ML20151H499
| ML20151H499 | |
| Person / Time | |
|---|---|
| Site: | Neely Research Reactor |
| Issue date: | 07/18/1988 |
| From: | Grace J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Crecine J Neely Research Reactor, ATLANTA, GA |
| References | |
| NUDOCS 8808010314 | |
| Download: ML20151H499 (11) | |
See also: IR 05000160/1987008
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Ge gia Institute of Technology
TN: Dr. J. P. Crecine, President
225 North Avenue
Atlanta, GA 30332
Gentlemen:
SUBJECT: RESPONSE T0 QUESTIONS CONCERNING INSPECTION REPORT N0. 50-160/87-08
This is in reference to (1) the letter dated May 13, 1988, which responded
to NRC concerns regarding progress toward renewed operation of the Georgia
Institute of Technology (Georgia Tech) .Research Reactor, and (2) the letter
dated June 13, 1988, asking specific questions concerning recent NRC actions.
It appears from the May 13, 1988, letter that NNRC management may still be
focusing their attention on specific issues and individuals involved with the
August radioactivity contamination event rather than evaluating the program
and management controls over the program that allowed the specific event to
occur.
The fact that the event had minor radiological consequences is
fortuitous.
The event, in and of itself, showed management and program
weaknesses that are slowly being addressed by Georgia Tech.
Further, the
Order issued on January 20, 1988, requires an evaluation of the management
controls that allowed this situation to exist.
The information received thus far indicates that many of the identified
problems relate to issues that are "proximate" causes.
We believe the
"ultimate" or "root" cause is a weakness in management controis and programs
at your facility.
The information we have received from Georgia Tech to date
does not recognize that this root cause exists which causes us to question
the long-team effectiveness of any corrective actions.
Thus, we find this
submittal to be inadequate.
Surprisingly, the questions in the letter of June 13, 1988, and the content
of the interim report both indicate that NNRC management's investigation into,
and understanding of, the event were apparently somewhat superficial.
The
questions indicate a lack of full discussion with facility staff and also
an inadequate assessment of the consequences of the contamination event.
Enclosure 1 is a general response to the questions.
Enclosure 2 is a response
to the specific questions.
If you have any questions on the above, or the enclosures to this letter,
I would appreciate it if you would contact me personally for resolution.
Sincerely,
itX
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J. Nelson Grace
Regional Administrator
Enclosures:
(see page 2)
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Georgia Institute of Technology-
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Enclosures:
1. ' General. Response to-Questions
2.
Response to Specific Questions
cc w/encls:
. M T. E. Stelson, Senior Vice President
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Df. R.'A. Karam, Director.
Meely Nuclear Research Center
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ENCLOSURE 1
General Response
The June 13, 1988, letter appears to question the conclusions concerning the
degree of contamination of the reactor building in Inspection Report
19, 1987, survey result showed only minor
50-160/87-08, since the Au
contamination (100-200 cpm) gust
in a small area of the reactor building floor.
(The August 1987, survey document did not show contamination on the catwalk,
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the second floor, or on the first floor except for a 10 square foot area.)
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This apparent lack of understanding, at this the time, of the circumstances
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associated with this event is quite surpris.'ng.
It should be clearly
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understood that:
(1) The referenced August 19, 1987, documented survey gave the initial
indication of contamination above normal; it was not a documentation of
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all of the surveys of the reactor building associated with the
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radioactivity contamination event.
Licensee personnel (operations and
health physics) stated that after noting the widespread contamination,
they began to survey and decontaminate areas without recording results.
(2) Surveys for contamination were conducted throughout the NNRC.
The
contamination was indicated to be spread in discrete locations over
approximately one-third of the building area.
(3) Licensee personnel stated that the catwalk approximately 60 feet from the
top of the reactor shield was contaminated.
(4) Licensee personnel and the Director, NNRC, steted that the Director, NNRC,
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was directly responsible in overseeing the decontamination effort over
large areas of the facility.
(5) Licensee personnel stated that during decontamination efforts, the
personal clothing (pants) of an operator involved were contaminated to
levels exceeding release limits.
