ML20199J986

Forwards Response to CAL 1-97-025 Showing Dose Calculations as Required for Bioassay Results Air Emission Tests & Review of Radiation Safety Program for 1997.Review Had Been Scheduled Prior to Insp,But Postponed Due to Conflict

ML20199J986
Person / Time
Site:	07003061
Issue date:	01/26/1998
From:	Binetti L IMAGING & SENSING TECHNOLOGY CORP.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
70-3061-97-01, 70-3061-97-1, CAL-1-97-25, NUDOCS 9802060074
Download: ML20199J986 (1)

Text

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6 IMAGING & SENSING TECHNOLOGY 300 westingnouse cucie u m.n.a. m s<s (607) 796 4400 F AX (607) 796-4579 January 26,1998 Unhed Stahm Nuoiser Raguisksy C==i=ias ATIN:Doocsaset ControlDesk

. Washington, DC 20555 -

n:Replyto aNatioe o(Violation Dookst No.07003061 l

InspectionNo.070 03061/97 001 IJoense No. SNM-1982 Deer sire:

Ir. mply to the raisanord Notice o(Viakth=:

A. Rnala=d is tbs response to the Con 6rmatory Action letter, CAL No.1-97 025 showing the does a=hdaniam as sequimd for the bionsasy resuhs and sh amiamina tests. 'Ibene anhdaniaam were not pseviously done due tc the hiosassys being close to daa-*=hla limits rol the air och were within levels y 10CFA20 Appendix B (edBuset concentrations). However, theue dose anhd=*ia== will be perfonned for au fbaurs tests, l

l B. A myiew of the Radiation Safety Pmgram was perfonned for 1997(copy anala==f) and

=d==Imad in response to the Comannatosy Acaba Isteer. ' Ibis had been aahAM prior to the NRC inspection but postponed due to a comaiot with an inspootion by the NYSDOL Radiation Bureau. 'Ibn 1996 review bed been partially completed but not fonnaDy suporned.

1

'lhis annual audit of the Radiation SafiWy Pmenen wiB now be established as a part of the IST Quality Assurneos Pmgram and placed on tbnir aahada of annual audits 'Ibe Padiatian Safety e-ia-win also be n.pansible to con 6nn the audit is p f d.

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Ereoutive VicePresident 1

oo: Jobr.D. Einaaman, NRC Region 1 l

' thomas M. Mike, Radiation Safety Of5cer 9902060074 980126

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PDR ADOCK 070030614

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• f' UNITED STATES ri NUCLEAR REGULATORY COMMISSION

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4 476 ALLENDALE ROAD KING OF PRUSSIA. PENNSYLVANIA 194061415 January 6. 1998 Docket No. 070-03061 License No. SNM 1982 Lou Binetti,' Executive Vice President immging and Sensing Technology Corporation'.

Westinghouse Circle -

Horseheads, NY 14845 2299

SUBJECT:

INSPECTION NO. 070-03061/97 001

Dear Mr. Binetti:

On September 1718,1997, Keith Brown of this office conducted a safety inspecticn

- at the above address of activities authorized by the above listed NRC license. Tha

. Inspectica was an examinatiori of your licensed activities as they relate to radiation safety and to compliance with the Commission's regulations and the license conditions. The inspection consisted of observations by the inspector, interviews with personnel, and a select 8ve examination of representative records. The findngs of the inspection were discussed with you during a telephone conversation on September 25, 1997 at the conclusion of the inspection.

Based on the results of this inspection, it appears that your activities were not conducted in full compliance with NRC requirements. A Notice of Violation is.

enclosed and categorizes each violation by severity levelin accordance with " General Statement of Policy and Procedure for NRC Enforcement Actions," (Enforcement -

Policy), NUREG 1600. You are required to respond to this letter and shou!d follow the instructions specified in the enclosed Notice when preparing your response, in your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence..Your response may reference or include previous-docketed correspondence, including your response to CAL No.~ 197 026,if the correspondence adequately addresses the required response. After reviewing your response to this Notice, including your proposed corrective actions and the results of future hopections, the NRC will determine whether further NRC onforcement action is necesary to ensure compliance with NRC regulatory requirements.

