ML20236S788

Insp Rept 70-0687/87-04 on 870518-22.Violations Noted.Major Areas Inspected:Conditions at Licensee Facilities to Determine Existence of Potential Safety Hazards Which Could Impact Upon Public Health & Safety

ML20236S788
Person / Time
Site:	07000687
Issue date:	11/23/1987
From:	Amato C, Clark A, Gary Comfort, Madden P, Mcfadden J, Pasciak W, Prell J, Roth J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I), NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20236S726	List: ML20236S724 ML20236S764 ML20236S788
References
70-0687-87-04, 70-687-87-4, NUDOCS 8711300095
Download: ML20236S788 (38)

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U. S, NUCLEAR REGULATORY COMMISSION REGION I l

Report No. 70-687/87-04 Docket No.70-687 License No. SNM-639 Priority 1 Category UHBR Licensee: Cintichem, Incorporated P. O. Box 816 Tuxedo, New York 10987 Facility Name: Hot Laboratories and Reasearch Reactor Inspection At: Tuxedo, New York Inspection Conducted: May 18-22, 1987 Inspectors: i [

oth, Project Engineer, RI

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(~Specialist, 2arRI , ~k r.~G. Amato Emergency Preparedness nb3h

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A T.' CTark, ~Licejsing Project Manager, SM r omf6rt,NuclearPrpessEngineer, oAdw

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ProteytionEngineer,

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J..R. cF eff,; Radiation Spe(1alist, 1

/datf ij(/ ,)) y/.a/8T J .-Prell, Reactor Engineer, RI. / vdate Other accompanying individuals:

R. R. Keimig, Chief, Safeguards Section DRSS, RI A. Chibbaro, Senior Radiophysicist, NYSDOL.

.G. Kasyk ~Se

• Radiophysicist,.NYSD0L f

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Approved by: 1M_.J_ Meu~ b W. J. P4sdiak, Chief,

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' / dafe s Radiation Protection Section, Effluen"D DRSS' Inspection-Summary: Inspection on May 18-22, 1987 (Inspection Report No.

70-687/87-04)

' Areas.Inspe:ted: Special, announced inspection by a team composed of NRC

. Region I, NRC Nuclear Material Safety and Safeguards and New York State Department of Labor personnel, to review conditions at the licensee's facili-ties to determine whether there are potential safety hazards that, when combined with routine facility operations, could impact upon public health and safety.

Results: Five apparent violations of NRC requirements were identified. In addition, 32 observations were made that resulted in 18 recommendations to improve safety conditions at the Tuxedo, New York site. Apparent violations:

failure of the Nuclear Safeguards Committee to review all procedures covering processes which involve greater than 15 grams SNM and failure to control those procedures in accordance with written administrative requirements (Paragraphs 5.d. and 5.j.(1)); . failure to use raschig rings in bottles containing uranium i bearing solutions in accordance with license requirements (Paragraph 5.j.(1)),

failure to maintain the exhaust fan room free of combustible r"erials (Para- l graph 5.j.(2)(a)); failure to conduct biennial reviews of the Radiological l Contingency Plan (RCP), annual verification of emergency rosters and telephone

. listings in the RCP and update Letters of A L. offsite agencies (Paragraphs 6.a. and 6.d.)greement  ; failure to maintain with all applicable a back-up power source or alternate emergency communication system (Paragraph 6.c.). A summary of the observations and recommendations is contained in Paragraph 3 of the report.

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DETAILS r . .

1. Persons Contacted ,

• .D. Gallagher, President

• • • J. McGovern,1 Plant Manager. l

• • • R T. L. Vaughn, Manager, Health Safety and Environmental Affairs-

• • • . W. Ruzicka, Manager,LNuclear Operations

• • • . D. Grogan,' Manager, Radiochemical Production-

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• • L R. Quackenbush, Manager, Radiopharmaceutical Production

• • L G. Nardella, Supervisor, Site Operations

• • R.'Johnston, Safety Officer.

• • J. Ditton, Lead Health Physics Technician

• F. J. Morse Manager, Engineering and Technology Sales

• L. C. Thelin, Health. Physicist

• Present'at the exit interview

• • Present at the entrance interview

• • • Present at-the entrance and exit interviews Other employees were also interviewed during the course of the  !

assessment.

