ML20151C244

Insp Rept 70-0371/88-02 on 880229-0318.Violations & Unresolved Items Noted.Major Areas Inspected:Radiation Protection Program,Status of Previously Identified Items, Radwaste Mgt,Training & Implementation

ML20151C244
Person / Time
Site:	07000371
Issue date:	04/05/1988
From:	Gresick J, Loesch R, Shanbaky M, Thomas W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20151C242	List: ML20151C239 ML20151C244
References
70-0371-88-02, 70-371-88-2, NUDOCS 8804120270
Download: ML20151C244 (16)

Text

a U.S. NUCLEAR REGULATORY COMMISSION REGION I Report No. 70-371/88-02 Docket No.70-371 License No. SNM-368 Priority 1 Category VHFF Licensee: UNC Naval Products Division 67 Sandy Desert Road Uncasville, Connecticut 06382 Facility Name: UNC Naval Products Inspection At: Montville, Connecticut Inspection Conducted: February 29 - March 18, 1988 Inspectors: M Md R.Loesch, Radiation Specialist t/' //N date kM .GresicK, Radiation Specialist vNn

~date A ub' 4' rz' "W.~ Thomas,Radi&tiorgpedialist / date Approved by: M %~ M M.M.5hanbaky, Chief, Fac Wities Radiation 4/[f//ff/

date Protection Section Inspection Summary: Inspection conducted on February 29 - March 18, 1988 Report No. 70-371/88-02 Areas Inspected: Routine unannounced inspection of the licensee's Radia' tion Protection Program. The following areas were reviewed: status of previously identified items, training, radioactive waste management, and implementation of the Radiation Protection Program.

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Results: Nine apparent violations and one unresolved item were identified: l failure to perform an adequate evaluation for exposures in excess of 40

failure to use suitable MPC-hours measurements in seven consecutive of airborne days (Section concentrations 6.1.1)ive materials (Sections 6.1.1 of radioact and 6.2 ; failure to perform radiological surveys 6.1.1, 6.1.4.1 and 6.2); fa)ilure to maintain an individual's exposure (Sections to airborne radioactivity less than 520 MPC-hours in one calendar quarter report an exposure in excess of 520 MPC-hours a in(Section 6.1.4.1);tofailure calendar quarter the NRCto within 30 days (Section 6 1.4.1); failure to maintain plant air balance failure to ha)ve adequaterocedures (Section to 6.2ensure

failure to perform compliance withadequate 10 CFR 20hood flow measure requirements (Section 6.3 ; failure to perform adequate audits of the Health Physics Program (Section .4); and licensee's evaluation of urinalysis bioassay data (Section 6.1.4.2).

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DETAILS 1.0 Persons Contacted 1.1 Licensee Personnel N. Kaufman, President, UNC Naval Products

• G. Waugh, Executive Vice President

• R. Greg, Director, Technical Services

• W. Kirk, Manager, Nuclear and Industrial Safety

• D. Luster, Radiological and Environmental Specialist

• T. Gutman, Criticality Specialist 1.2 NRC Personnel

• M. Shanbaky, Chief, Facilities Radiation Protection Section, I FRSSB, DRSS, Region I

• Denotes attendance at the exit interview on March 18, 1988.  ;

Other licensee personnel were contacted or interviewed.

2.0 Purpose The purp'ose of this routine, unannounced inspection was to review the licensee s Radiation Protection Program with respect to the following elements:

- Status of Previously Identified Items

- Training

- Radioactive Waste Management

- Implementation of the Radiation Protection Program, including:

- Internal Exposure Controls

- Air Sampling Program

- Engineering Controls

- Respiratory Protection

- Bioassay Program

- Control of Radioactive Material

- Procedures

- Audits 3.0 Status of Previously Identified Items 3.1 (0 pen Proced)ures.87-08-01 (Violation). Failure to have approved Health Physics The inspector verified the licensee's corrective actions, as stated in their letters to the NRC, dated January 15, and February 16, 1988.

Although Health Physics Task Instructions were formally issued,

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problems still exist as to their overall adequacy to provide the needed controls to ensure compliance with all the applicable regulatory requirements in 10 CFR 20 (Section 6.3).

3.2 (Closed) 87-08-02 (Inspector Follow-up). Discrepancies in vendor results for uranium spiked urine samples.

