ML20236A831

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Forwards Commitment Status Update Resulting from Corrective Actions for Violations Delineated in Notices of Violation, Enforcement Conferences,Confirmatory Action Ltrs & Mgt Meetings
ML20236A831
Person / Time
Site: 07001100
Issue date: 02/13/1989
From: Mcgill P
ABB COMBUSTION ENGINEERING NUCLEAR FUEL (FORMERLY
To: Russell W
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
Shared Package
ML20236A818 List:
References
NUDOCS 8903200184
Download: ML20236A831 (50)


Text

{{#Wiki_filter:_ _ _ _ _ _ _ _ - - _ _ _ r 4 .j y-l CONIBUSTION ENGINEERING February 13, 1989 i Docket No. 70-1100. . License No. SNM-1067 Mr.-William T. Russell Regional Administrator, Region I U. S. Nuclur Regulatory Commission i 475 Allendala Road King of' Prussia, Pennsylvania 19406

Subject:

Update of Windsor Nuclear Fuel Manufacturing Commitments i

Dear Mr. Russell:

This letter is in response to a request to confirm or update information on commitments made oy Combustion. Engineering with regard to the need for improvement in operations at our Windsor Nuclear Fuel Manufacturing Facility. The commitment' ~ resulted from corrective action for cited violations i s delineated in. Notices of Violation, Enforcement Conferences,l Confirmatory Action Letters and manage:nent meetings. The need for this update became apparent during a Region I inspection conducted the week of January 30, 1989. The stated purpose of the inspection was to as.tess the status of'various programs which were to address long term actions f to improve deficient facility operations. Early in the inspection it became clear that a misunderstanding existed between Combustion Engineering and Region 1 with regard to the ongoir) nature of some program commitments. During the cout se of the aforementioned inspection, and as a result of telephone conversations with Region I management, Combustion Engineering agreed to providi the update information in an effort to bring all parties back to a common point of reference. The Attachment to this letter contains our latest status and -projections for further action. .m i A 's C Power Systems 1000 Prospect Hill Road (203) 688 1911 l Combustion Engineenng, Inc. Post Office Box 500 Telex: 99297 Windsor, Connecticut 06095-0500

,.7 5 ,g 'Mr. William.T. Russell z, _ February'13, 1989

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d o ~ If I can be 'of further' assistance on this matter, please do not liesitate.to - call me or Mr. A. E. Scherer _of my, staff at (203) 285-5200. 1 Very truly.yours, 'l a COMBUSTION ENGINEERING, INC. m ff(f f I L. McGil -Vice President Nuclear Fuel j PLM:dmb' i

Attachment:

As Stated xc: M. Austin-(NRC Region I) R. Bellamy (NRC Region I) G. Bidinger (NRC) S. Ebneter (NRC Region I) D.'McCaughey (NRC) W. Pasciak (NRC Region.I) l J. Roth (NRC Region I) ~ L. Rouse (NRC) i i f

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i N t l l ?- L1__E________._._ a

0 B Combustion Engineering Comitment Status Update l The information provided herewith is intended to updth the status of various commitments Combustion Engineering has made to the Nuclear Regulatory Commission. Following the guidance of Mr. J. Roth (NRC Region I) at the January 30, 1989 inspection, we are providing update information for commitments originating from cited violations of license conditions or l regulatory requirements between October,1987 and the present time. These commitments originated from Combustion Engineering responses to Nuclear Regulatory Commission Notice of Violation, Enforcement Conferences, Cor.firmatory Action Letters and management nuetings. The commitments updated on the following pages have been extracted from the following sources: Confirmatory Action Letter 87-14 dated October 27, 1987 l Enforcement Conference of December 1, 1987 Ir.sp. 87-05, Notice of Violation dated January 25, 1988 Enforcement Conference of May 10, 1988 Insp. 88-03, Notice of Violation dated June 6,1988 ) Enforcement Conference of August 3, 1988 I l Confirmatory Action Letter 88-23 dated September 9,1988 I Insp. 88-05 & -06, Notice of Violation dated October 7,1988 ) I Management Meeting held in Region I November 10, 1988 j Management Meeting held in Region I January 17, 1989 A review of the above sources indicates that commitments originating from cited violations are captured in Combustion Engineering's responses to the Notices of Violation. Discussions at Enforcement Conferences and management meetings was, for the most part, based on the Notices of Violation. As such, the attached material focused on the Notice of Violatior. responses as the source for commitments. Although Part 2 of Combustion Engineering's Nuclear i Fuel Integrated Improvement Program contains many more commitments than l addressed here, they do not originate from cited violation; or they are l outside the time frame requested. Combustion Engineering will address the status of these remaining commitments as part of the new Action Plan which we agreed to submit to Region I by March 31, 1989. The following pages document each commitment. A summary Table is provided l which gives an overview of the status of each commitment. This table is l followed by more detailed information on each commitment. In general the l source of each commitment is identified, the commitment is cross referenced to I the cammitment line item number (s) given in Part 2 of Combustion Engineering's Nuclear Fuel Integrated Improvement Program report, the original violation and Combustion Engineering's original response are provided along with the current status and any projections for additional effort. l l 1

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SUMMARY

OF COMMITMENT STATUS

6. )

g INSPECTION. NOV. LETTER VIOLATION NFIIP, PART 2 ACTION STATUS ',.7 REPORT NO. LINE ITEM 87.- 0 5 '. .Jan. 25, 1988 A 34 Completed i B .35,36 Completed-l C 37,38 RPI-207.to be i 1 f i-issued by;2/24/89; i CAM test procedure 1. 1 o by 2/18/89 D 39,40,41,42 Completed E 43,44 Completed. c 'g F 45,46 . Completed- .4 G 48,49,50 Completed

n.,

O H 51,52 Compieted. .I 53-Completed a, J 54,55 Completed ' "Y. 88-03 June 6,.1988 A 74 Completed, B 75,76 Incorporation of-y'. safety precautions in Op.-Sheets to N be done 3/31/89. C 77 Completed-D 83 Admin procedure on criticality safety: o control to be written by 5/1/89. 3.. E 84,85,86,87 Operation evalua-tion to be done by 3/31/89. F 89 Completed o s G 90,91 Completed 88-f:d/88-06 Oct. 7, 1988 A 115,116,117 Completed B 118,119 Completed n C 103 Completed 0 104,105,106 Completed E 107,108 Completed F 107,108 Completed G 107,108 Completed H 109,110,111 Completed I 112,118 Completed _j

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Reference:

j -NRC Letter.(Russell to McGill) 1 Dated January 25, 1988 j .NRC Inspection Report No. 70-1100/87-05 i Violation A' NFllP Part 2 item No. 34' l l VIOLATION i A. Specia! Nuclear Materia! License No.1067 (Sh'Y-1057), Part 1, License j Condition. Section 3.2.8.1, "Contar.ination' Surveys" requires thal fo* Pellet Shop Euilding #17 removable; alpha, cont:ur.ination of 10,000 dpm -l per 100 square centimeters. be immediately cleaned up. Contrary to the -above; from September 15, 1987, to October 23, 1987, plant alpha contamination levels were idendfied in certain locations of the pellet shop to be as high as 160,000 dpm per 100 square ] centimeters and the contamination was not cleaned'.up. i

RESPONSE

i 1. Combustion Engineering admits the violation. 2. This violation.resulted from (1) reliance on a surface contamination e control program which emphasized conterination on the.fioor and did not sufficiently monitor other surfaces in the pellet shop and (2) assignment of an inadequate number of personnel to clean al! contaminated surfaces immediately after ine surface contam: nation program indicated the presence of contamination at action levels. 3. Additional temporary decontamination personnei were brought in to help reduce the pe.' Jet shop contamination level below the license limit. l A supervisor is currently charged w-ith the primary responsibility for the decontamination program to assure that continuing attention is given to contamins. tion control measures. Contamination levels have. been reduced and are controlled in accordance with license l. i req uirements. l l. l l )

y l x,.. l ^ An improved method for monitoring contamination and identifying ) ,,1 ] needed corrective action has been implemented.. This involves a contamination control board located in the pellet shop. The I contamination control board displays the status of approximately 84 i locations to keep shop personnel, supervisors, health physics l technicians and management ir. formed of contamination levels. Prompt .i action is ttken to decontaminate the locations noted on the board whenever unacceptable contamination levels are posted. \\ Further, management now receives a daily summary report on I contamination control survey data. 4. Additional contamination control instructions have been written to supplement existing procedures in this area. These instructions are i being used in a training program for all pellet shop personnel to re-emphasize the'importance of contamination control. The training - program covers good work practices, contamination control and I acceptable decontamination procedures. Copies of applicable instructions are maintained at work stations. i 5. The actions noted above have corrected Violation ( A). l Status Update In addition to the action taken after this violation was identified, it was felt that an improved contamination control procedure was needed. This procedure (RPI 209 - Monitoring For Radiation & Contamination) has been prepared and was implemented on February 10. 1989. The C-E action on this violation is considered to be complete. l l I l

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Reference:

NRC. Letter.(Russell to McGill). Dated January 25, 1988 NRC Inspection Report No. 70-1100/87-05 ' Violation B NFIIP Part 2 Item No. 35, 36 VIOLATION B. -10 CFR 20.103(b)(1) requires that the.llcensee, as a precautionary procedure, use process or other engineering controls, to the extent l practicable to limit. concentrations of radioactive materials in air to I levels below those which delimit an airborne radioactivity area as, 1 defined in 20.203(d)(1)(ii). j H Contrary to the above, from August 12, 1987, to October 23, 1987, l process or other engneering controls were not used to'the extent I practicable to limit concentrations of radioactive materials in air in the .) pellet shop. These controls were deficient in that certain equipment i associated w-ith the manufacturing of pellets (such as hoses)', which 1 are designed to confine the uranium oxide to the ventilated enclosures- .I

j that contain the pellet presses, were not adequately maintained, resulting in leakage of uranium in the pellet shop.