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L. Binetti 2-Imaging and Sensing Technology Corporation in accordance with Section 2.790 of NRC's " Rules of Practice," Part 2, Title 10, Code of Federsl Isegulations, a copy of this letter and your reply will bs placed in the Public Document Rocm (PDR). To the extent possible, your response should not include any personal privacy, proprietary, or safeguards informa'.lon so that it can be placed in the PDR without redaction. However, if you find it neesssary to include such intormation, you should clearly indicate the specific information that you desire not to be placed in the PDR, and provide the legal basis to support your request for withhelding the information from the public. The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96 511.

Your cooperLtion with us is appreciated.

Sincerely, John D. Kinneda,:

Chief Nuclear Mater i Safety Branch 2 Division of Nuclear Materials Safety Docket No. 070-03061 License No SNM-1982

Enclosure:

.1, Notice of Violation 2.

Inspection Report 070-03061/97-001 cc w/ enclosure:

Thomas M. Mike, Radiation Safety Officer State of New York

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p NOTICE OF VIOLATION iniaging and Sensing Technology Corporation Docket No. 070 03061 Horseheads, New York -

License No. SNM 1982 During an NRC inspection conducted on September 17-18,1997 a violation (s) of NRC requirements was (wore) identified. In accordance with the " General Statement of I

Policy and Procedure for NRC Enforcement Actions," the violation (s) is (are) listed below:

A.

10 CFR 20.1501 requires that each licensee make or cause to be made surveys that may be necessary for the licensee to comply with the regulations in Part 20 and that are reasonable under the circumstances to evaluate the extent of radiation levels, concentrations or quantitles of radioactive materials, and the potential radiological hazards that could be present.

1 Pursuant to 10 CFR 20.1003, survey means an evaluation of the radiological conditions and potential hazards incident to the production, use, trensfer, release, disposal, or presence of radioactive material or other cources of radiation.

I Contrary to the above, as of September 18,1997, the licensee did not make surveys to assure compliance with 10 CFR 20.1201, which limits radiation exposure to occupational workers, and 10 CFR 20.1101(d), which limits radiation exposure to individual members of the public. Specifically, the licensee did not evaluate the results of urinaly41s to determine the dose to the -

worker, and did not perform an evaluation of the dose received by the individual likely to receive the highest dose from air emissions from licensed operations.

This is a Severity Level IV violation (Supplement IV).

B.

10 CFR 20.1101(c) requires that the licenses shall review the radiation i

protection program content and implementation at least annually.

Contrary to the above, between June 29,1995 anu September 17,1997, the licenseo did not review the radiation protection program content and implemerstation.

This 16 m Severity Level IV violation (Supplement lV).

Pursuant to the provisions of 10 CFR 2.201, imaging and Sunsing Technology Corporation is hereby required to submit a written statement or explanation to the U.S.

Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C.

20555, with a copy to the Regional Administrator, Region I, within 30 days of the date of the letter transmitting this Notice of Violation (Notice). This reply should be clearly marked as a " Reply to a Notice of Violation" and should !nclude for each violation:. (1) the reason for the violation, or, if contested,' the basis for disputing the

=

e Notice of Violation 2

violation, (2) the corrective steps that have been taken and the results achieved. (3) the' corrective steps that will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Your response may reference or include previous docketed correspondence, if the correspondence adequately addresses the required response. If an adequate reply is not received within the time specified in this Notice, an order or a Demand for Information may be issued as to why the license should not be modified, suspended, or revoked, or why such other action as rney be proper should not be taken. Where good cause is shown, consideratior, will be given to extending the response time.

Escause your response will be placed in the NRC Public Document Room (PDR), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction. However, if you find it necessary to include such information, you should clearly indicate the specific information that you desire not to be placed in the PDR, and provide the legal basis to support your request for withholding the information from the public. If safeguards information is necessary to provide an acceptable response, please provide the level cf protection described in 10 CFR 73.21.

