ML20138G765
| ML20138G765 | |
| Person / Time | |
|---|---|
| Site: | Oregon State University |
| Issue date: | 12/23/1996 |
| From: | Dodd B Oregon State University, CORVALLIS, OR |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9701020253 | |
| Download: ML20138G765 (10) | |
Text
RADIATION CENTER
- s*
OnEcos STATE Umvtastry 100 Radiation Center. Corvallis. oregon 97331-5903 J Telephonc $41-737-234i Fax 54I-737 0480 December 23,1996 U.S. Nuclear Regulatory Commission ;
Document Control Desk Washington, D.C. 20555 i
Reference:
Oregon State University TRIGA Reactor (OSTR)
Docket No. 50 '?43, License No. R-106
Subject:
Two Inadequacies in the Implementation of Procedural Controls Gentlemen:
The purpose of this letter is to report two recent incidents in which there were observed inadequacies in the implementation of procedural controls. It is our belief that neither of these incidents is required to be reported; however, we are doing so to demonstrate our commitment to eliminating such events, and to maintain the open and cooperative nature of our relationship with the Nuclear Regulatory Commission. An initial verbal notification of these events was ir de to Mr. Alexander Adams Jr., the OSTR's Project Manager at the NRC, on December 19,199. The first occurrence involves irradiation of samples in the pneumatic transfer facility and the s~ %d relates to shipments of radioactive material which were made in violation of 10 CFR 30.41 b INCIDENT I Background Information OSTR experiments fall into one of three classes. Class A experiments involve running the reactor only, with no use of any of the facilities. Class C experiments are reserved for very unusual applications of the reactor and thus are almost never used. Class B experiments include virtually all of the standard experiments for which safety evaluations have been performed and approved by the Reactor Operations Committee (ROC). Amongst other things, Experiment B-3, " Irradiation of Materials in the Standard OSTR Irradiation Facilities", allows irradiation of elements with atomic numbers 1 through 83 (except mercury) in sample quantities up to 30 grams, and includes irradiations in the pneumatic transfer facility. Samples may be stable solids, powders or other loose j 970102O253 961223 PDR ADOCK 05000243 6
S PDR
w a a ,- . . + ->-a.,a -a -~~ ~ ~ ~ - ~ . - .--- ...,~..,._- .- ---, ~.. .. -.~ ~ a~,-- +-m,. ._ - +
U.S. Nuclear Regulatory Commission Page 2 December 23,1996 solid materials, or may be gases or liquids, and all samples must be encapsulated according to the requireinents of Oregon State University TRIGA Reactor Operating Procedures (OSTROP) 18.
)
Once a particular experiment (such as B-3) has been approved by the ROC, subsequent uses of that experiment are controlled via Irradiation Request forms (irs). The OSTR employs irs to fulfill a variety of tasks including review and approval ofirradiations, reactor use record keeping, material transfer, billing uses and other such accounting requirements. Use of Class B experiments requires 1
~t he signature of both the Senior Health Physicist (SHP) and the Reactor Supervisor on the IR. The SHP checks for the types and quantities ofisotopes expected to be produced as well as for other health physics and radioactive material license related aspects of the irradiation. The IR is then
~
passed on to the Reactor Supervisor who checks the form to ensure that the irradiation can be performed under one of the currently approved reactor experiments. He also ensures that the encapsulation method meets the experiment requirements and that other reactor license related aspects of the requested irradiation are in order.
Description of the Incident
' On December 3,19% a member of the OSU Radiation Center's staff was performing a routine series ofirradiations using the pneumatic transfer (rtbbit) facility. The work was scheduled to last all day and involved irradiating samples from several different research projects. The Center's procedures call for a separate IR for each research project because this helps keep the sample tracking and billing clearer. The experimenter started the irradiations at about 0905 and continued on with samples from three separate research projects, each with its own approved IR (96-250 through 96-252). The researcher fmished the irradiations for the three projects at about 1415 and decided to irradiate samples from two other projects. These projects consisted of 15 samples each and were later identified as irs96-253 and 96-254. For these projects the individual completed the .
experimenter's portion of the irs, but did not submit them to the SHP or the Reactor Supervisor for i approval prior to irradiation. On completion of the irradiations, the experimenter brought the irs !
to the control room for signatures. At this point, the Reactor' Operator notified the Reactor )
Supervisor and instructed the experimenter to immediately net with the SHP. The Reactor l Supervisor notified the Reactor Administrator. The SHP, Reacte Supervisor, Reactor Operator and j Reactor Administrator met in the reactor control room, the SHP briefed the group regarding the i meeting with the experimenter and it was determined that the event did not meet the criteria for immediate reporting to the NRC but could potentially be a 30 day reportable event. The Reactor Administrator immediately suspended the experimenter's authorization to use the reactor experimental facilities until further notice. The Director was out of the building at the time, but was i notified the following moming. The Director notified the Chairman of the Reactor Operations Committee (ROC).
