ML20217B263

Insp Rept 99990002/99-01 on 990701-0816.Violation Noted But Not Being Cited.Major Areas Inspected:Review of Circumstances & Events Surrounding Reported Loss of Two Generally Licensed Devices Which Contained Licensed Matl

ML20217B263
Person / Time
Issue date:	09/30/1999
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20217B250	List: ML20217B247 ML20217B263
References
REF-QA-99990002-990930 99990002-99-01, NUDOCS 9910120197
Download: ML20217B263 (6)

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. U.S/ NUCLEAR REGULATORY COMMISSION '

' REGION ll

. Docket No.: 999-90002. )

License No.: General License Pursuant to 10 CFR 31.5 Report No.: 999-90002/99-01 Licensee: Department of the Army L'ocation: Fort Knox, Kentucky Dates:. July 1- August 16,1999

. Inspector: ' Hector Bermodez, Senior Radiation Specialist Materials Licensing / inspection Branch 2 Division of Nuclear Materials Safety -

Approved by: Mark S. Lesser, Chief 1 Materials Licensing / Inspection Branch 2 Division of Nuclear Materials Safety J l

i 9910120197 990930 RE02 GA999 EUSDODA Enclosure 99990002 PDR

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EXECUTIVE

SUMMARY

Department of the Army, Fort Knox NRC Inspection Report No. 999-90002/99-01 This special inspection was conducted to review the circumstances and events surrounding a reported loss of two generally licensed devices (tritium exit signs) which contained licensed material. The inspection revealed that the licensee's safety staff did not have adequate means to ensure that, once installed, tritium exit signs would be handled, removed and disposed of in accordance with regulatory requirements. This was identified as the root cause of the loss and presumed disposal of the exit signs in the Fort Knox landfill in addition, poor communication between the licensee's safety staff and the Directorate of Public Works contributed to the loss and the licensee's inability to recover the devices. Within the scope of the inspection, the following violations of NRC requirements were identified:

Failure to maintain records to demonstrate that installation, removal from installation and servicing of generally licensed devices was performed as required.

Unauthorized disposal of licensed materials.

Attachments:

List of Persons Contacted l Inspection Procedure Used l List of Acronyms I

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~ REPORT DETAILS

1. Sequence of Events Through interviews with licensee personnel and reviews of records the inspector determined the following:

On November 15,1998, personnel from the licensee's safety staff learned that buildings in the 1500 block of the licensee's site were to be demolished and proceeded to review ,

the site's radioactive material inventory to determine where tritium exit signs tvere )

installed. The staff determined that building 1540 had a Safety Light Model No. 2040 tritium exit sign installed and that also building 1109, which had been under renovation for months, had another model No. 2040 sign installed. Each sign contained 1 approximately 9.5 curies of tritium, mostly in gas form. The licensee's safety staff )

requested that the Directorate of Public Works' (DPW) Radiation Protection Officer  !

(RPO), whose group was in charge of building demolitions and renovations, determine )

whether these signs had been recovered. On December 15,1998, the DPW RPO was j again requested by e-mail to provide the status of the signs. i On January 19,1999, the DPW RPO informed the licensee's safety staff that the tritium .

exit signs in buildings 1540 and 1109 had not been recovered. The safety staff I concluded that, according to standard practices when removing electrical equipment I such as conduit, light fixtures and electric exit signs, the tritium exit signs were most likely inadvertently removed and along with other debris disposed of in the licensee's 1 landfill months before. On January 29,1999, the licensee made the required notification l of the loss and presumed inadvertent disposal of the devices.

2. Consequences Since the exit signs were handled as debris, the most likely outcome is that the seals which contained the tritium in the device broke, thus releasing most of the tritium to the i atmosphere. A review of the Sealed Source and Device Registry fur this device revealed that, under accident conditions, there is a negligible probability that a person would receive a dose commitment in excess of the dose to the appropriate organ as specified in Column IV of the Table in 10 CFR 32.24. As to any remaining tritium in the debris disposed of in the landfill, the landfill is located in a remote area where disposals take place on a daily basis. Based on this, given that it took months to confirm their loss and likely disposal in the landfill, any remaining tritium would be buried in the landfill with mininial potential to expose any member of the public to any dose in excess of regulatory limits.

