ML20136E115
| ML20136E115 | |
| Person / Time | |
|---|---|
| Issue date: | 03/10/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20136D955 | List: |
| References | |
| REF-QA-99990004-970310 99990004-96-02, 99990004-96-2, NUDOCS 9703130114 | |
| Download: ML20136E115 (9) | |
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f 4 ENCLOSURE 2' U.S. NUCLEAR REGULATORY COMMISSION REGION IV.
i Docket No.:
999-90004 9
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' License No.:
General License Pursuant to 10 CFR 31.5 1
j Report No.:
999-90004/96-02 Licensee:
Department of Veterans Affairs Veterans Administration Medical Center (VAMC) i Facility:
VAMC j
Location:
2202 Holcombe Boulevard l
Houston, Texas s
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Dates:
October 18,1996, through January 10,1997 Inspector:
Richard A. Leonardi, Jr.
Radiation Specialist i
Approved By:
Linda L. Howell, Chief i
Nuclear Materials inspection and Fuel Cycle / Decommissioning Branch Division of Nuclear Materials Safety 4
i Attachments:
Supplemental Inspection Information 5
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9703130114 970310 REG 4 OA999 EUSVA 99990004 PDR
EXECUTIVE
SUMMARY
Department of Veterans Affairs Veterans Administration Medical Center, Houston, Texas NRC Inspection Report No. 999-90004/96-02 This reactive inspection was conducted in response to a report of the loss of a generally-licensed sealed source to the NRC Operations Center on October 10,1996. The inspection included review of the licensee's radiation protection program as it related to the possession and use of generally licensed sources and devices.
Purpose of Inspection and Licensee Proaram Overview The purpose of inspection was to review the facts associated with the loss of a generally-licensed sealed source. The licensee has possessed and used sealed sources in liquid scintillation counters under the provisions of a generallicense pursuant to 10 CFR 31.5.
Transfer of Generallv-Licensed Sources The inspection determined that the transfer and subsequent disposal of a generally-licensed sealed source was not in accordance with the provisions of 10 CFR 31.5(c)(8),in that the source was not transferred to a individual holding a specific license issued by the NRC or an Agreement State and was instead transferred to a scrap metal dealer and possibly to a steel mill.
Licensee Corrective Actions Corrective actions implemented b, 6e licensee included: (1) labeling the remaining liquid scintillatiori counters with two warning signs indicating the presence of radioactive materials; (2) documents used for inventory control willinclude a warning statement providing notice of the presence of radioactive sources; and (3) initiation of more frequent physicalinventories of all liquid scintillation counters containing sources, including counters held in storage.
A review of the licensee's corrective actions revealed that the licensee had some program controls that should have prevented the improper disposal of the source; however, greater caution should have been exercised pric o releasing the liquid scintillation counter containing the source from the research department.
Notwithstanding the above, corrective actions taken by the licensee in response to the event appeared comprehensive.
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Report Details 1
Purpose of Inspection and Licensee Program Overview (87100)
On October 10,1996, the VAMC reported the loss of a 130 microcurie americium-241 sealed calibration source (Model AMCK599) contained in a liquid scintillation counter. The VAMC's radiation safety officer (RSO) stated that he became aware that a liquid scintillation counter containing the source was no longer at the facility as a result of a specialinventory performed on October 8,1996,in the medical center's research building, i
The RSO further indicated that the counter had not been used for some period of time and
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had been stored in the basement of the research building. The licensee initially reported that the counter with its associated source had been sold to a scrap metal dealer located in l
Austin, Texas, but the VAMC later determined that the source and counter had been 4,
transferred to a different scrap metal dealer and were subsequently sold to a steel mill l
located in Sequin, Texas. Region IV initiated a reactive inspection to review the circumstances associated with the incident and to review pertinent aspects of the licensee's radiation safety program.
i The VAMC conducts a variety of research activities under a broad-scope license issued by the NRC (License No. 42-00084-06). To support its research projects, the VAMC possesses and uses a variety of counting and analytical equipment. At the time of the
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inspection, the VAMC possessed 32 calibration sources, contained in liquid scintillation counters, under a generallicense pursuant to 10 CFR 31.5. The counter that was sold for scrap metal (Model No. 3385) and discovered missing on October 8 had been in storage with several other liquid scintillation counters for some time in the basement of the research building. VAMC representatives indicated that the majority of its liquid.
scintillation counters (with associated sources) were in active use and that only a few counters were in storage awaiting final disposition.
2 Loss of Source incident Description 2.1 Inspection Scooe The inspector interviewed VAMC personnel involved with the incident, contacted the sealed source manufacturer regarding source description, and reviewed pertinent records maintained by the VAMC.
2.3 Observations and Findinas Based on interviews with VAMC personnel and the VAMC's written report dated November 1,1996, the sequence of events involving the incident are as follows:
I On October 8,1996, while conducting a specialinventory of liquid scintillation counters at the VAMC facility in Houston, Texas, VAMC personnel discovered that a liquid scintillation
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. l counter containing a 130 microcurie americium-241 sealed source was missing from storage in the basement of a -
research building.