(6) One additional record showed smearable contamination of 20 mrem /hr.
(7) When records are incomplete, interviews of personnel must be utilized to
provide missing information.
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ENCLOSURE 2
Response to Specific Questions
1.
Did the Manager of the Office of Radiation Safety (MORS) or other Office
of Radiation Safety (0RS) personnel in fact inform the Radiation
Specialist Inspector of the existence of the August 1987, survey document
or its contents?
At no time during the inspection did licensee personnel provide a copy of
the survey to the inspector and inform him that this survey documented the
extent of contamination after the August event.
The August 19, 1987, survey document was not reviewed by the inspector
until after the January 22, 1988, exit interview.
Licensee personnel
informed the NRC that this survey document recorded the -routine surveys
conducted up to and including the initial finding of contamination within
the reactor building, but did not include the specific details regarding
the subsequent surveys conducted during decontamination efforts. Licensee
personnel, both operations and health physics (HP) staff members, stated
that they conducted additional contamination curveys, including the top of
the reactor shield, areas of the reactor building floors and equipment
located there, and other building areas such as the corridors and access'
point leading into containment of the Neely Nuclear Research Center
(NNRC).
The inspector specifically asked for these survey results.
The
inspector was informed that when a contaminated area was found, the area
was immediately decontaminated without recording the survey results.
Initially, there may have been a misunderstanding between the inspector
and MORS regarding the information requested, the information available,
and the final records provided to the inspector for review.
At no time
during the inspection did the MORS appear to deliberately _ withhold
information as noted by the availability of other pertinent data, for
example, air sampling records and memoranda detailing the contamination
event, which were provided to the inspector.
The failure to document the detailed survey results was attributed to both
operations and HP licensee staff.
The extent of surveys should have been
known by the Director, NNRC, who was responsible for and observed the
decontamination efforts in progress.
Although the Director, NNRC, was
responsible for the decontamination activities, at no time during the
onsite NRC inspection did he present the August 19, 1987, survey results.
Neither did he provide any additiona'. information, either qualitative or
quantitative, regarding other surveys conducted and which indicated the
extent of (or absence of) contamination levels measured.
It should also
be noted that the person responsible for decontamination activity in the
reactor building (Director, NNRC) limited access to the area for an
extended period of time.
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Enclosure 2
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2.
Did the inspector ask to see all pertinent records and if so.were they
provided to him for his inspection?
The inspector requested of all licensee personnel (operations, HP, and the
Director, NNRC) to provide any information which would assist in properly
evaluating the cadmium contamination incident.
Data reviewed and
discussed with HP personnel included the radiological analyses of air
samples collected within the reactor building for August 1987, routine-
radiation survey levels in the reactor building, post-decontamination
survey records, and memos relating to the building and personnel
contamination surveys.
The inspector was informed by HP and operations
personnel that, although they did perform decontamination work, data
indicating the measured radiation survey results were not recorded because
personnel were involved in decontamination activities and failed to record
the measured survey results as the work progressed.
In addition, on January 14, 1988, both the radiation specialist and the
NRC Region II Section Chief discussed explicitly with the Director, NNRC,
the importance of obtaining, either from himself or his staff, all data
relating to the August incident.
The Director stated that the NRC would
be provided with all data.
The rationale for detailing the NRC concerns
to the Director, NNRC, and requesting his input in gathering til facts
regarding the August event is outlined below.
The Director, NNRC, stated to NRC personnel that he previously had
evaluated the August spill himself when it had occurred, had been
responsible for decontamination activities, and had informed the campus
radiation safety officer (RS0) of the incident.
In addition, the
inspector was informed by staff and the Director, NNRC, that the Director
observed the decontamination activities.
Given the above information, the
inspector concluded that to complete the evaluation of the event, the
Director had reviewed all pertinent survey documents.
At no time during
the inspection did the Director, NNRC, take exception to the inspector's
comments regarding the spread of contamination nor did he voluntcar the
August 19, 1987, survey data.
Throughout the onsite inspection period (December 16, 1987 through January
22,1988), the Director, NNRC, was aware of the NRC's concern regarding
the extent of contamination and was reauested to provide all data
necessary to evaluate the August incident.
