ML20151C302
| ML20151C302 | |
| Person / Time | |
|---|---|
| Site: | 07000371 |
| Issue date: | 07/12/1988 |
| From: | Kaufman N UNITED NUCLEAR CORP. (SUBS. OF UNC, INC.) |
| To: | NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| NUDOCS 8807210307 | |
| Download: ML20151C302 (15) | |
Text
,
N.C. Kaufman l
President uma Naval Products M MFM UNC Naval Products er s-UncasvWe.connecocut 06382 0981 203/848 1511 July 12,1988 U. S. Nuclear Regulatory Commission Director, Office of Enforcement Attn: Document Control Desk Washington, D. C.
20555 Gentlemen:
Reference:
Notice of Violation and Proposed Imposition of Civil Pena 4y (NRC Inspection Report No. 70-371/8802),
W. T. Russell to N. C. Kaufman, dated' June 13, 1988 This letter is in response to the referenced letter, which transmitted a notice of violation and proposed civil penalty, based on an inspection of our activities in the period February 19 - March 18,1988.
We have fully considered the contents of that letter and the earlier transmitted inspection report, as well as the discussions at the April 25, 1988 enforcement conference. We have concluded that we must enhance our overall Health Physics Program, to provide greater assurance that all aspects are in full concert with the NRC's standards and emphasis. We believe that our existing program, while lacking in areas identified by the NRC, provides a high level of assurance that the exposure of our employees has been maintained within regulatory limits.
However, we also believe that we must' improve the management and documentation of our program, and we are undertaking an aggressive program to identify and make the necessary improvements.
As directed by the referenced letter, we have enclosed payment of the civil penalty.
Attached to this letter is our detailed response to your letter, which is broken into two sections. The first is a discussion of our overall health physics performance improvement program, and the second is a response to the specific items detailed in the notice of violation. We believe that we have been responsive to the NRC concerns discussed in your letter, and look forward to discussing this program with you and your staff at your earliest convenience.
I declare to the best of my knowiedge and belief that the attached statements are true and accurate.
Very truly yours,
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If I 8l Enclosures
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UNCNavalProducts cc:
U. S. Nuclear Regulatory Commission Region I William T. Russell, Regional Administrator 475 Allendale Road King of Prussia, PA 19406 l'
C osseosso A UNC Company
ATTACHMENT TO LETTER.N.
C.
ENFORCEMENT. USNRC. 7/13/88 KAUFMAN TO DIRECTOR, OFFICE OF IMPROVEMENT PROGRAMSECTION I - UNC NAVAL PRODU i
YSICS PERFORMANCE inspection stated,The letter transmitting the notice of in part:
violation for this inattention to these activities"Given the extent of management's assessment by you of all aspects of your man f, a rigorous and thorough is needed to determine the adequacy of thi u acturing operation should include an evaluation of the respo s program.
This authorities of organizational personnel withnsibilities and health physics program and, respect to the oversight to ensure all activities are condthe adequacy of the health physics accordance with the terms of your license a ducted safely and in requirements of 10 CFR Part 20".
"Further In addition, the letterall the applicable n
stated:
performing an, assessment of your radiation pyou should desc (1) program, particularly, with regard to proc d improvements in supervisory oversight e ures, training and rotection activities; and to upgrade the pr(og) ram based on theinstituting appropriate corrective mof 2
This section of our response address assessment findings".asures e
subsequent section deals with our respones those points, violations identified in the notice of vi lse to the specific and the o ation.
ORGANIZATIONAL REVIEW UNC Naval Products has reviewed th responsibilities and au health physics program. thority of the personnel within thee organizational from UNC Geotech. assistance of experienced nuclear safety To provide perspective, we utilized the budgetary considerations have played tBased on our re there has been limited upwards comm unication of problems, e
that decision making and planning, oo great a role in has been lacking.
Work loads for the health physicsand oversight of program significantly decreased time for supervi development and pursuit of improved s staff sory oversight, skills
- ystems, i
To address those issues organizational changes., First,UNC Naval Products has made Director, Technical Services have bthe responsibilities of the
{
deletin change,g his data processing responsibilities.his responsi een more sharply focused, l
With this by regulatory activities.
i
- Second, rely to now reports directly to the Director moving him up one step in the managem,entthe Health Physics S
{
closer supervision of day-to-day activitiestaffing will i
chain.
thus Additional s cs area to provide opportunities for training, and provide ti s, increase evaluations and improvements.
me for program Page 1
e ATTACHMENT TO LETTER.