- i I
4
- U.S. Nuclear Regulatory Commission Page 3 December 23,1996 l
' A post-occurrence review of the unapproved irradiations indicated that they were not unusual and would have received the SHP's and Reactor Supervisor's signatures without question. Documentary :
evidence of the fact that the samples were of a normal nature includes the sample data on the IR forms, the typical range of dose rate readings taken after each sample had been irradiated, the data from the gamma spectrometry analysis performed as part of the experiment, and the reactor power j chart recorder.; The latter provides no indication of any unusual reactivity effects from the insertion
]
and semoval of the samples. '
OSTR Technical Specification 6.7.c.4 states that: "Any observedinadequacies in the implementation
- ofadministrative orprocedural controls such that the inadequacy causes or could have caused the existence or development ofan unsafe condition with regard to reactor operations."is an event requiring a written report within 30 days. While this incident is clearly an " observed inadequacy in the implementation of a procedural control", it is our belief that the circumstances associated with this specific event (i.e., the insertion and removal of these samples via the pneumatic transfer p facility) did not cause and could not have caused "an unsafe condition with regard to reactor i operations". Nonetheless we recognize the absolute importance of adhering to the procedure regarding pre-irradiation approval ofIRs, and therefore have chosen to report this occurrence in the interest of maintaining an open and frank relationship with the NRC's Non-Power Reactors and
- Decommissioning Projects Directorate.
1 Cause of the Occurrence 3
The significance of this event was not initially realized by the experimenter, since as far as this
[ individual was concemed the work involved irradiating a large number of very similar rock samples.
This staff member is a very experienced person who has probably irradiated more samples than anyone else in the facility. We are confident this member of our staff would never' knowingly put anything into the reactor which would be of a hazardous nature or would be contrary to the license conditions. However, this person was not aware of the purpose behind the procedural controls '
involved in this occurrence and therefore did not recognize their priority and importance. In addition, it was discovered that this person had not recently read Experiment B-3 and was not ,
completely familiar with all ofits restrictions and limitations. I In the past it has been the practice of experimenters running multiple irs using the rabbit facility to notify the control room each time they complete an IR and prior to starting the next one. If this had been done, then the reactor operator would have known what was happening and could have prevented it, because the operator would not have had copies of the unsigned irs in the control ;
room. However, there is currently no procedural requirement for the experimenter to notify the !
operator when work progresses to a ditTerent IR.
l
(
i
. y g . \"
U.S. Nuclear Regulatory Commission ,
j Page 4 -
.. December 23,1996 ,
~ Corrective Actions
- 1. The experimenter's authorization to use the reactor's experimental facilities was suspended ,
- l. immediately and was not reinstated until December 16,1996, after items 3 and 4 below had !
l been completed.
l
[ 2. In the interim two weeks, all irs needing to be run by this experimenter were run under the ' j Reactor Administrator's radioactive material use authorization. In essence, this provided another level of review for this person's work for the stated time period.
- 3. The Senior Health Physicist and Radiation Center Director separately met with the l experimenter and discussed the seriousness and significance of the event.
- 4. The experimenter was provided with copies of, and required to read: Experiment B-3:
" Irradiation of Materials in the Standard OSTR Irradiation Facilities"; OSTROP 10:
" Operating Procedures for Reactor Experimental Facilities"; OSTROP 18: " Procedures for the Approval and Use of Reactor Experiments" which includes the " General Limitations on Experiments Performed Using the OSU TRIGA Reactor".
- 5. The experimenter underwent further training by the SHP on proper completion of' irs.
