ML20141F634

Insp Rept 99990003/97-06 on 970516-0623.Apparent Violations Being Considered for Escalated Enforcement Action.Major Areas Inspected:Insp to Identify Sequence of Events & Contributing Factors Re Licensee 970516 Rept

ML20141F634
Person / Time
Issue date:	06/27/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20141F625	List: ML20141F622 ML20141F634
References
REF-QA-99990003-970627 99990003-97-06, 99990003-97-6, NUDOCS 9707030117
Download: ML20141F634 (11)

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U.S. NUCLEAR REGULATORY COMMISSION REGION lil Docket No.: 999-90003 License No.: General Licensee Licensee: Anheuser Busch, Inc.

One Busch Place  !

St. Louis, MO 63118-1852 l 1

l Location: Anheuser Busch, Inc.

I One Busch Place  !

St. Louis, MO 63118-1852 Dates of Inspection: May 16- June 23,1997 Inspector: Andrea Kock, Radiation Specialist 1

Approved By: Monte P. Phillips, Chief j Nuclear Materials inspection Branch 2 i

Division of Nuclear Materials Safety 4

9707030117 970627 REG 3 GA999 ENVANBU 99990003 PDR

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EXECUTIVE

SUMMARY

Anheuser Busch, Inc.

NRC inspection Report 999-90003/97006 (DNMS)

This was a reactive, announced inspection to identify the sequence of events and contributing factors associated with this general licensee's report that two gauges, -

each containing 100 mci (3.7 gigabecquerels) of americium-241, had been disposed of through transfer to a scrap metal processing facility. Although one source was recovered by the licensee, a second source remained missing at the time the NRC Operations Center was notified on May 16,1997.

Two apparent violations were identified during the inspection. The first violation

- concerned a failure to comply with all instructions provided by the manufacturer's device labels. Specifically, while the manufacturer's instructions stated that only specifically licensed individuals dismantle the gauges, the licensee removed the

devices from their installed position in preparation for disposal. The second violation involved the transfer of two generally licensed devices to an unauthorized recipient for disposal. The direct cause of both violations appeared to be an erroneous determination that the devices did not contain radioactive material.

The inspection identified several contributing factors associated with the licensee's l unauthorized removal and disposal of the two devices. Specifically, the licensee's lack of specific procedures for the removal and disposal of devices containing radioactive material fostered communication breakdowns among the individuals responsible for radiation safety, in addition, deficiencies in personnel radiation safety training augmented communication breakdowns.

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Report. Details l

1.0 Organizadaa =d Ecopa_of_Rrneram Anheuser Busch, Inc. is authorized to possess and use level measurement gauges, containing americium-241 in sealed form, under a general license. At the time of the inspection, the maximum activity in gauges possessed by the licensee was '

! approximately 300 millicuries (11.1 gigabecquerels). At the time of the inspection, l- the licensee possessed approximately sixty-six gauges containing americium-241.

l Gauges containing radioactive material were used for level measurement and for detecting whether bottles were present inside packages. The gauges involved in this incident were once used in ensuring empty packages no longer contained bottles.

The conveyor system on which the gauges were installed had been inactive for approximately twelve years at the time of the inspection.

The licensee employed a regulatory affairs staff who were delegated the

,. responsibility of ensuring that devices containing radioactive materials were handled l safely. Members of the regulatory affairs staff reported to a regulatory affairs j manager, who reported directly to the plant manager. In addition, the licensee had contracted with radiation specialist consultants, tasked with installation, relocation, source removal, and leak testing of sealed sources possessed under the general license.

2.0 Nuclear f =nga Removal 2.1- Inspection Scope l l

! The inspector reviewed the circumstances surrounding the unauthorized removal of two devices through interviews. Specifically, the group manager responsible for the demolition project, the bargaining unit employees responsible for dismantling the i conveyor system, and a member of licensee's regulatory affairs staff were  !

interviewed. These interviews provided the inspector with information concerning:

(1) the sequence of events resulting in the unauthorized removal of the devices; (2) the licensee's procedures to be followed during the removal of gauges containing radioactive material; and (3) the radiation safety training provided to personnel, i

l 2.2 Observations and Findings

a. Circumstances of incident l On April 25,1997, the group manager of maintenance was informed that he l would be responsible for the demolition of an inactive portion of the l- licensee's conveyor system. The conveyor system housed two Peco Pro Max 1000 gauges, each containing 100 millicuries of americium-241.