2. Background.

As.a result of the accident involving the release of uranium hexafluoride

'from.Kerr-McGee's Sequoyah Fuels Facility in Gore, Oklahoma, on

~ January 4,1986, the NRC is conducting; operational. safety. reviews at l selected fuel cycle and by-product material facilities.

.The operational safety review is designed to evaluate existing conditions at each facility'and to determine whether there are potential safety hazards that, when combined with facility operations, could impact upon public health and safety. Further, the ' review will assist the NRC in

. determining if additional license conditions are needed to deter such impact. During each review,.the review team determines whether the licensee has systems and procedures in place to identify and correct inplant industrial safety problems that could result in radiological safety consequences, and determines whether the licensee is adequately e implementing those procedures which exist to prevent or mitigate such

. problems. The areas reviewed include personnel training, waste management, and facility operations and encompassed procedure control, equipment maintenance, nonradioactive chemical control, fire protection, and emergency planning. Upon completion of the review, based upon observations made during the review, recommendations were made to the licensee. Those observations and recommendations will also be forwarded to the appropriate NRC Program Offices for their consideration in effecting program changes.

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The operational safety review at tne Cintichem, Incorporated Research Reactor and Hot Laboratory facilities in Tuxedo, New York was conducted  ;

from May 18-22, 1987. A summary of findings, including general observations, recommendations and apparent violations is provided in .

Paragraph 3. A detailed discussion of each area reviewed is presented in paragraphs 4, 5, and 6.

3. Summary of Observations, Recommendations and Violations In general, the NRC review team found that the licensee had adequately addressed the work control practices and overall management controls, with the exceptions discussed below, as required by the NRC facility license. There do not appear to be any hazards associated with facility operations that could have a significant offsite impact on the public.  !

However, improvement.in the fire safety, industrial safety, radiation j safety, administrative controls, training and emergency planning programs is needed. During the review, the team made 32 observations that resulted in 18 recommendations that should be considered by the licensee l to further enhance and strengthen safety programs. Five apparent i violations of NRC requirements were also identified. I

a. Observations and Recommendations l l

Observations and recommendations made by the inspectors during this review, concerning the operations, facilities, equipment, and pro-cedures examined are as follows:

(1) Chemical, Explosion, and Fire Safety (a) Observations There does not appear to be a chemical, explosion or fire hazard associated with normal facility operations that could result in a significant impact on the workers at the site or on public health and safety. However, a significant impact on the workers could occur from a fire involving the gasoline-fired emergency generator located '

in the facility electrical switchgear room. The operation of all ventilation systems in the reactor and hot laboratory buildings will be disrupted by a fire in the electrical switchgear room. Disruption of the ventilation systems to the hot cells would result in the inadvertent release of radionuclides throughout the hot laboratory building. Paragraphs 4.a. and 4.c,

-- An extensive maintenance (preventive and corrective) program is established and implemented for all equipment handled by the Nuclear Operations group but not for equipment handled by the Site Operations and Engineering groups. Paragraph 5.e.

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-- The licensee's' fire prevention' administrative control-program is weak with respect to the control of combustibles (housekeeping), storage, handling'and l dispensing of flammable and combustible liquids .and welding and cutting.- Paragraphs 4.b. and 5.j.(2)(a).

-- There is no formal established, site-wide fire prevention control training program. Paragraph 5.j.(2)(b).

-- There is no established maintenance,. testing and inspection program to assure operability of thel31te fire detection, suppress' ion and. control systems.

- Paragraph 5.j.(2)(c).

-- There is no emergency brigade at the site which has been trained to properly respond to fires in accordance with established fire emergency plans. Paragraph 5.j.

(2)(d).

-- Fire protection equipment located in Buildings 1 and 2 is not adequate with regard to the rapid detection and suppression of fires. Paragraph 5.j. (2)(e).

('b ). Recommendations

-- Assure the gasoline-fired emergency generator located in the facility electrical switchgear room is

. isolated from the~ electrical switchgear by a seismically qualified two hour fire rated wall and that this enclosure is equipped with adequate fire detection and suppression systems.