Measures to Prevent Recurrence of Such an Event 1, . Each approved user of the pneumatic transfer facility has been provided with a copy of ;
Experiment B-3, OSTROP 18, and the part of OSTROP 10 relating to this facility and has l
been asked to read them prior to further use. (This is the only experiment.where the experimenter has control over inserting and removing samples from the reactor. In all other experiments samples are inserted or removed by the reactor operations or health physics j l- staff.) l l i
- 2. Approved users have been reminded of the need to notify the control room at the start and end of each IR. This information will also be included in the pneumatic transfer facility l l training program.
- 3. The part of OSTROP 10 relating to the pneumatic transfer facility will be reviewed for completeness, and will be changed to include a requirement for experimenters to notify the control room whenever an IR is started and completed.
- 4. The Radiation Ct nter Director called a mandatory, special meeting of the Center's staff on December 18,1996 (see referenced meeting below).
i a
U.S. Nuclear Regulatory Commission !
. Page 5 ! . .
December 23,1996 l
INCIDENT 2 i l
Description of the Incident l On December 16,1996 a member of the Radiation Center's health physics staff was preparing a j shipment ofirradiated fission track samples to a regular user at the State University of New York ,
(SUNY), Plattsburgh. OSU Radiation Center Health Physics Procedures (RCHPPs) require l checking th: license of the recipient to ensure that the licensee is authorized to receive the j radionuclides and quantities involved. When this was done for the December 16th shipment, it became apparent that the SUNY, Plattsburgh license (No.1064 Amendment 18) did not allow for .
the activation products being shipped. . At this point the processing of the shipment was halted.
3 Upon further checking of shipping records, it was noted that several previous shipments had been '
made to this same experimenter at SUNY, Plattsburgh. Records show that there have in fact been a total of seven shipments, all made by another member of the health physics staff. A summary of !
. thd e ates an dtotal quant ties i of radioactive material for these prior shipments is given below, and j complete details are provided in Attachment A.
~
April 7,1995 0.11 pCi !
June 13,1995 0.01 pCi j August 17,1995 0.17 pCi !'
September 6,1995 0.20 Ci March 28,1996 15 pCi July 18,1996 0.27 pCi September 10,1996 0.01 Ci
. Because of the status of the SUNY, Plattsburgh license, it appears that these shipments were made 4
. contrary to the requirements of 10 CFR 30.41(c). The Radiation Center Director and the Chairman of the Reactor Operations Committee were notified of this fact on December 17,1996. Despite the fact that there does not appear to be a regulatory requirement to report violations of this nature, we ;
have chosen to do so.
' U.S. Nuclear Regulatory Commission -
Page 6 -
December 23,1996 Cause of the Occurrence The health physics staff member who made all of the previous seven shipments joined the Radiation Center's staff in September 1994. This individual received and passed the radioactive material shipment training on November 15,1994, and made the first shipment to this user at SUNY,
- Plattsburgh in April 1995. The individual can offer no definitive explanation as to how the original mistake of thinking this user was licensed to receive the material might have occurred. Relevant shipping records of the OSTR contain many user licenses, and it is possible that this person looked at the wrong one. With subsequent shipments, since they were all essentially of the same nature, and since it was known that prior shipments had been made to the SUNY user, there was no recheck of the license each time and hence the original mistake was repeated.
RCHPP 6: "OSU Procedures for Transfer, Packaging and Transport of Radioactive Materials Other .
Than Radioactive Wastes" has a requirement for a second certified shipper to review and initial the shipping documentation prior to shipment. However, the emphasis of this review is to ensure that the appropriate packaging, labels and documentation have been correctly selected and applied, and not to completely redo the whole shipment.
Corrective Actions
- 1. The person who made the seven shipments met separately with the Senior Health Physicist and the Director to discuss the seriousness of this event and the importance of following established procedures in detail.
- 2. All previous shipments for 1996 including those shipped from OSU's broad scope state license as well as the OSTR license, a total of 91, were reviewed for similar errors. No other violations of 10 CFR 30.41(c) were found.
- 3. The SUNY, Plattsburgh experimenter and the Plattsburgh Radiation Safety Officer, Dr.
Roger Heintz, were notified of the subject shipments on December 17,1996. Dr. Heintz later informed us that he had applied for a change in the license to accommedate receipt of such materials for this experimenter.
- 4. Mr. Charles Bums of the New York State Department of Health, Radioactive Material Section was informed on December 19,1996 of the shipments.
. U.S. Nuclear Regulatory Commission Page 7_ -
December 23,1996 Measures Taken to Prevent Recurrence of the Event :
- 1. The State University of New York, Plattsburgh Radiation Safety Officer has applied for an amendment to add the experimenter and radioactive materials in question to their license.