N.
C.
KAUFMAN TO DIRECTOR. OFFICE OF ENFORCEMENT, USNRC. 7/13/88 SECTION I - UNC NAVAL PRODUCTS HEALTH PHYSICS PERFORMANCE IMPROVEMENT PROGRAM The letter transmitting the notice cf violation for this inspection stated, in part:
"Given the extent of management's inattention to these activities, a rigorous and thorough assessment by you of all aspects of your manufacturing operation is needed to determine the adequacy of this program.
This should include an evaluation of the responsibilities and authorities of organizational personnel with respect to the health physics program and, the adequacy of the health physics oversight 'co ensure all activities are conducted safely and in accordance with the terms of your license and all the applicable requirements of 10 CFR Part 20".
In addition, the letter stated:
"Further, you should describe in detail your plans for (1) performing an assessment of your radiation protection program, particularly, with regard to procedures, training and improvements in supervisory oversight of radiological control activities; and (2) instituting appropriate corrective measures to upgrade the,rogram based on the assessment findings".
This section of our response addresses those points, and the subsequent section deals with our response to the specific violations identified in the notice of violation.
ORGANIZATIONAL REVIEW UNC Naval Products has reviewed the organizational structure, responsibilities and authority of the personnel within the health physics program.
To provide perspective, we utilized the assistance of experienced nuclear safety management personnel from UNC Geotech.
Based on our review, we have concluded that there has been limited upwards communication of problems, budgetary considerations have played too great a role in decision making and planning, and oversight of program details has been lacking.
Work loads for the health physics staff significantly decreased time for supervisory oversight, skills development and pursuit of improved systems.
To address those issues, UNC Naval Products has made organizational changes.
First, the responsibilities of the Director, Technical Services have been more sharply focused, by deleting his data processing responsibilities.
With this change, his responsibilities are dedicated entirely to regulatory activities.
Second, the Health Physics Specialist now reports directly to the Director, Technical Services, thus moving him up one step in the management chain.
Additional staffing will be added in the health physics area to provide closer supervision of day-to-day activities, increase opportunities for training, and provide time for program evaluations and improvements.
Page 1
t ATTACHMENT TO LETTER.
N.
C.
KAUFMAN TO DIRECTOR. OFFICE OF l
ENFORCEMENT. USNRC. 7/13/88 l
SECTION I - UNC NAVAL PRODUCTS HEALTH PHYSICS PERFORMANCE l
IMPROVEMENT PROGRAM (Continued)
QRQ3NIZATIONAL REVIEW (Continued)
The long period involved in locating, hiring and clearing qualified personnel makes it impossible to identify a specific date for obtaining additional people.
In the interim, we are utilizing the part time assistance of a health physicist from our Rhode Island facility and our Criticality Specialist, who has previous health physics experience.
We have also established new contacts within the industry, to help in the establishment of improved programs.
HEALTH PHYSICS OVERSIGHT The actions reviewed above will significantly improve the level of oversight of the health physics program.
Additional oversight is recognized to be needed, and UNC Naval Products has taken the folloving actions to address that need:
(1) the annual independent health physics program audit will no longer be performed by ANI.
The 1988 audit was performed in April and May by the combined efforts of three experienced nuclear safety /
health physics personnel from UNC Geotech.
As discussed earlier, these individuals not only audited our health physics program but reviewed it for management and procedural improvements.
Future audits will be performed by equally qualified individuals; (2) a review of health physics activities will be made quarterly by the Naval Products Executive Safety Committee, consisting currently of the President, Executive Vice President for Operations, Operations, Quality Control and Engineering Vice Presidents, Director of Technical Services, and designated safety professionals; and (3) a system has been established wherein items of significance can be readily communicated upwards, in writing, to management to prompt action / follow-up.
OVERALL PROGRAM REVIEW AND UPGRADE In addition to the above, UNC Naval Products has laid out a broad plan to assess the radiation protection program and implement upgrade / improvement actions.
The basic program is designed to provide improved (1) compliance to applicable license and regulation requirements, (2) exposure monitoring, assessment and reduction (3) procedural controls and (4) technical knowledge and capability for the technician staff.
j The details of this assessment program are discussed below.
Page 2
1 ATTACHMENT TO LETTER.
N.
C.