1

RESPONSE

l ~ 1. Combustion Engineering admits the violation. 2. Combustion Engineering relied on process and engineering controls which had been in place for many years without periodic review to ascertain their continued acceptability. As time passed and the pellet shop throughput increased, the existing process and/or engineering j contr* became more difficult to keep in good repair. As a result, interur, repr_ irs were made as necessary to, correct problems as they occurred. This led to a situation in which the existing process and'or engineermg controls were not as effectvs as desired in limiting conta:unatien. l l [ 3. All damaged hoses at the pellet presses have been replaced. Hoses t I and hose connections at the pellet presses will also be enclosed in 1 ventilated engineered containments. A comprehensive program has been initiated to refurbish existing process and'or engineering controls, e.g. by rebuilding hoods and glove boxes around powder w_ __,w

w;tn sheet meta., where necessary, te reduce the spread of ce r.t trr.:nr.u er.. In additior., the improved peDet shop contarranaucr. control program discussed in the response to Violation ( A) helps assure that, even what this corrective action is in progress, peuet shop contamination concerns 5-iU ba ad d res sed. 4. san equipment refurbishment program has been implemented to remove ,the layers of interim fixes and return the faciUty process and engineering controls to a fuUy functioning condition. In addjtion, an upgraded me.intenance program is being developed and implemented. The refurbishment of process and engineering controls as well as the use of ar upgraded ma:ntene.nce program wi!! assure that the Ucense conditions are met. 5. Completion of the upgrading propre.m as discussed above is expected by the third quarter of 19SE. Status Update C-E has completed an upgrade program to incorporate engineered controls, to the extent practical, in the installation of containment eqJipment and additional local ventilation to minimize uranium oxide powder leakage out of the equipment. The upgrade Maintenance Program is completed and is being used for maintenance activities. The C-E action on this violation is considered to be complete.

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Reference:

- 4 l NRC Letter.(Russell to McGill) Dated January 25, 1988 NRC Inspection Report No. 70-1100/87-05 Violation C NFIIP Part 2 Item No. 37, 38 VIOLATION s C. 10 CFR 20.103(a)(3) requires, in part, that the licensee, for purposes of determining compliance with 10 CFR 20.103, use suitable measurements of conecntrations of radioactive materials in air for detecting and evaluating airborne radioactivity in restricted areas. Contrary to the above, from August 12,1987, to October 23, 1987, suitable measurement were not made of the concentrations of. radioactive materials in the air for detecting and evaluating airborne radioactivity in the pellet shop, a restricted ama, in order to 1 determine compliance with 10 CFR 20.103, in that the samples taken i were not representative of the air breathed by' the employees. _ESpONSE R 1. Combustion Engineering admits the violation. 2. This violation resulted from reliance on Combustion Engineering's fixed air sampling program which had been in use for a number of i years. Tests conducted periodically, as requimd by the license, to correlate fixed alt sampling results with an independent air sampling method had not revealed sigruficant variations. 3. Combustien Engineering recently acquired new Breathing Zone Air q Samplers (BZs). A monitoring progra:r. was conducted for a selected l number of pellet shop personnel and it was determined that calculatec activity ranged fron. levels comparable to the faed air sampler results I to. levels several times higher. Additiona' B2s have been ordered to permit more extensive monitoring of personne! working in the pelle: p l

shop, i

t l l The improved pellet shop contamination control program, discussed in i the response to Violation ( A) helps assure that even while this corrective action program is in progress, pellet shop contamination i concerns wi!) be addressed. l I....______------____..__

}- t .1 ; 4. . Combustion Engineering has procured cnd will coon' install a contmuous air monitor.(with an aud.ible alarm)sfor use in early detection of increases in airborne radioactivity in the' pellet shop. Following installation of the continuous air monitor and receipt of the additional BZs, these will be incorporated into a comprehensive-airborne activhy monitoring program. 5. The actions noted will enhance the previous air. sampling program. It is expected that all new air sampling equipment will'be in place by .the' third quarter ot' 1985. Status Update 1 37. In order to bring this item into compliance with NRC N9uiations, additional lapel air sainplers were purchased. On July 11, 1988,.C-E' started using the lapel air samplers to assign dose for all worl:ers who i handle unclad uranium. A procedure, RPI 207 (Internal Exposure Control),. in support.of the lapel air sample program has been prepared, however,- the document needs improvement prior to implementation. This procedure will-be in effect by February 24, 1989.

38. C-E also committed to install a Continuous-Air tionitor (CAM).in the vicinity of the pellet. presses. The CAM was purchased, calibrated, and

' installed by September 30, 1988 in accordance with the commitment date. After a short period of operational experience with the CAM, it was discovered that some operational test data would be needed to establish a more' accurate relationship between the CAM and the worker's breathing A test procedure is in preparation and testing should begin by zone. February 28. 1989. We ar,ticipate running the test program for 30 to 45 days in order to collect enough data to make an evaluation of the CAM's performance. I l f

Reference NRC Letter (Russell to McGill)' Dated January 25, 1988 NRC Inspection Report No. 70-1100/87-05 Violation D NFIIP Part 2 It'em No 39. 40, 41, 42 VIOLATION D. 10 CFR 20.103(a)(3) requires, in part, that the licensee, as appropriate,.use measurements of radioactivity in the body, ' measurements of radioactivity excreted from the-body, or any_ combination of such measurements as may be necessary for timely detection and assessment of individual intakes of radioactivity by exposed individuals. Contrary to the above, on August 12 and September 26,1987, air samples taken indicated that a potential existed for intake.of radioactive materials by workers, and appropriate measurements of . radioactivity in the body, measurements of radioactivity excreted from the body, or any combination of such measurements werc not made as 7 necessary in each case to ensure timely, detection and' assessment of individual intakes or radioactivity. Specifically, i 1. On August 12, 1987, the licensee determined, based on the air sample measurements in the pollet shop, that eleven individuals .i received between 21 and 68 maximum permissible concentrations (MPC) hours, and only urinalysis for insoluble umnium cxide was performed on these individuals rather than a whole body count and/or fecal analysis which would have been necessary in these circumstances to assess the individua.!'s intakes; and 2. On September 26, 1987, the licensee determined, based on air sample measurements, that an individual received about 38 MPC hours, and only urinalysis for insoluble uranium oxide was performed on this individua! rather than a whole body count j i and!or fecal analysis which would have been necessary in these l circumstances to assess the indWiduars antake. l l l R ESPONSE 1 1 1. Combusuen Engineering admits the violation 2. Combustion Engineering had re!.ied on an existing bioassay program which had bean in place for several years. Changes to the prog am were not made because the air sampling program in use did not 1 indicate any marked increase in airborne contam: nation levels nor did the in-vivc program reveal any marked increases in personnel lung bu rrie ns, Based on this information, Combustion Engineering did not recognize the need to make changes to the in-place bioassay program. L

E. .m i 2 ' 3 '. 'A Helgeson mobile uranium lung counting unit was brought onto the i site for a normally scheduled visit during, December,1987. The number of individuals' lungs counted was expanded to include personnel not normally counted to establish an improved data base. Fecal ana.!ysis and a more sophisticated urinalysis were performed by L an offsite vendor on the 25% of the personnel who were found to have o the highest uranium lung count values. Uranium lung count, fecal, and urinalysis results have been received and are now in the process of review, Preliminary results, however, do not indjeate any personnel overexposure nor meaningful deviations from previous i findJngs. 4. The bioassay program is being upgraded to include the foljowmg: 1 I Lung counting twice a year for all personnel who routinely work in the pellet shop, 1 Fecal and urinalysis sampling twice a year for the highest 254 of i pelle'. shop personnel based on lung count data, and Feca and ur:na'ysis sampling to be conducted immediately for any personne! who are suspected to have received an intake above the a!!cwable quarterly lirr.it (>520.Y3C houri for airborne radioacuve material. Lung counting of these people will be conducted Mihin four weeks of the suspected intake, j l I 1 When implemented this program wili assure that appropriate f measurements of radioactivity in the body or excreted from the body { will be made on a timely basis to assess the interna! exposure of { personnel. ( 5. Although features of the new program were employed in December } 1987, as dinsssd in Item 3 above, the formal upgraded bloassay program including implementing procedures and appropriate training is I expected to be in place by the fourth quarter of 1986. l

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3. m ~ i d IStatus-Update j c j u -In response;to.this violatirn, C-E increased in-vivo lung counting-to twice -per year and backed up the ag counting with urine'and fecal. analysis. A bioassay program in support r:'. this. action has been. prepared.in the.. form of -a-- Radiological Protection Instruction, RPI 208 (Bioassay Prograni) 'and was implemented on February 10, 1989.

