ML20148E216
| ML20148E216 | |
| Person / Time | |
|---|---|
| Issue date: | 05/28/1997 |
| From: | NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | |
| Shared Package | |
| ML20148D897 | List: |
| References | |
| NUDOCS 9706030033 | |
| Download: ML20148E216 (56) | |
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l INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW OF REGION III HATERIALS PROGRAM APRIL 21-25, 1997 i
DRAFT REPORT Office of Nuclear Material Safety and Safeguards U.S. Nuclear Regulatory Commission 9706030033 970528 PDR ORG NOMA PDR
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1.0 INTRODUCTION
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This report presents the results of the review of the Region ll1 (Rill) radioactive materials licensing and inspection program as well as the Rill fuel cycle inspection, and Site Decommissioning Management Plan (SDMP). The review was conducted by an interoffice team from the Offices of Nuclear Material Safety and Safeguards (NMSA) and State j
l Programs (OSP), Regions I and II, and an Agreement State team member from the State of J
l Colorado, over the period of April 21-25,in Lisle, Illinois. Members of the review team are j
listed in Appendix A. The review approach was based on the common performance j
j indicators of the integrated Materials Performance Evaluation Program (IMPEP) as described
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in SECY-94-011, Management Directive (MD) 5.6, " Integrated Materials Performance Evaluation Program," and the various non-common indicators circulated to the Region in advance of the review. Preliminary results of the review -- which covered the period of April 1995 to April 1997 -- were discussed with Rlli managemeat through the Acting Deputy Regional Administrator on March 25,1997. The Region will have the opportunity to comment on this draf t, and the comments will be factored into the final version of this report following a Management Review Board (MRB) meeting.
[ Paragraph on results of MRB meeting will be included in the final report. The Region's response will also be included in the final report.)
The Rlll materials, fuel cycle, and SDMP programs are administered by the Division of Nuclear Materials Safety (DNMS). Within DNMS, responsible branches include the Materials Licensing Branch, Materials Administrative Support Branch, Materials inspection Branch 1, Materials inspection Branch 2, Fuel Cycle Branch, and Decommissioning Branch.
The Rlll organization is shown in Appendix B.
The H!!! materials program included licencing, inspection, and enforcement for
.approximately 2200 materials licenses at the time of the review. This figure accounts for approximately 36 percent of all materials licenses under Nuclear Regulatory Commission J
(NRC) jurisdiction.
Section 2.0 below discusses Rlil's actions relative to the findings of the previous IMPEP review held in Spring 1995. The results of the current review for the common performance indicators of the IMPEP are presented in Section 3.0 below. Section 4.0 discusses the results of the review outside the common performance indicators, including the fuel cycle inspection, and SDMP programs. Finally, Section 5.0 summarizes the review team's findings and recommendations.
2.0 STATUS OF ITEMS IDENTIFIED IN THE 1995 iMPEP REVIEW Five recommendations were identified as part of the April 1995 IMPEP review. The status of these recommendations was formally addressed by Ritt in a memorandum dated September 21,1995. The 1997 review team assessed the status of these items to determine whether or not the Rlli program took actions to close the recommendations. A brief discussion and evaluation of each recommendation is summanzed below:
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l Region III Draft Report Page 2 Recommendation 1. Rlli should take appropriate steps to ensure that initial inspections of new licenses take place according to the requirements of Inspection Manual Chapter (IMC) 2800, ' Materia!s Inspection Program."
Current Strtus: This recommendation is closed. Rlll has revised its process for tracking the next inspection date for new licenses. New licenses are assigned a next inspection date of three months port issuance. At three months, the administrative staff contacts the licenseo to determine if it has possessed material or begun operations. Quarterly contacts continue until either material has been possessed or operations begun or until nine months (post license issuance) have elapsed. At that time, the next inspection date is established as 12 months post license issuance and an inspection is conducted.
Recommendation 2. NMSS should review Policy and Guidance Directive (P&GD) 92-04," Issuances of New Licenses for Materials Use Programs," to determine if additional guidance is necessary or if the region's piactice relative to issuance of new licenses is acceptable.
Current Status: This recommendation is closed. NMSS completed its review of P&GD 92-04. Actions are underway to delete the P&GD.
Recommendation 3. NMSS should review the region's trial program against the guidance of MD 8.8 and IMC 2800 and provide appropriate guidance to ensure uniformity for documentation of allegations throughout NRC.
Current Status: This recommendation is closed. NMSS reviewed the region's trial program. Comments were provided to the region in a memorandum dated September 8,1995. NMSS indicated that H the Rlll Trial Program was modified so as to ensure references to allegations are confined to allegation files and excluded from licensing files, then the Program would be consistent with agency policy.
flacommendation 4. Rlli should continue its efforts to improve inspection planning and ensure coverage of IMC 2600," Fuel Cycle Facility Operational Safety and Safeguards inspection Program," inspection procedures at fuel facilities and keep NMSS informed of its progress.
Current Status: This recommendationis closed immediately following the April 1995 IMPEP review, and during the succeeding review period, Rill developed and maintained a matrix displaying the types of fuel cycle inspections performed, and the frequencies with which they were conducted. In addition, NMSS has now developed a Fuel Cycle Master inspection Plan (MIP) to coordinate all regional and Headquarters fuel cycle inspections. This MIP will permit automated review of all fuel cycle inspections to establish that IMC 2600 inspection requirements are being met.
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Region III Draft Report Page 3 Recommendation 5. NMSS/ Division of Fuel Cycle Safety and Safeguards (FCSS) should revise the appropriate inspecticn procedure and coordinate with Rlli as well as other regions to ensure that fuel facility inspections cover licensee record retention required for decommissioning.
Current Status: This recommendation is closed. Following the April 1995 IMPEP review, NMSS revised IMC 2600 to provide specific guidance to inspectors reviewing licensee records, that records required for decommissioning are to be included in such inspections.
In summary, the team considers all of the above 1995 recommendations closed.
3.0 COMMON PERFORMANCE INDICATORS The IMPEP is based on five common performance indicators to be used in the review of both NRC Regional and Agreement Stato matarials programs. These indicators include: 1)
Status of Materials inspection Program: 2) Technical Staffing and Training: 3) Technical Quality of Licensing Actions: 4) Technical Quality of Inspection; and 5) Response to incidents and Allegations. In preparation for the review, NMSS issued a questionnaire to Rlll on February 20,1997. Rlli responded to the questionnaire on March 21,1997. A copy of that response will be included in the final version of this report.
The review team's approach consisted of: 1) examination of the regional response to the questionnaire; 2) review of selected quantitative information from the Licensing Tracking bystem (LTS); 3) technical review of selected licensing, inspection, incident, and allegation files; and 4) interviews with staff and management to clarify issues raised by 1),2), and 3) above. With assistance from inspectors in RI and Rll, the team also acconipanied three Rlli inspectors to observe their conduct of inspections at six facilities. The team evaluated the information that was gathered against the performance criteria contained in MD 5.6 and made a preliminary assessment of regional performance.
3.1 Status of Materials insoection Prooram The team focused on four f actors in reviewing this indicator: (1) inspection frequency, (2) overdue inspections, (3) initial inspections of new licenses, and (4) timely dispatch of inspection findings to licensees. The review team examined the Rlli questionnaire responses relative to this indicator, reviewed data gathered independently from the LTS, and examined docket files. In addition, the team interviewed the DNMS Acting Director, DNMS Acting Deputy Director, and the two DNMS Branch Chiefs who have principal responsibility for scheduling inspections.
The team's review of Rill's inspection priorities found that the inspection frequencies for dif ferent types of Rllilicenses are established in the LTS. The LTS inspection frequencies are managed by the Division of Industrial and Medical Nuclear Safety (IMNS), NMSS, and are based on the inspection frequencies in IMC 2800. Therefore, the Region is using
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4 Region Ill Draft Report Page 4 exactly the same standard frequencies in IMC 2800. The team determined that the Region is aggressively implementing the IMC 2800 policies that direct individuallicensee inspection frequencies to be extended or reduced, based on inspection findings and previous licensee performance. The Region implements this performance-based measure l
by indicating the next inspection date on the fieldnotes which are signed by their immediate supervisor and on their inspection planner. The administrative staff enters the i
next inspection date into the LTS system when they receive the inspection planner. If the supervisor changes the next inspect date after reviewing the fieldnotes, the Branch Chief forwards the revised date to the administrative staff via an LTS Data Entry Form. Printouts of the " inspection due lists" from LTS showed numerous examples where Rlll had extended or reduced inspection frequencies, and appropriately coded the change in the LTS. The Region appeared to extend more inspections than it reduced, which is consistent with IMPEP teams' observations in other NRC regions. In general, the review team determined that Rlli is following the IMC 2800 inspection frequencies and is actively extending or reducing individual licensee inspection intervals, based on licensee performance, in its response to the questionnaire, the Region indicated that (as of the date of the i
questionnaire)it had no inspections overdue by more than 25 percent of the assigned frequency in IMC 2800. The team noted that there were no overdue inspections at the time of the review. In FY 96, the region performed 732 inspections as compared to 705 inspections that they had budgeted to complete. As of February 1997,the region had performed 248 inspection as compared to the regional projection of 225 inspections. The team noted that in early FY 97 there was a small backlog of core and non-core inspections.
Regional management had identified the backlog and took immediate actions to reduce the backlog.
With respect to initial inspections, the review team examined a LTS listing of 17 new licenses issued by Rlli between January 1996 and June 1996,and cross-checked the new l
licenses with dates of initial inspections. Of the 17 new licenses issued,14 were inspected within the time frames for initial inspections specified in IMC 2800. Of the remaining three licensees, one was scheduled for inspection during the month of the IMPEP review, one was not required to be inspected because the new license was issued because the licensee had allowed its license to expire, and the third license was not inspected because the license was issued because of a change in the ownership of the organization.
In the second case, MC 2800 does not require an initialinspection if the licensee files for a new license within six months of license expiration. In the third case, MC 2800 does not contain any guidance. The review team recommends that NMSS examine the need for guidance for initialinspection of new licenses that are issued in the case of an ownership change, mailing office location change, or change in control. Overall, the Region is within the IMPEP evaluation criteria that inspections of new licenses are " generally conducted" within six months of issuance or in accordance with IMC 2800 provisions.
The timeliness of inspection findings was evaluated during the inspection file review. The majority of inspection findings were communicated to the licensee within 30 days after completion of the inspection. The team did note a trend regarding the number of reports exceeding the 30 day goal in the decommissioning area. In FY 96, approximately 11% of
-d Region III Draft Report Page 5 the inspection reports were issued after 30 days. Correspondingly, in FY 97, approximately 33% of the reports were issued after 30 days. During interviews with the DNMS Acting Director and Acting Deputy Director,it was learned that in early FY 97, DNMS management instituted a policy that all inspection findings were to be signed by the Director or Deputy Director of the Division. They recognized that this might delay the transmittal of inspection findings however, believed it was necessary to review the correspondence at this level. This policy change was made to ensure consistency within the Division and to ensure the reports were technically accurate. The DNMS Acting Director indicated that in the near future the plan was to return some signature authority to the Branch Chiefs. The team considered this information and determined that Rillis meeting the IMPEP evaluation criteria that "a large majority" of inspection findings are communicated to licensees in a timely manner.
l In its response to the questionnaire, Rlli provided statistics regarding the number of initial reciprocity requests and the number of reciprocity inspections completed during the review period. The region received 33 initial reciprocny requests during the review period (many licensees had filed more than one initial request during the review period). Of these, six licensees were industrial radiography; two were teletherapy and panoramic irradiator source installers, source changers, or source removals; and eight were for other services.