3. Licensee's Corrective Actions A listing of the buildings that have tritium exit signs was provided to the RPO of the licensee's Directorate of Base Operations Support (DBOS), which is the organization responsible for getting contracts for building renovations or demolitions. Also, the DBOS Real Property Manager (RPM) was notified and provided a listing of tritium exit sign locat!ons. The DBOS RPM indicated that prior to any demolition / renovation activity in

. any building, he would ensure that tritium exit signs would be removed and disposed ci properly.

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2 As this case has generic implications Army-wide, this case was referred by the licensee to the Headquarters of the Department of the Army, Director of Army Safety.

Headquarters personnel committed to enhance tritium safety awareness throughout the Army by transmitting a message on the subject to preclude recurrence at other facilities.

4. Regulatory Analysis 10 CFR 31.5(c)(3) requires, in part, that any person who possesses byproduct material in a device pursuant to the general license specified in 10 CFR 31.5(a) assure that testing, installation, servicing, and removal from installation involving the radioactive materials, its shielding or containment, are performed (1) in accordance with the instruct.'ons provided in the device's labeling, or (2) by a person specifically licensed by NRC or an Agreement State to perform such activities.

The inspector examined several of the licensee's recently purchased tritium exit signs, Safety Light Model No. 2040, which were stored in their shipping boxes in the licensee's warehouse pending distribution for installation. The inspector noted that none of the sigas inspected had any label indicating that the device contained radioactive material, how to install it, how to dispose of it nor any other special precautions. The shipping package did contain a separate sheet of paper with installation instructions only. This is contrary to the conditions in which the device was approved for commercial distribution and this issue will be handled separately from this case.

Although it is impossible to determine whether the lost signs were properly labeled, the inspe:: tor concluded that licensee personnel did not follow the instructions that are required to be on the labels approved by NRC for commercial distribution of the devices nor were specifically licensed to perform such activity.

10 CFR 31.5(c)(4) requires, in part, that the licensee maintain records showing compliance with the requirements in 10 CFR 31.5(c)(3) stated above. " cugh interviews with licensee personnel and review of records, the inspector determined that  !

the licensee maintained a record of each time a new tritium exit sign was removed from the warehouse for installation at a particular location. However, the inspector noted that the licensee did not have records to demonstrate that testing, installation, servicing, and removal from installation involving the tritium exit signs were performed either in accordance with the instructions provided in the device's labeling, or by a person j specifically licensed by NRC or an Agreement State to perform such activities. This was  !

I identified as a violation of 10 CFR 31.5(c)(4).

10 CFR 31.5(c)(8) requires, in part, that the licensee dispose of devices containing byproduct material only by transfer to persons specifically licensed to receive the devices. The failure to dispose of two tritium exit signs by transfer to a person specifically licensed to receive them, as described in Section 1 above, was identified as a violation of 10 CFR 31.5(c)(8).

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5. - EXIT MEETING

SUMMARY

At the conclusion of the inspection, the inspection results were discussed with the licensee representatives indicated in the Attachment. No dissenting comments were received from the licensee. Licensee representatives indicated that the necessary measures to prevent recurrence will be promptly taken. Proprietary information is not contained in this report.

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ATTACHMENT

1. PERSONS CONTACTED

• COL F. Gehrky, Chief of Staff, U.S. Army Armor Center and Fort Knox

• R. King, Safety Director, Fort Knox

• L. Potter, Safety Specialist, Fort Knox

+ COL R. Cherry, Army Radiation Safety Officer  !

Other persons contacted incluaed warehouse, service anc clerical personnel.

• Attended exit meeting

+ Via e-mail

2. INSPECTION PROCEDURE USED IP 87103 Inspection of Materials Licensees involved in an Incident or Bankruptcy Filing

3. LIST OF ACRONYMS DBOS Directorate of Base Operations Support DPW Directorate of Public Works RPM Real Property Manager l RPO Radiation Protection Officer l

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