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UNITED STATES h

NUCt. EAR REGULATORY COMMIS810N h

f REGloN I j

475 ALLENDALE ROAD l

KING oF PRUSSIA, PENNSYLVANIA 19406-1416 6...

JAN 2 01998 1

CAL No.197-025-Lou Binetti, Executive \\#4ce President 1

= lma9 ng and Sensing Technology Corporation 1

1 Westinghouse Circle Horseheads, NY 14845 l.;

SUBJECT:

- CLOSURE OF CONFIRMATORY ACTION LETTER 1 97-025

Dear Mr. Binetti:

)

1 This refers to your letters dated November 20,1997, December 16,-1997 and December 22,1997; in response to our Confirmatory Action Letter (CAL) 1-97-025, L

dated Setember 26,1997._ Based on your response letters, th6 NRC has found that no further response is required regarding the CAL. V.*e will review the revised--

Radiation Safety Manual and Special Nuclear Material Inventory Procedvee, included with the letter, as part of the amendment requesnd in your letter of December 16,1997. You will receive a separate letter requesting any additional information necessary to complete that amendment. Your annual audit for_ calender year 1998 will 3

be reviewed as part of a future inspe_ction of your licensed activities. -

Thank you for informing us of the actions documentea in your letter. Based on the -

documents submitted, it appears these actions have been effective 'in bringing your program into compliance with our regulations. These actions will be examined in more E

~ detail during a futura inspection of your licensed program to ensure that they are effective in correcting the violations identified in recent inspections.1Your cooperation with us is appreciated.

In accordance with 10 CFR 2.790, a copy of this letter will be placed in the NRC l

Public Document Room.

Sinc ly,-

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A. R ndolph Alaugh,

' ctor Div' lon of Nudicar terials Safety Docket No. 070-03061-j License No. SNM 1982 i.

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Thomas M. Mike, Radiation Safety l Officer

~ State of New York--

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6 IMAGING & SENSING TECHNOLOGY 300 watmghouse circle Horscheads, NY 1484$

(607) 796 4400 F AX (607) 796-457$

December 22,1997 Keith D.Bmwn U.S. Nuclear Regulatory ('anneniamina Region 1 475 A11ervlataRoad King ofPmania,PA 19406-1415 re: Imaging and Sensing Toobnology Corporation (IR Con 5nnatoryAadonlmtter OAL No.1-97 025

Dear Mr. Brown:

As aquired by the Con 5nnstory Action letter dated September 26,1997, enckmod are the evaluations of air anniemiana, showing compliance with 10CFR20.1101(d) and bioe-mys, showing l

dose to each worker, to satisfy Items 2 & 3 of the action letter, b evab=tiana were pi.4 by

'Ihomas MoOhT, a Certi6ed Health fly. kist, whom IST retains as a consultant.

' Ibis sid=nimaion completes all actions aquired by the referenced C-6anatary Action Letter.

Please advise if you aquim airyf.iq fbrther at this time.

Vesytrulyyours, YA meas u.w.

Radiation SafetyOfficer oc: L. Binetti, Executive Vios Pasident, IST boo: C. Negri K.DeWalt C. Amrino T. Hughes J. Lynch qu@?

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A 3069 North Triphammer Road -

Lahsing, NY 14882 1

(007)533-7084 l.

l December 20,19g7 j

i Imaging and Sensing Technology 300 Westinghouse Circle Huseheads, NY 14845

- Attn: Thomas M. Mike L

Dear Mr. Mike:

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- Per your request, I ' determined does estimates for the bionssay results that you provided i

- to me.' The results are listed on the attached calculation summary. IndMiurls are i

i identified by their initials. The intake of each radionuclide was calculated from the biosessy res ults, the time lapse between exposure and urine collection and the intake retention function for the radionuclide sooording to " Interpretation of Bicessty -

Measurements, NUREG/CR-4884. Dosen were calculated as the ratio of the calculatad intake of the nuclide to the All of the nuclide times 5,000 mrom. Additional assumptions

- used in the calculations ere listed as notes to the calculation summary.