No further shipments will be made until this amendment is in place or the appropriate, authorized approvals from the State have been received.
~
- 2. The Radiation Center Director called a mandatory, special meeting of the Center's staff on December 18,1996 (see referenced meeting below).
It is difficult to envision further measures to prevent recurrence of this event considering the follow'mg:
- a. The OSU Radiation Center has in place a radioactive material shipment training qualification and training program. This occurs at least annually, and the person involved had attended and passed this training on November 15,1994, November 27,1995, April 1,1996, and November 26,1996.
- b. RCHPP 6 already has a procedural requirement to check the license of the recipient to ensure that this person is licensed to receive the material.
- c. The OSU Radioactive Materials Shipping Record has locations to write in or check: the recipient's license number; whether or not it is on file ~or there is a phone authorization with copy to follow (per 10 CFR 30.41(d)(3)); and whether the license is within the expiration date or whether it is under timely renewal.
- d. RCHPP 6 has a procedural step that states: "The shipment paperwork (including shipping papers, shipper's declaration, waybills, and/or commercial invoices, as applicable) and the '
package marking and labeling should be reviewed by a second OSU-qualified shipper of radioactive material. If the shipment is acceptable for transport, the reviewer shall initial and date the shipping paper."
- e. The person who performed the Plattsburgh shipments is a very conscientious and experienced worker, having made a total of 138 radioactive materials shipments in approximately two years of employment at the Center.
- f. . The OSU Radiation Safety Officer performs a review and audit of the complete radioactive material shipping program each year, and the ROC performs an audit of the shipping records each quarter.
U.S. Nuclear Regulatory Commission
. Page 8
-December 23,1996 MANDATORY SPECIAL MEETING OF THE RADIATION CENTER'S STAFF
- On December 18,1996, the Radiation Center Director called a mandatory special meeting of all of the Radiation Center's staff. The key points communicated to the staff are briefly noted below:
- 1. It is time to take a long, hard look at ourselves.
- 2. Within the last few wecks we have had three events which we felt needed to be reported to the USNRC. Our previous reportable event was in February,1993.
- 3. Each of the three events was discussed in detail in a frank, and open manner.
- 4. The purpose of the discussion was not to assign blame or make the individuals involved feel guilty, since they are very conscientious employees deserving of the highest respect. They are already feeling bad enough.
- 5. The purpose was to team from these events, to be aware that any one ofus can make a mistake.
- 6. The recently issued draft AEOD report (AEOD C96-xx, "Non-Power Reactor Survey") was - i discussed in the context of the three events. In particular the question was asked as to what lessons are there in this report for us?
I
- 7. Copies of the AEOD report were distributed as required reading for each of the licensed 1 operators, and each member of the health physics staff. Members of the ROC will be requested to read the report. Other staff members were also encouraged to review it.
- 8. The Director communicated the seriousness with which he was approaching the recent' events and exhorted the staff to a renewed dedication to the high standard of professionalism for which we have been known.
l
- 9. Staff were encouraged to meet with the Director and fmther discuss any of the events or to share any ideas they had with respect to root causes or further preventive actions.
About half of the Radiation Center's fourteen staff later came to the Director to express their appreciation of how the meeting was handled and to commit their support. l l
l
,m.
a l
' U.S. Nuclear Regulatory Commission Page 9 f December 23,1996 l
l 1
Conclusions !
While the events reported here clearly had no reactor safety or radiation safety consequences, the l OSU Radiation Center is fully aware of their importance. This is especially so in the current climate l of heightened sensitivity in the nuclear industry. Anytime even unrelated events occur in groups, '
close scrutiny is called for. Be assured that we are giving these events a very close review and !
evaluation. We believe that we have a good record of not just complying with the NRC's regulations, but have demonstrated a continuing commitment to go significantly beyond these requirements. It is our intention to ensure that our reputation is not only continued, but that it is justifiably earned 1 Should there be questions regarding the information in this report or should you require more information, please let me know. -l l
4 ours sincer ly, r
\ V]
W B an Dodd, PhD Director ]
l l
c: Al Adams, Senior Project Manager, Non-Power Reactors and Decommissioning Projects Directorate, U.S. Nuclear Regulatory Commission, M.S. 0-11-B-20, Washington, D.C.20555 Regional Administrator, USNRC, Region IV,611 Ryan Plaza Drive, Suite 400, Arlington, TX 76011-8064 Oregon Depanment of Energy,625 Marion Street, NE, Salem, Oregon 97310, Attn: David Stewart-Smith G. H. Keller, Vice-Provost for Research and International Programs S. E. Binney, Chairman Reactor Operations Committ 2 J. F. Higginbotham, Reactor Administrator !