The C-E action on this violation is considered to be complete.

n l i i 1 1 NRC Letter-(Russell.to McGill) v -Dated January 25, 1988 '+ NRC Inspection Report No. 70-1100/27-05 I Y ' Violation E' NFIIP Part 2.. Item No. 43, 44' ' y J OLA TION ' f E.

10. CFR 20.103(c) specifies, in part, that. when respiratory protective-

/ equipment is used to. limit the -inhalation.of airborne radioactive-material, the licensee may make allowance for this use of respiratory protective equipment in estimating exposures of; individuals: to this material, provided that the licensee satisfies certain conditions, a i including maintaining and implementing a respiratory protection I prog"am which includes.certain elements set forth in-10 CFR 10.103(c)(2) and (3) includin { to evaluate actueJ. exposures; g surveys' and bioassays as appropriate ~ wTitten procedures ;regarding a supervision and training of personnel; and written procedures regarding ' selection, fitting, and maintenance of' respirators, and a j issuance of a written policy statement on respirator usage. Contrary to' the' above,:as 'of October 21, 1987, and for an ~" indeterminate period of time prior to that date, respiratory protective ,;) equipment' was used. to limit the inhalation of airborne radioactive l material and an. allowance' was made for this use in estimating' I evposures, but the respiratory protection progmm did 'not include the following e' lements required by 10 CFR 20.103(c)(2), and (3): ,l adequate bioassays and other surveys, as appropriate, to a. evaluate individual exposures and to assess protection; b. l written procedures for. training of personnel in the proper use of respiratory protective equipment; written procedures for properly fitting respiratory protection c. devices to individuals; and 1 q d. issuance of a written policy sistement on respirator usage. R ESPONSE 2. Combustion Eng neering air.itt the viclation.. 2. This violatien resultes from reliance on a rospira:ory protection program which had been in place for several years and inadequate verification that the program conformed in all respects to the regulatory requirements for such programs. l-o .--__--____--_J

le 3 3 4 .immediate cetion-was taken to review cnd' revise the respiratory prot 2ction program. The follow-ing steps have been impl3mantad j

' t toward ~ improving the mspiratory protection,1mgram

a A management policy statement.to plant managers on respirator

usage was issued, Replacement NIOSH/MSHA approved filter respirators for.use in 1

R the respiratory protection program were purchased, A respirator program administra" tor who has completed'an industry accepted training course in admir.istering such. programs j was appointed, 1 l a Written procedures which address all areas suggested by l i Regulatory Guide 8.15 for respiratory protection were implemented, A-respirator qualitative fit test chamber was purchased-and l i ins taued, 1 a ) All persennel who are designated to use respirators in if accordance with guidance specified in NUREG-0041 and ANSI Z88,2-1980 were fit tested and trained, i The training of all health physics technicians in the daily administration of the respiratory protectier prognm was k completec, f 4. In addition to the actions out!1ned above, Combustion Engineering is I implementing an audit program which will be conducted on a routine basis to evaluate all phases of the respiratory brotection prograrh. This will be an ongoing program through which auditing personne! J will verify the program's conformance to regulatory and other req uirements. Where necessary, procedural upgrades will be prepared and implemented. J

These e$ ions' Will rectify the previous program shortcomings. + 5. 3 The 1 , respiratory protection program is in place and procedures for the bicassay program will be ' completed by the fourth quarter of 1988. 1 d Status Update This violation identified some elements missing from the respiratory-protection program. In addition to adding the missing elements, C-E made a l concerted effort to improve the entire respiratory protection program. By j June 1, 1988 new respirators, test equipment, and implementing procedures were in place. On February 10, 1989, Radiological Protection Instruction'216 " Respiratory Protection Programs" was implem.*nted. This RPI is to be'used in conjunction with the respiratory protection procedures already in place. We believe this program is in full compliance with the requirements of ] 10CFR20.103. l l The C-E action on this violation is considered to be complete. c 9 q i i ) 1 ) L-______________.

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Reference:

.NRC Letter (Russell.to McGill) l Dated January'25,'1988 j NRC Inspection Report No. 70-1100/87-05 ' Violation F-NFIIP Part 2 Item No. 45, 46 j - 1 VIO1ATION F. 10 CFR 20.201(b)- requires that each licensea make such surveys as may be necessary to comply with the regulations in Part 20, and are reasonable under the circumstances to evaluate-the extent of radiation hazards that may be present. As defined in 10 CFR 20.201(a), a " survey"' means an. evaluation of the radiation hazards incident to the. _j production, use, release, disposal, or presence of radioactive. j materials or other sources of radiation under a specific set of conditions. j Contrary to the above, t 1. Surveys were not made to assure compLance with 10 CFR 20.10Ma) which limits the exposure of individuals to l concentrations of radioactive materials in air in restricted areas, in that: J "i a. On September 26, 1987, an evaluation was not made of the radiciogiceJ hazards existing at the Pellet Press No.1 i enrichment hood to ensure that a worker assigned to perform an enrichment clean-up on the highly contaminated i equipment was provided with appropriate protective . equiptnent. i b. As of October 23, 1987, evaluations of the radiological hazard to workers drinking water in the Pellet Shop frorn 1 two water fountains contaminated with radioactive materia! had not been made until after decontamination of the i fountains. j 2. On October 23, 1957, an adequate survey was not made to assurs compliance with 10 CFR 20.103(a) tc evaluate the extent of hazards presert when individuals and equipment exited the Felle: Shop, in that the frisker used to de:ect the presence of con:a :unation on Individuals anc equipmer.: exiting the Pellet Sno; was malfunctioning. RESPONSF 1. . Combustion Engineering admits the violaticn.

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Reference:

NRC Letter (Russ' ell to McGill) i Dated _ January 25,.1988 i NRC Inspection Report No. 70-1100/87-05 Violation G -l ~ NFIIP Part 2 Item No. 48, 49, 50 l l VIOLATION i i G. Procedures for Nuclear Fuel Manufacturing" stat 1, License Condition,- Section 2.7.2, " Operating operations involving radioactive materials shall have written that all procedure s and whier st.111 be followed.afch shall include the appropriate safety requ Section 3.1.1, " Radiation Work Permit . Procedures' states, in part, that' written operating procedures for. th Health and Safety. group are provided and followed. Contrary to the above, as of October 23, 1987, te irr.plement the radiation protection program. group w Specifically, no activities including the requirements for writing Rad { Permits as requir4ad by SNM-1067 respintory protection program as, required by 10 CFR 20.103(c impletoenting a bioassay program as required by 10 CFR 20.103(a)(3 or for sampling liquid waste tanks as required by 10 CFR . 20.10S(c)( 7). ":c R ESPON_._S_E. 1. Combustion Engineermg admits the violation. l 2. i This violation resulted from (1) prior reliance on an existing s'ystem of procedures which had been in place for en extended period of. time i and (2) inadequate verification that the procedures conformed in all i, L respe:ts to the. regulatory and license requirements. Combustien Engineering had, in fact, identified the need for, and had begun wcrh on, revisions to some of these procedures before the inspection. 3. Re view, revision. and/or preparation of new procedures in in progress. The results with respect to the procedures for the respiratory protection and bicassay programs are noted in the response to Violations (D) and (E). A procedure for sampling liquid waste is in place. The existing Radiation Work Permit Procedure is undergoing upgrading. YL _- O

- 3. (, t., T Alreyised mastcr list. of procedures will be developed based ' or; e V ;' '. Leomparison of existing proerdures with regulatory and license ~ requireme'nts. Additional procedures will then be prepared as necessary.; AsL new procedures are developed and approved, Combustion Engineering's personnel wi]! receive appropriate trairting. t 5. Completion 'of the. procedure upgrade program is expected by the third quarter of 1985. Status Update j On' February 10, 1989 the following Radiological Protection Instructions were implemented RPI 204 Radiation Work Permits 'I RPI 216 Respiratory. Protection Program l RPI 208 Bioassay Program RPI 218 . Processing Liquid Radioactive Waste j The C-E action on this violation is considered to be complete. l I 1 J 1 1 l l l i 4 e

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Reference:

NRCLetter(Russeilto..McGill) j Dated January 25, 1988 NRC: Inspection _ Report No. 70-1100/87-05' Viciation Hl NFIIP Part 2' Item No. 5, 52 VIOLATION-l w H. 10 CFR 19.12 requires that all individuals working in a restricted' i.rea be' instructed in the precautions and procedures 'to minimize t

axposure to radiation and radioactive materials,' and 'in the applicable provisions of the Commission's regulations and licenses.