KAUFMAN TO DIRECTOR, OFFICE OF ENFORCEMENT, USNRC. 7/13/88 SECTION I - UNC NAVAL PRODUCTS HEALTH PHYSICS PERFORMANCE IMPROVEMENT PROGRAM (Continued)
MEASUREMENTS AND SURVEYS To assure suitable measurements and surveys of airborne radioactivity in restricted areas, UNC Naval Products is.taking the following actions.
I 1.
The locations of all room and process air samplers are being reviewed for adequacy of coverage.
Samplers will be.
relocated and added as necessary to assure all necessary 1
work stations are covered.
)
2.
Additional lapel air samplers are being purchased, and the use of these samplers will be expanded to (a) develop statistics on the adaquacy of fixed air sampling and (b) provide representative sampling for those activities which j
cannot be adequately evaluated by fixed air sampling.
3.
Air sampler filter self absorption factor evaluation, particle size analysis, and other actions are being pursued to develop a basis for categorization of measurements.
4.
The above activities are being done on a phased basis, with i
priority given to those which have the greatest potential to reduce exposure to airborne radioactivity.
Completion of the overall program is targeted for the second quarter of 1989.
EXPOSURE CONTROL While suitable measurement of airborne radioactivity is essential, UNC Naval Products feels that the control of airborne materials must be the program focus.
This is particularly true for the alpha emitting materials, inasmuch as inhalation is a prime concern.
A task group has been established to assure that personnal exposure to and inhalation of radioactive materials is maintained ALARA.
The task group will look at such things as:
(a) existing activities which do not use engineered controls (e.g., hoods),
(b) existing engineered controls for effectiveness and potential improvements.
This task group has targeted completion of the evaluation portion of their work for October 1988, and a complete upgrade proposal for the first quarter of 1989.
It is expected that i
some specific actions will be taken in key areas prior to development of the overall upgrade proposal.
i Page 3 1
ATTACHMENT TO LETTER.
N.
C.
KAUFMAN TO DIRECTOR, OFFICE OF ENFORCEMENT, USNRC, 7/13/88 SECTION I - ONC NAVAL PRODUCTS HEALTH PHYSICS PERFORMANCE IMPROVEMENT PROGRAM (Continued) j EXPOSURE CONTROL (Continued)
A second task group has been appointed to establish programs to assure accurate and complete monitoring of personnel expocure/
inhalation and implement procedures to maintain that exposure and inhalation ALARA.
This ttsk group will evaluate such things as:
(a) introduction of a formal respiratory protection program (b) improved monitoring and feedback systems, (c) work practices, such as self monitoring, use of protective clothing, etc.
Some actions have already been implemented by this task group, and their evaluations and change implementation will continue on a phased basis, with initial priority given to those activities which have the greatest potential for improvement.
PROCEDURES The overall health physics performance improvement plan includes the review and assessment of existing procedures for adequacy and completeness, and the development of new procedures as necessary to 1) address the specific situations identified by the NRC in the notice of violation and 2) assure that all essential topics and activities are properly documented in procedures.
Item 1) will be complete during August 1988, and the overall upgrade will be complete by the end of 1988.
TRAINING UNC feels that it is essential to provide for further development of health physics technician staff, to enhance their technical background and knowledge in the health physics discipline, and to enhance their ability to perform additional health physics tasks.
UNC will develop an expanded and documented health physics technician training program which will include on-site training and off-site training.
Completion of this program depends on successful recruiting of additional health physics staff as discussed earlier.
Therefore, no
)
specific date can be projected at this time.
However, on-site training will continue as it has in the past.
Page 4
ATTACHMENT TO LETTER, N.
C.
KAUFMAN 1N) DIRECTOR, OFFICE OF ENFORCEMENT, USNRC, 7/13/88 SECTION I - UNC NAVAL PRODUCTS HEALTH PHYSICS PERFORMANCE i
IMPROVEMENT PROGRAM (Continued)
SUMMARY
In addition to responding to the concerns expressed by the NRC, UNC has initiated a broad, comprehensive review of our overall health physics program, including management, organization, procedures, systems and equipment / facilities.
Our objective is to build upon our fundamentally sound program over the coming months so as to provide improved exposure monitoring and personnel protection.
UNC would be happy to meet with the NRC in the near future to discuss our performance improvement program in more detail.
I i
l Page 5
ATTACHMENT TO LETTER, N.
C.
KAUFMAN TO DIRECTOR, OFFICE OF ENFORCEMENT, USNRC, 7/13/88 SECTION II - UNC NAVAL PRODUCTS REPLY TO NRC NOTICE OF VIOLATION This section presents UNC's response to the specific items identified in the Notice of Violation EA 88-94.