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I l The manager performed an inspection of the area containing the gauges on April 28,1997. _ At that time, he noted that the power to the conveyor j

system had been disconnected. After noting tags on the gauges indicating )

that the licensee's regulatory affairs department must be contacted prior to i t gauge removal, the manager left a message for the regulatory affairs staff on April 28,1997. While awaiting a response from regulatory affairs, he -

l contacted a plant environmental engineer regarding proper handling of the e

devices. Through a visual comparison with a similar device, the environmental engineer erroneously determined that the devices no longer

contained radioactive material; therefore, he informed the manager that the gauge housings could be disposed.

On April 29,1997, the group manager spoke with the licensee's regulatory

affairs staff, requesting verification that the sources had been removed from .

tha devices. The group manager informed the regulatory affairs department l

a that the portion of the conveyor system containing the gauges was to be dismantled on approximately May 2,1997. Due to an apparent l

miscommunication, the licensee's regulatory affairs staff contracted a i

consultant and requested removal of the sources on May 18,1997. During

} the April 29,1997 conversation, the licensee's regulatory affairs staff j requested that the gauges not be removed until the group manager received

positive confirmation that the sources had been removed from the devices, j However, following this conversation, the group manager assumed that the licensee's regulatory affairs staff would ensure the sources were removed from the gauge housings prior to the May 2,1997 demolition. Accordingly, the group manager instructed bargaining unit employees responsible for dismantling the conveyor system that disposal of the devices was authorized. )

l After the supervisor informed the employees that the devices could be I discarded, the employees removed the gauges on May 2 or 3,1997. One gauge was unbolted from the conveyor system, while the second had been previously detached. However,10 CFR 31.5 (c)(1) states that individuals generally licensed pursuant to that section comply with allinstructions i provided by the manufacturer's labels. The manufacturer's labels, affixed to l both gauge housings, stated that dismantling the devices shall be performed by persons specifically licensed by the Nuclear Regulatory Commission.

Removal of the devices by individuals not specifically licensed by the Nuclear Regulatory Commission appears to constitute a violation of 10 CFR 31.5 (c)(1). The gauges, fully intact, were placed in an area dumpster. The dumpster was subsequently emptied into a trailer located in a secured section of the licensee's facility.

Neither employee recalled noting indicator lights on the gauges. According to the manufacturer, power interruption to the gauges causes shutter closure. It is therefore unlikely that this unauthorized removal posed a significant safety hazard to the employees. However, removal of the gauges was a precursor to the unauthorized disposal of the gauges, which resulted in the rolease of radioactive material to the public domain.

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During an evaluation of the conveyor area in preparation for source removal on May 15,1997, an individual of the licensee's regulatory affairs staff  ;

realized that the gauges had been removed. This individualimmediately I notified his supervisor On May 16,1997, tha licensee contacted a l consultant and inquired as to whether the sources had been removed from the  !

gauges prior to disposal. The licensee's consultant confirmed that the i I

sources had not been removed in addition, on May 16,1997, the licensee determined that the gauge manufacturer had not received the gauges.

I Disposal of the gauges'is addressed in Section 3.0 of this report. l

b. Procedures for Gauge Removal The licensee's procedures for nuclear gauge removalinvolved contacting regulatory affairs prior to gauge removal. Attached to each gauge was a tag I indicating that the licensee's regulatory affairs department must be contacted prior to gauge removal. Once contacted, the licensee's regulatory affairs staff would contact a consultant and request that the sources be removed from the

, device. Following removal of the source, the authorization for gauge housing l

removal would be verbally granted by the regulatory affairs staff.