Contrary to the above, j i -j 1. On Septeinber 26,.1987, an individual working'in a restricted area'was not instructed in the proce~ ures and precautions d necessary to perform the' enrichment hood clean-up, and to minimize an intake of con:_entrations~ of radioactive material. i 2.~ As of October 23,;1987, Individuals working in the Pellet _ Shop - a I restricted area, had r.ot been instructed in the purposes and l 1 functionr cf protective. devices (i.e. respiratory protective. equipment), or in. proper frisking techniques to minimize their - exposure to radioactive materials. 1

RESPONSE

l 4 ') 1. Combustion Engineering admits 'the violetion. 2. With respect to Violation (H)(1), insufficient instruction was given 1 j because of an inadequate understanding by cognizant personnel of the j ' work to be performed. With respect to Violation (H)(2), personne! had been instructed and trained but there were no formal procedures or lesson plans to support the training. Further, there was no 1 documentary evidence -(e.g., test results) wh2ch could be used to I l asceruun whether or not an acceptable leve2 of comprehension hac been attained. Won: on formal procedures and lesson plans was already in process at the time of the October,1987 inspection. L 3. interim training sessions have been conducted to inform pellet shop i personnal regarding possible sources and levels of contamination in ) l the. shop and actions to control contamination. Pellet shop personne!, l .w.,

p have been re-instructed on the proper use and interpretation of the f,-[ information on th2 contamination control board. New written instructions for contamination control have been developed and shop persc nnel and supervisors have been trained in these instructions and the actions to be taken concerning shop contamination. Upgraded written procedures for the preparation, implementation and close out of Radiation Work Permits are also being developed. Health physics technicians, shop employees and staff personnel wil] be trained in the use of these procedures. Interim training has been l provided to users of breathing zone air sampling apparatus and personnel have been re-trained on donning / removing protective clothing and proper contamination frisking. 4. The upgraded procedures and retraining will provide a more comprehensive prograrr aimed at the proper instruction, documentation and conduct of operations necessary to minimize exposure to radiation and radioactive materials and to inform employees of the applicable provisions of the NRC regulations and license requirements.

Further, the upgraded program will measure the level of employee compmhension through the use of appropriate testing.

Additional personnel have been brought in to prepare and upgrade the j procedure and re-training program. i 5. The upgraded procedure and re-train 2ng program is expected to be completed by the fourth quarter of 1988. Status Update Immediate corrective action was taken on a one-to-one basis or in small groups to retrain personnel emphasizing the radiological protection requirements. A General Employee Training (GET) program was prepared, and all employees who ) work in radiological control areas were trained using this interim training program by mid 1988. In November 1988, this interim GET program was replaced with an improved program, and we are presently initiating the refresher training program. As job specific training progresses, and as the radiological protection program is improved the personnel training program will be modified. 1 The C-E action on tnis violation is considered to be complete. l {

3; y

Reference:

NRC Letter.(Russell to McGill) '0ated January 25, 1988-4 NRC Inspection Report No; 70-1100/87-05 ] Violation I~ NFIIP Part 2 Item No 53 j ~ VIOLATION 'l 1. '10 CFR 19.11(a) requires, in part, that aach licensee post any notice j of violation involving radiologicd working: conditions, and any licensee _t response to the Notice. i Contrary to the above, as of October 23,19S7,,neither.the Notice of-j Viola ion sent to the licensee on May 26, 1967, with NRC' Inspection:. 1 Report No. _70-1100/87-01, nor the licensee's response, dated. June 17, -{ 1987, to the Notica, had ever.been posted. j

RESPONSE

1. Combustion Engineering admits the violation. a .{ 2. Combustion' Engineering had, in -god faith, misinterpreted the words j o " involving radiological working conditions" used in 10 CFR 19.11 as' spplying only to Notices of Violation referring directly to personnel,- L and therefore did not post' the :noted documents. 3. The Notices of Violation and the respactive responses to such f violations noted c.bove wen posted in accordance with 10 CFR 19.11. 4. Individuals responsible for posting of such notices have been made aware of the correct interpretation of 10 CFR 19.11. l t 5. Combustion Engmeering has completed its corrective actions wi.h j regarc to this violation. I Status Updato The C-E action on this violation is considered to be complete. l i ( l o_ i

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, b Refererce: ,;i NRC Letter (RussellJto McGill) I' ' Dated January.25,.1988 l P' 'NRC Inspection. Report No.. 70-1100/87-05 1 Violation J.-

NFIIP Par
t 2LItem No. 54,<55

~ y L< ^ ' VIOLATION 'J; 10 CFR -20.401(b) requires, in part. that each licensee maintain; records. showing the results of surveys required by'10-CFR'

20. 201(b).

' Contrary ' to' the above,-: as lof.' October 23, 1987, records of. surveys u for an: incoming damaged fuel assembly on April 6,1987, and of ', surveys to support the RWP which controlled the workon the fuel l assembly on April 7,1987, wore not maintained in accordt oce 'with '10. I CFR - 20. 401( b ). L t ' RESPONSE j o .. \\ '. e '1. Combustion Engineering admits the violation. ) .i-y 2<- I! insufficient documentation of survey findings resulted from a lack (of, 4 i detailed formal procedures for the recording and retention of survey, 1 I ^ / results at the time the work was performed. l ?. Interim training has beer providedJin the proper coQpletion and filing-of survey related paperwork. In addition, -the health physics supervisor will, for the time being, review survey records'for l completeness and proper documentation of results. 4. An overal) health physics traming program is now being developed. l hs requirements for retention of survey results: will be included in re'hsec survey procedun.s. Once inis effort is completed, health physics technicians will be fully apprised of, and have more detailed procedures pertaining to, the proper completion and filing of survey l results. i ) .i (at, 5. It is expected that the above action will be completed by the fourth I m. quarter of 1988. yy~ e -_ - - - - = - a m u, -z

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y, I'I % The'C-E action on this violation'Lis' considered to be complete,. ..i 3 .l j < i s i j;,5 1 g 1 e 1 i s i 4,,. I .ll c 9 ~I f -_ t + l _a'). ' l t' ' b j,' } i 4' q -+ 'j I 5,b ' d. a g ~ ',i 5 .,) 3 y y,. - g'u[f,g 1, s L ;.

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Reference:

NRC Letter (Sjoblom to McGill) -l L Dated June 6, 1988 70-1100/88-03 'l NRC Inspection Report No. Violation-A NFIIP Part 2 Item No 24, Violation A Amendment No. 9 to License No. SNM-1067 dated April 8, 1987-i 1 incorporates Section 4.1.6, " Marking and-Labeling of SNM," dated j October 22, 1986 into the NRC-approved license application (Part 1-Criteria) which states, in part, that all mass-limited containers shall be labeled as to enrichment-and content.- Contrary to the-above,:on February 29-March 1, 1988, the. lids on H seven mass limited containers (drums labeled as Noc-5121, 4565, " contaminated oil", 4564,.4570, 4586, and 4611), containing I unmeasured quantities of uranium-235, had been secured'between December 20, 1987 and February 2, 1988, and the containers were { not labeled with the actual uranium-235 content-and enrichment.: )l o

Response

c a 1. The seven (7) drums in question have been labeled as to ) estimated uranium-235-content and enrichment limits. 2 Additionally, a review was conducted of all secured mass-limited containers in use to ensure that they were properly 1 labeled. 2. To~ prevent recurrence, we have. increased surveillance of materials in mass-limited. containers to ensure that they j are appropriately-marked and labeled. In addition, we are I reviewing our operations procedures'against the requirements .j of Section 4.1.6 of the NRC-approved license application. Changes will be made as necessary. We anticipate that the procedure / application compatibility review will be completed by the fourth quartur of 1988. 3. All secured mass-limited containers are appropriately lkbeled in compliance with Section 4.1.6 of the NRC-approved license application at this time. Status Update ) i Operation sheets / travelers were reviewed / revised on 11/30/88 to ensure that all LLW drums are properly marked indicating U235 cor. tent and enrichment. t The C-E action on this violation is considered to be complete. I I i I l l l l