Spectroscopic results from Idaho National Laboratories indicate that vendor analyses for total enriched uranium are adequate. The vendor identified computer data entry errors in previous results and has issued corrected urinalysis reports.

4.0 Training of Personnel The licensee's program for training of plant employees was reviewed with respect to criteria contained in:

- 10 CFR 19.11, "Posting of Notices to Workers"  !

- 10 CFR 19.12, "Instructions to Workers" ,

- SNM License No. 368, Part I, Section 2.8, "Training" l The adequacy of the licensee's program related to the above criteria was determined by:

- Review of training records and documentation

- Discussions with Health Physics staff and plant workers Within the scope of this review, no violations were identified.

All new employees received initial indoctrination training. Topics concerning the safety aspects of handling source and special nuclear materials were presented by a representative of the Nuclear and Industrial Safety (NIS) Department. Understanding of the material presented was ,

documented by a written examination. Health Physics technicians and 1 individuals working with radioactive materials in a readily dispersible i form received refresher training in radiation safety and nuclear l criticality controls annually. Although the training provided may meet minimal regulatory requirements, observations of conduct of operations indicated that the training was limited in its effectiveness to minimize intake of radioactive materials by workers (Sections 6.1 and 6.2).

5.0 Radioactive Waste Management l The licensee's program for the control of liquid and gaseous radioactive effluents was reviewed with respect to criteria contained in:

- 10 CFR 20.106, "Radioactivity in effluents to unrestricted areas"

- SNM License No. 368, Part I, Sections 4.4.2, "Ventilation", and 4.4.3, "Radioactive Liquid Waste System"

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1 5 l The licensee's performance relative to the above criteria was determined by:

- Tours of the liquid waste processing area

- Review of process and analysis records

- Discussions with licensee personnel j Within the scope of this review, no violations were identified.

Incoming radioactive liquid waste streams were seg to gotential uranium content and were referred to as ,regated according uranium bearing" and trace uranium bearing." The liquid wastes were collected and processed in the basement of BuiTding B prior to release to the sanitary sewerage system. Samples of the waste streams were taken at various points in the processing cycle to determine uranium content.

Gaseous effluents were handled by sixteen filtered air exhaust systems.

99.95% particulate Exhaust filter air was passed through a high efficiencyand was continuously sampled for release.(HEPA)

The inspector reviewed both the liquid and gaseous effluent records for l 1987 and 1988 and noted that all discharges were well within the regulatory  !

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6.0 Implementation of the Radiation Protection Program 4 The implementation of the licensee's Radiation Protection Program was reviewed with respect to the following criteria:

- 10 CFR 20, "Standards for Protection Against Radiation"

- SNM License No. 368, Part I, "Conditions and Specifications", Chapters 2.0 and 4.0, and Part II, "Safety Demonstration", Chapter 4.0 6.1 Internal Exposure Controls 6.1.1 Air Sampling Program The licensee has installed a centralized vacuum system which was used in lieu of individual air sampling pumps. At various locations around the plant, the licensee has installed fixed sampling lines which include a flowmeter and a quick disconnect coupling to accommodate the air sampling head. Samaling rates are typically 20 liters per minute.

Fixed head samples which were used to monitor general conditions in large work areas or rooms were changed once or twice per week. Samples were which changed measured more daily. The localized filters concentrations were removed (i.e. Sectioning) and subsequently analyzed by the Health Physics technicians for both alpha and beta activities.

Breathing zone (lapel) air samplers were available for use when

l 6 i warranted, as determined by the Health Ph staff. Individual exposures to airborne radioactive materials,ysics as determined from air sample results and the duration of the work, were recorded by the Health Physics technicians. Exposures were expressed as a function of time and the Maximum Permissible Concentration limits of 10 CFR 20 (MPC-hours).

Within the scope of this inspection, the following items were identified by the inspector:

- During a review of the MPC-hour logs for 1986 and 1987, the inspector noted that during the. period November 19-25, 1986, an individual appeared to have exceeded 40 MPC-hours in seven consecutive days. A further review of the air sampling data showed a total exposure of 48.5 MPC-hours for the seven day period. The operation that the individual had been performing was one that had been previously identified by the licensee as a primary source of i airborne contamination. During this exposure period, the air concentrations averaged 135% of MPC and, at times, were as high as 300% of MPC. Similar airborne concentrations continued to occur as identified during this inspection. The licensee stated that a i meeting of management was held on December 3,1986, to discuss this incident and that a written evaluation was subsequently performed.