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The group manager did not receive specific instructions to be followed during l this demolition project. He was unaware of procedures to be followed; i l however, the tag attached to the gauges prompted him to contact regulatory I l- affairs. Because no specific documented authorization was required prior to gauge removal, the supervisor assumed that the sources would be removed from the gauges prior to the May 2,1997 demolition. The bargaining unit employees tasked with dismantling the con <eyor system indicated that they did not receive specific instructions regarding disposal of the devices. Both employees relied on their supervisor's instruction in determining when the devices could be disposed.

During discussions with the inspector, the plant manager agreed that specific l procedures, requiring written authorization prior to gauge removal, may have l precluded communication breakdowns between individuals. The plant manager indicated that the licensee would implement a procedure requiring written authorization from the licensee's regulatory affairs staff prior to l removal of gauges. This procedure would also require that documentation of l the date of gauge removal be returned to the regulatory affairs department.

! In addition, the plant manager presented new tags, larger and more colorful I than the tags previously attached to gauges, indicating that regulatory affairs l be contacted prior to gauge removal.

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c. . Training The member of the licensee's regulatory affairs staff interviewed indicated that he had been informed of the regulatory requirements regarding the disposal of radioactive material. In addition, he had attended training in 1991 5

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l or 1992 which addressed both radiation safety and compliance with pertinent Nuclear Regulatory Commission regulations.

1 The group manager responsible for the demolition project indicated that he had attended environmental training, which included information regarding radiation sources in the plant. However, this individual was unaware of the j' procedures to be followed in disposing of radioactive material. He knew to contact the licensee's regulatory affairs department only through inspection of the tags attached to the devices.

i Neither bargaining unit employee tasked with dismantling the conveyor l program could recall receiving radiation safety training. One bargaining unit  !

employee stated that he had no knowledge that such devices contained l radioactive material.

l l Demolition projects at this facility were uncommon. Neither the group I manager nor the bargaining unit employees had ever been involved in a project involving the handling of radioactive material. The plant manager explained that the novelty of the project may have contributed to this incident.

l During the discussions with the inspector, the plant manager concurred that l training allindividuals potentially responsible for handling radioactive material may be necessary to ensure that radioactive materials would be handled safely. The plant manager indicated that all plant engineers, maintenance supervisors, area managers, electricians, and contracted personnel will be retrained in the proper handling of radioactive materials.

3.0 Nuclear Gauge Disposal 3.1 Inspection Scope l

The inspector evaluated the circumstances surrounding the disposal of the gauges.

The inspector toured the scrap metal yard where the gauges were disposed and the l area of the licensee's facility where the gauges were once mounted. The inspection l included interviews with workers at the scrap processing facility and a member of the licensee's regulatory affairs department. The inspector completed independent measurements at the scrap metal facility and the licensee's facility. Scrap metal l smelting facilities which may have received the source were contacted, in addition, j the inspector reviewed documentation of leak test results of the recovered and mis. sing sources and of the disposition of metal processed by the scrap metal facility.

3.2 Observations and Findings The scrap metal facility log indicau a that the trailer containing the gauges was

, picked up from the licensee's facility on approximately May 6,1997. A scrap metal i worker recalled unloading the gauges, chich were intact, on May 7 and 8,1997.

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' The scrap metal worker dropped a magnet on the gauges in order to separate the j gauge housing from the inner stainless steel source housing. He then placed the gauge and source housings in separate containers.10 CFR 31.5 (c)(8) requires that

devices generally licensed pursuant to 10 CFR 31.5 be disposed of only through 4

transfer to persons holding specific licences pursuant to parts 30 and 32 of that chapter. Disposal of generally licensed devices through transfer to a person not i specifically licensed pursuant to part 30 and 32 of Chapter 10 of the Code of Federal j Regulations appears to constitute a violation of 10 CFR 31.5 (c)(8).

l The owner of the scrap metal processing facility explained that material was j unloaded and separated in a receiving building. Material was then separated into i stainless steel and non-ferrous material. Stainless steel was placed in a dumpster,

, while non-ferrous material was placed in a trailer. Stainless steel was then sold,

} while non-ferrous material was baled and placed on a tail car. The rail car was transported to four possible smelting facilities. The scrap metal processor's last sale

of stainless steel occurred on April 28,1997, prior to receipt of the missing sources.