-- ' Establish an administrative control program with respect to the handling, storage, and/or dispensing of flammable and combustible liquids; control of 4 solid combustible materials (housekeeping); and control of the welding and cutting program at the site.

-- Establish a fire detection, suppression and control system maintenance testing and inspection program.

-- Establish and train a fire emergency brigade in accordance with written fire emergency plans.

-- Assure that fire protection equipment installed in Buildings 1 and 2 are adequate to assure the rapid detection and suppression of fires.

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-- Establish ~and implement a preventive and corrective maintenance program for all applicable equipment-handled at the~ site.-

Industrial and Radiation Safety (2)..

(a) Observations- j

-- The industrial safety program at the Tuxedo site did l 4 not contain all of the, required elements of a good program. Paragraph 5.b. ,

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-- There is no centralized storage location for

-hazardous chemicals or waste containing hazardous chemicals. Paragraph 5.j.(3)(b).

-- Incompatible chemicals and gases were being stored  !

together in an e.rea located above the reactor offices in Building 1. Paragraph 5.j.(3)(b).

-- Machine shop machines are not securely anchored to .

the floor and not all slings used with cranes, to t

1 E lift equipment, were labeled with rated capacity.

Paragraph 5.j.(3)(b). l Radiation detection instruments used as hand and foot-counters may not be properly calibrated since there is no comparison between the output of the source and the detection capability of the instrument.

Paragraph 5.j. (3)(a).

-- Th'e _ background radiation in the vicinity of the hand and foot counters located at the facility exits is so high that the instruments will not detect low levels of radioactive contamination. Paragraph 5.j.(3)(a). j

-- The stack measuring devices located on the stacks in  !

the exhaust stack ventilation room may not be provid- )

ing accurate sample results. Paragraph 5.j.(3)(a). l 1

(b) Recommendations l I

L -- Establish a formal Industrial Safety Program for the Tuxedo site that contains all of the required elements.

l J -- Provide a centralized storage location for hazardous  ;

chemicals or waste containing hazardous chemical and assure that incompatible chemicals and gases are not being comingled in storage.

-- Securely anchor machine shop machines (lathes, etc.)

to the floor and assure that all slings used to lift equipment are properly labeled.

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Re-evaluate the hand and foot counter calibration procedure to assure that the intruments are properly calibrated; reduce the background radiation in the vicinity of the hand and foot counters located at the facility exits; and, assure that the exhaust stack radioactive material measuring devices are accurately recording releases from the facility.

(3) Housekeeping, (a) Observations l

-- Housekeeping in various areas of the facilities I including the second level of Building 2 and the exhaust stack fan room was not adequate. Paragraph 5.j.(2)(a).

l (b) Recommendations

-- Develop and implement a program to assure that sig-nificant quantities of combustible trash and other materials are not allowed to accumulate throughout the facility.

(4) Reviews and Audits (a) Observations

-- No routine audits or overviews of the health physics, the industrial safety, the fire safety programs or the Radiological Contingency Plan are conducted by groups or organizations not involved in the activities. Paragraph 5.c. and 5.f.

-- The criticality safety consultant, who conducts annual criticality safety audits in the facility, attends only one meeting of the Safeguards Committee each year and therefore cannot maintain cognizance of activities at the site that could effect nuclear criticality safety. Paragraph 5.g.(1).

-- Safety audits arE not conducted in accordance with documented plans and checklists. Paragraph 5.g.(2).

-- There is no tracking system established to assure that all audit and inspection findings have been corrected. Paragraph 5.g.(2).

(b) Recommendations

-- Establish a program to assure that reviews and audits

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.in'the following~ areas are conducted by persons not asscciated with the operations.(i.e., knowledgeable, butindependent):

b health physics program industrial safety; program fire safety. program -

' Radiological. Contingency Plan.

-- Assure that the nuclear criticality safety consultant attends a sufficient number of Safeguards. Committee meetings each year so that he.can maintain cognizance-of activities'at the site which might effect nuclear .!

criticality safety.  !

-- Assure that safety audits and inspections are conducted in accordance with documented plans and checklists and that a tracking system has been estab-lished to assure that all audit and inspection find-ings have been corrected.