The region conducted 15 reciprocity inspections during the review period. The team determined that the region has a program in place to process reciprocity requests and to identify those licensees that should be inspected and appears to meet the inspection goals detailed in IMC 1220," Processing of NRC Form 241,' Report of Proposed Activities in l
Non-Agreement States,' and Inspection of Agreement State Licensees Operating Under 10 CFR Part 150.20."
Based on the evaluation criteria contained in MD 5.6, the team recommends that the Region's performance with respect to this indicator, Status of Materials inspection Program, be found satisfactory.
3.2 Technical Staffino and Trainino Issues central to the evaluation of this indicator include the DNMS materials program i
staffing level, technical qualifications of the staff, training, and staff turnover. To evaluate these issues, the review team examined the Rlli questionnaire response relative to this indicator and met with the DNMS Branch Chiefs to discuss staffing and training issues, including the qualification status of license reviewers rnd inspectors.
Technical and licensing support staff in the Rlll materials program are organized into the three t, ranches within DNMS: Materials Licensing branch, Materials Inspection Branch 1, Materials inspection Branch 2, Fuel Cycle Branch, and Decommissioning Branch.
At the present time, there are 15 materials inspectors (one inspector is currently on a detail outside DNMS) and 11 license reviewers (three individuals are part-time and one is on detail to NMSS). There are also nine technical staff in the fuel cycle area and eight in the decommissioning area. Recently,it was noted that regional management has transferred
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I Region III Oraft Report Page 6 individuals within the region to address workload variations. The review team concluded that the Region has a good mix in staffing for licensing and inspection activities. In l
addition, it appears that adequate administrative support is available. Additional discussion of resource utilization appears in Section 4.1 c' this report.
In its response to the IMPEP questionnaire, the Region reported that ten individual had left DNMS during the review period. Three left for other careers, two retired and five transferred out of the Division. Six individuals were hired during the review period. Of the six, one left the NRC and two transferred to another Division. The team noted some positions within the Division had been lost during the budget process it was also noted that some vacant positions had been filled by rotation assignments.
Wnh respect to qualifications, NMSS and the regions undertook a major effort during the review period to establish formal training standards for most materials-staff positions, culminating in the issuance of IMC 1246," Formal Qualification Programs in the Nuclear Material Safety and Safeguards Program Area," on June 7,1996. This resulted in the training requirements for many of the regional materials inspectors and license reviewers changing in the middle of this review period. Individuals already qualified in a discipline were given three years to complete any new formal classroom training requirements.
Personnel in the process of qualifying when IMC 1246 was issued were allowed to continue to qualify under the original requirements, with three years from the revision date to complete any new requirements. Regional Administrators may waive or extend any IMC 1246 requirements, and materials staff with prior experience and education may, on rare i
occasions, request to complete equivalency examinations in lieu of course attendance.
The Region reported in its response to the questionnaire that five individuals in the non-fuel cycle area have not been qualified to IMC 1246. (Qualification of fuel cycle inspectors is discussed in detail in Section 4.2.) The region expects that three will be qualified in the next few months. One individual will be qualified within the year and the other individual is currently on rotation to NMSS and will pursue qualification when she returns to Rill. The region indicated that in Fall 1996, DNMS management made a decision that all license reviewers would be required to take the Health Physics Technology Course (H-201). Prior to this, regional management had waived the requirement to complete this course. The region's plan is to have all license reviewers complete this course by October 1999.
The review team determined that Rlli has a well-organized system for planning, approving, and tracking training. The team noted that the region has established a Training Council.
This Council functions to ensure consistent and effective implementation of the 9111 training program and to assign priority to training needs. The Acting Division Director is i member of the Council.
In addition, the team noted that DNMS managers were fully cognizant of the qualification l
status and training plans for their staff, and management displayed a commitment to training. Technical staff regularly attended specialty training courses and refresher training, and appeared to maintain technical currency for their assigned positions. All j
technical staff appeared to the review team to have the basic technical skills to perform their jobs.
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Region III Draft Report Page 7 j
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Based on the evaluation criteria contained in MD 5.6, the review team recommends that
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the Region's performance with respect to this indicator, Technical Staffing and Training, be j
found satisfactory.
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3.3 Technical Quality of Licensina Actions The review team examined license files and related documentation and interviewed the responsible license reviewers for 21 specific licenses that had licensing actions completed during the review period. The 29 licensing actions examined by the team included 4 new licenses,7 renewal,12 amendments, and 6 terminations. Nine of the license files reviewed involved complex license types, including the following e
1 Academic broad scope j
e 1 R/D Broad Scope e
4 Medical, one required quality management plan e
1 HDR Brachytherapy, quality management plan required 2 Industrial radiography, temporary job sites e
Completed casework from several license reviewers as well as several types of licensed facilities were included in the team's evaluation. A list of the licensing actions reviewed is j
contained in Appendix D. In addition, the team interviewed license reviewers and supervisors, as necessary, to supply information regarding the team's questions on licensing decisions or docket file contents.
The licensing actions were reviewed for completeness, consistency, proper isotopes and quantities, qualifications of authorized users, adequate facilities, operating and emergency procedures, and authorized user training su'ficient to establish the basis for the licensing action. Casework was reviewed for timelinesa, adherence to good health physics practices, reference to appropriate regulations, documentation of the basis for the licensing decision, and consideration of enforcement history on renewals. The files were checked for orderliness and retention of necessary documents and supporting data.
The licensing actions were thorough, complete, consistent, and of acceptable quality with health and safety issues properly addressed. Tie-down and specific conditions were clearly stated, backed by information contained in the file and were considered to be inspectable.
In instances where compliance actions had not been completed, or where license reviewers had questions about the status of inspections, the reviewers routinely discussed the issues with the inspection staff to assure that licensing actions were in agreement with the compliance actions. The team noted that license reviewers provided information to the inspectors for follow-up during the next inspection. New licenses contained the appropriate license conditions.
The supervisory review of licenses is accomplished monthly by a tearn of three staff, including a senior licensing person and two other licensing staff, based on availability. Six to eight licenses are selected at random from licenses which are completed and rer.dy to mail. The review consists of either individuals reviewing licenses and then meetir.g % a
Region III Draft Report Page 8 group for discussion, or a review by the team of each license as a group. If minor errors are found which need to be corrected, the license is given back to the staff person for correction. If a major issue were observed by the review team, the team would review the issue with the Branch Chief. No major issues of a systematic or programmatic nature were apparent in the discussion of supervisory review with a senior licensing person.
The review team found that any deficiencies in the licensing actions reviewed were minor, isolated or administrative in nature, and most deficiencies were corrected during the on-site review. The Region's system for licensing remains formal, structured, clear, and appears to work well, as noted in the 1995 IMPEP review. No potentially significant health and safety issues were identified in the team's review of Rlil's licensing practices.
The review team examined Rlll licensing actions regarding terminated sites to determine if sufficient radiological surveys were performed before license termination and release, to ensure that residual radioactivity levels comply with release criteria, and to ensure that licensee survey results were validated through use of a closeout inspection or confirmatory survey, as required. All of the 'iles tSat the team reviewed were for facilities that did not require final status surveys or decommissioning plans. Most of Rlll's terminated licenses were facilities that possessed radioactive materials in the form of sealed sources or gauges, with documented leak tests, and the sources were shipped back to the manufacturer for disposal. Based on a sampling of terminated license files, the review team determined that the license reviews for these terminations were conducted properly by the Region. In addition, the regional staff, on their own initiative, prepared a document entitled, "Information that Should be Submitted to the NRC Staff for Decommissioning and Termination of Licensed Facilities." This document, for distribution to the licensee community, list the sections of 10 CFR Parts 30,40, and 70 applicable to decommissioning sites. The regional document also provides information regarding surveys during and after license termination. The review team identifies this document for terminating licensees as a good practice and recommends that its use be considered by other regions and Agreement States.
The Rlli decommissioning financial assurance instrument program was evaluated for routine, non-SDMP decommissioning projects and active licensees to determine if financial assurance instrument security programs are in place and to ensure that complete instrument files are being maintained. The evaluation was performed in accordance with MD 8.12, " Decommissioning Financial Assurance Instrument Security Program."
The staff provided the review team complete, detailed, well-organized inventories 'that listed individual financial assurance instruments. Access to the safe in Rlli was controlled and two sta ff members have the combination. A Financial Assurance instrument Custodian (FAlC), an alternate (AFAlC) and a Branch Chief have access to the combination. NRC Security Forms 702 (Security Checklist) have been observed to be used, and a log for removal or input of financial assurance instruments has been developed. During the review, the review team identifiad no performance-based issues regarding the financial assurance files.
MD 8.12, Section E, requires that the financial assurance instruments be maintained in a
" fire rated safe."
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Region !!! Draft Report Page 9 Based on the evaluation criteria in MD 5.6, the review team recommends that the Region's performance with respect to this indicator, Technical Quality of Licensing Actions, be found satisfactory.
3.4 Tecnnical Quality of Insoections The team reviewed the inspection field notes and other follow-up documentation and interviewed the responsible inspectors, when available, for 30 files documenting 36 materials inspections conducted during the review period. These inspections were performed by 21 Rlll inspectors. The reviewed cases covered 17 license types including limited and broad licenses of medical, academic, and industrial programs. In the file review, the team observed that Rlliinspectors useu the appropriate and most recent version of the inspection field notes and the Quality Management field notes to document inspections, as well as reports where appropriate. Appendix E provides a list of the inspection cases reviewed in full.
A senior health physicist from Region il and a team member from Region I accompanied three Rlliinspectors on a total of 6 inspections of 7 licenses. Inspector accompaniments were performed of three limited medicalinstitutions, an academic facility with a limited research license and a PuSe license, an academic Type B broad scope facility, and an assist inspection of a RIV manufacturer and distributor of gauges with a location in Rill.
On the accompaniments, the Rlli staff demonstrated appropriate inspection techniques and knowledge of NRC regulations and policies. The inspectors were well-prepared and thorough in their reviews of the licensees' radiation safety programs. Inspectors observed the licensee activities, toured facilities, ano reviewed licensee records. Overall, the performance of the inspectors was satisfactory, and their inspections were adequate to assess radiological health and safety at the licensed facilities.
The docket files appeared to be complete and in order. In almost all cases inspection results were well organized and easily retrievable. The team determined that Ritiis performing inspections of materials licensees on an unannounced basis, except for initial inspections or when necessary to insure the presence of licensee personnel (i.e., special inspections or geographically distant licensees or inspections), inspectors issued NRC Form-591 appropriately in the field. Documentation was complete and consistent with NRC guidance. Documents reviewed were of sufficient detail to substantiate the findings of the inspection, and were completed in a timely manner. Generally, inspection results were reviewed and approved by the supervisors within a few days after completion of documentation. However, a large number of inspections were given additional time prior to completion for the purpose of review of information in the office. In some cases, the end date of the inspection was several weeks later than the initial date of the site inspection. A self-assessment performed by Rillinspectors, as part of a new program discussed later in this report, also determined that some inspections were unnecessarily extended for in-office review. This resulted in clarification of circumstances for which extension is appropriate. Division managers are aware of this and monitoring work to ensure that fewer inspections will be extended unnecessarily for in-office review in the coming year.
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Region III Draft Report Page 10 The review team also interviewed 10 materials inspectors and the two materials inspection l
branch chiefs regarding the inspection process. Inspections were performed on an unannounced basis, except in the case of initialinspections. Inspections were scheduled using a list of licensees' inspection due dates, which is issued monthly, inspectors selected for inspection those licensees having the closest due dates so that no overdue l
inspections resulted, and then filled trips efficiently with other inspections due in the near l
future. Branch chiefs approved trips prior to inspection preparation. Inspectors also briefed supervisors as needed, bringing unusualissues, such as an apparent violation of security requirements, to their attention.
l The review team determined the accompaniments by supervisors were performed as required. The review team also examined the communication between Rllilicensing and inspection staff and found that appropriate information was discussed between inspectors and license reviewers before and after inspections.