I Upon review of the evaluation and through interviews with the management personnel involved, the inspector noted the following:

- Documentation of the incident consisted of limited review notes for the management meeting held 12/3/86. The raw data relating to the occurrence was attached, but the 48.5 MPC-hour value was not clearly stated.

- A licensee representative who attended the management l meeting informed the inspector that a recommendation to l install an additional blower in the local exhaust line l to reduce future airborne levels i had been made. This suggestion, wh(anich wasengineering control) not documented, was later dismissed by the licensee because of how it might affect the building's air balance.

- The evaluation was inadequate in that it failed to identify the root cause or to specify what actions were taken to prevent recurrence.

The inspector stated that this was an apparent violation of 10 CFR 20.103(b 2 which material)b(y)any dates that individual "whenever exceeds the intake this 40-hour of measure" control radioactive (40 MPC-hour, in seven consecutive days), "the licensee shall make such i evaluatiot, and take such actions as are necessary to assure against recurrence." In addition, "the licensee shall maintain records of l

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i such occurrences, readily identifia bleevaluations, and actions form suitable taken in review for summary a clear and and evaluation." (70-371/88-02-01)

- The inspector reviewed records of positive in-vivo measurements with respect to the nature of the work the individuals (lung counts)he performed. T inspector determined that all of these individuals worked in areas in which loose uranium material could be present Routine air sampling was performed using fixed location sampling heads. Inspection of the placement of the air sampler showed that the air sampling heads were located. away from the breathing zone area of the worker's face and approximately one to five feet away.

Review of the air sampling data indicated that there were no documented airborne concentrations of uranium present that could explain the positive lung counts. When work was performed that had the potential to generate airborne concentrations of uranium, breathing inspector zone (lapel)ith discussed w theair samplers licenseewere not routinely used. The the representativeness of their air samples. The ins 3ector stated that considering the nature of the process potential "or localized airborne activity and the material involve (d (high density particulates), the relative) location and distance of the fixed air samplers from the worker's breathing zone did not represent suitable measurements for evaluating the intake of radioactive material by workers. The inspector noted the following examples of air sample locations that were not considered representative:

- Sample location 75 (Sectioning) was used to monitor shearing operations on March 1, 2, 11 and 15, 1988, and was located approximately 1-1/2 feet above and to the right of the operators head. The source of the p(otential airborne materials was a work enclosureapproximately one c and in front of the operators breathing zone.

- The "Rework" room (approximately 5'x6') has a work table with local exhaust located on the left side of the room.

The air sampler (location 39T) was located on the right wall, roughly five feet off the floor. This placed the air sampler approximately 4 to 5 feet from the breathing zone of any worker.

- On March 14, 1988, a vacuum cleaner was cleaned using the "old" decon hood. The distance from the work table to the ,

hood opening was approximately 3 feet. The fixed air sample location was 3 feet above the table at the entrance to the hood.

- On March 14, 1988, a maintenance worker entered into one  !

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l end of a large contaminated process enclosure. He placed approximately 3/4 of his upper body inside the enclosure opening. Prior to performing any maintenance operations, the ,

individual decontaminated the immediz.te work area within the l enclosure with alcohol. The fixed air sampler was located  !

outside and above the opening from which the individual i entered.  ;

- Through discussions with workers in the radiologically controlled area, the inspector determined that certain equipment cleanups were performed by opening selected glove ports to wipe down accessible equipment surfaces with alcohol. After the initial cleanup, the Health Physics technicians performed a contamination survey of i those areas reachable through the glove port o)enings. l Results of the survey were used to determine w1 ether or not personnel should be allowed to enter into the equipment.

The inspector found through review of records that contamination levels inside the equipment in November, 1986, I February, 1987, and August, 1987, were typically a few l thousand digintegrations per minute per 100 square centimeters (dpm/IO0cm)ofalphaactivity.Inoneinstance,thg  !

contamination level was as high as 37,000 dpm/100 cm .

Results indicated a highly nonuniform distribution of l equipment contamination. Cleanup of the equipment was further I accomplished by allowing at least one individual to crawl l inside the equipment. During the cleanup operations, no air l samples were taken inside the equipment to evaluate the I concentrations of airborne radioactive material that the individual may have been exposed to as a rer., ult of the l decontamination activities.