. }

All estimated doses were considerably less than one mrom. All urine analysis results I

were less than or seemed close to the detection limit of the analysis procedure. This may i'

be the reason that the reported ratios of U234, U235 and U238 are not the same ratios expected from the composition of the uranium metal. The results' confirm no significant l

Intake occurred.

To assist you in performing a quick assessment of future bionssay results, I suggest I

comparing them to the activity that will result in a dose of approximately 100 mrern. The l

relationship between actMty in the urine and dose changes dramatically as the time

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between the day of exposure and the day of urine collection changes. If the time

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j difference is either 1 or 4 days, the following reference values can be used.

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1 day _ - 5,700 pCi total activity of U234, U235 and U238 in the entire urine sample 4 days - 490 pCi total actMty of U234, U235 and U238 in the entire urine sample -

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- You also requested a dose assessment for an air sample that found an activity concentration'of 1.6E-12 uCl/mi during a 5 hour5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> sampling period. The simplest assessment approach is to compare this to the Derived Air Concentration or DAC listed in ICRP 30. An exposure to a' concentration of airbome radioactive mate, rial equal to one DAC for 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> will result in a committed effective dose egylvelent equal to 5,000 i

mrom.

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The ' measured concentration of 1.6 E-12 uCl/mi is equal to 5.9E-02 Bq/m3. The DAC for urenlum as a class D serosol is 2.0E+01 Bqlm3 The air concentration reported is 3.0E-03 DAC. If an individual were exposed tu this concentration for 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />, the resulting dose would be 0.04 mrem.

If you have any additional questions, let me know and I'll be happy to try to answer them.

Thank you, Sincerely, Thomas McGiff l

ml971220.itr--

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..l Conversion of Urine Bicassay Results to Committed Effective Dose Equivalent l

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I verker dsfes of date # De2aT

sins t&xEce (pO!Q (cQ) 1RF for24h Make intake inhalshen,SU Does(can) j emme se.5s. (days) vd.:ms ur:ns estmate. es5mais(B$

ClanD U238 j

(0 (500 iM ca 3.6E44. 3/13/97 1

0.962 U234 0.11 G106 1.87E-01 5.66E-01 2.09E42 5.00E44 2.E03 U235 0.03 0.029 1.87E-01 1.54E41 5.71E-03 500E44

' 6 E 04 U238 0.04 0.038 1.87E-01 206E-01 7.61E-03 500E44 8.E-04 total 0.173 3.E43 -

sd 3.5E44 2f2196 4

1.034 3.5E44 U234 01 0.103 1.82E-02 5.68E40 -

2.10E41 500E44 2E42 3.5E44 U235 0.1 0.103 1.82E-02 5.68E40 2.10E-01 ;

5.00E44 2.E-02 U238 0.1 0.103 1.82E-02 5.68E40 2.10E41 5.00E44 2E42 fotal 0 310 6.E-02 sd 3.5E+04 3/8/97 4

0.895 3.5E+04 U234 0.14 0.125 1.82E-02 6.88E40 2.55E-01 E00E+04 3.E42 3.5E+04 U235 0.06 0.054 1.82E42 2.95E40 1.09E-01 5.00E44 1.E-02 U238 0.1 3.090 1.82E-02 4.92E40 1.82E41 5.00E44 2E-02 total 0.269 5.E 02 1

Notes:

When exposure takes place over several days, dose is calculated as if al exposure takes place on the first day.

Intakes of radioactive meterial calet.!ated according to "Interpreta6cn of Bioassay Measurements, NUREGlCR-4884.

Doses were calculated as the ratio cf the calculated intake of the nuclide to the All of the ntrJide times 5,000 mere.

All amounts taken from

• Annals of the ICRP, ICRP Puti: cation 30 Part 1. Limits for intakes of Radocuclides by Workers".

Exposure was assumed to be inhalation of uranium as a class D aerosol of 1 micrometer AMAD.