During the IMPEP review, a team member attended an Enforcement Panel of two materials cat.as and selected five inspection-related Regional Procedures for review, inspectors were prepared to discuss the enforcement-related issues. The five Regional Procedures, each new or revised during the past two years according to the Rllt response to the IMPEP questionnaire, were consistent with other NRC guidance.
The team also reviewed information regarding the " quarterly inspection self-assessment" program which began in 1996. Each quarter, a senior inspector and a GG-13 inspector from each inspection Branch spend a day reviewing one area of inspection. Topics to date have included documentation using the field notes, completion of IFS data, and inspection of misadministrations and events. The inspectors selected appropriate documents for review and presented their findings in writing to the inspection branch chiefs. Findings have resulted in development of additional written guidance in the form of memoranda to the staff, as well as additional in-house training. The review team finds the " quarterly inspection self-assessment to be a " Good Practice".
The review team supplemented its case review with a review of the survey meter calibration, availability, and use. Adequate and appropriate instrumentation was available for, and was used by, inspectors to perform surveys during inspections. Confirmatory and independent measurements were reported in the inspection documents, with a description of the instrumentation used. The team reviewed the database used to track the inventory and assignment of survey instruments. This database is also used to track calibration information, and is used to ensure that meters are calibrated in a timely manner. The team found that survey meter calibration, availability, and use to be adequate, i
The review team also supplemented its case review with a review of the Rlli laboratory used for analysis of samples by Rill and RIV. The principle counting equipment in use include an intrinsic germanium detector with a multi-channel analyzer for gamma l
spectroscopy, a gas-flow proportional counter for alpha and beta analyses, and a Packard 2500 liquid scintillation counter primarily for analyses of tritium and low-energy beta emitters. At the time of the IMPEP review, the liquid scintillation counter was not operational. Although both the gamma counter and the gas-flow proportional counter are
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1 Region III Draft Report Page 11 operating and in calibration, there are deficiencies in the procedures and practices to demonstrate good quality assurance (QA) and quality control (OC) programs for the laboratory instrumentation. Laboratory personnel stated that they are in the process of upgrading the laboratory QA/QC programs to ensure that results of sample analyses are defensible.
Laboratory personnel stated that, prior to 1995, the emphasis was on use of the mobile laboratory in the Confirmatory Measurements Program, and little use was made of the Rlli
" fixed" laboratory. With the change to use of the Rllilaboratory primarily for analyses of samples from decommissioning sites, and to provide analyses for the RIV office, they are working to improve in-house laboratory procedures. Standard counting geometries have been established for the gamma counter, the instrementation in use has been calibrated, i
and data is being collected to establish control chaits for instrumentation operation.
However, additional improvements in the OA/QC programs are needed prior to re-establishing participation in a sample analysis cross-check program.
1 A self assessment of the laboratory performed during the period of February 14-23,1996, was documented in an undated " audit report" provided to the review team. Overall, the self-assessment determined that data from the laboratory was reliable, but that improvements were needed in the OA/OC programs, particularly in the area of documentation of procedures. A plan for improvement of the laboratory was described in a memorandum dated December 5,1996 from the DNMS Division Director to the Rlll Acting Deputy Regional Administrator. This memorandum, known in Rlli as the "get-well plan" for the laboratory, addresses 27 findings in 7 areas, and provides proposed corrective actions for each finding. Sixteen findings related to the need to revise or develop procedures for laooratory activities, including QA/QC procedures. Two findings directly related to the OA/QC programs. A third document entitled " Lab Accomplishments" was undated, but stated to be the status summary as of February 1997 of the progress on the corrective actions in the "get-well plan". The document appears to be the quarterly report of laboratory activities that is required by regional procedures, but it does describe improvements made recently in the laboratory. Based on a comparison of this report to the "get well plan", it appears that progress was made in completing actions in accordance with the schedule in the "get-well plan".
Although Rlil is aware of the problems in the laboratory and is workir.g on corrective action, the review team believes that the validation of the data from the laboratory is important to the support of the inspection program for both materials and decommissioning programs. The team recommendations that (1) NMSS and Rlll management closely monitor implementation of the laboratory QA/OC program and progress on the "get-well plan" and (2) Rlli, in coordination with NMSS and its contractor (RESL), ensure that independent audits of the laboratory are conducted to ensure that an adequate QA/QC program is implemented and maintained.
4 Based on the evaluation criteria in MD 5.6, the review team recommends that the Region's performance with respect to this indicator, Technical Quality of Inspections, be found satisfactory.
Region III Draft Report Page 12 3.5 Resoonse to incidents and Alleoations i
The review team examined the Rll! questionnaire response relative to this indicator and reviewed 10 incident report files and 17 allegation files. In addition, the team interviewed the Regional Office Allegations Coordinator and his technical staff, the Regional State Agreements Officer, a Materials inspections Branch Chief, and several materials inspectors.
Within Rill, the responsibility for follow-up actions of material events is located in DNMS.
Rill follows the guidance provided in IMC 2800," Materials Inspection Program," and Inspection Procedure 87103," Inspection of incidents at Nuclear Material Facilities".
The team examined the regional response to 10 selected events that the Region identified as significant events in response to the questionnaire. The 10 incidents included: 1 medical misadministration (brachytherapy), 2 potential overexposures, 2 damaged equipment / sources (due to heat and explosion / fire),1 unintentional exposure,3 contamination (loss of control) incidents, and 1 incident involving sto!en material. A list of the incident reports examined is contained in Appendix F.
The examination of incident investigations found that the Regional response to incidents was timely, appropriately coordinated, well documented, and of acceptable quality with health ard safety issues properly addressed. The medical misadministration included am W u follow-up and a consultant was on board within 5 days. Any questionable i
stemr, wees resolved during discussions with the staff. Licensee corrective actions were identified as adequate to the licensee and appropriate follow up measures were taken.
Discussions with management indicated that NMED had recently been made available to the Region and that they were currently incorporating it into their incident management program.
The Regional Allegations Coordinator has the responsibility for tracking all allegations, and coordinatin'; the Allagadon Review Board. Agency guidance for processing allegations is containd in Allegatu;n Guidance Memoranda (AGM) 96-01," Additional Measures to Protect the Identity of Allegers and Confidential Sources," dated November 12,1996; AGM 96-02,"Asswing the Technical Adequacy of the Basis for Closing and Allegation,"
t dated November 12,1996; MD 8.8, " Management of Allegations," and IMC 2800.
Regional guidance for processing allegations is contained in Regional Procedure 0517A, "V3nagement of Allegations," dated September 16,1996 and a " Branch Trial Program for Documenting Allegations," memorandum dated June 8,1993.
Discussions with the Regional Allegations Coordinator and his staff indicate they utilize MD 8.8, both AGMs, IMC 2800, Regional Procedure 0517A, and the Branch Trial Program memorandum as guidance. Discussion with DNMS management indicated that the Branch Trial Program memorandum is no longer in offect. The Branch Trial Program was recommended for revision in a NMSS memorandum issued September 8,1995 in response to a 1995 IMPEP team recommendation. Although Rlll practice in the handling of i
l allegations is in compliance with MD 8.8 and IMC 2800, the current status of the Branch Trial Program, and the NMSS suggested revisions to it, was not clear. The team recommends that Rlli examine all procedures or documents relating to the handling of
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allegations to ensure that they are consistent with MD 8.8 and IMC 2800. Guidance on j
electronic transmittal of allegation related material should be included in the procedures, in addition, the procedures or documents should explicitly state that information referring to an allegation should not to be included in the docket file.
During the review period,151 material allegations were opened in Rill. Of those,130 t
cases were closed and 21 remain open. Seventeen allegation files were selected for review involving a variety of technical and administrative issues from a list provided by the NMSS Allegations Officer. The allegations involving materials were reviewed for j
responsiveness, coordination, control, technical effort commensurate with the potential health and safety significance of the allegations, corrective actions, notifications to a
i appropriate internal and external organizations, follow-up and documentation. There were I
only two instances of improper handling of allegation related material noted. The first
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instance was found in an allegation file and involved the electronic transmittal (e-mail) of i
an allegers identity from an inspector to manageme,1t. Although the e-mail documentation was correctly placed in the allegation file, MD 6.8 states that the identity of an alleger or j
confidential source should be deleted from e-mail transmittals. Discussion with the j
Allegations Coordinator indicated that regional policy is to delete the e-mail on the receiving and sending end when it contains allegation related material. The other instance was found in a docket file which included a cover memo to field notes that stated the
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inspection was porformed as a follow-up to an allegation concerning improper radiography.
The Allegations Coordinator was informed and the docket file was delivered to his office.
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The team fou id that allegations were responded to promptly, actions taken were 4
l appropriate, and internal and (when necessary) external coordination was taken with the appropriate parties on a timely basis. With the two exceptions noted above, proper procedure for control of information and maintenance of records was followed and information was available in the allegation files, docket files, and electronic records maintained by the Regional Allegations Coordinator.
Based on the evaluation criteria in MD 5.6, the review team recommends that the Region's performance with respect to this indicator, Response to incidents and Allegations, be found satisfactory.
4.0 NON-COMMON PERFORMANCE INDICATORS in addition to the common performance indicators addressed in the preceding Section 3.0, the review team also examined Rill's performance relative to various NMSS programs or initiatives. For Rlll, the team examined the Region's performance relative to operating plan goals, its use of NMSS program resources, the fuel cycle inspection program, SDMP program, and uranium recovery inspections. These areas are discussed in the following sections:
Region III Oraft Report Page 14 4.1 Performance aaainst Ooeratina Plan Goals Materials Licensina. In FY 96, Rlll completed 1892 materials licensing actions, compared with a goal of 1475. (Note, many of these caces were a result of the one-time extension in license duration.) As of the end of February 1997,the region had completed 520 actions, as compared to a budget of 590 actions. The review team determined that the number of non-core (renewals) licensing cases exceeding ninety days has decreased significantly since FY 96. At the end of FY 96,73 cases exceeded the ninety day mark.
At the end of March 1997, only 31 cases exceeded the ninety day mark. The number of core (new and amendments) cases has also decreased from FY 96. At the end of FY 96, 68 cases exceeded the mark as compared to the current backlog of 40 cases.
In FY 96, performance goals no longer measured completions against a prescribed target.
Rather, the emphasis was shifted to control of pending casework and reduction of backlog.
The review team discussed the licensing backlog, and Rlli's plans to eliminate the backlog, with DNMS management. DNMS has been working to reduce the backlog, with steady success.
Backlog reduction remains a very high priority for Rlll and NMSS managers.
DNMS has committed to the Rlli Regional Administrator that all renewals exceeding the ninety day mark would be completed by the end of calendar year 1997. In an effort to accomplish this task DNMS management has taken the following actions: (1) reassigned individuals from the inspection Branch to the Licensing Branch; (2) requested bi-monthly
(????) briefings on the status of outstanding actions; and (3) limited licensing staff to licensing issues, e.g. used inspection staff for special projects such as support to NMSS.
Rlli and IMNS management will continue to monitor progress on reducing the licensing backlog.
Materials Insoections. See Section 3.1. Regional performance on materials inspe.ctions is compared in Section 3.1 to timeliness goals, rather than total numbers of inspections performed. The Rlli FY 97 Operating Plan also provides DNMS' nuclear materialinspection assignments and standards in terms of inspection timeliness and quality, rather than gross numbers of inspections completed.
Resource Utilization, in FY 96, Rill expended 39.8 full time equivalents (FTEs) vs. 41.8 FTEs budgeted for NMSS program activities (95 percent). Based on expenditure data through December 31,1996, Rlli had expended 9.8 FTEs as compared to a prorated budget of 11.1 FTEs for the first quarter of FY 97 (annual budget 39.7 FTEs). FY 96 regional expenditures for event evaluation (151 %) and FY 97 expenditures, to date, for event evaluation (140%) and decommissioning (158%) dominate resource utilization of budgeted resources.