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Reference:

i -NRC Letter (Sjoblom to-McGill). . Dated June 6, 1988 NRC Inspection Report No. 70-1100/8803 . Violation B NFIIP Part 2 Ite

o. 75, 76

..i violgtion B .j . Nnendment No. 9 to License No. SNM-1067, dated April 8, 1987 incorporates Section 2.7.2, dated October 22, 1986 into the l NRC-approved license' application (Part 1-Criteria) which states, in part, that it is the responsibility of the Plant Manager to. assure that all operations invol,ving radioactive materials have ') written procedures which include the appropriate safety a requirements. Those procedures must be approved by the Manager, ) Nuclear Licensing,. Safety, Accountability.and Security-(NLSA&S), The Nuclear. Criticality Scfety Specialist,-or the Supervisor, Health Physics and Safety prior to the start of any operation. .l Contrary to'the above, as of February 29,.1988, the Plant Manager j did not assure that all operations involving-radioactive 1 materials had properly approved written procedures in'that the. { Quality Control procedures did not contain safety precautions nor 1 were'they properly approved. For example, Operations Sheet No. j 945, Revision 39, dated December 10, 1987, did not include any - safety precautions, and there was no written approval by the Manager, NLSA&S, the-Nuclear criticality Safety Specialist ~or the Supervisor, Health Physics and Safety. J

Response

1. The specific operation Sheet (No. 945, Revision 39) noted in the Notice of Violation has been reviewed and approved by the Manager NLSA&S. l Combustion Engineering recognizes that room for improvement

2..

exists in our controls for including appropriate safety precautions in shop operating procedures. We have already 3 i begun to correct this problem. In this regard, the following actions have been or will be completed during the fourth quarter-of 1988: (a) The new Plant Manager has been instructed to ensure that all changes to Operations Sheets are reviewed and approved and contain the appropriate safety precautions i before being authorized. (b) As committed in a response to a related violation from a previous inspection, all operation Sheets are presently being rewritten and upgraded to include appropriate safety and criticality precautions. These upgraded Operation Sheets will be reviewed and approved by the appropriate personnel. s 3. Completion of the procedural upgrade task is expected by i the fourth quarter of 1988. i ]

P . Status Update- ~ .= Item 75. .The~NFM Plant' Manager issued instructions on July 18, 1988 directing that thel 4 Manager, Radiological and Industrial Safety approve all Operations Sheets that affect radiological controls and/or criticality safety. Item 76 Incorporation of appropriate safety requirements into Quality Control l Procedures and other required procedures is progressing. This effort will be completed by March 31, 1989.. The required changes are being made to active procedures only. j 3 l l .i I h q l i n

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Reference:

NRC Letter'(Sjoblom to McGill) e Dated' June 6,' 1988 NRC Inspection' Report No. 70-1100/88-03 Violation C-1 i ~ .NFIIP.Part 2 Item No. 71 jViolation'C-r i Amendment No. 7 to License'No..LNM-1067, dated August 4,_1986, l Incorporates Section 4.3.S,_ dated December 16,o1985 into'the NRC-approved license application (Pt.rt'l-Criteria) which states-

that the uranium oxide thickness on each of the Pelle't Storage

'o Shelves'sha11 be less than fouri(4)_ inches.' '\\ Contrary to the above,'on February 29,.1988, the uranium oxide thickness, at five locations on the Pellet Storage Shelves, 4 exceeded four inches by an amount of 1/8 to 3/4 of and inch.

Response

1 1. Criticality limits on the pellet storage shelves were implemented by:the following: '(a), A nuclear criticality sign was located at the . shelves specifying a 4 inch high slab limit, + -(b) ' Pellet trays measuring twd inches in height 't were limited _to stacking two high so that the four inch slab limit would not be exceeded, and i (c) An engineated safeguard-in'the form of a steel-bar'was installed on the shelves. (The purpose of. 4 this bar was to limit the stack ~ height of trays'to ] four inches.-) i T In the process of loading pellets into the trays, employees would occasionally ' load the pellets non-uniformly, resulting in the tray, covers being slightly raised.. When stacking two trays in'this condition on the shelves, the steel bar'would t be, at times, raised slightly to slide the pellet trays j under the bar. To correct this situation, the following additional steps have been taken: Procedures have been modified to require leveling of j pellets in trays, Employees have been instructed on the importance of leveling pellets, and As an additional engineered safeguard, an inflexible steel bar has been installed on the storage shelves to preclude its being raised beyond the 4 inch slab limit opening. e

2. Recurrenco of this viointion'is-procludsd by tha'cetionc ? circady taken and outlin;d in Ittm 1. f 3. Combustion Engineering. believes that it is now in J compliance with the 4 inch slab requirement of Section 4.3.9 ( of the NRC-approved license application. l i Status Updatej j k The height of the existing trays was reduced to 2", and the height . tolerance for new trays was revised to reauire that new trays will not exceed two inches in height, thereby assuring all double trays can me'et the four inch slab limit. The C-E action on this violation is considered to 'be complete. i l 1 1 l 1 l L .1

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Reference:

L > NRC Letter:(Sjoblom to McGill) Dated' June 6, 1988 h LNRC Inspection Report No. 70-1100/88-03 Violation D i' ~ '.NFIIP Part 2 Item No. 8_3_

]

1 Violation D Amendment-No. 3'to License No. SNM-1067 dated October 1, 1984-incorporates Section-4.1.3 " Requests for Changes and Criticality .Analysisd dated June 15, 1984 into the NRC-approved license ~S: " application'(Part 1-Criteria) which statesLthat all proposed j . changes in process, equipment, and/or facilities that.could- .i . affect nuclear criticality, radiological or industrial safety' 1 shall be approved in;accordance with the requirements set forth in Section'2.'2.2.of this part.. Amendment 3 also-incorporates-SectionL4.1.S." Internal Review Requirements";which states,nin part, that all process / equipment / facility changes which.could affect'. nuclear criticality safety shall-be reviewed and approved' in writing by the Nuclear Criticality Specialist. Sectiors 2.2.2-li states that the General Manager. delegated to the Production and-l Material Control Managers and to thef Engineering Manager H ^ responsibility >to assure that all operations! involving nuclear. -materials have'been analyzed to establish the required safety ) limits'and controls. The Manager, NLSA&S or Nuclear Criticality Specialist shall assist the Engineering-Manager and the Production and Material Control Manager by'performingJthe- . analysis required and establishing the appropriate: controls.. Contrary to the.above, at.some time prjor:to March 1, 1988, a-change was made'at the facility, namely, covering the BatchL l Makeup Hood Conveyor, resulting.in the potential accumulation-of uranium oxide powder under the conveyor, and an analysis was not c performed prior to the change to establish the required' safety limits and controls. Further, this change in equipment, which could affect nuclear criticality safety, was not reviewed-and approved in writing by the Nuclear Criticality Specialist. .)

Response

1. Subsequent to the NRC inspection, the gap between the Batch Makeup Hood and the conveyor was' reduced by the addition of a piece of sheet metal to minimize residual powder from potentially entering and accumulating under the conveyor. This change was reviewed and approved in writing i by the Nuclear Criticality Specialist for acce.ptability. 2. The Manager, Radiological and Industrial Safety or the Nuclear Criticality Specialist will review all future proposed process / equipment / facility changes and determine if a' specific safety analysis is required. All credible nuclear criticality scenarios will be analyzed before being approved.

, 'J. Combuction Engineering'bslisvss that it is now in complianca-With the rsquircmsnt of its NRC-Opprovsd licanes application as regards anelysis of credible' nuclear criticality scenarios. l l ' Status Update l In addition, we recognize the need for a single comprehensive criticality safety program document; in particular, a document to address the administrative control requirements. The administrative control requirements i i document is in' preparation and will be issued by May 1, 1989. l 1 i ) l Y l n

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Reference:

NRC Letter (Sjoblom to McGill) j Dated June 6, 1988 NRC Inspection Report No., 70-1100/88-03 g 91olation E 1 'NFl!P Part 2.ltem No. 84,85,86,E j Violation E' l Amendment No. 3 to License No. SNM-1067 dated October 1, 1984 incorporates Section'4.1.4 " Potting of-Limits", dated June 15, 1984, into=the NRC-approved license application (Part 1-Criteria) which states, in part, that all work stations shall be. posted with a nuclear safety sign approved by the Manager, Nuclear Licensing, Safety, Accountability and Security (NLSA&S).or the Nuclear Criticality Safety Specialist. Section 4.1.2 states,-in j part, that it shall be the responsibility ofLthe supervisor to assure that Leach work station is properly posted ar.d that operations are-performed in compliance with posted limits. 3 contrary to the above, on February 27, 1988, a work etation was-not properly posted in that the posted nuclear safety-limit of 24.0 kilograms uranium oxide appeared to be exceeded by about 1.1 kilograms as the reruit of a weighing error.