When analysis results are given as "less than" values, due is calctelated on the va'ue given.

Worker:

CA ChadesAmrine SD ShideyDeugynty e

6 IMAGING & SENSING TECHNOLOGY 300 wesinionouse cucie Horseheads, NY 14845 (607)796 4400 F AX (601) 796-4$79 November 20,1997 KehhD.Bnma U.S.NuclearRegulatoryCW A Region 1 475 AllendaleRoad King o(1% sala,PA 19406 1415 m: Imaging and Sensing Technology Corporation (IST) c-AnnaMActionImr CALNo.1+97 025

DearMr. Brown:

As toquired by the Comennatory Action letter dated September 26,1997, anntanad is the annual j

audit for 1997. ' Ibis audit was pedbrmed by our consukant, 'Ihoenas MoOiff, CIIP.

l l

IST will ycosed to implement, through the Radiation Safety c==niMaa, those suggestions that we feel ar.) necessary to improve the Radiatlan Protection Program.

'Iho nmaining issues of tlw ConArmatory Actkalet6er aro'a===nai=11y comple6ed and will be submitted toyou shortly.

Very tndyyours, Pr"#9 Thomas M. Mike Radiation SafetyOfficer a

oc: L. Binetti, Executive Vice pia IFT boo: C. Negri K. DeWah C. Amrino T.Hughes J. Lynch wrg a

Radiation Safety Program Audit for Imaging and Sensing Technology Corporation l

t Submitted by:

Thomas McGiff Novembor20,1997 O

r y

4 Introduction This report is a summary of the discussions that took place during an audit of Imaging and Sensing Technology Corporation's radioactive materials safety program. The goal of the audit was to review the policies, procedures, records

. facilities associated with the program and provide feedback on the degree to.

. which the program in achieving protoction for workers and the environment and l

to offer suggestions for program enhancements.

4 L The audit was not a comprehensive review of the program's compliance with

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regulatory requirements. Rathei, is was a peer review process whereby the t

policies'and methods of the program were compared to thosa femmer to the author, it is up to the Radiation Safety Officer and the Radiation Safety

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Committee to determine if the opinions and ruggestions contained in this report should be rdopted.

1.

- Program Administration 4

i 1.1 Safety Committee has written' charter.

- Yes.-

See section 1-2.0 of RSM.

i 1;2 Committee charter la adequate <

i I

Yes.

1.3' Committee memborahlp is adequate.

Yes.

Suggestion Appoint an additional member who is appropriate to represent the compr.ny administration.-

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1.4; committee meets at required frequency, j

' Yes.

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Comment-The committee meets quarterly as specified in the RSM.

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. '1.5 Committee documents activities and actione.

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Yes.

j

- Suggestion - Wording of committee minutes could be more explicit about decisions,

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. reached and actions taken. Also, consider using an ' action list" to track progress on iteme selected for action by the committee.-

1.6' Committee actively' reviews and approves operations.

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I No..

Comment-.The committee does not actively review rsperations, except those that appear

- on the agenda for meetings.

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Suggestion Implement 4 system through which the Committee issues ' permits' for use of rauloacdve material. Permits can specify such issues as personnel, locations, inventory limits, superHsory responsibility and any special precautions deemed appropriate by the Committee. Esa operation involving radioactive material has a written standard operating procedure (SOP) that the worker is trained to follow. The Committee oould review these documents to see that appropriate precautions for radiation protection r.re includec' 1.7 Committee has enforcement policy or other demonstrated means of 4

enforcement.

Yes.

Comment- !!em 5 in section 12.1 of RSM states that the committee has enforcement authonty.

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Suggestion Document the decision to empower the committee with an additional communication from the company administration.

1.8 Committee reviews radiation safety program on annual basis.

Not in reunt years. This audit was undertaken to correct this issue.

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. 1.9

' RSO has written definition of responsibility and authority.

Yes.

Comment See section 12.3 and 1-3.0.

I 1.10 RSV's reporting structure is adequate to ensure support for both policy decisions and emergency actions.