On balance, the review team found the Region's resource utilization to be responsive to program needs, and in accordance with program office goals. Attachment 2 presents this data in more detail in tabular form.
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Region III Oraft Report Page 15 The Region's FY 97 Operating Plan specifies that, " Emphasis should be placed on eliminating the number of backlogged licensing actions, and overdue inspections, particularly those in the core program, and issuing inspection reports in a timely manner.
The Region will also apply resources to conduct reactive inspections, and to respond to incidents and allegations in a timely manner. Priority will be given to reactive inspections, core licensing, core inspections, decommissioning activities associated with Site Decommissioning Management Plan sites, non-core licensing, non-core inspections and non-routine decommissioning activities not addressed in the SDMP,in that order. Also, the Region will apply resources to program initiatives to enhance and improve program activities as appropriate. ' Based on the review team's interviews with regional managers, 1
examination of PMDA's budget data, and consideration of the Region's performance aiross all materials areas, the review team concluded that Rlli is closely adhering to the prioritiet given in the Operating Plan in accomplishing DNMS' mission.
Based on the review team's analysis of the resource expenditures and the Region's productive use of the resources, the review team recoinmends that the Region's performance with respect to this non-common indicator, Performance Against Operating Plan Goals, be found satisfactory.
4.2 Fuel Cvcle Insoection Proaram 4.2.1 Introduction The Rlli IMPEP review was conducted while pilot-testing a new draft non-common performance indicator (and accompanying evaluation criteria) for regional fuel cycle inspection programs. This indicator is composed of four sub-indicators covering (1) Status of Fuel Cycle Inspection Program, (2) Technical Staffing and Training, (3) Technical Quality of Inspections, and (4) Response to incidents nd Allegations. These sub-indicators parallel the corresponding common performance indicators for the materials program, with the exception of the licensing function which is performed exclusively by FCSS in NMSS.
The fuel cycle inspection program at Rill, and NRC-wide, has undergone significant modifications during the review period. Two new FCSS inspection programs for nuclear criticality safety (NCS) and chemical safety were initiated, with the regions retaining responsibility for operational aspects of NCS inspections.
A MIP now encompasses all fuel cycle facilities regulated by the NRC. This plan coordinates fuel cycle inspections conducted by all regions and FCSS. As part of this new, integrated approach, inspectors are now conducting inspect;ons across regional boundaries in a process called " Cross-Fertilization." This program broadens the experience base of the inspectors, and helps promote cross-regional consistency. It also provides a larger cadre of inspectors who are knowledgeable of all the fuel cycle facilities, which may be important in incident response, and in ensuring the availability of certified inspectors.
Region III Draft Report Page 16 A new Fuel Cycle Licensee Performance Review (LPR) Program also has been initiateo by FCSS. This LPR Program is designed to render a " big picture" view of licensee performance for senior NRC management, and provide a basis for adjusting the fuel cycle facility inspection program, including such areas as inspection focus, frequency, and resources. It also informs licensees on how NRC management perceives their performance in protecting public health and safety. Each region has the lead responsibility for conducting LPRs for its own facilities. The details of the program are described in a new IMC 2604," Licensee Performance Review," which was issued on August 26,1996.
During the review period, FCSS also developed, and is in the process of refining, a new Fuel Cycle Inspection Management System (FCIMS), which will provide automated tools to improve the management of the fuel cycle inspecticn program, both in the Regions and FCSS. FCIMS is used to schedule inspections. identify specific inspectors for each inspection, and specify what functional areas the inspections should cover. IMC 2600,
" Fuel Cycle Facility Operational Safety and Safeguards inspection Program," and several inspection procedures were revised, and new inspection procedures were developed during the review period. The draf t non-co.1 mon performance indicator for the regional fuel cycle inspection programs also recognizes these new developments.
The Rlll fuel cycle inspection program includes the ABB Combustion Engineering (CE) fuel fabrication facility in Hematite, Missouri, the Allied Signal uranium conversion facility in Metropolis, Illinois, and two gaseous diffusion plants (GDP) in Paducah, Kentucky and Portsmouth, Ohio, j
The GDPs were recently placed under NRC's regulatory oversight after a 120-day transition period, following certification. (The GDPs, which are being operated by the United States Enrichment Corporation (USEC), were certified rather than licensed, as established under the Energy Reorganization Act of 1992, and each have compliance plans for coming into iull compliance with NRC regulations.) During this iransition period, and for an extended period before certification, beginning early in the review period, Rlli and Headquarters conducted extensive observation visits. Two NRC Resident inspectors are assigned to each GDP.
4.2.2 Status of Fuel Cvele insoectio, Proaram During the review period, Rill conducted 48 inspections or observation visits at licensed fuel cycle facilities and the GDPs. (Reports on the GDP visits were identified as
" observation reports" prior to March 3,1997, since the GDPs were not under NRC regulatory oversight.) No reports were available of NRC inspections that occurred af ter March 3,1997, when NRC assumed regulatory oversight. Rill maintains a timeliness goal of issuing inspection reports no later than 30 days following the conclusion of each inspection, consistent with IMC 0610," Inspection Reports". During the review period, fuel cycle facility inspection reports were issued an average of 21.8 days after conclusion j
of each inspection. FCSS did not expect that the timeliness goals normally established for I
inspection reports would be imposed on the observation reports, a
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l Region III Draft Report Page 17 As the result of a finding during the 1995 IMPEP review for Rlli, the Fuel Cycle Branch, l
DNMS, established the practice of keeping a log in the form of a matrix to track the l
completion of fuel cycle inspections by type. The reviewer examined the matrix and determined that 4 was current and that it permitted an independent reviewer to establish quickly and cle
> &at the body of inspections performed during the review period conformed to ths rerjuirements of IMC 2600. In the future, it is expected that there will be l
an automated way of checking conformance of both completed and planned inspections with IMC 2600 requirements, based on the FCIMS now being used for integrated management of the fuel cycle inspection programs in all regions and at Headquarters.
4.2.3 Technical Staffina and Trainina i
During the review period, the Rlli fuel cycle program added four new staff members and lost two resident inspectors to other positions within NRC. One existing project inspector for fuel cycle facilities, and one of the newly hired staff, became resident inspectors for the GDPs, to replace the two residents vho left. The turnover of two resident inspectors who took other NRC positions are considered normal attrition. The remaining three new hires j
were being trained as project inspectors for fuel cycle facilities. However, one of them was recently reassigned to NRR, and is no longer in the Fuel Cycle Branch. Of the j
remaining two new project inspectors, one is expected to be certified as a fuel cycle inspector within a month, and another within six months. They both have appropriately maintained qualification journals. The reviewer determined that they are making normal progress towards certification.
In addition to the prescribed training for tuel cycle inspectors in IMC 1246, Rlll fuel cycle inspectc: who inspect GDPs, including the residents, are also provided training in the safety of overhead crane operations and in other safety areas significant to GDP operations. After the recent hiring there are currently tv$o resident inspectors at each GDP, however, only one resident inspector at each facility is a certified resident inspector.
Recently,it was announced that the Branch Chief of the Fuel Cycle Branch, DNMS, will be transferred to a position in the Rlli reactor safety program, and the vacant slot is likely to be filled by a manager from Rlll's reactor safety program, who is not expected to have experience with fuel cycle facilities. The availability of experienced technical staff, who are certified inspectors, and of management who are knowledgeable of fuel cycle facilities, is an area needing increased management attention. The review team recommends that Rlll management focus attention on staffing stability and qualification in the fuel cycle and GDP area.
4.2.4 Technical Quality of Insoections During the review period, the Fuel Cycle Branch Chief, DNMS, accompanied fuel cycle inspectors on 22 separate inspections. Each fuel cycle inspector was accompanied at least once during each calendar year during the time they were assigned to the Fuel Cycle Branch.
Region III Draft Report Page 18 Much of the inspection effort at the GDPs is provided by the four resident inspectors.
There appears to be a strong program for integrating the residents' inspection efforts with those of the project inspectors, both irom the Region and Headquarters. The region conducts daily telephone conferences between the Region and both GDPs to discuss inspection-related matters. To address the large number of anticipated potential violations j
that will be identified during the initial inspections of the GDPs, after March 3,1997, enforcement panel teleconference meetings are now being held during the week following i
completion of each regional or Headquarters inspection. Regional and Headquarters j
inspectors and management, the Office of Enforcement, the NMSS Enforcement Coordinator (a new position), and the GDP Resident inspectors, all participate in these enfPcement panels to ensure a consistent NRC position in handling violations.
I The GDP Resident inspectors cumulatively report taeir findings to the Region and to the i
manegement of the GDPs every six weeks. At the conclusion of each six-week reporting j
period, a teleconference pre-exit briefing is held between the Resident inspectors and regional management, and a post-exit briefing is also conducted, if necessary, to convey to j
redonal management any significant responses the cer'tificate holder provides at each exit meeting. Furthermore, the Fuel Cycle Branch, DNMS, rotates the locations of Branch meetings among Rlli and each of the GDP sites.
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4.2.5 Resoonse to incidents and Alleaations i
There were six safety significant incidents at licensed fuel cycle facilities during the review period. Two of these incidents gave rise to reactive inspections, and an additional one was investigated by an Augmented Inspection Team (AIT). The reviewer examined the AIT report, and several reports for the reactive inspections. The fuel cycle inspection staff also monitored incidents that occurred at the GDPs. The incidents reviewed occurred before i
NRC assumed regulatory oversight responsibility for the GDPs, and were investigated by the Department of Ene.rgy (DOE).
The Region's responses to incidents were well grounded technically, and focused primarily
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on safety. It was not clear, however, what procedures should be used by staff when responding to incidents at fuel cycle facilities. Guidance for reactive inspections and inspections by AITs exist (e.g., MD 8.3, "NRC incident investigation Program;" IMC 0325,
" Augmented Inspection Team;" IMC 1301," Response to Radioactive Material incidents That Do Not Require Activation of the NRC incident Response Plan:" and IP 87103,
" Inspection of incidents at Nuclear Materials Facilities"), but they were developed for application to the regional materials inspection programs, other than for fuel cycle, and rarely provide examples or specific references to fuel cycle safety concerns.
For example, the section on " Additional Guidance on Non-Reactor Events"in IMC 0325, for selection of operational events for AIT responses (0325-05.03),does not address significant nuclear criticality issues, such as events where significant pathways to a nuclear criticality may be identified with no controls remaining in place. it was noted that some of these documents are included in the qualification journals of the two inspectors currently being trained, but IP 87103, which has the most practical guidance for conduct
4 Region III Draft Report Page 19 of reactive inspections, is not included. The review team recommends that NMSS review existing inspection procedures and manual chapters regarding performance of reactive inspections to ensure applicability and adequacy for fuel cycle facility inspections.
Supplements to the Response Technical Manual, developed by Headquarters for each GDP, are available in Rill for response to major incidents at the GDPs. In addition, updated maps of the surrounding areas for each facility are available in the Rlli incident Response Center, as well as in the Headquarters Operations Center.
Rlli participated in a " table top" exercise for emergency response at a GDP in November 1996, along with Headquarters, DOE, USEC, and GDP site representatives, and they plan to participate in a site exercise for Portsmouth in Saptember 1997. During the " table-top" exercise, participants discussed possible implementation of two additional communications measures that could prove valuable during an emergency at a GDP. These included i
establishment of a Health Physics Network (HPN) for maintaining open line voice communications during an emergency, and maintaining a direct digitalinformation connection with the NRC Operations Center fer transmitting health physics information, also termed a Historian Data Line. Although neither of these measures are required in NRC regulations, nor recommended in existing or draft NRC guidance, USEC had expressed a willingness at the " table-top" exercise to consider their implementation. In recently reviewing preparations for incident response at the GDPs, Rlli made inquiries to determine the status of these communications proposals, but had not yet received a response from Headquarters. The team has since learned that transmission capability for the Historian Data Line has been established between the GDPs and the NRC Operations Center, and that Rlli may also be able to access the Historian Data Line through the NRC's Response Communications System, which links the NRC Operations Center with the Regions.
