regulation by telephone on August 7,1991, and to NhC Region til by telep' hone on August 9,1991. A written report was submitted to the NRC by letter dated September 4,1991.

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.d (2) The cause of both violations was the inadvertent placement of a sample into the wrong lead shipping pig in the hot cell during the initial stage of sample packaging for ,

shipment. j The samples were removed from the reactor pool under health physics monitoring, and - l transported in a transfer cask to the hot cell for opening and initial packaging in preparation for shipment. In keeping with the principles of ALARA, samples to be procesced in the hot cell are transferred in groups to reduce the number of transfers and openings of the hot cell. Prior to moving the transfer cask into the hot cell, the required shipping pigs are marked and placed in the hot cell.

The transfer cask was then placed inside the hot cell, opened, and the cans were removed. The double verification of the irradiation capsules prior to opening in the hot cell, which had been instituted in September 1990, was accomplished. Processing included a determination of the activity using a shielded Capintee inside the hot cell.

Each sample was then loaded into a plastic bag which had been preplaced inside each of i the shipping pigs. Iluman error in not properly identifying each shipping pig resulted in switching the placement of these two samples between the two shipping pigs. Tops were manually placed on the shipping pigs afi.er the hot cell was opened under health physics supervision, and surface dose rates and external contamination assessments were made.

The shipping pigs for these Type A shipments were then transported to the shipping preparation area where each was placed in a can and sealed. Contact and one foot dose rate readings were takan and recorded on each can to provide information for the receiver. The scaled cans were placed in identified expanded polystyrene overpacks which were strapped and sealed in a cardboard box shipping contair.cr. Contact dosc rates were read and recorded at the top, bottom, and all sides of the chipping containsa and the TI's were measured to determine the proper shipping label (i.e., White I, Yellow II,_ Yellow III).

.(3) MURR dispatched a certified shipper and a QA inspector (who is aln a Certified !!calth j Physicist) to NASA on August 8 to retrieve the Re-186 under a MUht. Radiation Work l

Permit. Since the required equipment to prepare MURR Type A shipments is not I portable, we had sent a Type B container t,. NASA to use in the retrieval. Mallinckrodt Medical needed to have the Re-186 by August 9 fer treatment of a patier.t. so the Re-186 was sent by MURR from NASA to Mallinckrodt Medical as a Type A shipment made in a Type B container. Repackaging of the Re-180 vial by MURR perst nnel required that da Wal was out ofits shielding (handled with forceps and behind a leaded glass chield) for approximately 35 seconds. During this repackaging, MURR personnel wore whole body film badges, and TLD wrist and ring badges. All dosimetry badges registered minimal (below to mrem).

MURR also sent a shipper to Mallinckrodt Medical on August 8, a . he brought the activated rocks back to MURR. The activated rocks were re-irradi ted on August 12 and were shipped to NASA on August 13.

Target preparation, irradiation, post-irradiation processing, and shipping procedures were reviewed and levised to incorporate independent, dual, recorded verification of steps at which samples could be inadvertently switched. Identification markings on lead shipping pigs were improved to increase legibility. All sh:pping personnel were iaformed of the misshipment, reminded of the importance of correct processing and shipping, and trained in the revised procedures. The person responsible for the misshipment was counseled and placed on restricted duty pending further evaluation.

Organization actions, which had been initiated prior to August 1991 to bolster the shipping group from a Supervisor, a Technician, and two assistants to a Supervisor and four Technicians, were expedited and completed, All positions are now stafTed.

(4) liefresher and update training for shipping personnel will be performed annually to assure adherence to improved procedures and regulations.

(5) Shipment of radioactive materials have been in full compliance since the two switched shipments on August 5,1991.

l.A.3. On September 4,1990, the licensee delivered 17.9 curies of palladium 103, and 18 curies of palladium 109 to a carrier for transport to Mallinci rwL Medical with the description on the shipping papers and the radioactive label stating that the shipment contained 6.19 curies of rhenium 186, and the 1,ackage was not excepted from labeling.

(1) This Wolation is admitted. MUltIt informed the NitC of this event during an inspection on Augu t 21,1991 and included it in the September 4,1931 voluntary report to the NltC.

(2) The cause was the misidentification of an irradiation caps ile during opening in the hot cell as part of the processmg of the sample for shipment. The sample processing is described in item (2) under Violations 1.A.1 and I.Al On September 4,1990, -

irradiation capsules were removed from the host irradiation can in the hot cell in preparation for shipping. The capsules are identified by unique markings on the bottoms. In this instance, the marking on the bottom of the capsule was misread which led to placemmt of the sample into the wrong load whipping pig.