Each item starts with the NRC comment (paraphrased for brevity) and is followed by UNC's reply as (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved.
A.
Contrary to the requirements of 10 CFR 20.103 (b) (2), UNC did not maintain adequate records of an individual's radioactive intake occurrence or the evaluation and actions taken relative to that occurrence.
1.
UNC acknowledges the deficiency.
2.
This exposure resulted from the employee's work at a work station which had previously been recognized is having a high potential for generation of airborne materials, and for which improvement actions had been underway for some time.
It was UNC's opinion that adequate records exlsted relative to that overall improvement program, including this specific exposure,
)
to meet the 10 CFR records keeping requirements.
We agree that the specific records documenting this incident were not summarized in one formal report in a clean and readily identifiable form.
However, the root cause of the incident was identified and cc,rrective actions were taken, as evidenced by the fact that there have been no additional occurrences of >40 MPC hours related to this equipment since the 1986 iF01 in question.
3.
We have developed a specific format and implementing procedure for investigating and formally documenting any unusual occurrence such that the evaluations and associated corrective actions are identified in one clear report.
The situation cited by the NRC has been formally documented using this format.
4.
Use of the "Unusual Occurrence Report" format discussed above will avoid further violations.
5.
We are currently using the format and procedure in draft form to ensure full compliance with the record keeping requirements of 10 CFR 20.103 (b) (2).
The procedure will be formally issued by August 15, 1988.
Page 6
ATTACHMENT TO LETTER. N.
C.
KAUFMAN TO DIRECTOR. OFFICE OF ENFORCEMENT. USNRC. 7/13/88 B.
Contrary to the requirements of 10 CFR 20.103 (a) (3), UNC did not use suitable measurements of concentrations of radioactive materials in air, for three identified situations.
1.
UNC acknowledges thu deficiency.
2.
Items B1 and B3 UNC Naval Products has previously relied on extensive cleaning of this particular enclosed area from the exterior of the enclosure.
Surface contamination surveys wege required to show levels less than 100 dpm/100 cm in the accessible perimeter areas prior to releasing the enclosure for opening.
An approximately 15 square foot floor area that could not be reached from the exterior was covered with paper and then incrementally cleaned from inside.
Air samples were not taken inside the area because wc evaluated the potential for airborne to be low based on (a) the surveys and partial cleaning already completed, (b) the "heavy" nature of the material (c) the uneven distribution with the worst case areas being within the perimeter area already cleaned, and (d) the small surface remaining to be cleaned, using the covering / incremental clean technique noted above.
Item B2 This particular operation was conducted under a health physics approved special work permit.
A review was made of the results of a similar job completed earlier using a lapel air sampler.
Based on those acceptable results, coupled with the short term nature of this job
(~ 3/4 hour) and the set up of the two air samplers as close as possible without interfering with the job, Health Physics did not specify a lapel air sampler.
3.
Items B1 and B3 UNC is now requiring additional surveying and cleaning of the 15 square foot area from outside the enclosure by mechanical means, prior to personnel entry.
In addition, air sampling is being performed during personnel entry into the area.
Item B2 UNC Health Physics now requires the use of lapel / breathing zone air samplers on special work permits for these types of operations.
Page 7
i ATTACHMENT TO LETTER, N.
C.
KAUFMAN TO DIRECTOR. OFFICE OF ENFORCEMENT. USNRC. 7/13/88 4.
Items B1 and B3 The actions taken in 3.
above should avoid further violations.
Item B' A program for cvaluation of work area air samplers is being undertaken, to assure that sampling is representative of personnel inhalation and to correct any which are not.
Also, additional breathing zone air samplers are being procured and will be used for those types of operations which have a high potential for generation of airborne radioactivity and which cannot be adequately represented by fixed location samplers.
These actions, in conjunction with that indicated in 3.
above will avoid further violations.
5.
While we are currently in full compliance for these specific items, assurance that we are in full compliance on an overall basis is contingent on completion of the program for assessment of air sampler locations and their representativeness of personnel inhalation.
That effort is scheduled for completion in the second quarter of 1989.
C.
Contrary to the requirements of 10 CFR 20.201(b), UNC did not perform surveys adequate to demonstrate compliance with the regulations for three identified situations.
1.
UNC acknowledges the deficiency.
2.
Item C1 The long term use of these pa: ticular glass fiber air filters in UNC's air sampling program was based on reputable information from several published sources.