Neither NMSS, nor AEOD, are aware of any further progress on implementing the HPN, although FTS 2000 lines are currently in place to link the NRC Resident inspector offices at the GDPs with Headquarters and Rill.
The Region has had to respond to relatively few allegations during the review period. Only one allegation was required to be fully investigated, involving a possible mis-shipment of sewage sludge. Two additional allegations had been received and were scheduled for review by an Ailegatons Review Board during the weeks following this IMPEP review. It appeared that these alNgations were being addressed appropriately, with concomitant safety implications being duly considered.
4.2.6 Summary Based on the draf t evaluation criteria for the fuel cycle inspection program non-common performance indicator, the review team recommends that Rill's performance with respect to this indicator, Tuel Cycle Inspection Program, be found Satisfactory.
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Region III Draft Report Page 20 l
l 4.3 Site Decommissionina Manaaement Plan (SDMP)
This non-common indicator was reviewed in a pilot program to evaluate the Site Decommissioning Management Plan (SDMP) program at the Rill office in Lisle, Illinois. The non common performance indicator for evaluating the SDMP includes: 1) quality of SDMP l
decommissioning reviews; 2) Financial assurance for decommissioning; 3) termination j
radiological surveys; 4) inspections; 5) staff qualifications; and 6) SDMP Milestones. In performing this review the reviewer conducted interviews with the Rllt decommissioning inspection and licensing staff and examined inspection, licensing and financial assurance files in the Regions' Administrative Support Branch. Staff interviewed in R14 included four decommissioning inspectors and two license reviewers from the Materials Licensing j
Branch. The Branch Chiefs from the Material Licensing Branch and tha Decommissioning Branch were also interviewed. In addition, severa, licensing-SDMP project managers from the Division of Waste Management, NMSS, located in Rockville, Maryland, were interviewed.
4.3.1 Quality of SDMP Decommissionina Reviewji Files for 7 SDMP sites were examined. These included the Chemetron Corporation, BP l
Chemicals, Dow Chemicals, Mallinkrodt Chemicals, Jefferson Proving Ground, and Elkem Metals.
The quality of SOMP actions taken in Rlll was assessed by performing an evaluation to determine if sitnificant decommissioning actions at facilities listed on the SDMP (and inspected in Rill) were reviewed and approved in advance of a':tual decommissioning activities by the licensee. Second, a determination was made to evaluate if decommissioning plan reviews are conducted in accordance with IMC 2605,"NMSS Handbook for Decommissioning Fuel Cycle and Materials Licensees."
Regional success with the first element often requires coordination between Rlll inspectors and DWM licensing project managers because the staff and licensing project manager responsibilities are functionally and physically separated. The review team found good indication that this communication process is working well as evidenced by documentation in the docket files showing that many inspections were conducted just before significant decommissioning actions. Rlll was also found to conduct inspections following a request from the licensing project manager. Information obtained from interviews with licensing project managers and inspectors indicate that Rlliinspectors often contact the licensing project managers when issues are raised on inspections regarding the meaning or intent of conditions in the SDMP facility license or when policy issues are raised during inspections.
Regional success with the second element is demonstrated by inspecting decommissioning sites at appropriate milestones and periorming the inspections in accordance with IMC.
Rill was evaluated by determining if inspections that were conducted following issuance of l
the IMC 2605 (November 1996) used the methodology contained in the IMC and if l
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1 Region III Draft Report Page 21 decommissioning inspection reports covered areas referenced in the two new IPs (IP 87104," Decommissioning Inspection Procedure for Materials Licensees" and 88104,
" Decommissioning inspection Procedure for Fuel Cycle Facilities") identified in IMC 2605.
An examination of the 7 SDMP inspection files (and corresponding inspection reports) evaluated for this review indicates that the new decommissioning guidance contained in IMC MC 2605 and referenced in IP 87104 and 88104 has been used extensively since its formalissuance in July of 1996.
All of the inspection reports reviewed indicate that decommissioning inspectors are aware that licensee decommissioning activities must be in accordance with decommissioning timeliness requirements. Interviews with inspectors in Rill reveal that inspectors are aware of the new inspection manual chapter, associated check lists, and the new inspection procedures. Decommissioning inspectors are usually aware of major inspection issues regarding decommissioning activities and are using the new inspection guidance in an effective manner.
4.3.2 Financial Assurance for Decommissionina This sub-performance indicator contains three areas for examination by the review team: 1) has adequate financial assurance for the decommissioning of SDMP sites been established in accordance with regulatory requirements: 2) has financial assurance been provided for the estimated costs for an independent third party to perform decommissioning and 3) have financial assurance mechanisms been reviewed and maintained properly.
The Rlli financial assurance review focused on the security of instruments contained in the Region's financial assurance safe. There is a Financial Assurance Instrument Custodian and an Alternate Financial Instrument Custodian. Three people in the Region have the combination to the safe. In addition, a check of 63 files found that the access to the log and the safe is properly controlled, a proper accounting log is being maintained, the log accurately reflects the cost and number of instruments, and the safe is properly fire rated as required by MD 8.12, 4.3.3 Termination Radioloaical Survevs This sub-indicator assesses how the Region insures that sufficient radiological surveys are conducted, as outlined in IMC 2605, for license termination and that licensee survey results are validated by the Region through a closeout survey. To assess this indicator, inspection files for 10 terminated sites were reviewed along with license files for these same sites.
New request for terminations in Rlli are first handled by license reviewers in the Materials Licensing Branch. If a licensee's request for termination is a Type 1 decommissioning, as described in the Decommissioning Handbook (i.e. the radioactive materialis contained in a sealed source or gauge that hasn't leaked and/or the half life of the radioactive materialis I
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Region III Draft Report Page 22 less than sixty days), the license reviewer will make the determination that a final survey is not required, make sure that the licensee provides for disposition of the remaining
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radioactive material, and issue an amendment to terminate the license. If the reviewer has a question regarding the type of decommissiodng action that should be assigned, the reviewer will refer the case to the Decommissioning Branch and an experienced license reviewer / inspector frorn this Branch will oversee termination of the license. Based on i
interviews with inspectors and license reviewers, this procedure is working, in all cases reviewed, reviewers have used the guidance provided in IMC 2605.
The review team found evidence that NUREG 5849 (Manual for Conducting Radiological Surveys in Support of license Termination) was used for review of the decontamination of partially contaminated areas, as recommended in IMC 2605.
I 4.3.4 INSPECTIONS This sub-indicator of the SDMP program establishes whether the Region conducts i
decommissioning inspections in accordance with established frequencies and procedures j
contained in IMC 2605 and IPs 87104 and 88104. The review team examined the Rlll I
decommissioning inspections with focus on safety of licensee procedures, release of effluents to the environment, general public and worker exposure, and suitability of decontaminated areas and structures for release.
The review team found that the Region performed in accordance with frequencies established in IP 88104 and IP 87104. The review team also examined the decommissioning inspection files and observed that most Rlli decommissioning inspections referenced the use of IP 87104, of ten covered the areas listed in the new procedures, and made extensive use of the check list contained in the procedures.
4.3.5 Staff Qualifications All of the decommissioning inspectors in Rlli are qualified as materials inspectors, with the exception of two inspectors relatively new to the Decommissioning Branch. The two new inspectors are pursuing additional qualification courses in IMC 1246 for decommissioning inspectors (the staff has a 3 year period to complete qualification course requirements).
One inspector is an experienced reactor inspector and should add expertise to the Decommissioning Branch inspections. The Region has a highly qualified staff.
4.3.6 SDMP Milestones Successful performance under this sub-indicator would require that decommissioning milestones summarized in the SDMP and applicable to the Region are being met, that any delays are identified in the SDMP data base, that mechanisms are in place to ensure that appropriate corrective actions are taken by the Region, that policy issues affecting the decommissioning of SDMP sites are being identified to DWM, and that Regional staff are i
updating the SDMP data base in a timely manner.
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Region III Draft Report Page 23 The areas of 'his sub-element are not applicable to Rlll because the licensing functions are managed by DWM with the exception of identifying policy issues to the SDMP site project managers in DWM. The regional office has only inspection responsibility for SDMP sites.
The regionalinspectors have raised important policy issues for resolution and often recommend corrective actions to the SDMP site project manager. This communication helps to speed along licensing actions.
Based on the draft evaluation criteria for the fuel cycle inspection program non-common performance indicator, the review team recommends that the Region's performance with respect to this indicator, SDMP Program be found satisfactory.
The IMPEP team identifies the Rlll document entitled, "Information that Should bo l
Submitted to the NRC staff for Decommissioning and Termination of Licensed Facilities,"
for distribution to licensees with terminating sites, as a good practice, and recommends that its use t'e considered by other regions and Agreement States.
4.3.7 Summarv i
Based on the draft evaluation criteria for this non-common performance indicator, the review team recommends that the Region's performance with respect to this indicator, Sito Decommissioning Management Plan, be found satisfactory.
5.0
SUMMARY
As noted in Sections 3.1 through 3.5, the review team found the Region's performance with respect to each of the common performance indicators to be satisfactory. In addition, the team found that Rlil was making appropnc.te use of budgeted resources and that the quality of the fuel facility inspection program was satisfactory. The review team also found that Rlli's implementation of its SDMP and uranium recovery programs was satisfactory. Accordingly, the review team recommends that the MRB find the Rill program to be adequate to protect public health and safety.
Recommendations. Below is a summary list nf recommendations, as mentioned in earlier parts of this report, for action by Rlli, or NMSS:
1.
NMSS should examine the need for guidance for initial inspection of new licenses that are issued in the case of an ownership change, mailing office location change, or change in control. (Section 3.1) 2.
NMSS and Rlll management should closely monitor implementation of the laboratory QA/QC program and progress on "get-well" plan. (Section 3.4) 3.
Rill, in coordination with NMSS and its contractor (RESL), should ensure that independent audits of the laboratory are conducted to ensure that an adequate OA/QC program is implemented and maintained. (Section 3.4)
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Region 111 Draft Report Page 24 l
4.
Rlll should examine all procedures or documents relating to the handling of allegations to ensure that they are consistent with MD 8.8 and IMC 2800.
l Guidance on electronic transmittal of allegation related material should be included
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.in the procedures. In addition, the procedures or documents shnuld explicitly state that information referring to an allegation should not to be included in the docket file. (Section 3.5) 5.
Rill management should focus attention on staffing stability and qualification in fuel cycle and GDP area. (Section 4.2.3) 6.
NMSS should review existing inspection procedures and manual chapters regarding performance of reactive inspections to ensure applicability and adequacy for fuel cycle facility inspections. (Section 4.2.5)
Good Practice. Along with the recommendations for Rlli or NMSS improvement, the review team identified the folicwing lood practices:
1.
The team identified the Rlli " quarterly inspection self-assessment" program as a good practice. Each quarter, a senior inspector and a GG-13 inspector from each inspection Branch spend a day reviewing one area of inspection. Topics to date have included documentation using the field notes, completion of IFS data, and inspection of misadministrations and events. The inspectors selected appropriate documents for review and presented their findings in writing to the inspection branch chiefs. Findings have resulted in development of additional written guidance in the form of memoranda to the staff, as well as additionalin-house training.
2.
The review team identified the Rill document entitled "Information That Should Be Submitted To The NRC Staff For Decommissioning and Termination of Licensed Facilities," for distribution to terminating licenseac. as a good practica, and recommends that its use be considered by other regions and Agreement States.