D. S. Pratt, Senior Health Physicist 1 A. D. Hall, Reactor Supervisor )
i
, e-
, Attachment A State University of New York College at Plattsburg Authorized: Maximum NYS 1064, Expiration Date: 9/30/97 Nuclide Possession Roger Heintz. Ph.D., Radiation Safety Officer Hydrogen 3 50 mci Carbon 14 20 mci Shipped to: ,. Phosphorus 32 10 mci-Dr. Mary Roden'-Tice Sulfur.35 30 mci Center for Earth & Environmental Sciences .,
Calcium 45 2 mci State University of New York Conege at Plat'sburg lodine 125 5 mci (518) 564 2028 SHIPMENTS:
- 1496 04/07/95 #1507 06/13/95 #1517 08/17/95 #1520 09/06/95 Sc 46 4.5E-05 mci Sc 46 1.25E-06 mci Sc 46 3.43E-05 mci Sc43 3.61E-05 mci Fo 59 2.2E-05 mci As 76 9.45E-07 mci As 76 1.67E-05 mCl Rb 86 4.93E-05 mCl Hf181 4.2E-05 mci Na 24 3.63E-07 mCl RbBG 4.95E-05 mci Hf181 3.75E-05 mci Co 60 7,1E-06 mci Fe 59 5.94E-07 mci Sb 124 7.83E-06 mCl As 76 1.4E-05 mci Total: 1.1E-04 mci Rb 86 1.63E-06 mci Fe 59 1.56E-05 mCl Fe 59 1.38E-05 mci Co 60 3.34E-07 mci Br 82 7.28E-06 mci Eu 152 1.02E-05 mci Hf181 1,16E 06 mci Co 60 2.99E-06 mci Lu 177 1.37E-05 mci Yb 175 1.08E-06 mci Hf181 1.02E-05 mci Br82 3.11E-06 mci Eu 152 4.24E-07 mci Sc 47 4.79E-06 mci Sb 122 1.22E-05 mci Br82 1.72E-07 mci Sb 122 5.65E-06 mci Sc 47 5.8E-06 mci Sb 124 1.25E-07 mci Ce 141 3.97E-06 mci Ce 141 2.93E-06 mCl Lu 177 6.21E-07 mci Ba 131 3.82E-06 mci La id'0 2.62E-06 mci Sm 153 2.87E-07 mci La 140 2.66E 06 mci Total: 2.0E-04 mCl La 140 2.77E-07 mci Total: 1.7E-04 mci Ce 141 2.14E-07 mci Sc 47 1.69E-07 mci Zr 95 1.56E-07 mci Sb 122 1.61E-07 mci Ba 131 1.73E-07 mci Se 75 9.7E-08 mci Pa 233 1.87E-07 mci Yb 169 1.15E-07 mci Cr 51 4.42E-07 mci Total: 1.1E-05 mci
- 1567 03/28/96 #1593 07/18/96 #1607 09/10/96
~ Na 24 8.2E-03 mci Re 186 1.7E-04 mci Ta 182 3.5E-05 mci As 76 6.3E-03 mCl Sc 46 2.6E-05 mCl F.b 86 ^ 1.7E-05 mci Br82: 4.6E-04 mci As 76 4.0E-06 mci Sc 46 1.1E-05 mCl Sb 122 - 4.1E-04 mCl Yb 175 1.8E-05 mci Hf181 1.8E-05 mci Total: 1.5E-02 mci Hf181 1.5E-05 mci Fe 59 9.0E-06 mci Fe 59 1.2E-05 mci 8.9E-05 mci sum (Nuclides w/ activity Lu 177 1.1E-05 mci > 95% of the total)
Eu 152 6.7E-06 mci Total: 9.68E-05 Total mCl in the shipment Co 60 ' 2.6E-06 mci Ce 141 3.0E-06 mci 2.7E-04 mci sum (Nuclides w/ act. > 95% of total)
Total: 2.8E-04 Total mCiin the sh'pment j