We selected this type because it represented the best combination of filter properties for the intended use -
good handling properties, compatibility with a laboratory environment and surface collection of alpha particles.
Documents issued by the International Atomic Energy Agency included test data which established that similar glass fiber filters yielded alpha absorption correction factors between 0 and 9% (i.e., confirmed surface collection of particulates).
Unuer these circumstances we felt that our activities were in compliance with 10 CFR 20.201(b) in that quantitive measurements of airborne concentrations were sufficiently accurate to enable UNC to comply with the regulations of 20.201(b) and sufficiently accurate under the circumstances to evaluate the extent of radiation hazards that may be present.
Page 8
ATTACHMENT TO LETTER.
N.
C.
KAUFMAN TO DIRECTOR, OFFICE OE ENFORCEMENT. USNRC. 7/13/88 C.
2.
(Continued)
Item C2 Historical information had led us to the conclusion that the amount of external contamination which a person would receive from normal operations would be below that which would be detected by the available alpha monitors used for personal monitoring at the exit to the potentially contaminated areas.
Therefore, monitoring of the hands has been the only mandatory requirement for exiting personnel.
The NEC is concerned about potential contamination of other parts of the body or clothing.
As discussed in our 4/22/88 response to the inspection report, the sensitivity of the whole body counter which detected the external contamination in the situation in question is far greater than that of the hand-held personal monitors.
Thus, there is significant doubt as to whether the external contamination would have been detected, had the individual scanned the area of his body where it l
existed.
It9ASl 1
As discussed in our letter of 4/22/88, UNC had i
determined at the time of the in-vivo count that there was no over-exposure.
However, that finding was not documented at the time, due to the lack of an internal procedure requiring formal documentation of such evaluations.
3.
Item C1 We are applying a 15% correction factor against all calculated airborne concentrations pendino completion of a program to determine the absorption factor of the filters in use.
Item C2 l
UNC has implemented new requirements for personal survey prior to exit from the potentially contaminated l
area.
Specific survey requirements are related to the areas involved and the activities in which the personnel were engaged.
Item C3 UNC has formally documented the evaluation of the individual in question.
Page 9
l s
ATTACHMENT TO LETTER, N.
C, KAUFMAN TO DIRECTOR, OFFICE OF j
ENFORCEMENT, USNRC, 7/11411
{
4.
Item C1 The action indicated in 3.
and the completion of the evaluation program will avoid further violation.
l Item C2 The action indicated in 3.
above will protect against-further violations.
Item C3 UNC has written and is using a procedure for performing evaluations of bioassay resulta, which includes a requirement that such evaluatte.ns be properly documented.
5.
We are currently in full compliance for Itecs 2 and 3.
While the use of 15% correction factor for filter absorption for stem 1 is considered to be conservative and thus in compliance, our demonstration of that fact will not be complete until September 30, 1988.
D.
Contrary to the requirements of SNM License No. 368, Part I, Section 4.4.2.2, UNC did not make adjustments in air balance to achieve proper directional flow for three identified situations.
1.
UNC acknowledges the deficiency.
2.
Cne noted air balance conditions occurred ontirely within our "B" South facility between an area of slightly higher contamination potential to an area of lower contamination potential as noted, and not to an area free of contamination.
The number of separate ventilation systems, rooms, doors, hoods, vents and temperature preferences have made it difficult to maintain continuous localized flow direction within "B" South.
In the specific case of the Pack Assembly Room / Change Room, government contract technical code reqvirements req' tire positive pressure to meet clean room requirements, and thus are in con *lict with the license requirements.
In the specific case of the Chem. Lab./ Spec. Lab., the rooms are exho'asted by the same ventilation system making it difficult to create pressure differentials.
Page 10
ATTACHMENT TO LETTER, N.
C.
EhUFMAN TG DIRECTOR, OFFICE OF ENFORCEMENT. USNRC, 7/13/88 D.
2.
(Continued) l We had previously addressed this problem in our renewal application.
Revision of Paragraph 4.4.2.2 proposed recognition of DAC (Derived Air Concontration) bases as a means of determining air flow direction concerns.
Resolution of the license renewal was not complete at the time of the violations, thus leaving the existing license requirements in force.
Prompt fo low-up submittal of a licensing amendment request was not conducted nor was prompt engineering resolution of identified ventilation deficiencies.
D.
3.
Air flow has been restored to the license requirements for the Spec. Lab./ Sectioning room.