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i LIST OF APPENDICES AND ATTACHMENTS APPENDIX A:
REGION lli IMPEP TEAM MEMBERS APPENDIX B:
REGION lil ORGANIZATIONAL CHART APPENDIX C:
REGION lil RESPONSE TO QUESTIONNAIRE APPENDlX D:
LICENSING FILES REVIEWED
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APPENDIX E:
INSPECTION FILES REVIEWED APPENDIX F:
INCIDENT FILES REVIEWED APPENDIX G:
DECOMMISSIONING FILES RdVIEWED ATTACHMENT 1:
GOOD PRACTICE DOCUMENT: "lNFORMATION THAT SHOULD BE SUBMITTED TO THE NRC S FAFF FOR DECOMMISSIONING AND TERMINATIOr.' OF LICENSED FACILITIES" ATTACHMENT 2:
TABULAR
SUMMARY
OF REGION lli MATERIALS BUDGET AND EXPENDITURES 1
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4 APPENDIX A REGION lil IMPEP TEAM MEMBERS i
i Name Areas of Responsibility Cathy Haney, NMSS/IMAB
, Team Leader Technical Staffing and Training Status of Materials inspection Program Operating Plan / Resource Utilization -
j' Chuck Mattson, Colorado Technical Quality of Licensing i
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Betsy Ullrich, Region i Technical Quality of Inspections Inspection Accompaniments i
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Tom O'Brien, OSP Response to incidents and Allegations i
t Lance Lessler, NMSS/FCSS Fuel Cycie Inspection Program LeRoy Person, NMSS/DWM Decommissioning /SDMP 1
David Collins, Region 11 Inspector Accompaniments 4
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APPENDIX B REGION lil ORG ANIZATIONAL CHART (Will be added to final version of the report) l i
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APPENDIX C I
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1-REGION lli RESPONSE TO QUESTIONNAIRE i
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4 APPENDIX D REGION lli LICENSING FILES REVIEWED File No: 1 i-Licensee: Hiram Walker & Sons License No: 21-20408-01 l
j Location: Livonia, Michigan.
Amendment: 5 License Type: Gas Chromatograph Type of Action: Amendment l
Dates Amendment Issued: 12/20/96 Reviewer: GW
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File No: 2
]
Licensee: Computerized Medicalimaging License No: 48-24533-01 Location: Eau Claire, Wisconsin Amendments: 25/26 License Type: Medical Type of Action: Amendment Dates Amendments issued: 8/26/96 Reviewer: EM i
j Comments:
a) Cover letter said " Amendment 10.A. has been amended..." It should have i
been " Condition 10.A."
i File Noi 3 Licensee: Edward W. Sparrow Hospital License No: 21-01430-02 Location: tansing, Michigan Amendments: 23/24
}
License Type: Teletherapy Type of Action: Amendment; Term.
j Dates Amendments Issued: 7/28/95 Reviewers: PP (23); EM (24-Term) i File No: 4 5
Licensee: Carondelet Foundry Co.
License No: 24-26136-01 l
dba The Carondelet Corp.
j Location: Pevely, Mir,souri Amendments: 5/6 l
. License Type: Indus: rial Radiography Type of Action: Amendments Dates Amendments issued: 11/1/96; 11/27/96 Reviewers: RG (5) JM (6) l 1
File No: 5 l~'
Location: Madison, Wisconsin Amendments: 3/4 Licensee: Genetic Visions, Inc.
License No: 48-26077-01 License Type: R&D Type of Action: Amendments
{
Dates Amendments Issued: 8/26/96;10/17/96 Reviewer: JM (3) RG (4)
File No: 6 i
Licensee: Midwest Imaging Diagnostic Inc., LTD License No: 34-26753-01 i
Location: Cincinnati, Ohio Amendment: New I
License Type: Medical Type of Action: New j
Date issued: 10/14/96 Reviewer: MW i
1
..__-._.-_.___.____._---__.__m.~-__._.
i l
i Region IV Draft Report Page D.2 Licensing Files Reviewed File No: 7 Licensee: Mid America Inspection Services, Inc.
License No: 21 26060-01 Location: Gaylord, Michigan Amendments: 10/11 License Type: Ind. Radiography Type of Action: Amendments Date Issued: 10/15/96; 4/9/97 Reviewers: DP (10) KN (11)
I File No: 8 Licensee: Thorn Automated Systems, Inc.
License No: 34-23722-01 l
Location: Westlake, Ohio Amendment: 2 License Typ:: Possession of Smoke detectors
. Type of Action: Amendment l
incident to distribution under 34-23722-02E.
Reviewer: JJ Date Issued: 8/26/96 Comments:
a) Typographical error -Item 3 should reference application dated 5/25/95 File No: 9 Licensee: Westside Imaging & Oncology Center License No: SUB-1464 Location: Brook Park, Ohio Amendment: 2 (Renewal)
License Type: Shielding for Linear Accelerator Type of Action: Renewal Date issued: 6/12/96 Reviewer: GW Comments:
a) Second line of "U depleted in" shifted to " Cadmium plated metal Uranium 235" (Typo).
File No: 10 Licensee: Aurora Health Center License No: 48-26600-01 Location: Kenosha, Wisconsin Amendments: 1/2 License Type: Medical Type of Action: Amendments Date issued: 7/12/95; 7/20/96 Reviewer: PV (1); CC (2)
i
(
Region IV Draft Report Page D.3 Licensing Files Reviewed l
File No: 11 l
l Licensee: Voith Sulzer Paper License No: 48-18811-02 l
Technology North America, Inc.
Amendment: New Location: Appleton, Wisconsin License Type: Kr-85 Thickness gauge Type of Action: New Date issued: 4/11/96 Reviewer: PV i
1 File No: 12 Licensee: Copper Range Co.
License No: 21-11806-01 Location: White Pine, Michigan Amendment: 17 License Type: Fixed and Portable Gauges Type of Action: Termination Date Issued: 5/21/96 Reviewer: MW File No: 13 Licensee: Ingham County Road Commission License No: 21-24465-01 Location: Mason, Michigan Amendment: 06 (Renewal)
License Type: M/D Gauge Type of Action: Renewal Date issued: 12/14/95 Reviewer: CG Fih No: 14 Licensee: Regional Oncology Center License No: 34-26535-01 of Williams County, Inc.
Location: Bryan, Ohio Amendment: New License Type: HDR Brachytherapy Type of Action: New Date Issued: 9/19/S5; 10/26/95 (corrected)
Reviewer: CC Comments:
a) Original license contained four " minor" typos.
File No: 15 Licensee: Krones, loc.
License No: 48-20448-01 Location: Franklin, Wisconsin Amendment: 5 (Termination)
License Type: Serv ce/ Installation Type of Action: Termination of Am-241 filllevel gauges Date issued: 10/30/95 Reviewer: PV I
Region IV Draft Report Page D.4 Licensing Files Reviewed 1
File No: 16 Licensee: Trijicon, Inc.
License No: 21-19874-01 Location: Wixom, Michigan Amendments: 7(Renewal)/8/9 License Type: R/D; Type of Action: Renewal (7); Amend (8/9)
H-3 gun sights; C 14 luminescent light sources Dates issued: 8/1/95;10/4/95; 3/12/97 Reviewer: JM File No: 17 Licensee: Circuit Scierce L cense No-22-24422-01 Location: Plymouth, Minnesota Amendment: 6 (Termination)
License Type: Lixiscope (Industrial)
Type of Action: Termination Date issued: 6/21/95 Peviewer: WR File No: 18 Licensee: Spect Imaging, Inc.
License No: 21-26636-01 Location: Madison Heights, Mc' "1an Amendment: New License Type: Medical Type of Action: New Date issued: 4/6/95 Reviewer: JM File No: 19 Licensee: Mallinckrodt/NMA Medical Physics Licence No: 34-16272-01 24-26664-01 Location: Cleveland, Ohio Amendment: 26 (Term); New/1 License Type: Services Type of Action: Term; New: Amend 1 Date issued:
Reviewer: LH File No: 20 L'icensee: Ferris State University License No: 21-15237-01 Location: Big Rapids, Michigan License Type: Specific R/D Comments:
a) The LTS still lists the Univ. as."1100" which is Type A Broad Academic.
File No: 21 Licensee: Eli Lilly & Co.
License No: 13-01133-02 Location: ludianapolis, Indiana Amendment: 49 License Type: R/D Broad Scope Type of Action: Amendment Date Issued: 1/20/95 Reviewer: PP
4 APPENDIX E l
REGION lli INSPECTION FILES REVIEWED 1
I File No. 01 i
Licensee:
Michigan State University City, State:
East Lansing, MI License Number:
21-00021-29 j
Priority:
2 Program Code:
01100, academic broad scope Type A Lead Inspector:
RH Inspection Type:
limited to closure of NOV items, j
inspection Date:
2/14/96 lssue Date:
see comments i
Comments:
- 1) No letter transmitting inspection results in docket file; no copy of 591 in docket file.
3 File N o. 0 2 i
Licensee:
Michigan State University City, State:
East Lansing, Mi License Number:
21-00021-29 i
Priority:
2
)
Program Code:
1100, academic broad scope Type A Lead inspector:
DS j
Inspection Type:
routine, unannounced
]
inspection Date:
10/23-27/95 issue Date:
12/12/95 File No. 03 Licensee:
Ferris State University City, State:
Big Rapids, MI License No.:
21-15237-01 Priority:
2 - see comments Program Code:
01100, academic broad scope Type A, see comments Lead Inspector:
MM Inspection Type:
special, unannounced Inspection Date:
2/6/96 issue Date:
2/16/96
L Region IV Draft Report Page E.2 Inspection Files Reviewed File No. 04 Licensee:
Ferris State University City, State:
Big Rapids, Mi i
License No.:
21-15237-01 Priority:
2 - see comments
[
Program Code:
01100, academic broad scope Type A, see comments Lead Inspector:
MM inspection Type:
special, unannounced Inspection Date:
7/10/95 i
Issue Date:
8/7/95 Comments:
- 1) Inspection report issued 8/7/95 states that licensing action changed this to an academic croad scope Type C license (program code 01120, Priority 3) but LTS was not updated to reflect this change.
File No. 05 Licensee:
University of Wisconsin - Milwaukee City, State:
Milwaukee, WI License No.:
48-09944-01 Priority:
3 Program Code:
01110, academic broad scope Type B Lead Inspector:
ML Inspection Type:
routine, unannounced Inspection Date:
4/7-9/97 (site), open for additional office review of information as of 4/23/97 Issue Date:
Not issued as of 4/23/97 File No. 06 Licensee:
Washington University Medical School l
City, State:
St. Louis, MO License No.:
24-00167-11 Priority:
1 Program Code:
02110, medicalinstitution broad scope Lead Inspector TY Inspection Type:
routine, unannounced inspection Date:
4/19 through 5/2/97; additional sites 5/23-24/97:in office through 8/8/97. Telecon exit meeting 8/8/96.