The inspector stated that this was an apparent violation of 10 CFR 20.103(a)(3) which states "the licensee shall use suitable measurements of concentrations of radioactive materials in air for detecting and evaluatin airborne radioactivity in restricted i areas." (70-371/88-02-02) g l

- Glass fiber filters were being used for both the fixed head (process)theair Due to samplers nature andfilter of the for breathing media,zone (lapel)particles uranium air samplers. are l collected within the filter fiber matrix rather than on the surface. ,

Some of the alpha particles subsequently emitted may be absorbed by  ;

the glass fibers and therefore are unavailable for counting. This  !

biases the quantitative measurements and may result in a significant under estimation of the actual airborne activity collected on the filter. During a review of the calculations performed for the evaluation of airborne activities, the inspector noted that "filter self-absorption factors" were not being used and, as a result, l

9 quantitative measurements of airborne concentrations of radioactive material were inadequate. The inspector stated that failure to provide adequate air sampling to detect and evaluate airborne radioactivity was an apparent violation of 10 CFR 20.201(b) which states "each licensee shall make or cause to be made such surveys as (1 for the licensee to comply with the regulations of) this the part,may arenecessary(2) reasonable underfthe circumstances to extent o beradiation and evaluate hazards that may be present" (70-371/88-02-03).

6.1.2 Engineering Controls Engineering controls have been used to minimize the potential for intakes of airborne radioactive materials by workers. Major equipment associated with the process and various types of glove boxes were sealed. Operations involving fuel were typically performed under inert atmospheres. When this type of containment is not possible, small I enclosures and/or local exhausts were provided to limit intakes by l individuals. Air flow balances for the facility, an example of '

engineering controls, is further discussed in Section 6.2. In light of the fact that a significant number of workers have exhibited positive bioassay results (see Section 6.1.4), the effectiveness of en controls will continue to be reviewed in future inspections. gineering 6.1.3 Respiratory Protection When the use of engineering controls were not possible to limit an individual's exposure to airborne radioactive material, respiratory protection devices have been used. Respiratory protection devices of varicus ty)es were available from both the Heal th Physics staff and from the ndustrial Safety Department. Although these devices were used to limit potential intakes of radioactive material to workers, the licensee has not established many of the necessary program elements nor has the licensee formally submitted the program to the NRC. Therefore, no allowance has been made for these devices when determining whether an individual has been exposed to airborne concentrations in excess of the limits specified in 10 CFR 20. In light of the fact that a significant number of workers have exhibited positive bioassay results see Section 6.1.4 the respiratory protection program will contin (ue to be reviewed in)' future inspections.

6.1.4 Bioassay Program 6.1.4.1 In-vivo Measurements In-vivo measurements of uranium deposition in the lung were performed semiannually by an outside vendor utilizing a mobile trailer equipped with a gamma spectroscopic lung counting system. The industry standard

. 1 10 practice for measuring an individual's exposure to mixed isotopes of uranium is through the quantitative measurements of the 186 kev gamma-ray from Uranium-235.

All individuals to be counted were expected to shower prior to arrival '

at the trailer. Prior to the cctual count, which is typically 20 minutes, che individual removes all personal clothing except for underclothes and dons ) ape

• coveralls. These precautions are to prevent both contaminat on of the equipment and to prevent false indications of internal deposition due to the presence of external contamination.

The operator of the equipment, supplied by the vendor, makes both preliminary evaluations of the data and recommendations to the licensee if additional measurements may be warranted (i.e. possible external contamination). Preliminary data sheets for each individual are left with the licensee. After further data review by the vendor, a final report is forwarded to the licensee.

The final values reported of Uranium-235 (micrograms)takenare only, and have not quantitative into accountmeasurements the other isotopes of uranium that may be present. With the composition of the material used by the licensee, the radiological hazard is not only due to Uranium-235, but is also due to the existence of Uranium-234 in the mixture.

Within the scope of this inspection, the following items were identified by the inspector:

- The inspector reviewed in-vivo lung data for 1986 and 1987 and noted that a significant number of individuals counted (approximately 55) showed uranium deposition in the lung. Further, one individual's in-vivo count on May 22, 1986, at 0829, indicated that he had been

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expor;e5 to approximately 1932 MPC-hours equivalent. The spectrum indicated the presence of the 17 kev x-ray of Uranium-235 which is absorbed by the body except in cases of external contamination.