On October 10,1996, after conducting a search for the counter and source contained inside, the VAMC determined that the counter and sealed source could not be located at the j
medical center.
On October 10,1996, VAMC's RSO notified the NRC Operations Center of the missing source, and the NRC Region IV office was notified of the incident later that day.
During the VAMC's incident investigation, it was determined that the liquid scintillation counter containing the sealed source had been retrieved from the research buildhig by property
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management staff on February 22,1996, and placed into a scrap metal bin located at the medical center.
On March 25 or tipril 9,1996,(the RSO was unable to determine the exact date) VAMC's property managernent staff sold the liquid scintillation counter (with the source still in place) along with other items contained in the bin to a scrap metal dealer. The bin was subsequently transported to the
- dealer's facility.
The scrap metal bin taken by the dea'er was unloaded at the scrap yard, and the scrap metal was cut-up and subsequently-loaded onto trucks and transported to a steel milllocated in Sequin, Texas.
During the investigation, VAMC staft members conducted searches and performed radiation surveys at the medical center and scrap yard, but were unable to locate the source.
A dose assessment was performed to assess the maximum radiation exposu'e that a member of the general public could have received from transporting or handling the counter and source. This atsessment included evaluation of the dose which could have been received had the source been melted at the steel mill.
The VAMC issued a written incident report dated November 1, 1996, describing the details of the incident and the results of their investigation.
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. 3 Transfer of Generally Licensed Sources (87100,87103) 3.1 Ln_soection Scooe The inspector interviewed personnel involved with the incident and reviewed pertinent records maintained by VAMC.
3.2 Observations and Findinas The VAMC possessed and used the standard source contained inside the liquid scintillation counter cabinet under the provisions of a generallicense pursuant to 10 CFR 31.5. Representatives of Packard lnstrument Company, the counter manuf acturer, verified that the source contained inside the counter had been distributed under a specific license (Illinois License No. ll-01741-01)which authorized distribution of the source within the counter to persons subject to a general license.
The VAMC's RSO reported that loss (transfer) of the source was discovered while performing a specialinventory on October 8,1996. Inventories had been performed by the radiation safety staff on a regular basis at the medical center and included counters in active use as well as those placed in storage in the basement of the research building awaiting final disposition. Personnel performing the inventory on October 8 noted that a counter identified during the previous inventory (performed in early 1995) was missing. In accordance with instructions provided by the radiation safety office, staff members performing the inventory began to investigate the disposition of the counter and sources housed in it. (The counter also housed a radium-226 source.) The RSO subsequently determined that the source in question had not been removed from the counter prior to its removal from the research building by VAMC property management staff on February 22,1996. The counter was placed into a scrap metal bin at the medical center on February 22. The RSO indicated that on either March 25 or April 9,1996, a local scrap metal dealer retrieved the bin (containing the counter) and transported it to the scrap dealer's f acility where the counter was cut-up into small pieces (using large cutting equipment) and sold to a steel milllocated in Seguin, Texas.
The RSO's subsequent investigation concluded that there were two likely possibilities as to the source's final disposition. The RSO indicated the first possibility was that the source may have fallen out of the counter while it was being handled or transported at the VAMC facility, the scrap metal yard, or the steel mill. The RSO disclosed that he had contacted the manufacturer and was informed that the source was normally stored in a brass tube that in turn was placed between two lead bricks in the bottom of the counter. The manufacturer indicated that the lead bricks were not secured to the cabinet and that significant movement of the counter (such as tilting or lifting) could l
dislodge the source. The RSO believed that the source was most likely separated from the counter when the counter was unloaded into the VAMC's i
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scrap bin or when it was cut-up and processed at the scrap yard. During this investigation the radiation safety office staff performed radiation surveys i
at the medical center and scrap yard; however, they were unable to locate l
the source.
The RSO indicated a second possible disposition of the source was that it was melted at the steel mill along with the counter cabinet. The RSO disclosed that although both the scrap yard and steel mill used radiation I
monitors at their facilities to monitor scrap metal, he felt it unlikely that either radiation monitor could detect the low energy gamma emission of the americium-241 source. In addition, the source was of low activity and was shielded by metalin the counter frame and cabinet. The RSO noted that during discussions with representatives of the steel mill, he was informed that due to the significant amount of scrap metal that is melted and processed at the steel mill (100 tons at each melting with several batches processed per day), if the source was melted with scrap metal, the specific activity of the resulting processed steel or slag would be exceedingly low.
The inspector noted that the RSO had performed a dose assessment to evaluate the maximum radiation exposure that could have been received by a member of the public. This assessment included evaluation of external exposures but did not include evaluation of any potentialinternal exposure.