Issue Date:
Letter dated 8/29/96 i
1
Region IV Draft Report Page E.3 inspection Files Reviewed i
i File No. 07 Licensee:
Crittenton Hospital Radiology City, State:
Rochester, M1 l
License No.:
21-13562-01 l
Priority:
3 l
Program Code:
02120, medical institution, OMP Lead Inspector:
TG Inspection Type:
routine, unannounced Inspection Date:
10/2/95 l
Issue Date:
Form 591 dated 10/3/95 File No. 08 Licensee:
Amherst Hospital City, State:
Amherst, OH License No.:
34-26314-01 Priority:
3 Program Code:
02120, medical institution, QMP Lead Inspector:
ML Inspection Type:
routine, unannounced Inspection Date:
1/23/96 and 2/7/96 issue Date:
Clear letter dated 2/27/96 File No. 09 Licensee:
Huron Memorial Hospital City, State:
Bad Axe, MI 48413 License No.:
21-17093 01 Priority:
3 Program Code:
02120, medical institution, OMP Lead inspector:
TG Inspection Type:
routine, unannounced Inspection Date:
12/20/96 issue Date:
Form 591 dated 12/20/96 File No.10 Licensee:
H.B. Magruder Memorial Hospital City, State:
Port Clinton, OH License No.:
34-11202-02 Priority:
3 Program Code:
02120, medical institution, QMP Lead inspector:
DW Inspec' tion Type:
routine, unannounced l
Inspection Date:
11/25/96 l
Issue Date:
Form 591 dated 11/25/96 l
l
Region IV Draf t Report Page E.4 Inspection Files Reviewed fji.bt!Ao.11 Licensee:
VA Medical Center City, State:
North Chicago, IL License No.:
12-10057-04 Priority:
3 Program Code:
02120, medical institution, OMP; also R&D Lead Inspector:
SM Inspection Type:
routine, unannounced inspection Date:
6/11/96 (site) through 6/25/96 (in office), with telecon exit 6/25/96.
a Issue Date:
Letter with NOV dated 7/9/96 Comments:
- 1) Not clear what additional issues were reviewed in-office.
- 2) Licensee is also authorized for R&D (primary program code 02120 with secondary 03620) and may be required to be considered a medical broad scope license (program code 02110).
File No.12 Licensee:
Cardiology Associates of Western Michigan City, State:
Kalamzoo, MI License No.:
21-26690-01 Priority:
5 Program Code:
02201, medical private practice, no OMP Lead Inspector:
TG Inspection Type:
routine, announced, initial Inspection Date:
8/6/96 issue Date:
Form 591 dated 8/6/96 File No.13 Licensee:
American Oncologic Associates of Michigan City, State:
Pontiac, MI License No.:
21-26488-01 Priority:
1 Program Code:
JC Inspection Type:
routine, unannounced Inspection Date:
5/24/96 issue Date:
Form 591 dated 5/24/96
l Region IV Draft Report Page E.5
-l Inspection Files Reviewed File No.14 Licensee:
Farmington Hills Radiation Oncology Center City, State:
Farmington Hills, MI License No.:
21-26516-01 Priority:
1 Program Code:
TY Inspection Type:
routine, unannounced Inspection Date:
could not be verified j
issue Date:
unknown - see comments
}
Comments:
- 1) According to " inspections completed" list, this licensee was inspected in 9/95 by TY. However, documentation is not in docket file.
File No.15 Licensee:
Community Hospital of Indiana,inc City, State:
Indianapolis, IN License No.:
13-06009-01 Priority:
1 Program Code:
02230 (primary) HDR,02120 (secondary) medical institution, QMP Lead Inspector:
JM Inspection Type:
routine, unannounced Inspection Date:
1/30/97 issue Date:
Form 591 dated 1/30/97 Comments:
- 1) Priority code listed in field notes does not match that for the program code (HDR is Priority 1).
- 2) Tony Go is listed as the inspector under PEFs.
l File No.16 Licensee:
Mallinckrodt Medical, Inc City, State:
Maryland Heights, MO, inspection at Dayton, OH licensed location of facility.
License No.:
24-04206-18MD Priority:
1 Prograrn Code:
02500, nuclear pharmacy Lead Inspector:
ML Inspection Type:
routine, unannounced (both)
Inspection Date:
3/24/97 (site) through 3/31/97 (of fice)
Issue Date:
clear letter dated 4/15/97 I
Region IV Drafi Report Page E.6 Inspection Files Reviewed File No.17 Licensee:
Mallinckrodt Medical, Inc City, State:
Maryland Heights, MO, inenection at Dayton, OH licensed location of facility.
License No.:
24-04206-18MD Priority:
1 Program Code:
02500, nuclear pharmacy Lead Inspector:
95-001 JJ Inspection Type:
routine, unannounced (both)
Inspection Date:
12/26/95 and 1/3/96 issue Date:
1/11/96 File No.18 i
Licensee:
Mobay Chemical Corporation, now Bayer Corporation City, State:
Kansas City, MO License No.:
24-03830-01 Priority:
5 Program Code:
03120, measuring systems - fixed gauges Lead Inspector:
RH Inspection Type:
routine, unannounced inspection Date:
7/16-18/97 issue Date:
Form 591 issued 7/18/97 Comments:
- 1) LTS lists this license as program code 03620, R&D other. License appears to be primarily R&D but does have gauges.
t File No.19 Licensee:
Newman Manufacturing Incorporated City, State:
Kendallville, IN License No.:
13-24902-01 Priority:
5 Program Code:
03120, fixed gauge Lead Inspector:
RG Inspection Type:
routine, unannounced inspection Date:
4/28/95 (site), telephone exit 5/30/95 Issue Date:
Letter with NOV issued 6/12/95
~
[ -
i..
I-i Region IV Draft Report '
Page E.7 Inspection Files Reviewed File No.20 l
Licensee:
Kinnscan, incorporated i
City, State:
Williamsburg, MI License No.:
21-21045-01 Priority:
5 Program Code:
03121, measuring systems - portable gauges
' Lead Inspector:
TY Inspection Type:
routine, unannounced Inspection Date:
7/30/96 issue Date:
Form 591 dated 7/30/96 l
File No. 21 Licensee:
Ingham County Road Commission City, State:
Mason, MI License No.:
21-24465-01 i
Priority:
5 l
Program Code.
03121, measuring systems - portable gauges Lead Inspector:
AK Inspection Type:
routine, unannounced l
Inspection Date:
9/17/96 issue Date:
Form 591 dated 9/17/96 File No. 22 Licensee:
Michigan Department of Transportation City, State:
Lansing, MI Ucense No.:
21-03039 01 Priority:
5 Program Code:
03121, measuring systems - portable gauges Lead Inspector:
AK inspection Type:
routine, unannounced Inspection Date:
9/16/96
. Issue Date:
Letter with NOV dated 10/9/96 File No. 23 Licensee:
Pitiik and Wick, Inc.
City, State:
Eagle River, WI License No.:
48-26650-01 Priority:
5 Program Code:
03121, measuring systems - portable gauges Lead Inspector:
DG inspection Type:
routine, announced, initial Inspection Date:
11/13/95 issue Date:
Form 591 dated 11/13/95 l
l
i
+
i Region IV Draft Report Page E.8 Inspection Files Reviewed File No. 24
. Licensee:
PCC Airfoils City, State:
Mentor, OH License Nn.:
34-21109-02 Priority:
7 Program Code:
03122, measuring systems (Kevex analyzer)
Lead Inspector:
TS.
i Inspection Type:
routine, unannounced, initial inspection Date:
7/22/96'
!ssue Date:
Form 591 dated 7/22/96 i
File No. 25
(
Licensee:
Advanced Medical Systems City, State:
Cleveland, OH License No.:
34 19089 01 i
Priority:
1 i
Program Code:
03211, manufacturing and distribution broad scope Type A Lead Inspector:
MM Inspection Type:
routine, announced, limitad to shipment of sources from hot cell for disposal inspection Date:
11/13 through 12/6/96 i
Issue Date:
Clear letter dated 3/7/97 File No. 26 Licensee:
Apollo Fire Detectors Ltd.
City, State:
Pontiac, MI License No.:
21-23805-01 i
Priority:
3 Program Code-03214, manufacturing and distribution other Lead Inspector:
JJ Inspection Type:
routine, unannounced Inspection Date:
10/24/96 lssue Date:
Form 591 dated 10/24/96
\\
l
)
1 I
Region IV Draft Report Page E.9 inspection Files Reviewed File No. 27 Licensee:
GE/Reuter Stokes City, State:
Twinsburg, OH License No.:
34-18156-01 Priority:
3 Program Code:
03214, manufacturing and distribution other Lead Inspector:
TS Inspection Type:
routine, unannounced Inspection Date:
7/25/96 (site) through 8/9/96 (office)
Issuo Date:
Clear letter dated 10/2/96 Comments:
- 1) Notes are not clear as to why inspection continued in the office.
File No. 28 Licensee:
Missouri Steel Castings City, State:
Joplin, MO License No.:
24-15152-01 l
Priority:
1 l
Program Code:
03310, industrial radiography - fixed l
Lead Inspector:
RH Inspection Type:
routine, unannounced l
Inspection Date:
5/8/95 issue Date:
Form 591 dated 5/8/95 File No. 29 Licensee:
Glitsch Field Services /NDE inc City, State:
North Canton, OH License No.:
34-14071-01 Priority:
1 Program Code:
03320, radiography - temporary job sites Lead Inspector:
WS Inspection Type:
routine, unannounced (both)
Inspection Dates:
3/29/95 Dates issued:
letter with NOV dated 11/9/95
Region IV Draft Report Page E.10 Inspection Files Reviewed File No.~ 30 i
Licensee:
Eli Lilly and Company City, State:
Indianapolis,1N I
License No.:
13-011330 02 Priority:
2 - see comments Program Code:
03610 R&D broad scope Type A: 03611 R&D broad scope Type B Lead Inspector:
MB Inspection Type:
unannounced, limited special to review corrective actions inspection Dates:
7/19-20/1995 issue Dates:
clear letter issued 8/8/95 File No. 31 Licensee:
Eli Lilly and Company City, State:
Indianapolis,1N License No.:
13-011330-02 Priority:
2 - see comments Program Code:
03610 R&D broad scope Type A: 03611 R&D broad scope Type B Lead Inspector:
TG Inspection Type:
routine, unannounced Inspection Dates:
1/28-29/97 through 2/11/97 issue Dates:
clear letter issued 2/21/97 Comments:
- 1) Licensing action in August 1992 changed this from an R&D broad scope Type A license to an R&D broad scope Type B license but LTS not updated. This was noted in the 97-001 inspection, not in 95-001 inspection.
File No. 32 Licensee:
Proctor and Gamble Company City, State:
Cincinnati, OH License No.:
34-01572-01 Priority:
2 Program Code:
03610, R&D broad scope Type A Lead Inspector:
DP inspection Type:
routine, unannounced Inspection Date:
6/18-20/96 issue Date:
Clear letter dated 7/25/96 Comments:
- 1) Section 8 states that "RSO collects samples at nearby sanitary plant on 6 occasions per month. These water samples are analyzed via LSC to ensure releases are within Part 20 limits." However, concentrations at the sanitary plant would not demonstrate compliance with 20.2005 release criteria from the licensee's facility.
l
i Region IV Draft Report Page E.11 Inspection Files Reviewed Eile No. 33 Licensee:
Mallinckrodt, Inc.
City, State:
St. Louis, MO License No.:
STB-401 Priority:
3 Program Code:
11700, rare-earth extraction and processing Lead inspector:
KL inspection Type:
routine, announced Inspection Dates:
2/13/96 issue Date:
clear letter and report dated 3/14/96 File N Q Licensee:
Mallinckrodt, Inc.
City, State:
St. Louis, MO License No.:
STB-401 Priority:
3 Program Code:
11700, rare-earth extraction and processing Lead inspector:
DM Inspection Type:
ro'Jtine, announced, limited to a review of decommissioning plans Inspection Dates:
11/21/96 issue Date:
clear letter and report dated 1/27/97 File No. 35 Licensee:
Remtex, Inc City, State:
Worth, IL (inspection at home office of records of field activities in NRC states)
License No.:
11-01137-01 Priority:
NA - reciprocity inspection Program Code:
NA: activity is for service of teletherapy units Lead Inspector:
RH inspection Type:
routine, unannounced, reciprocity Inspection Date:
2/4/97 issue Date:
Clear letter dated 2/25/97
Region IV Draft Report Page E.12
)
Inspection Files Reviewed File No. 36 Licensee:
Glitsch Field Services /NDE inc City, State:
North Canton, OH License No.:
34-14071-01 Priority:
1 Program Code:
03320, radiography - temporary job sites Lead Inspector:
WS Inspection Type:
routine, unannounced (both)
Inspection Dates:
1/29/97 (site) through 2/11/97 (in-office review)
Dates issued:
clear letter dated 2/14/97 in addition, the following inspection accompaniments were made as part of the on-site IMPEP review:
6_Ccomoaniment No.1. D. J. Collins Ril Licensee:
NDC Systems / Instrumentation Resources, Inc.