Response

1. Combustion Engineering has instructed supervisory personnel and operators of the hammermill hood on the correct i procedures for determining total weight, tare weight and the balance of material remaining in the hammermill hood. l 2.- To prevent recurrence,;the operating. procedure for the ha'mermill hood will be revised to include'an administrative m safeguard action ibnit. This action limit will be I established at a value less than the criticality safety limit and will require ' supervisory personnel to verify the actual quantity of material in the hood..Should the action limit be reached, the hammermill will be shut down if -verification can not be established. In additien, we intend i to conduct an evaluation to determine if other means exist to ensure'that safo criticality limits are not exceeded. l 3. Combustion Engineering believes that it is now in compliance. In addition, we will complete the action limit l and evaluation' identified in item 2 by the first quarter of j 1985. j ( 1 Y

. s. 1 l -Status Update g,_ A Items 84. 85; 86' - The operating' procedure for the hood has been' revised and now includes: i

1) verification of the net weight of material going into the hood by.

1 actual reweigning of the pail, j 1 2). an action limit which is less than the criticality safety limit which will be checked prior to placing the pail into the hood, and )

3) verification of the log entries by the area supervisor.

i Item 87 i I The operation of the Hammermill Hood is still being evaluated. ~This evaltation will be' completed by 3/31/89 as partoof our original commitment. 1 i l l l 1 l [ l l t ,e l 1 i

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Reference:

1 NRC Letter-(Sjoblom to McGill) Dated June 6, 1988 NRC Inspection Report No. 70-1100/88 03 Violation F-NFl!P Part 2 Item No. 89_ Violation'F 10 CFR 70.51-(b)(1) states that each licensee shall keep records a showing the' receipt, inventory (including location), disposal,. .I acquisition and transfer of all special nuclear material in his j . possession regardless of its origin or method of acquisition. Contrary to the above, on March 2, 1988, the inspector determined ' ~ that the licensee did not maintain inventory' records, including location, of between 70 to 300 grams of uranium-235 in enriched ~ uranium oxide that was found in liquid waste tanks and pipes r, during~1985. q Response. 1. The subject material was previously identified to the NRC and--added to the formal inventory records on May 2, 1988. -} 1 -It was subsequently shipped to the Barnwell Waste Management Facility on May 13, 1988. j 2. In the future, the Manager of Accountability and-security ' l will ensure that all materials aretinventoried, as-necessary, without undue delay. R 1 3. The actions noted above have corrected the inventory I records discrepancy. Combustion Engineering believes that 9 it is'now in compliance with 10 CFR 70.51 (b)(1). .\\ Status Update j The C-E action on this violation is considered to be complete. l I-i +

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Reference:

1 NRC Letter.(Sjoblom to McGill) ' h Dated' June 6,.1988 _.NRC Inspection Report No.- 70-1100/88-03 ' Violation G' .NFIIP Part 2 Item No. 90; 91

Violation G s

Amendment No. 9 to. License No. SNM-1067-dated-April.8,.1987; incorporates section 2.6.1 " Initial Training", dated October 22, s '1986 into the NRC-approved license application (Part.1-Criteria) which states, in part,-that all new employees shall~ attend'a-formal training. session prior to working in restricted areas. Specialized. training for radiation protection and nuclear criticality safety'shall;be commensurate with the extent of the employees contact with radioactive materials. All personnel who 1 will be working with radioactive materials must satisfactorily complete a test-to ascertain the effectiveness of the. training.- l contrary to the'above, as of March 28,.1988, personnel workinge with radioactive material, who' required specialized training in' nuclear, criticality safety, were not required to satisfactorily complete a test to ascertain the effectiveness of that training. Response-A 1. As committed in a response to a'related violation from' l prior-inspections, Combastion Engineering is~ presently upgrading our General Employee Training Program..The revised program, which will containl modules covering radiation protection ~and nuclear criticality' safety, will.be given to.'all employees,who work with radioactive materials., j The employees will befrequired'to complete a test to ( ascertain the. effectiveness of the training 2. The upgraded training and testing program should preclude-recurrence of the subject violation. 3. Combustion Engineering expects the upgraded training.and testing program to be completed by the fourth quarter of-1988. Status Update l l Subsequent to this violation, criticality safety training, including test requirements, has been incorporated into the GET program. In addition, all workers, as applicable, were retrained to 5% enrichment criticality safety requirements and satisfactorily completed a written test prior to implementing the 5% amendment. The 'C-E action on this violation is considered to be complete. 3

i O-1 I

Reference:

NRC Letter'(Russell to Brewer) Dated October 7, 1988 l NRC Inspection Report Nos. 70-1100/8805 & 70-1100/88-06 l Violation A NF11P Part 2 Iter, No. 15,116,117 VIOLATION A. 10 CFR 20.201(b) recuires that each licensee make such surveys as may be necessary to comply with the regulations in Part 20, and are reasonable under the circumstances to evaluate the. extent of radiation hazards that may be present. As defined in 10 CFR 20.201(a), " survey" means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presences of radioactive materials or other sources of radiation under a specific set of conditions. Contrary to the above, on June 14, 1988, a survey. was not raade, as necessary, to assure compliance with 10 CFR 20.103(a)(3), which requires the licensee to use suitable measurements of concentrations of radioactive materials in air for detecting and evaluating airborne radioactivity in restricted areas. Specifically, on that date, a rM*.ation worker was using a Chicago Trash Packer Corporation Model Mu0 compactor to compact material contaminated with uranium powder, and no radiological surveys were performed to determine.the extent of radioactive contamination on the material being compacted, and appropriate air sampling was not performed in the immediate work area to ensure compliance with the requirements set ferth in 10 CTR 20.103.

RESPONSE

1. Combustion Engineering accepts the violation. 2. This violation resulted from reliance on an understanding that past evaluations of the radiological hazard, using' a high volume air sampler, indicated no need for special controls. (Docuraentation of this evaluation is not available). In addition, the procedure gcoverning Radiation Work Permits (RWP's) has been found to be deficient in clearly identifying activities that require coverage. 3. Immediate action was taken to establish trash compactor operation as an activity governed by an RWP., /Jso, personnel are now required to wear a lapel air sampler while operating the compactor. In addition, for approximately three (3) months, the operation of the compactor was evaluated to determine if ventilation modifications would improve unit operation with respect to ALARA consideratims. Contamination surveys and air sarnple results indicate jhat operation of the compactor is not a radiological hazard requirfng special controls. A formalized Radiological Work Permit procedure has also been developed which contains specific criteria for determirdng which hetivities are to be governed by an RWP. 'this procedure is awaiting final approva).

4*. Radiological Protection, Instructions (RPI) procadur s ara b ing devalopsd e. which will provide Health Physics.s'f aff with detailed guidance in the proper performance of Radiological Control activities. As part,of the. RPI program technicians will receive training on the new procedures when they are completed and prior to implementation. 5. All Radiological Protection Instructions will be completed by-the fourth'- quarter of 1988. Combustion Engineering is presently in compliance with 1 radiological requirements es regards trash compacting operations. - Status Update The C-E action on this violation is considered to be complete. . + l I .s \\'

<y q q k 'd Referencei f NRC Lett.er (Russell to Brewer) Dated October 7, 1988 NRC Inspection Report '40s. 70-1100/88-05 & 70-1100/88-06 Violation B NFilo Part 2 Item No. 118, 119 s l VIOLATION ~ l B. Amendment No. 09 to License No. SNM-1067, dated April 8,1987, incorporates into the facility license Section 3.2.6, " External exposure (Dosimetry Requirements)," of the NRC-approved license application - . (Part I - Criteria),' dated October 22, 1986, which states that all visitors be supplied with.ii.dium foil badges. Contrary to the above, from June 14-17, 1988, certain visitors and - contractor personnel were permitted access to the Pellet Shop without being supplied with indium foil badges. RESPONSE- ' I'. Combustion Engineering accepts the violation. 2. At the time of the violation sufficient controls were not in place to prevent all visitors and/or contract personnel from entering the Building 17/21 complex without' indium foil badges. The indium foil is attached to the TLD for plant employees having a TLD, and on the visitor badges. There was, however, a limited class of individuals having permanent. badges but no TLD that did not heve an indium foil. 3. Indium foil has been added to all identification badges issued et the site entrance and the guard force has been instructed not to allow i anyone into the facility without an indium foil on either their identification badge or TLD. .4. The actions listed in Item (3) above should prevent recurrence of similar L incidents in the future. j 1 5. All necessary corrective actions have been completed and Combustion Engineering is in compliance with the subject Ifconse condition. Status Update f i The requirement for including iridium foil on all badges war incorporated into MFG-19-02 on 2/8/89. The C-E action on this violation is considered to 'e complete. o ./ ' l.