4 in an attempt to recover the sources, the licensee began to survey areas of the scrap l

! metal processing facility on May 16,1997. Surveys were completed with calibrated

Ludlum Model 49 and 2350 sodium iodide scintillators. The receiving and separation

.. areas were surveyed. Every piece of metalin the stainless steel dumpster was j surveyed. Every piece of metal on the baling trailer was surveyed, in addition, the

licensee's baler, and several bunches of baled material, were surveyed. The rail car,

filled with baled material, was surveyed. Both gauge housings were recovered from a

{i barrelin the receiving area. Attached to both gauge housings were the manufacturer's instructions and " Caution-Radioactive Materials" postings.

During surveys of the stainless steel dumpster, the licensee recovered one of the missing sources. A leak test of the recovered source, completed on May 16,1997, verified that the source was intact. Measurements of the radiation levels on the exterior of the source housing were approximately 0.5 mR/hr. A leak test of the missing source, completed on March 13,1997, confirmed that the source was intact at that time. Independent measurements taken by the inspector did not detect radiation levels above background in the stainless steel dumpster, the ground where material was separated, the trailer, the baler, baled material, or the rail car.

On May 17,1997, the licensee removed the bales from the rail car and resurveyed this material. One barrel of material deemed inappropriate for recycling was surveyed. At the inspector's request, the vehicle used to transport the metal from the licensee's facility and all dumpsters which may have previously contained the source, were surveyed. However, the missing source was not recovered. The licensee requested that the rail car at the scrap processor not be released until an environmental assessment was completed.

The licensee provided the scrap metal workers with a physical diagram of the source.

Scrap metal workers interviewed were aware that a source was missing and indicated that they had not sighted a device meeting the physical description of the source housing.

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l At the time of the incident, two of the smelting facilities to which scrap material was sent had processed all metal received. Therefore, two smelting facilities possessed scrap metal which potentially contained the missing source. The licensee surveyed l

all material, in the form of loose metal, at one processing facility. When it was determined that the source was not intermixed with this metal, the material was released for smelting. The licensee surmised that 5-35 bales were smelted at the

- second facility prior to the licensee's identification of the lost material. The {

remaining metal at the second smelting facility,in the form of bales, was also l surveyed. The'se surveys did not detect the missing radioactive material. This could be expected, as the source would be compressed inside a metal mass, providing for attenuation of the low energy photon associated with the missing source.

Both smelters' utilized scintillation detectors to monitor material entering and exiting 'j the facilities. The sensitivity of these detectors was reported to range from 0.001  ;

mR/hr to 0.006 mR/hr. The facility which received baled material from the scrap processor had implemented a program' dictating that a sample of each melt be l surveyed. In addition, the exhaust associated with the melting process was monitored at this facility. The licensee requested that this material not be released for smelting until a dose assessment was completed.

A tour of the area from which the gauges were removed indicated that debris from )

the demolition was no longer present. Independent measurements verified that  !

radiation levels in this area were not distinguishable from background. l 1

1 The licensee's dose assessment indicated that the potential doses to members of the '

public were below regulatory limits. However, given the stringent disposal requirements to which transuranic elements are subject, unauthorized disposal of licensed material is a significant regulatory concern.

4.0 Written Report i 4.1 Inspection Scope i

l The inspector reviewed the licensee's written report, submitted to the NRC in '

accordance with 10 CFR 20.2201(b).

4.2 Observations and Findings The licensee's written report was submitted on June 13,1997. The licensee submitted a supplement to the report on June 23,1997. The report included a description of the material involved, the circumstances under which the loss of material occurred, the probable disposition of the lost material, estimates of exposures to those individuals involved, and estimates of the total effective dose l equivalent to persons in unrestricted areas.