City, State:
Minnetonka, MN (Branch Office, assist inspection to RIV)
License No.:
04-23264-01 l
Priority:
5 i
Program Code:
03121, portable gauges Lead Inspector:
SM Inspection Type:
routine, unannounced, assist inspection Date:
April 7,1997 Accomoaniment No. 2. D. J. Collins. Ril Licensee:
Mankato State University City, State:
Mankato, MN License Nos.:
22-05944-03,SNM 397 Priority:
5 (both licenses)
Program Codes:
03620 R&D other,22120 SNM sealed Pu source Inspection Type:
routine, unannounced Lead Inspector:
SM Inspection Date:
April 8,1997 Accomoaniment No. 3. D. J. Collins. Ril Licensee:
Naeve Hospital City, State:
Albert Lea, MN License No.:
22 15252-01 i
Priority:
3 Program Code:
02120, medical institution, OMP inspection Type:
routine, unannounced Lead Inspector:
SM Inspection Date:
April 9,1997
l
\\
Region IV Draft Report Page E.13 Inspection Files Reviewed Accomoaniment No. 4 E. Ullrich RI Licensee:
University of Wisconsin - Milwaukee City, State:
Milwaukee, WI License No.:
48-09944-01 l
Priority:
3 l
Program Code:
01110, academic broad scope Type B i
Inspection Type:
routine, unannounced Lead inspector:
ML l
Inspection Date:
April 7-9,1997 Accomoaniment No. 5 E. Ullrich. RI Licensee:
Lorain Community /St. Joseph's Hospital City, State:
Lorain, OH License No.:
34-04474-01 Priority:
3 Program Code:
02120, medical institution, OMP Inspection Type:
routine, unannounced Lead Inspector:
TG Inspection Date:
April 10,1997 i
Accomoaniment No. 6. E. Ullrich. RI Licensee:
Kaiser Permanente Medical Center City, State:
Parma, OH License No.:
34-26092-01 Priority:
3
)
Program Code:
02120, medical institution, GMP Inspection Type:
routine, unannounced Lead Inspector:
TG Inspection Date:
April 12,1997
i
}
APPENDlX F REGION lli INCIDENT FILES REVIEWED File No.1 Licensee:
University of Mich"an Location:
Ann Arbor, MI License #:
21-00215-04 Date of Event:
April 20,1995 -
Investigation Date:
April 24,1995 Incident Log Number:
950118 investigation Type:
Inspection Type of Event:
Loss of Control of Radioactive Material (Offsite Contamination)
Summary of incident:
Re::earchers had insufficient understanding of proper survey pro:edure for lab workers resulting in P-32 contamination on i
and off-site of the University.
File No. 2 Licensee:
MOS Inspection Location:
Elk Grove Village, IL License #:
12-00622-07 Date of Event:
December 13,1995 Investigation Date:
December 20,1995 incident Log Number:
Not in NMED investigation Type:
Inspection Type of Event:
Potential Whole Body Overexposure Summary of incident:
116 rem on WB film badge of radiographer. RSO determined only badge was exposed (to x-ray unit). REACT-TS cytogenetic study done and indicated results did not correlate to dose.
File No. 3 Licensee:
Indiana Department of Transportation Location:
Seymour, Indiana License #:
13-26342-01 Date of Event:
June 30,1995 Investigation Date:
July 3,1995 Incident Log Number:
950921 investigation Type:
Phone Type of Event:
Stolen Moisture Density Gauge Summary of incident:
Moisture Density gauge (8 mci Cs 137,40 mci Am 241) stolen from trailer construction site in Columbus, IN.
_n i
l Region IV Draft Report Page F.2 Incident Files Reviewed File No. 4 Licensee:
Providence Hospital Location:
Southfield, MI License #:
21-02802-03 Date of Event:
July 251995 investigation Date:
August 3,1995 incident Log Number:
951007 investigation Type:
Inspection Type of Event:
Misadministration j
Summary of Incident:
Brachytherapy using 9.5 mci tr-192. Failure to treat intended site and to furnish written report to patient within 15 days.
j File No. 5 Licensee:
North Star Steel Company Location:
Youngstown, OH License #:
GL Date of Event:
August 27,1995
)
Investigation Date:
September 5,1995 l
Incident Log Number:
951136 Investigation Type:
Inspection Type of Event:
Damage to Level Gauge Summary of Incident:
Gauge dama;;d oy metten steel. Lead shielding partially melted resulting in 830 mrem /hr at gauge surface. Maximum personnel dose was 25 mrem.
File No. 6 Licensee:
US Army Location:
ACALA-Ft Irwin License #:
12-00722-06 Date of Event:
October 18,1995 Investigation Date:
See comment Incident Log Number:
951185 l
Investigation Type:
N/A Type of Event:
Damage to Sources Summary of incident:
Three H-3 (approximately 19 Ci total) and one Am-241(250 Ci) sources involved in explosion and fire.
Comments:
This event and many other issues currently being addressed in a Confirmatory Action Letter sent to the Army on 3/26/97.
1
Region IV Draft Report Page F.3 Incident Files Reviewed i
j-File No. 7
}
Licensee:
Allied Signal Location:
Metropolis, IL License #:
' SUB-526 Date of Event:
December 3,1996 l
Investigation Date:
December 16,1996 Incident Log Number:
960809 I
investigation Type:
Inspection Type of Event:
Loss of Control of Radioactive Material Summary of incident:
Loss of power caused dust collectors to fail and natural uranuim ore dusts were released into Feed Materials Building.
File No. 8
}
Licensee:
University of Wisconsin i
i Location:
Madison WI License #:
48-09842-28 Date of Event:
September 11,1995 investigation Date:
October 16,1995 Incident Log Number:
951144 investigation Type:
Inspection Type of Event:
Unintentional exposure of workers Summary of incident:
Two individuals performing maintenance / repair activities on a JL Shepard irradiator disabled shielding interlock and were exposed to scattered radiation (maximum dose received was I
20 mrem).
File No. 9 Licensee:
Ohio State University Location:
Columbus, OH License #:
34-00293-02 Date of Event:
March 6,1996 -
Investigation Date:
April 26,1996 incident Log Number:
960160 investigation Type:
Inspection Type of Event:
Loss of Control of Radioactivity (Contamination)
Summary of incident:
Stopper on vial of P 32 (2.5 mci) leaked. Individual was not wearing gloves and contaminated thumb. Hand was subsequently decontaminated.
l Region IV Draft Report Page F.4 incident Files Reviewed File No.10 Licensee:
Longview Inspection Location:
Temporary Jobsite in Indiana License #:
48-17480-01 Date of Event:
February 26,1997 investigation Date:
February 27,1997 incident Log Number:
Not Yet Entered in NMED i
investigation Type:
Inspection Type of Event:
Potential Whole Body Overexposure Summary of _ Incident:
Radiographer TLD read 240 and 510 rem (dual chip readout).
Operations Center notified by licensee of potential whole body overexposure. Awaiting cytogenetic testing results and confirmation of dosimeter readout.
1 I
1
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g 4
APPENDIX G REGION lli SDMP AND DECOMMISSIONING FILES REVIEWED i
SDMP SITES File No.1 Licensee:
Chemetron Corporation Location:
Newburgh Heights, Ohio License Number:
SUB-1397 License Type:
Source Material File No. 2 Licensee:
BP Chemicals Location:
Lima, Ohio License Number:
SUB-908 License Type:
Source Material File No. 3 Licensee:
Dow Chemical Location:
Midland & Bay City Michigan License Number:
STB-527 License Type:
Source Material File No. 4 Licensee:
Mallinkrodt Chemical, Inc.
Location:
St Louis, MO.
-l License Number:
STB-401 License Type:
Source Material File No. 5 Licen.see:
Jefferson Proving Ground Location:
Madison, Indiana License Number:
SUB-1435 License Type:
Source Material File No. 6 Licensee:
RMI Titanium Company Location:
Ashtabula, Ohio License Number:
SMB-602 License Type:
Source Material
7_....__
4 f
Region IV Draft Report Page G.2 Decommissioning Files Reviewed File No. 7 I
Licensee:
Minnesota Mining and Manufacturing Company Location:
Minneapolis-St Paul Minnesota License Number:
SNM-764 i
License Type:
TERMINATED SITES i
File No.1 i-Licensee:
Elkem Metals Location:
Marietta, Ohio License Number:
34-19812-01 3
License Type:
Measuring system i
File No. 2 Licensee:
Assgrow Seed Company Location:
Kalamazoo, Ml License Number:
21-26656-01 License Type:
R&D File No. 3 Licensee:
Apex Bioscience, Inc.
Location:
Detroit, Ml License Number:
21-17174-01 License Type:
In-vitro File No. 4 Licensee:
Detroit Police Department Location:
Detroit Ml License Number:
21-26339-01 License Type:
In-vitro File No. 6 Licensee:
Epikon Corporation Location:
Bedford, Heights, Ohio License Number:
34-26625-01 License Type:
R&D
.. _.... ~. _ _
9 Region IV Draft Report Page G.3 Decommissioning Files Reviewed File No. 7 Licensee:
Stolle Research & Development Corp.
Location:
Cincinnati, Ohio License Number:
34-26227-01 License Type:
R&D File No. 8 Licensee:
Case Western Reserve University Location:
Cleveland, Ohio License Number:
SNM-159 License Type:
Special Nuclear Material File No. 9 Licensee:
inland Steel Mining Company Location:
Virginia, Minnesota License Number:
SNM-1974 License Type:
Special Nuclear Material File No.10 Licensee:
Cyprus North Shore Mining Location:
Silver Bay, MN License Number:
SNM-1562 License Type:
Special Nuclear Material File No.11 Licensee:
University of Michigan-Dearborn Location:
Dearborn,
Ml License Number:
SNM-1570 License Type:
Special Nuclear Material File No.12 Licensee:
Radiation Safety Service Location:
Morton Grove, il License Number:
12-20424-1 License Type:
Service Organization
Good Practice Document "Information that Should be Submitted to the NRC Staff for Decommissioning and Termination of Licensed Facilities" (Will be added to final versinn of the report)
F
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I l
TABULAR
SUMMARY
OF REGION 111 MATERIALS BUDGET AND EXPENDITURES 4
5 i
e I
t 01/31/97 The following table shows FTE allocations and expenditures for the review period.
REGION III RESOURCE UTILIZATION FY 1996 FY 1997 ANNUAL ANNUAL BUDGET EXPENDED PROGRAM ACTIVITY BUDGET EXPENDED BUDGET OCT-DEC OCT-DEC Materials Lic & Insp 25.30 22.30 88 23.90 6.00 4.90 82 Event Evaluation 3.70 5.60 151 3.90 1.00 1.40 140 Fuel Fac Lic & Insp 1.50 1.10 73 1.50 1.60 0.50 31 Fuel Cycle Pgm Asses 0.50 0.10 20 0.40 0.10 0
0 Uranium Enrich Insp 5.00 5.00 100 5.00 1.20 1.10 92 LLW Lic & Insp 0.20 0
0 0
0 0
0 l
l Decommissioring 5.60 5.70 102 5.00 1.20 1.90 158 TOTAL 41.80 39.80 95 39.70 11.10 9.80 98 NOTES:
1 1.
FY 1996 expenditures from regional input provided in response to the j
FY 1997 President's budget update during 11/96.
2.
FY 1997 expenditures from RWAT report dated 1/29/97.
Expenditures are through 12/31/96.
l