(3) On September 1,1990 the shipping procedure was revised to include independent, dual, recorded veri fication of irradiation capsule identification prior to opening in the hot cell for carr.ple processing fer shipment. Shipping personnel were informed of the error, and frequent meetings were held to discuss processing and shipping adivities for the next workday.

(4) With the reoccurrence of this similar type of mistake on August 5,1991,it was realin that the corrective actions taken in September 1990 needed to be extended to cover all situations where samples could be inadvertently misidentified. Therefore, the corrective actions discussed in 1.A.1 and 2.(3) were initiated on August 7 after a simdar problem occurred. Itefresher and update training for shipping personnel will be performed annually to assure adherence to improved procedures and regulations.

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-p (5) Shipment of radioactive materials have been in full compliance since the inadvertent '

switch of shipmenta on August 5,1991.

1. B. On August 6,1991, the licensee transferred a source containing i! curies rhenium 186 to NASAlJohnson Space Center, a person who was not authomed to receive such byproduct material under the terms of a specific or general license issued by the Commission or Agreement State.

(1) This violation is admitted and was discussed during the September 18,1991 NRC Enforcement Conference. This violation is intrint,ically embodied in violatirn I.A.1, above.

(2)- The cause of the violation was the inadvertent placement of a sample into the wrong lead shipping pig in the hot cell during initial sample packaging for shipment.

(3) MURR did verify t. hat NASA was authorized to receive the intended shipment of sodium 24. No further action is warranted beyond actions described above. MURR obtains and maintains en file licenses of all recipients cf radioactive shipments. The shipping checklist requires verification of authorizations prior to each shipment. The MURR program for and record of determining recipients' license authorization for intended shipments has been excelbnt and closely reviewed during previous NRC inspections.

(4) Since this violation is intrinsically embodied in violation 1.A.1. above, no additional corrective action is required besides what is listed under I.A.I.

(5) Full compliance has been maintained concerning verification of authorization for receipt of byproduct material as required by 10 CFR 30.41(a) and (b)(5).

!!. As of August 21,1991, the video documentation for the licensee's Type A containers did not provide an engineering evaluation or comparative data showing that the constrctction methods, packaging design, and materials of construction comply with the specification 7A. Additionally, the video documentation of testing did not provide complete documentation of tests performed. Specifically the licensee could not locate the completed checklists which document and certify that the Type A container testing acceptance criteria were met.

(1) This vic,lation is admitted and was discussed during the September 18,1991 NRC Enforcement Conference.

(2) The cause of the violation was failure to maintain adequate control of files.

Certi0 cation of DOT 7A packaging was conducted in accordance with a procedure requiring doeuraentation of environmental tests and video taping of performance tests. Tapes are on file containing performance testing conducted in 198J,1987, and 1989. Technicians conducting the testing of packages for which we could not locate the

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documentation have stated that they conducted the tests in accordance with the procedure and that documents were placed in the file. In addition, we have a letter on file from DOT stating that they had inspected our testing program on April 14,1988 and found it satisfactory. There have been major relocations of service personnel and files during the past two years and it is assumed that the Oles were misplaced during one of the moves.

(3) All packages have been completely recertified to meet DOT 7A in accordance with approved procedures. The performance testing for recertification was performed by Pro-Pack Testing Laboratory, Inc. and the environmental testing was performed by University personnel. All packages passed certification, htURR has made over 5,000 Type A shipment over the past 6 years with no reported failures or difficulties with the package. We have high confidence in the suitability and integrity of our Type A package.

(4) Duplicate copics of the compinted certification are being made for storage in a separate location.

(5) MURR is in ullr compliance by having the required DOT certifications on file for the Type A packages used by MURR.

Sineenely,

[ g, e u. V. k ['2 UE U/

William F. Reilly r- omgm q .i Assistant Director, terARY m e STATY 5tussatsli Fiscal / Reactor Services - M 1CCLMTV tiv catessa t'xp, ADQ.1s 1995 Reviewed and approved

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9 J. Chctles McKibben Associate Director

. WFR:bsj xc: NRC Region III S. Weii,s NRC/NRR

- Reactor Advisory Committee Reactor Safety Subcommittee Isotone Use Subcomtnittee J. Sheridan, Vice Provost J.Rhyne

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