Yec..

Suggestion - The information on the RSO's reporting structure in the current version of RSM is out of date and should be revised.

1.11 RSO receives adequate financial support for necessary operations and maintenance of professionallevel of knowledge.

Yes.

Comment-RSO Indicates financial resources are adequate and the RSO plans to attend a professional development course within one year, A technician was recently assigned to assist with radiation safety program on a part time basis.

2.

Personnel Dosimetry and B;oassay 2.1_

Written procedure defines when and how personal dosimeters must be worn.

Yes.

Comment - 0.iee section 11-5.1 of RSM.

- Suggestion - Confirm all entrances to areas with access restrictions for radiation safety

' purposes are marked appropriately.

2.2 Dosimeters are provided and processed by vendor with NAVLAP certification.

Yes.

2.3 Dosimetry results reviewed by RSO in a timely manner.

Yes.

Comment All Dosimetry reports are reviewed and initialed by the RSO.

2.4 ALARA guidelines established for doses to personnel.

Not formally.

Comment The RSO investigates all dosimeter readings that indicate a measurable dose.

This, or some other appropriate level should be formally designated as an AL. ARA investigation level.

2.5 RSO follows up on dose reports that exceed the ALARA guideline.

Yes, in effect. See item 2.4.

2.6 Dosimetry results are provided to the individu:1.

Yes.

Comment-All doslmeter readings that indicate a measurable dose are verbally reported to the worker by the RSO.

Suggestion - Use a form letter to the worker to document 1) the RSO's investigation into the circuinstances that may have caused the dose and 2) corrective actions, if any. Also, l

consider providing wurkers an annual written dosimetry summary [this may be available l

as a service by the dosimeter vender).

2.7 in lab check confirms dosimeters are worn when and how they are required.

Not dete: mined.

2.8 Written procedures define how and when bloassays are performed.

Yes.

Comment See section 11-5.2 of RSM.

Suggestion - Reword this section of the RSM to be more specific to your plant's specific operations. Have the vendor providing analysis services provide documentation of their qualifications and written procedures for collection, preservation storage and transportation of samples. Document that these procedures pra followed.

2.9 Bloassay results reviewed by RSO in a timely manner.

Yes.

Suggestion - Reports need to be initialed od dated by the RSO Intake and/or dose need to be calculated for samples that Indicate measurable radioactivity.

2.10 ALARA guidelines established for bloassay results.

Yes.

Comment See section 115.2 of the RSM.

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2.11 RSO follows up on dose reports that exceed the ALARA guideline.

No.

Comment ALARA guideline for bioassay results is specified as "10 percent of the Annual Limits of Intake (All's)". Bioassay results can not be compared directly to this criteria.

The information in the report is presented as activity concentrations in the sample. This information must be converted to intake activities.

Suggestion - A method to determine intake needs to be developed.

2,12 Bloassay results are provided to the individual.

No.

3.

Calibration of Radiation Detection Equipment 3.1 inventory listing of required equipment.

Yes.

Comment See section ll 7.1 of the RSM. The current list is correct.

3.2 Calibra3on procedures and contractor license on file.

No.

Comment The RSO indicated he is in th6 socess of obtaining them from the calibration service provider.

3.3 Calibration sources NIST traceable.

Yes.

Comment Calibration certifications on file indicate this is so.

3.4 Calibration Information available to user.

Yes.

Comment-The calibration information provided to the user was not always appropriate with the use of the instrument.

Suggestion - For each radiation detection instrument, review the calibration information provided by the calibration service and the information provided to the user to be sure the calibration data and calibration sticker provide the necessary information.

3.5 Calibration frequency adequate.

Yes.

3.6 Equipment calibrated within appropriate time period.

Yes.

Comment-Data verified for two instruments. Procedures and records for instrument calibration appear well maintaired.

3.7 Equip _ ment checked for proper operation-during use (check source).

Yes for some units, not on others.

Comment-RSO confirmed he is in the process of obtaining more check sources.