(The RSO noted that there was minimal potential for any internal dose, even if the source was melted. This conclusion was based on information provided by the steel mill.) The RSO estimated the maximum total effective dose equivalent to a VAMC employee would have been 45 microrem or 0.045 percent of the annual exposure limit for members of the public. Based on his assessment, the RSO concluded that the maximally t xposed individuals would have likely been VAMC employees. This was based on the fact that heavy equipment was used to handle scrap metal at the dealer's facility and the steel mill.
The inspector determined that the licensee did have some controls in place to prevent improper disposal of generally-licensed sources contained in liquid j
scintillation counters. These included: (1) instructions had been provided to the Administrative Officer of Research and Development Service of the l
necessity to remove sources from all counters prior to transferring or l
disposing of them; (2) instructions had been provided to property management personnel responsible for handling excess equipment regarding the source removal policy; and (3) periodic inventories of such equipment had been performed by the radiation safety staff. Notwithstanding the above noted controls, the source was improperly transferred and released to the public domain. In this particular incident, the source was housed in equipment that was destined to be sold for scrap metal, thus greater caution should have been exercised prior to releasing the equipment to the scrap metal dealer.
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d Based on interviews with VAMC personnel and a review of the sequence of events associated with the loss of the source as discussed in Section 2 of this report, multiple causes of the incident were identified. Failure to remove the sealed source from the counter prior to storing the device in the research building basement was identified as the direct cause leading to the incident. Although the administrative officer for research had been instructed to remove radioactive sources from counters prior to placing them in storage, this administrative control failed. Failure of the licensee's property management personnel to verify that radioactive sources were not contained in the counter prior to placing it in the scrap metal bin was identified as a contributing cause of the event. Had property management personnel checked the counter and noticed the manufacturer's warning label, they might have examined the contents of the counter for the presence of radioactive sources prior to placing the device in the metal scrap bin.
Although the research staff had primary responsibility for ensuring that the sources were removed from counters prior to releasing them to property management, the failure of the licensee to provide training for all property management personnel actively involved in the disposition of equipment known to house radioactive sources was identified as a root cause of the incident. Had these personnel been provided some awareness training, they may have recognized the need to check such equipment for sources that may have been inadvertently left inside.
10 CFR 31.5(c)(8) requires that any person who acquires, receives, possesses, uses or disposes of byproduct materialin a device pursuant to a d
general license, except as provided in 10 CFR 31.5(c)(9), transfer or dispose of the device containing byproduct material only by transfer to persons holding a specific license pursuant to 10 CFR Parts 30 and 32 or from an Agreement State to receive the device. The failure to properly transfer or dispose of generally-licensed material was identified as a violation of 10 CFR 31.5(c)(8).
3.3 Conclusions Based on interviews with VAMC personnel and a review of licensee records, it appeared that the licensee's investigation of the loss of the source was sufficient to identify causes leading to the incident and areas where additional controls could be implemented to prevent recurrence. A violation of 10 CFR 31.5(c)(8) was identified regarding the licensee's failure to properly transfer or dispose of a generally-licensed source.
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4 Licensee Corrective Actions (87100,87103) 4.1 Insoection Scope Through interviews with licensee personnel and a review of licensee records, the inspector reviewed the licensee's proposed corrective measures.
4.2 Observations and Findinas Several corrective actions were implemented by VAMC including:
(1) labeling the remainder of the counters in the licensee's possession with two (3-by-5 inch) metal warning and caution signs; (2) documents used for inventory control were modified to include a warning concerning the presence of radioactive sources; and (3) the radiation safety office planned to increase the frequency of inventories of all counters containing sources, including those in storage, to quarterly intervals.
During the course of the inspection, the inspector observed that the VAMC had completed the labeling of all counters containing calibration sources with two large warning and caution signs as proposed in the VAMC's written report.
4.3 Cnnelusions Based on interviews with licensee personnel and the review of the licensee's incident report, it appeared that the licensee's proposed corrective actions were adequate.
Exit Meetina Summary The inspection findings were presented to licensee management via telephone on January 10,1997. During the exit briefing, the violation and its regulatory and safety significance were discussed, in addition, the NRC Enforcement Policy was discussed with licensee management during the telephonic exit briefing. The licensee acknowledged the inspection findings and the corrective actions taken and planned, as described in this inspection report. Licensee management agreed that a predecisional enforcement conference was not necessary.
ATTACHMENT 1 PARTIAL LIST OF PERSONS CONTACTED.
~ Licensee A. Walmus, Associate Medical Center Director G. Cunningham, M.D., Chairnian, RSC J. Triebel, RSO S. Bravence, ARSO T. Teslow, Medical Physicist INSPECTION PROCEDURES USED 87100 Licensed Materials Programs 87103 Inspection of incidents At Nuclear Materials Facilities ITEMS OPENED, CLOSED, AND DISCUSSED Ooened l
i 999-90004/9602-01 VIO Failure to transfer or dispose of a generally licensed source in accordance with 10 CFR 31.5(c)(8).
C.Insed None Discussed None 4
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