The submitted report verified that two americium-241 sources containing a nominal 100 mci (3.7 gigabecquerels) were removed from the licensee's conveyor system on or about May 6,1997. The licensee attributed the inadvertent removal to an l

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r erroneous determination that the gauges no longer contained radioactive material.

The report indicated that an environmental engineer discovered that the gauges were missing on May 15,1997. Surveys of the scrap metal processing facility, initiated on May 16,1997, resulted in the recovery of one of the sources and both gauge housings removed during the demolition project. Surveys at the smelting facilities, conducted in an attempt to recover the lost source, were concluded on May 24, 1997.

! The licensee's report confirmed that the probable disposition of the material was as follows:

• On the ground or compacted at the scrap metal facility

• Compacted at the smelting facility at which bales were isolated or Incorporated into steel, slag, or baghouse dust at one of the smelting I

facilities.

The licensee's exposure evaluation indicated that the exposure to demolition and l

scrap metal workers due to handling the source housing should not exceed 0.01 mrem. The licensee determined that the maximum potential total effective dose  !

equivalent to an individual in an unrestricted area was 7 mrem. In addition, the l licensee determined that the potential skin exposure to individuals in unrestricted

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areas was 46 rad (46 rem).

Based on the licensee's assumptions and methodology involved in the dose assessment, potential doses to members of the public resulting from this incident would not exceed the 100 mrem total effective dose equivalent established by 10 CFR 20.1301 (a)(1). The licensee's estimated 46 rem skin dose does not exceed the limit established for occupational workers. The adequacy of the licensee's dose assessment is being reviewed by the Nuclear Regulatory Commission, j I

In addition to the corrective actions specified during the inspection, the licensee's written report indicated that the following corrective actions would be implemented

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1 in response to this incident:

• Once arrangements have been made for source removal, a member of the licensee's regulatory affairs staff will remove the tag dictating that the gauge not be moved.

• The licensee's regulatory affairs staff will maintain a log of the location of each gauge, and willinspect each unit periodically to confirm gauge placement.

5.0 Conclusion Coupled with the infrequent demolition of equipment which houses radioactive material at the facility, the unauthorized removal of two gauging devices indicated a 9

l need for both specific nuclear gauge removal procedures and provisions for informing all personnel who may handle radioactive materials of safe handing procedures.

Although the licensee undertook prompt and extensive corrective actions, the failure ,

to control licensed materialis a significant regulatory concern.

Two apparent violations were identified. The first related to failure to comply with all instructions provided by the manufacturer and the second involved the transfer of the generally licensed sources to an unauthorized recipient for disposal.

Exit _Maeting Summary 1

The inspector discussed the preliminary conclusions described in this report with licensee management during an exit meeting conducted at the licensee's St. Louis, Missouri facility on May 23,1997. The plant manager explained that the corrective actions specified in this report would be expanded to include all licensee facilities.  ;

The licensee did not identify any information reviewed during this inspection as '

proprietary in nature.

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Partial Unt nf Parnons_ Contacted John C. Nevin, Plant Manager

• Ronald A. Morgan, Director, Brewery Operations *

• Edward M. Bovier, Manager, Regulatory Affairs

• Francis J. Hruby, Associate General Counsel

• Chad Fisher, Environmental Engineer, Regulatory Affairs Mark Wiegers, Plant Engineer Kenneth Lordin, Group Manager, Maintenance l David Hergert, General Service Craft l Donald Carrolle, Bottler Gordie Gubin, President, Rimco, Inc. Scrap Metal Processors Michael Veniz,' Co-Owner Rimco, Inc. Scrap Metal Processors l Anthony Briner, Scrap Metal Worker Willy Phillips, Driver, Rimco Scrap Metal Processors l Joseph D. Koch, Ph.D., Health and Environmental Specialist, R.M. Wester and Associates i

• Indicates this individual was present during the on site exit meeting conducted on Ma -

! 23,1997.

l l LisLof_Acronyans_Used_in_ThisEeport

! CFR Code of Federal Regulations l DNMS Division of Nuclear Materials Safety l mci millicurie l

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