At no time during the
inspection, including the January 22, 1988, exit interview, did the
Director, NNRC, provide the August 19, 1987, survey results.
Thus, the
NRC concluded that all pertinent records had been provided.
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Enclosure 2
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3.
If the Radiation Specialist Inspector did not see the August 19, 1987,
smear survey as claimed by the Deputy Regional Administrator and Section
Chief responsible for GTRR, how could the description of the survey
results (as described in Inspection Report (IR) 50-160/87-08) appear in
the report?
It is clear that the information could not have come from
facts provided by NNRC at the related Enforcement Conference, since that
conference was not referenced in the IR.
The August 19, 1987, survey results were presented to the local news media
following the January 22, 1988, exit interview.
Following the exit
interview, the Region II Georgia Tech Research Reactor (GTRR) Section
Chief telephoned the Director, NNRC, and reques.ted the document for
review. The documents were transmitted to NRC Region II (as an attachment
to a letter dated January 22, 1988), by the Director, NNRC.
Thus the
surveys were made available to and reviewed by the radiation specialist
prior to the February 23, 1988, Enforcement Conference, contrary to what
is stated in the June 13, 1988, letter from the Director, NNRC.
Furthermore, the presentation of these surveys to the media following the
January 22, 1988, exit interview and their subsequent submittal to the NRC
Region II Office resulted in their review and inclusion as part of
IR 50-160/87-08, dated February 10, 1988.
4.
What documents contained the above referenced 100-200 cpm above background
levels on the containment (main) floor.
The forms provided by the licensee to the NRC following the January 22,
1988, exit interview.
Specifically, Form RS-51, Daily Masslin Survey
Report, August 1987, indicated that for Area 7 on August 19, 1987, count
rates approximately 100 to 200 counts per minute (cpm) above background
were measured.
These quantitative results were for routine surveys
conducted by a student HP technican.
The existence of elevated contamination levels was discussed by licensee
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staff prior to the inspector's review of the survey results.
During
interviews of the operations and HP staff, selected survey results were
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described as ranging from measurable to approximately 22 millirem per hour
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(mrem /hr).
Both operations and HP staff stated that contaminated areas
were located in the main reactor building which required more detailed
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surveys and decontamination activities which were not recorded.
These
contamination levels never were specifically quantified but were described
as "measurable," that is, detectable above background.
5.
Which documents contained the followup surveys?
Page 6, Paragraph 3, of IR 50-160/87-08 specifically states "Discussion
with cognizant licensee health physics staff indicated that ... the
reactor shield."
The inspector interviewed all personnel involved in the
decontamination activities including operations, HP, and the Director,
NNRC, and all stated that because of the contamination event and
subsequent decontamination activities, followup surveys of personnel and
areas within the NHRC were conductede
Both operations and HP staff
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Enclosure 2
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discussed with and showed to the inspector during tours of the facility,
those areas where they had performed surveys and subsequent
decontamination activities.
Several' of the areas requiring followup
surveys and decontamination efforts were corroborated between the
operations and HP staff, including an operations staff ' member who stated
that he had to decontaminate an area of the catwalk across from the top of
the reactor shield.
6.
Were any results conveyed verbally (without contemporaneous official
documentation backup) to the Radiation Specialist Inspector?
See response to Question No. 5.
By whom?
See response to Question No 5.
What results?
NNRC staff stated that surveys indicating contamination ranged from
measurable up to 20 mrem /hr.
During discussi.on of the contamination
levels, excluding the 20 mrem /hr reading, both operations and HP staff
referred mainly to elevated or measurable contamination levels for areas
within the reactor building where contamination was reported.
Excluding
several memoranda detailed in IR 50-160/87-08, both operations and HP
staff were unable to provide written records of the contamination levels
they measured.
For example,
operations personnel
conducted
decontamination activities on top of .the reactor shield in the area
designated by the licensee to be the location of the August spill and also
to have the highest contamination levels. However, no detailed records of
the survey results used to properly-conduct decontamination activities
were maintained.