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Reference:

a 1 NRC Letter <(Russell to Brewer) 3 L Dated October 7, 1988 j u NRC Inspection Report Nos. 70-1100/88-05 & 70-1100/88-06 j h Violation C l] ~ js,'

KFIIP'Part 2 Item No. 103 l-l

.h [ - VIOLATION lC Amendment No. 09 to-License No.- SNM-1067 dated April 8,11987 i incorporates into the facilit'y license Section 3.1.1 " Radiation Work Permit Procedures," of. the NRC-approved license application (Part l'- Criteria), dated October 22,.1986 which states,'in part, that the - E . Radiation ' Work Permit will include all safety l requirements, protective ~ .I clothing and equipment, and, health physics monitoring requirements. necessary to assure that the proposed operation is ' conducted in a safe' j. - manner. A Radiation Work Permit, issued on May 1,1988, authorized l work to be done' on the Pellet Press No. 4 ventilation system, and ' l - required the use of protective c.lothing, including rubber gloves. j J m . Contrary toithe above, on May 27,1988 two workers-handled. O radioactive. contaminated parts removed'from the Pellet PressL No.- 4 j u ventilation system, and these individuals were not ' wearing _ glovessas j required.;

RESPONSE

'1. ' Combustion Engineering accepts the violation. 2. Thir violation. occurred when two (2) contract workers, handling: m j X - potentially ' contaminated material removed their gloves in violation of the' i r' Radiation Work ' Permit (RWP). - Non-compliance to 'the applicable' RWP can be attributed to inadequate training of plant workers (both'per:nanent and contract employees) in radiological procedures. This shortcoming was compounded by insufficient job supervision.. .l .m l ,3. Upon being observed in violation of the RWP the workers were' directed l _ to immediatelycstop work and leave the pellet shop. A' Health Physics- ~ technician surveyed the contract Workers and found no detectible contamination on-their bodies. The two workers and their management i .were re nstruc et d on the necessity of following RWP's before entrance to -the shop was permitted. 4. The recently modified General Employee Training (GET) program places .j greater emphasis on the importance of full compliance 'with RWP's 'and .{ provides employees with a: stronger appreciation of the need to i understand and adhere to the requirements of RWP's. In addition, j Health Physics technicians ~have been instructed to ensure that workers fully understand and comply with the requirements of the applicable RWP before allowing work to begin. i ~ j i --wm,.m__._mw -_-mm .__m __-m. -a_

s Thi Radiation Protsetion Program at ths Nuclear Fus! Manufacturing facility is currently undergoing a thorough upgrade. Part of this upgrade is the development of Radiological Protection Instructions (RPI), a series of procedures by which the Health Physics staff will conduct their duties. Also included in the upgrade was the hiring of additional qualified Health Physics technicians. In addition to providing complete radiological coverage, the increased vigilance provided by a larger Health Physics staff serves to reinforce the training received in GET. Condit!ons resulting in this violation have been corrected b 5. detailed in Item (3) above and the improved GET program. y the actions Further improvements in radiological controls will be achieved with the implementation of the RPI's. Completion of the RPI's is scheduled for the fourth quarter of 1988. Status Update The C-E action on this viciation is considered to be complete. t I l 1 1 ) i j

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ence: J. j ' s.1 NRC' Letter (Russell to Brewer)

Dated October 7. 1988 NRC Inspection Report Nos. 70-1100/88-05 & 70-1100/88-06 Violation 0

~ NFIIP Part 2 Item No. 104, 105, 106 1 VIOLATION D..

10. CFR 19.11(a) requires that each licensee post current copies of (1) the regulations in this part and in Part 20 of this chapter; (2) the license, and license conditions, or documents incorporated into a license i

by reference, amendments thereto; (3) the operating procedures applicable to licensed activities; and (4) any-notice of violation involving radiological working conditions, proposed imposition of civil . penalty, or. order issued pursuant to Subpart B of Part 2 of this chapter, and any response from the licensee..10 CFR 19.11(b) states that if posting of a document specified in paragraph (a)(1), (2) or (3) of this section is not practicable, the licensee may post a notice which describes the document 'and states where it may-be examined. 10 CFR 19.13(d). states that the documents,. notices, or forms posted pursuant to this section shall appear in a sufficient number of places to permit individuals engaged in licensed activities to observe them on the way to or from any particular activity location to which the document applies,. shall be conspicuous, and shall be replaced if defaced or altered. ' Contrary to the above, between May 25 and May 27, 1988, the licensee did not post the documents specified in 10 CFR 19.11(a)(1), '(2) or (3), or the notice specified in 10 CFR 19.11(b), in a sufficient number of places in Building 5 to permit individuals engaged in licensed activities to observe them on the way to or from any particular licensed activity 3 location. For example, these documents were not posted at the south, southwest or northwest entrances to Building 5. In addition neither the documents specified in 10 CFR 19.11 (a)(4), nor a notice specified in 10 CFR 19.11(b) were posted at any location in Building 5.

RESPONSE

I ~1. Combustion Engineering accepts the violation.

2. -

At the time of the violation adequate management controls were not in place to ensure that the complete posting requirements of 10CFR19.11 were met since it was believed that the posted locations were in sufficiently traveled areas of the facility to adequately inform l personnel. 3.- A review of Building 5 access points was conducted and five areas were identified for posting documents pursuant to 10 CFR 19.11. All required documents have been posted or were verified to be posted at each posting area in Building 5. -4. An individual in Building 5 and another in Building 17/21 has been assigned responsibility for maintaining all postings pursuant to 10 CFR 1 19.11. Both individuals have been made aware of the posting requirements necessary to achieve compliance. 1 l m

T 1 .s\\ j C b stien Engin ering h s correctsd the dsfici2ncies that resulttd in ~

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a. ' Status Update The C-E action on this violation is considered to be complete. I I i i i i -__________._._m.

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Reference:

-NRC Letter (Russell to Brewer) . Dated October 7, 1988 i NRC' Inspection Report Nos. 70-1100/88-05 & 70-1100/88-06 Violation E, F, G NFIIP Part 2: Item No. 107, 108' VIOLATION i E.- 10 CFR 20.311(b) states, in part, that each shipment 'of radioactive. [ waste to a licensed land disposal facility must be. accompanied by a 1 shipment manifest that may be shipping papers used to meet Department i of Transportation or Environmental Protection Agency regulations or - - I requirements of the receiver,-provided that all the information required-- j by 10 CFR 20.311(b) is included. Contrary to the above, the manifests for. waste shipments sent to the l Barnwell, South Carolina burial site (a licensed land disposal facility) I on June 4 and November 2,1987, did not contain the information - 1 4 required by.10. CFR 20.311(b) in that the proper shipping name and hazard class for several B-25 boxes (Nos. 1103,1107,1109,1110) were ', l I indicated as Radioactive Materials, LSA, n.o.s. UN2912, instead of Radioactive Materials, Fissile, n.o.s. UN2918, as required.

RESPONSE

1. Combustion Engineering accepts the violation. q l ~2. 10 CFR 71.53 exempts shipments containing Special Nuclear Materials . ] (SNM) from being labeled as " Fissile" if the amount of SNM in any 10 liter volume does not exceed 5 grams. 'The procedure used to determine specific concentration of uranium-235 in the shipping containers allowed 1 the amount of Special Nuclear Materials (SNM) involved to be averaged over the entire volume of the container. This method did'not properly account for the localized concentrations of SNM that existed in packages inside of the shipping containers and caused containers to be improperly classi5ed as Low Spec!De - Activity (LSA) rather than Fissile. The -shipping manifests in turn reflected' this error. 3. The procedure for LSA shipments has been corrected to require all - discreet packages within a container to meet the specific concentration criteria of 5 grams SNM in any 10 liter volume. - 4. Combustion Engineering will also review the adequacy of its existing written proceduras in this area in an effort to correct any procedural j. inadequacies. l L 5. Correction of the inadequacy that resulted in this violation has been achieved by the action detailed in Item (3) above. The program to l review the adequacy of the procedures is scheduled to be completed by l the fourth quarter of 1988. l

s s. fiOLATION. j F. 10 CFR 71.3 states, in part, that a licensee subject to the regulations in this part may not deliver any ifcensed material to a carrier for transport except as authorized in a general IIcense or a specific license issued by the Commission, or as exempted in this part. 10 CFR 71.1(b)(1) states that a licensee is exempt from all requirements of 10 CFR Part 71 other than 10 CFR 71.5 and 10 CFR 71.88 with respect to shipment or carriage of a package containing more than a type A quantity of radioactive material if the package contains no Sssile material or if.the $ssile material exemption standard of 71.53 are satisSed. Contrary to the above, the licensee delivered to a carrier on June 4 and November 2,' 1987 for transport $ssile material (B-25 boxes Nos.1103, 1107,1109, and 1110) in amounts that did not meet the exemption standards set forth in 10 CFR 71.53, and the licensee did not meet the criteria for a general license, nor did they possess a specinc license issued by the Commission.