After showering, the x-ray and indicated a new value of 635 MPC-hours equivalent.a seco This reduction in activity and the lack of the 17 kev x-ray for the second count indicates that the individual was externally contaminated during the first count and may have been successfully decontaminated prior to the second count. Also, no further evaluations of the individuals intake were performed by the licensee. The inspector stated that, based upon the licensee's in-vivo lung data (spectrum and reported amount of uranium in the lung), this appeared to be an internal exposure and a resultant exposure in excess of 520 MPC-hours equivalent.

l 11 The inspector reviewed the 1985 and 1986 MPC-hour logs for this individual. The individual's only documented exposure prior to the lung count was during the quarter of the in-vivo measurement (May, 1986 . Also, on the day of the lung count, the individual stated that)he may have been performing operations in the Sectioning area earlier that morning. Activities performed in this area involve significant potential for the generation of airborne activity. The inspector stated that 10 CFR 20.103(a)(1) requires, in part that "no licensee shall possess, use, or transfer licensed materlal in such a manner as to permit any individual in a restricted area to inhale a quantity of radioactive material in any period of one calendar quarter greater than the quantity which would result from inhalation for 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> per week for 13 weeks at uniform concentrations (520 MPC-hours) of radioactive material specified in Appendix B, Table 1, Column 1." The inspector stated that the exposure of the individual is an apparent violation of to approximately 10 CFR 20.103(635 a)(1)MPC-hours requirements (70-371/88-02-04).

The inspector discussed with licensee representatives the evaluation of this intake incident. The discussion focused on the licensee's analysis of the gamma spectroscopy results, calculation of proper MPC-hours, identification of the cause of the exposure, any subsequent evaluations to assess the radiological airborne hazards involved and determination of proper actions to prevent recurrence.

The licensee stated that the MPC-hour calculations were not performed based on bioassay data. The licensee indicated that the MPC-hour calculations were based only on air sample results. The air sample data for the location and period in question showed a potential intake of approximately 17 MPC-hours. The inspector stated that, in light of the significant technical weaknesses associated with the air sampling program (see Section 6.1.1), and the lack of any evaluation of the bioassay data, the failure to perform an evaluation of the worker's intake is another example of an apparent violation of 10 CFR 20.201(b) (70-371/88-02-03).

The inspector discussed with the licensee the reportability of such incidents to the NRC. The inspector determined that no reports were submitted to the NRC. The inspector stated that failure to report this exposure to the NRC constituted an apparent violation of 10 CFR 20.405(a)(1)(ii)0 the NRC within 3 days (70-371/88-02-05 .which requires the re arting of thi 6.1.4.2 In-vitro Measurements  ;

In-vitro measurements were used to supplement the in-vivo measurements in determining possible exposures of workers to airborne radioactive materials. These measurements included both the analysis of urine for

12 total uranium and, when necessary (i.e. abnormal incidents) the analysis of fecal samples.

All individuals with the potential for being exposed to loose radioactive materials were included in a monthly urinalysis program.

Since samples were sent to an outside vendor for analysis delays of up to two mcnths between sample collection and receipt of the final report were common.

The licensee has not routinely performed fecal analyses. Any inhaled material which translocates to the gastrointestinal tract is effectively eliminated from the individual within 24 to 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />.

However, this form of diagnostic measurement could be valuable in the prompt evaluation of accidental acute exposures of uranium.

Within the scope of this inspection, the following item was identified by the inspector:

- The inspector noted upon review of the urinalysi; results for 1986 and 1987 that a significant number of individuals had positive results. Using Class Y intake retention factors for the material used at the facility, preliminary inspector review indicated that several of the individuals may have been potentially subjected to large initial intakes of radioactive material. The calculations and concerns were brought to the attention of the licensee. Neither evaluations of the original urinalysis results nor further sampling and analyses were performed by the licensee to verify the adequacy of the air sampling, engineering controls and respiratory protection programs. Pending further evaluations by the licensee and subsequent review by the NRC, this matter remains unresolved (70-371/88-02-06).