Details corroborating licensee statements were provided in the August 19,
1987, survey record and subsequent memoranda from the HP staff to the
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Director, NNRC.
For example, a survey indicating 20 mrem /hr was .
documented for a Masslin wipe survey conducted by a HP student technician
which was recorded in a personal log book and also detailed in a
memorandum (Boyd to Karam, August 20, 1987) reviewed by the radiation
specialist inspector. Additional documented survey results were noted for
contamination levels at the storage cask which remained elevated following
decontamination efforts (memorandum, dated August 27, 1987, Sharpe to
Karam).
7.
Given the obvious conflict between the inspector's determination and the
August 19, 1987, survey, how and based on what information did the
inspector determine that approximately one-fourth to one-third of the
reactor containment building had measurable contamination?
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Enclosure 2
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There is no obvious conflict between the inspector's determination and the
August 19, 1987, survey.
This referenced survey, because it was
incomplete, was not used to estimate the area of contamination. As stated
in the previous responses, the August 19, 1987, record only indicated
results of the routine surveys conducted up to the point in time when
definite contamination was observed.
For example, survey data indicating
the extent and levels of contamination on top of the reactor shield, an
area that the Director, NNRC, HP, and operations staff knew to be-
contaminated (memorandum from Boyd to Karam, dated August 20, 1987) and
which required extensive decontamination effort following the August
incident were not recorded on the August 19, 1987, survey.
Furthermore,
the August 19, 1987, survey results would not be used to estimate the
extent of contamination because these routine surveys only monitored a
small area of the reactor building containment floor, each area surveyed
was not drawn to scale on the data sheets, and the surveys appeared to be
conducted for locations near the shield wall of the reactor.
Results of
surveys for floor areas near the outer reactor building wall and equipment
located on the main floor were not listed on the survey.
Thus, the
inspector was required to use interviews of operations and HP staff to
determine the extent of contamination as described.
As previously stated, the Director, NNRC, was responsible for
decontamination efforts; however, he was unable to provide any qualitative
or quantitative survey data.
Furthermore, the Director never provided
information regarding the inspector's concerns of the extent of
contamination nor did he initially take exception to the NRC's comments
during the inspection.
8.
What amount of measurable contamination was found?
See response to Question No. 7.
By whom?
All personnel interviewed at the NNRC indicated that the ' contamination
above background was measured in various locations of the reactor
building.
9.
Is the NRC aware of any supporting documents which indicate contrary to
our best information, that the catwalk, the control room areas of the main
floor or any other area of the main floor (other than area #7) required
decontamination.
It is not at all clear as to what is meant by the phrase "contrary to our
best information" given the full awareness of the NNRC staff and
involvement of the Director in the decontamination efforts.
The inspector was informed by licensee representatives that results of
surveys associated with decontamination efforts in the aforenentioned
areas following the August incident were not recorded.
IR 50-160/87-08
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Enclosure 2
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noted an apparent violation for a failure to maintain appropriate records
for surveys.
However, interviews with operations and HP staff members indicated that
operations personnel physically decontaminated the reactor shield top,
reactor building floor, and an areas of the catwalk across from the
reactor. shield top.
In fact, the Director, NNRC, knew of this operator's
involvement as it was discussed during the February 23, 1988, Enforcement
Conference.
In addition, both HP and operation staff stated to the
inspector that locations in the reactor building other than Area 7 on the
August 19, 1987, survey record, were determined to be contaminated with
cadmium and were subsequently cleaned.
10. Are there any documents which support the numbers provided in the
memorandum from the MORS?
The NRC 'has not reviewed documents which could support nor refute the
numbers stated.
Furthermore, comparison of the 400 cpm contamination
results (memorandum, Boyd to Karam, dated August 20,1987) should not be
compared to the 100 cpm background results (letter from Karam to Grace,
dated June 13,1988).
For example, the 400 cpm was for a qualitative wipe
of a large area, whereas the referenced 100 cpm may represent a wipe
collected over a 100 cm2 area.
Additional data of the area surveyed,
instruments used and their associated efficiencies, and the actual san.ple
locations would be necessary to properly evaluate the numbers presented.