Suggestion As part of annual retraining, remind workers of the procedure for checking l

proper operation.

l 4.

Training L

4.1 Content of training program is documented.

Yes.

l Comment. See Radlaflon Safety TralnIng Manual dated December 1994 Course outline was attached to sign-in sheets for each training program. Each operation involving radioactive material has a written standard operating procedure (SOP) that the worker is trained to follow.

4.2 Content of training program is adequate.

Yes, 4.3 Attendance at training program is documented.

Yes.

4.4 Effectiveness of training is documented (test results).

No.

Comment-The RSO Indicated he planned to re institute the practice of requiring each worker using radioactive material to pass a quiz based on the material contained in the radiation safety training program.

4.5 In lab check confirms effectiveness of training.

Not evaluated.

5.

Un-sealed MaterialInventory 5.1 RSO tracks on-hand inventory and maintains levels within license limits.

Yes.

Comment. The quantity of radioactive material on-hand is tallied every 4 to 6 months and prior to giving approval to purchase new material.

Suggestion - Confirm the on-hand inventory on a monthly or quarterly basis, include all items in storage for disposal.

5.2 in lab checks confirm inventory is accurate.

Yes.

Suggestion - Review all procedures for tracking amount of rad'oactNe material uses and tn hand with the indNiduals keeping these records. Confirm that the procedures would catch situations where an un 9thorized or un-recorded use had talen place (ex, a slow leak from a gas cylinder).

6.

Sealed Source Wipe Test & Inventorf 6.1 RSO mainta!ns up-to-date list of all sealed sources.

Yes.

Comment The listis maintained as part of the RSM.

Suggestion -If the list of all sealed sources were maintained on s log apart from the RSM, it would be easier h update.

6.2 Wipe tests and inventory checks for all sources made at the required frequency.

Yes.

Comment - Frequency is 6 months. Wipe tests taken July 8,1997 results still pending.

Wipe tests taken January 22,1997 - results dated 2/20/97. Wipe tests taken July 12, 1996-report dated 7/22/96.

6.3 Labeling, signage and security adequate for all sources.

Not determined.

l

• 4 Documentation of wipe test results is adequate.

Yes for some reports, but not for all.

Comments - The format of wipe test analysis reports changed oetwwen 7/22/96 and 2/20/97. The latter report, the results do not indicate the total activity determined for the sample.

Suggestion - RSO needs to indicate on each report that the results for each source are or are not satisfactory. The report format should indicate the total activity determined per wipe. Leak tests are not required for sources #11 and #12 because of their low activity.

6.5 Follow up action taken as needed.

No follow-up action has been needed.

7.

Compliance inspections of Radioactive Material Use Areas 7.1 Inspections of use area are performed routinely.

No.

Suggestion - An inspection program should be developed and carrieri out on a quarterly or semi-annual basis. One individual should be designated as responsible for maintair compliance with inspection criteria. Prior to initiating Irispection program, the inspection criteria should be explained to the individuals responsible for maintaining compliance.

7.2 Inspections are properly documented.

No.

7.*J Inspections cover appropriate items.

No.

7.4 Inspections are reviewed by RSO.

No.

7.5 Follow up, if needed, is carried out.

No.

1.4, See inspection report for individual areas for results of inspection conducted by this auditor, inspect'.on conducted of Mounting Room Area 12. See attached report.

8.

Radiation Protection Surveys of Radioactive Material Use Areas 8.1 Surveys of use area are performed routinely.

Yes.

8.2 Surveys are properly documented.

Wipe test surveys satisfactory. Improvement needed for meter surveys.

Suggestion - A written procedure should be developed for how surveys are performed.

Survey data sheets should identify the radiation detection instrumentation used for the survey, Survey reports should show results in DPM and mrem /h.

l 8.3 Surveys are reviewed by the RSO.

Yes.

Suggestion - The RSO should indicate whether results are or are not satisfactory.

8.4 Follow up,if needed,is carried out.

Yes.

Comments - Records show the results of both pre and post decontamination results.

9.

Waste Management 9.1 Waste management procedures in place for all operations.