6.2 Control of Radioactive Material Within the scope of this review, the following were identified:

- Air ventilation systems were provided to minimize airborne concentrations of radioactive material and to decrease the potential intake of this material by workers. This was accomplished by minimizing the spread of radioactive contamination during plant operations and by controlling the transfer of contamination between areas. Air flow balancing was checked quarterly by the Health Physics technicians in accordance with Task Instruction 5-13, "B South Air Balance Measurement." Air flows in the wrong direction were documented as "rejected" and reported to the Health Physics Specialist. The license requires that air flows be maintained from contamination free areas into potentially contaminated areas and from areas of lower to areas of higher contamination. In addition, adjustments in air balance shall be made based on the inspection results to achieve proper directional flow. During a review of the

13 1986 and 1987 Air Balance Check logs, the inspector identified the following:

- Subsystem #1, from Chem Lab to spec Lab, Room B 186:

rejected since August, 1987

- Subsystem #3, from Spec Lab to Sectioning, (no room number):

rejected since October, 1986

- Subsystem #6, from Change Room to Pack Assembly, Room B-122:

rejected since February, 1986 The inspector independently verified the air flows to be in the wrong direction for some of the areas controlled by Subsystem #1. l The inspector stated that failure to maintain the propor air balance was an apparent violation of Special Nuclear Material License No.

368, Section 4.4.2.2 (70-371/88-02-07).

- Prior to exiting potentially high contamination areas of the Radiologically Controlled Area (RCA), the licensee requires that all individuals first wash their hands and then perform a hand frisk. I No additional parts of the body (such as the head, face, feet, etc.)

are required to be surveyed prior to exiting the area. Since the presence of contamination on the hands ma indicate potential contamination on other portions of the body, ycoupled with the lack I contaminated of requirements individuals to monitor may exit the RCAother portions since undetected of the han bodyd washing was performed prior to fricking. For example, on May 22, 1986, an individual was identified by the vendor's uranium lung counter located in the parking lot outside the radiologically controlleli area, as having the equivalent of 1932 MPC-hours of activity Bresent.

ranium-235The spectren which is indicated absorbedthe bypresence the bodyofexcept the 17 in kev x-rayof cases of external contamination. After showering,d a second count one hour later showed no presence of the x-ray an indicated a new value of 635 MPC-hours equivalent. This raduction in activity and the lack of the IT kev x-ray for the second count indicates that the individual was externally contaminated during the first count. The inspector stated that this practice constituted an additional exam of l failure to "make or cause to be made such surveys as (1) plemay be necessary(for part and 2 are thereasonable licensee to comply under with the regulations the circumstance of this to evaluate the I extent of ra)diation hazards that may be present" as specified in 10 CFR 20.201(b) (70-371/88-02-03). .

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- The inspector examined the control and maintenance of potentially y contaminated vacuum cleaners. Through discussions with licensee I personnel, the inspector identified that on March 14, 1988, a vacuum cleaner used in the radiologically controlled area had been cleaned in a hood located in a radwaste storage area. The inspector toured j t

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("old" <1ccon hood). In addition flow measurements were & Iso performed of the recently installed "new" decon hood located elsewhere '1 the radwaste facility. Measurements of face velocities in both hoods indicated that face velocity flow rates were less than 25 linear feet per minute (1fm). 1 The inspector reviewed the licensee's hood face velocity measurements log and noted that the "old" decon hood was not routinely surveyed for face velocities. In addition, the face vr city of the "new" decon hood was documented as 125 Ifm. Through d assions with the HP technicians, the inspector determined that U . "new" decon hood velocity was not a face velocity measurement but instead was a measurement of air flow at the intake of the air exhaust duct.

Air samples taken at the "old" decon hood during the vacuum cleaner cleamout showed that airborne radioactivity concentrations in the general work area were 80% to 90% of MPC during the work evolution.

No measurements were taken in the breathing zone of the worker. The inspector stated that this was another example of failure to use suitable measurements of concentrations of radioactive material in air for detecting ud evaluating airborne radioactivity as specified in 10 CFR 20.103(a)(3) (70-371/80-02-02).

Special Nuclear Material License No. 368, Part I, Section 4.4.2.1, "Local Exhaust" states that "ventilation exhaust equipment shall be required for routine operations generating airborno concentrations in excess of 25% of MPC with minimum air movement requirements for a general purpose hood face velocity of 100 linear feet per minute."

Failure to use adequate ventilation exhaust equipment during the I vacuum cleaner clean-out, which generated general area airborne concentrations of 80-90% of MPC was an apparent violation of this license condition (70-371/88-02-08).