11.
Did RII or the Office of Investigations (01) investigate the possibility
of personnel of the ORS deliberately misleading NRC inspectors as to the
impact of the August spill?
It would be inappropriate for NRC to comment on possible ongoing
investigative activity, especially to confirm or deny the specific focus
of such investigations.
This standing policy ensures that investigations
are pursued under the best possible conditions.
12.
Did RII make any attempt to independently verify (for example, through the
use of official records, required by the NRC to be maintained by the
licensee) just how accurate or inaccurate the information provided by
personnel of the ORS was?
The NRC did request that all written information pertaining to the August
1987 event be provided to the NRC, in order to better support the
interviews of the operations and health physics personnel.
The NRC has
substantial reason to believe, based on the actions of the entire NNRC
staff after the August,1987, event, that oral information provided by the
ORS staff regarding the contamination in the reactor building was correct.
In fact, the information provided orally was consistent with the limited
available documentation.
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Enclosure 2
13.
If such an investigation was per o'
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it done and what were its
findings?
It would be inappropriate for NRC to comment on possible ongoing
investigative activity, especially to confirm or deny the specific focus
of such investigations.
This position ensures that investigations are
pursued under the best possible conditions.
14. The regulations in 10 CFR 2.201 and 2.202 appear to provide opportunity
for the licensee to answer charges raised under any pretense and
regardless of accuracy. What chain of reasoning caused RII and the NRC to
issue an Order to Modify rather than an Order to Show Cause as is required
by the regulations?
This question only addresses 10 CFR 2.201 and 10 CFR 2.202 and ignores or
overlooks 10 CFR 2.204, "Order for Modification of License," which is the
regulatory basis for the Order that was issued on January 20, 1988.
Regarding the complaint that Georgia Tech was not afforded an opportunity
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to "answer charges," the January 20, 1988, Order specified that the
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licensee "may request a hearing on this Order within twenty day (s of its
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issuance."
Also the licensee erroneously cited Section 2.201 c) as
2.202(c) and cited Section 2.202(b) as 2.202(a)(6).
Regarding the chain of reasoning, it was apparent to the NRC that the
August contemination event occurred because of lack of management controls
over the conduct of irradiations.
Also, the event initially went
undetected, and subsequent documented surveys of the scope of the event
were sparse.
This indicated a lack of management controls over the
,
assessment of the consequences of the event, further exacerbated by lack
of management corrective actions to improve future operations.
It is true
that the NRC's judgement is that the particular contamination event in
August did not represent a significant threat to public health and safety.
However, the purpose of the order was not punitive -- it was imposed only
to avoid possible future misoperations of more consequences to public
health and safety and to send a clear message to Georgia Tech that future
irradiations would not be permitted unless suitable enhancements in
management controls were implemented.
15.
Is it policy and practice of the NRC to assume guilt or were these
utterances unauthorized and mistaker. impressions?
The policy of the NRC has always been to expect a licensee to meet the
appropriate requirements of its license and operate the facility in a safe
manner.
Inspections are conducted to verify whether the facility is being
operated safely and in accordance with its license.
During this
inspection process, if problems are identified, they are brought to the
attention of the licensee.
Thus, the inspection process has as its basis
a presumed "innocent" philosophy; but, of necessity, information obtained
is evaluated objectively to determine whether problems appear to exist.
In the case of an enforcement conference, where the NRC does have
information that shcws that there is an apparent safety problem or
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F.nclosure 2
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violation, the NRC expresses the concerns to be discussed.
Among the
issues to be discussed are the . items of . noncompliance; and there is a
presumption of guilt at this. stage to the extent that, unless new
information is provided that alters our initial judgement'on the issues,
there will be a conclusion that the violations occurred.
One of the.
purposes of an enforcement conference is to provide a licensee the
opportunity to clarify any misunderstanding concerning the information
associated with the apparent. violation.
Our conference summary dated
March 14,1988, clearly identified ' concerns with management control of
health physics and operation programs.
It is difficult, based on the information you provide, to assess whether
the alleged statements were made in the above context.
If not, we would
appreciate further information on this subject.
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