Yes.

Comment - SOP's explain how to handle radioactive waste.

Suggestion - The Radiation Safety Committee should reviev' GOP's to determine that waste procedures are adequate.

f..

9.2 Procedures provide waste minimization.

Yes.

Comment - The licensee uses re distillation and evaporation to reduce waste volumes.

9.3 Waste storage procedures minimize possibility of spills or improper handling.

Improvement needed.

Suggestion - Require secondary contument for containers of liquids. Line trash containers with disposable plastic liners.

9.4 in lab checks confirm workers familiar with waste procedures.

.Yes.

Comment - Based on a discussion with one worker in the Mounting Room.

9.5 Waste is collected at an appropriate frequency.

Yes.

Comment - One full container found in the Mounting Room with a date of 1995.

9.6 Waste is transported and/or stored in an appropriate manner.

Yes.

9.7 If practiced, disposal to the sanitary sewer is documented and conforms to appilcable regulations.

No waste is added to the sanitary sewer.

9.8 Weste is transferred to licensed facility via a licensed broker.

Yes.

10.

Authorization of Users and Operations of Radioactive Material 10.1 Standardized approval process.

Operations involving radioactive material are covered by SOP's. Some of these are reviewed by the RSO.

. All users receive radiation safety training prior to being allowed to work in any radioact!ve material use area.

Suggestion - D6velop a more formal process for the radiation safety committee to approve all of use of radioactive material. See suggestion for item 1.6. The review should take place prior to the initiation of any new procedure and take place periodically to confirm that operations continue to follow Committee requirements.

10.2 ~ Written operating procedures.

Exist for some operations.

i a

Suggestion - The Radiation Safety Committee should review all SOP's that involve the use of radioactive material and ensure that they address radiation safety adequately.

10.3 Responsibility for compliance delegated to specific individual.

No.

Suggestion - Designate one specific individual to supervise each area where radioactive materialis used.

10.4 Authorizations foi selected areas reviewed and adequate.

No.

10.5 in lab check confirms compliance with conditions of authorization.

Not reviewed.

11.

Emergency Response 11.1 Responsibility for emergency planning is delogated to a specific individual.

Yes, the RSO.

11.2 Potontial emergency situations documented.

No.

l 11.3 Emergency plan and procedures are appropriate to the potential for emergency situations.

No.

11.4 All internal and external groups with responsibility for emergency response have confirmed their willingness to fulfill their part in the emergency plan.

Need for;mprovement.

Comments 1.ocal horpital and fire department are aware that radioactive materials are used at the facility, Additional planning for emergency situations is recoramended.

11.5 All material and equipment needed to carry out,t,he emergency plan is in place ready for immediate use.

Yes.

11.6 Contents of emergency supplies checked on regular basis.

No.

11.7 Drills or other tralning activities are conducted with all groups at the appropriate frequency.

No.

'i.,...o 3

11.8 Appropriate emergency procedures, including ep-to-date contact

~

numbers, 'are pysted in all use areas.

Yes.

11.9; T Actual emergency siturations, if any, are' documented, reviewed to determine if changes s.re needed in the plan. If so, changes are :

-_ implemented.

No emergency situations hate occurret

12. 1 Receiving of Radioactive Materici-p 12.1 - All orders for rtdiotctive material receive prior approval c'

" 1 q

Yes.

i l.

12.2 Records of previous orders confirm RSO appreves all o -

.m advance.

Yes, ;

Comment - Putchase requests sor radioactive material must be signed by the RSO 'before the Purchasing Department w ill act on them.

12.3 Written proceduros available for opening incoming packages. -

Yes, eammec - See section 'il I ta&b of the Radiation Safety Manual.L 12.4. Procedures are adequate.

Yes.

-]

12.5 Arrangements s re made, for off-ht,urs deliveries.

Yes. No shipments are accer ted after hours.

12.6 Recorde of pas t shipments confirm all are received in a manner consistent with procederec.

No.

Procedures and form for receiving enly recently instituted.

4 9