6.3 Procedures l NRC Inspection Report 87-08 identified a Special Nuclear Material license the Manaper, violation whichand Nuclear required thatSafety Industrial all p(rocedures NIS) Department. be approved by In the licensee s letter of response to tne Notice of Violation, dated January 15, 1988, the licensee stated that the were formally approved by tne Manager, NIS, on November 1987. 16, procedures Although Health Physics Task Instructions (procedures) were issued for use by the Health Physics (HP) technicians, the insoector noted that certain other essential radiation protection procedures had not been written. The following specific examples were identified:

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- Special Work Permits SWPs are used to cover non-routine and various maintenance task (s. No) procedure was in place to describe the preparation of the SWP proper radiological and controls in to assist which maytheinclude HP stafftheinselection prescribing oi the appropriate protective clothing and HP monitoring requirements.

In addition, the existing SWP form had no provisions for including radiological survey information.

-A bioassay program, to include urinalysis, in-vivo and fecal sampling, has been established. However, the licensen has no procedure in place for the implementation of the program and which may include the evaluation of bioassa results to verify the adequacy of the air sampling program, yengineering controls, and respiratory protection equipment.

- Task Instruction 2-9, "Assessment of Individual's Exposure to Airborne Radioactivity", did not include procedures for the use of an alpha absorption correction factor when avaluating air samples utilizing glass fiber filters Section 6.2 . In addition, references were which was made to an MPC-hour not issued. In discussions track wit (ing procedur)e Task Instruction 2-14) (h kP ma.yagement, the inspector noted that they were not aware of this reference.

- SNM license section 4.4.2.1 specifies flew rates for fume and general purpose hoods in terms of "face velocities.' Typically this is a measurement taken in the center of the faca o hood. Task Instruction 5-3, "Hood Velocity Measurement"pening states that of the, the measuring instrument "should be held so that the left hand port of the meter is flush with the exhaust opening." Inadequate guidance as to the proper placement of the anemometer has resulted in improper flow measurements (Section 6.2).

The above mentioned procedural problems constitute lig.i+.ed examples of required proceduces that were either not in place or inadequate to perform their intended functions.

Special Nuclear Materials License No. 368, Part I, Section 4.1, "General Health Physics Requirements", requires that the Radiation Protection Program shall comply with the regulations established in 10 CFR 20. In addition, procedures shall provide the controls needed to insure compliance with all applicable provisions of the license and 10 CFR 20 requirements. The above examples represent an apparent violation of this license requirement. (70-371/88-02-09) 6.4 Audits Within the scope of this inspection, the following item was identified:

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16 The licensee currently uses Recommendation Letters from American Nuclear Insurers (ANI) to meet license requirements for annual independent audits of the Radiological Control Piogram. Through reviews of the audit letters for 1984 through 1986, and in discussions with both licensee personnel and ANI auditors, the inspector noted the following:

- The letters the licensee receives are only an executive summary of ANI findings as they relate to insurance underwriting and liability issues. The actual inspection report is maintained by ANI and licensee nor will record ANI copies release are for them notreview.

provided Audit to the reports, insured (herefore,)

t were not available for review by the inspector.

- ANI has stated in several past audit letters to the licensee that the type of inspections they perform do not, in their opinion, meet the license requirement for a "com)rehensive review" of the total Health Physics Program. In discuss ons with the ANI auditors, the inspector determined that the depth and scope of the audits were not appropriate to meet license requirements. The following aspects of the Health Physics Program have not been part cf audits conducted by ANI:

- Compliance with regulatory requirements

- Compliance with license requiraments

- Adequacy of Health Physics procedures

- Representativeness of the air sampling program Special Nuclear Materials License No. 368, Part I, Section 2.7.4 "Audits", defines an audit as "a comprehensive review of the total 3rotection or control aspects of the Criticality Control or Health

)hysics Program." In addition, it requires that "an audit shall be performed once a year" and that "license requirements, 10 CFR 20, and appropriate NRC Regulatory Guides shall be used in establishing the areas of review." The inspector stated that failure to perform comprehensive audits was an apparent violation of this license requirement (70-371/88-02-10).

7.0 Exit Interview The inspector meet with the licensee representatives (denoted in Section .

1.0) at the conclusion of the inspection on March 18, 1988. The inspector l summarized the purpose and scope of the inspection and findings as i described in this report. l

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