A license amendment request has been submitted to the NRC to modify the general requirements and to request specific recognition that the pressure of the Pack Assembly Room must be positive relative to surrounding areas due to Government Contract Technical Code Requirements.
UNC Facilities Engineering has performed an air balance review an.4 has established a written guideline to maintain ccrrect air balance in "B" South.
The review has also identified certain systems which may require upgrade / modification to provide improved balance.
4.
A system has been put in place to bring delays in corrective action to the attention of higher management for prompt resolution.
5.
We are currently in ccmpliance for the Spec. Lab./
Sectioning Room.
Compliance in the other areas will remain marginal until the engineering ALARA evaluation and conflicts in the government's manufacturing code and the license wording are resolved.
It is threfore important to achieve a timely resolution regarding the proposed license amendment.
Page 11
~
ATTACHMEN"T TO LETTER.
N.
C.
KAUFMAN TO DIRECTOR, OFFICE OF ENFORCEMENT, USNRC. 7/13/88 E.
Contrary to the requirements of SNM License No. 368, Part I, Section 4.4.2.1, UNC did not maintain compliance with minimum air movement requirements for a general purpose hood on an identified occasion.
1.
UNC does not acknowledge this deficiency.
Until the t.me of this NRC inspection, the cited license section was not considered to apply to non-routine operations such as vacuum cleaner cleaning, based on the wording in the license, our original intent in writing the license, and un-documented conversations with NRC licensing personnel at the time the wording was placed in the license.
The reinterpretation of the license by NRC personnel not party to that activ.ity is not considered by UNC to be a valid basic re; usn-compliance.
As pointed out in our 4/22/88 response to the inspection report, the hood was used in this instance for ALARA purposes and n21 because it was required by the license.
F.
Contrary to the requirements of SNN License No. 368, Part I Section 4.1, UNC did not maintain adequate procedures in a number of areas.
1.
UNC acknowledges the deficiency.
2.
Health Physics Special Work Permits - Since only experienced Health Physics technicians or the Health Physics Specialist participate in the completion of HPSWP's, we had considered that the form was self explanatory.
The need for use of the form is set forth in the Supervisor's Health Physics Guide and other UNC procedures.
Dioassay Procram Procedures - The basic procedural document has been Section 4.2.3 of the NRC approved license.
The Supervisor's Health Physics Guide seta forth the bioassay program for personnel information.
Task Instruction 2 The reference to TI 2-14 was accidental since it (TI 2-14) had been incorporated into TI 2-9 prior to formal issue.
The question of an absorption factor for a glass fiber filter is the subject of a separate item in this inspection.
Task Instruction 5 We agree that the guidance was deficient as stated.
Page 12
ATTACHMENT TO LETTER.
N.
C.
KAUFMAN TO DIRECTOR. OFFICE OF ENFORCEMENT. USNRC. 7/13/88 F.
3.
A review of existing procedures is underway for accuracy and improved instruction.
Revisions and i
preparation of additional procedures will be accomplished and we are utilizing the assistance of a specialist from an associated UNC operation to this end.
4.
A revised master list of procedures is being developed based on a comparison of. license and regulatory requirements.
Appropriate training will be conducted as new/ revised procedures are approved for issue.
5.
The procedure upgrade portion of our performance improvement program will be completed by the end of 1988.
u.
Contrary to the requirements of SNM License No. 368, Part I, Section 2.7.4, UNC did not have comprehensive Health Physics audits performed during a specified period of time nor did they maintain adequate records of those audits.
1.
UNC concurs that the available written record of the 1987 ANI audit does not reflect the level of detail needed to demonstrate compliance with the referenced section of the license.
The records for 1988 and future audits, which will be performed by parties other than ANI, will demonstrate such compliance.
2.
The available written record does not demonstrate full compliance, in part because ANI did not release to UNC their more detailed audit reports, and in part because 4
I UNC did not interpret the cited License requirement with the rigor implied in this inspection.
3.
Corrective actions are as follows:
UNC Naval Products has discontinued use of ANI to satisfy the license requirement for audits of our Health Physics program.
In April and May, 1988, UNC Naval Products had a comprehensive audit performed of our Health Physics program.
This audit involved an on-sito evaluation by experienced health physics management and technical personnel from UNC Geotech, totaling approximately 15 to 20 man-days 4
of on and off-site auditor activity.
Future audits will continue to utilize experienced (non-ANI) auditors.
4.
The action defined in 3.
above will assure full compliance in the future.
5.
UNC is currently in full compliance.
Page 13