RESPONSE

l 1. Combustion Engineering accepts the violation. 2. See Violation E(2).- Suosequent transport of this material as LSA resulted in a violation of 10 CFR 71.3. 3. See Violation E(3). 4. See Violation E(4). 5. Correction of the inadequacy that resulted in this violation has been achieved by the action detailed in Item (3) above. Review of the j adequacy of existing procedures is scheduled to be completed by the i fourth quarter of 1988. 1 1 i l 1 I I l l 1

t ,.TIOLATION '

10..- 49 CFR 172.403(a)~ requires, in part. that unless excepted from labeling

~ by 49 CFR 173.421 through 173.425, each package of radioactive materia] ' to be offered for transportation must be labeled with a Radioactive. White-I, a Radioactive Yellow-II, or a Radioactive Yellow-III. Contrary to the_ above,-B-25 boxes (Nos. 1103,.1107, 1109, 1110)- containing radioactive material were shipped to the Barnwell, South Carolina burial site on' June 4-and November 2,1987;lwere not labeled as. required in accordance with 49 CFR 172.403(a); and were'not excepted from labeling by 10 CFR 173.421 through 173.425 Specifically, the boxes were labeled Low Specific Activity (LSA), and not.with the Radioactive White-1, Radioactive Yellow-II, or Radioactive Yellow-III labels as required.

RESPONSE

1. Combustion Engineering accepts the violation. 2. See Violation E(2). As a result radioactive material was' transported from the Windsor site with the wrong labeling affixed to the shipping containers.- 3. See Violation E(3). 4. See Violation E(4). 5. Correction of the inadequacy that resulted in this violation has been achieved by.the action detailed in Item (3) above. Review of the adequacy of._ existing procedures is scheduled to be completed by the i fourth quarter of 1988.. I Status Update Operation sheets / travelers were revised on 11/30/88 to record and report actual volumes of items ~ packaged in LLW containers in order to' assign' proper l classification and labels for. shipments. The C-E action on these violations is considered to be complete. l I

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Reference:

NRC Letter.(Russell to Brewer)

'j Dated 0ctober.7, 1988 .NRC Inspection. Report Nos. 70-1100/88-05 & 70-1100/88-06 Violation H_ NFIIP Part 2 Item No. 109, 110, 111 ' VIOLATION. j H. 10 CFR 74.3(a)' requires each licensee who is authorized to possess and use more than one. effective. kilogram of special nuclear material of low

strategic significance to implement and maintain a Commission-approved

. material control and accounting system. - Section 4.2.1 of the NRC-approved Combustion Engineering Inc., Fundamental Nuclear Material Control Plant (FNMCP) states, in part, that (1)~ a measurement system has been established and will be maintained. for all SNM receipts, removals-and inventory items, and all quantities of SNM in the material ~ accounting records will be based on measured. values, including low level waste which the 'FNMCP defines in Table 1.4.1 as shop trash and filters; (2) a' system of measurement has been-l 3 - established for use in the control of and accounting for SNM,; including s measurements of U 'and U-235 at appropriate points on proper categories 1 of all nuclear material receipts, shipments, waste discards and ' material' } 'l inventories; and (3) all external transfers of SNM shall be based on measurements.. Shop trash is defined by licensee personnel as compactible' trash, which does not include non-compactible materials such. as springs, tubing, bricks, ventilation system ductwork, etc. Contrary to the above, several Radioactive Waste Drum Release Data Sheets dated between August 3,1987, and January 18,1988 (containing I entries' for waste ' discards, including shop trash,' wood, gloves, plastic. pipe, cardboard, brick, tile, rubber hose, ventilation tubing, wire, plastic, chairs, sheetmetal, zirconium ' tubing, stainless steel springs, and. graphite crucibles), indicated that there was no detectable amount (NDA) of the grams uranium, pounds uranium, grams U-235 and n'lllicuries radioactive. However, the U-235 content of those materials, with the exception of shop trash, was not based on 'any measurement. L

RESPONSE

1. Combustion Engineering accepts the violation. 2. This' violation is the result of inadequate procedural guidance. There was a failure to identify measurement techniques for non-compactible waste in Table 1.4.1 of the Fundamental Nuclear Material Control Plan (FNMCP). Since there was no calibration standard for assaying such materials, it had become practice to specify i non-compactible discards as containing "No Detectable Amount" of uranium-235 without performing measurements. t 3. Shipment of all containers which contain non-compactible waste were immediately suspended until procedures could be developed that provided E detailed guidance for the measurement of such discards. These procedures have been completed and are currently in use.

i .;f n .i l.:..? [ *: Status' Update. p* l '~ 'The operation' sheet was revised on 11/30/88 to include the requirement that if l i the assayed content' exceeds the U235. content of the' upper level: filter Estandard,Lthe filter wilI be rewashed and'reassayed~until.its final.U235 ~ content Lis below the upper. level filter standard value. The C-E action on this violation is considered to be complete. ' l i h l )

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Reference:

NRC Letter (Russell to Brewer) 1 Dated October:7, 1988 .NRC' Inspection Report Nos. 70-1100/88-05 & 70-1100/88-06 ' Violation I: l- '.NFIIP Part 2TItem No. 112, 113 ~ ] VIOLATION i 10 CFR 74.3(a) require' each licensee who is authorized to possess and 'I. s use more than one effective kilogram of special nuclear material of low strategic significance to implement and maintain a Commission-approved Lmaterial control and accounting system. Table 1.4.1 of the NRC-approved Combustion Engineering, Inc., Fundamental Nuclear i Material Control Plan.(FNMCP) which in part describes this system, indicates that the standards used for the calibration of the Nondestructive Assay devised for the determination of the U-235 content in absolute :Siters shall contain 0 ant! 90 grams of U-235. - Section 4.1.3 of the NRC-approved Combustion Engineering, FNMCP Annex states that should measurement results indicate.that process' material are outside the - calibrated range, the results' will not be used. Contrary to the above, although data on several of the Radioactive Waste Drum Release. Data Sheets indicated that the U-235 content of several filters was outside the range of 0 to 90-grams (101.6 grams, B-25 box - No.1107, dated August 3, 1987; 115.5 grams, B-25 box No. '1110, dated August 26,1987; and 130.5. grams, B-25 box No.1109 dated August 21, 1987), the results of these measurements were nonetheless used.and recorded for_ shipment to the Chem-Nuclear Systems, Inc., Barnwell j Waste Management Facility located in Barnwell, South Carolina, a burial j l' site, on November 2,1987.

RESPONSE

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1.

-Combustion Engineering accepts the violation, l 2. Use of measurements outside the calibrated range of the instruments j resulted from improper employee training and inadequate procedural guidance. 3. All employees who assay filters have been reinstructed on the ] requirements of the Fundamental Nuclear Material Control Plan (FNMCP). In addition, the procedure for assay of Alters contaminated with uranium-235 was changed to more clearly reject uring measurements outside of the range of the calibration standards. 4. Combustion Engineering will also review the adequacy of its existing written procedures in this area in an effort to correct any procedural inadequacies. 5. The procedural review is scheduled for completion in the fourth quarter of 1988. Combustion Engineering is presently in compliance with requirements regarding measurements of materials within the calibrated range of facility instrumentation. 1

q r r 'k "~ Ms " Ues of tha nsw ms sdrement tschniquss should precluda futurs o 'e V rIcurrence of this violation. The FNMCP will be revi;wed and revised to include the measurement methods developed for non-compactible waste. 5. Completion of the review of procedures is scheduled for the-fourth quarter of 1988. Status Update Procedure MFG-16-25 was written and implemented on 10/18/88 to cover this-requirement. The requirements of this procedure were incorporated into a traveler on 11/30/88. Further, this measurement method was incorporated into the FNMC Plan and approved by the NRC on 11/30/88. J C-E action on this violation is considered to be complete. I i i L_ i w 1 e _ _ _ - _ _ _ - _ _ _ - _ _}}