(5) Administrative Controls (a)_ Observations

-- With the exception of those. procedures identified in I Paragraph 5.d. of the report details, operating  !

procedures are written, reviewed, approved and t maintained in accordance with the techniques specified in Administrative Procedure No. AD-01. An apparent violation of license requirements with .,

regard to procedure control is discussed further in 2 Paragraph 3.c. and Paragraph 5.d.

No inadequacies were identified in the facility electronic and radiation monitoring / measurement equipment calibration programs. Paragraph 5.1.

(b) Recommendations None (6) Personnel Training (a) Observation The training program for hot laboratory operators has not been formalized, does not require a review of I

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operating procedures by new employees and completion of training is not fully documented. Paragraph 5.h.  !

(b) Recommendation

-- With regard to the employee training program:

i formalize the hot laboratory operator training program assure that operating procedures are reviewed by new employees during initial training i1 assure that training records include satisfactory completion dates for initial and requalification training ,

establish a mechanism to assure that >

employees are aware of areas for which additional training is required.

(7) Emergency Planning  ;

(a) Observations

-- The Radiological Contingency Plan (RCP) contains  !

several weaknesses that should be addressed. It was determined that the format of the RCP is not 4 consistent with the guidance contained in 10 CFR  ;

50, Appendix E, or NUREG-0762; that the RCP does  !

not provide a mechanism for level 1 or 2 ,

managers to take over as the Emergency Director '

upon arrival at the site; that the RCP does not identify the status of all current offsite support groups; and that the RCP does not identify the actions to be taken with regard to a General Emergency (GE), or provide the reasons for not addressing a General Emergency in the j RCP. Paragraph 6.a.  ;

-- Audits of the Radiological Contingency Plan were conducted by personnel (the Emergency Response Coordinator) who is responsible for implemen-tation of the Plan and cannot conduct an independent review. Paragraph 6.a.

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-- There is no' formal or controlled distribution of.the-L

, . Radiological Contingency. Plan. Paragraph 6.d.

-- The primary emergency control center.' located ;in Building 2'has only one telephonelline,available, and was not equipped to. provide the equipment necessary to help assess, control or mitigate an i emergency. Paragraph 6;b. ]

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-- The portable flow rate meters available'in' emergency 4 cabinets were not calibrated and iodine' collection cartridges were.not properly stored to prevent inadvertent contamination. Paragraph 6.b.

-- 'Available emergency call 1ists and employee emergency:

roster telephone lists are not current. Paragraph 4

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--- Written agreements with local agencies are either not' 1

current or are not available. Paragraph 6.d.

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-- Copies of the RCP are not provided to applicable offsite agencies and emergency drills or exercises are not periodically conducted with each.offsite-agency. Paragraph 6.d.  ;

-- There is no formal emergency planning training i

program.that includes a comprehensive training matrix,'a set of lesson plans, qualification criteria for -key emergency response personnel, requalification and testing procedures.

Paragraph 6.e.

-- Emergency drills and tests conducted at the facility are not designed to test all aspects of the emergency plan. Paragraph 6.e.

(b) Recommendations

-- Review and revise the Radiological Contingency Plan to: l 1

provide a format consistent with the guidance ,

contained in 10 CFR 50, Appendix E or NUREG-0762 l provide a mechanism for level 1 or 2  ;

managers to take over as the Emergency -

Director upon arrival at the site

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identify _the status of all current offsite support groups-discuss the use or.nonuse of' the General Emergency class of actions at the site assure formal or~ controlled distribution.of the RCP provide for audit of RCP implementation by independent personnel-assure that' emergency call lists and telephone rosters ara maintained current

< ' assure that written agreements have been executed with, and are understood by,'all required offsite support groups provide copies of the RCP to required offsite support groups provide for the establishment of a formal emergency planning program

-establish qualification criteria for_

emergency response personnel assure emergency drills and tests, 1

> conducted at~the facility, test all aspects i of the emergency plan and' include; participation by offsite agencies.

-- Provide the proper equipment and facilities for j the emergency control centers identified to handle '

each type of emergency.

-- Assure that all emergency equipment is properly ,

stored and calibrated. l

b. Violations The following apparent violations of NRC requirements were '

identified:

-- Failure of the Nuclear Safeguards Committee to review all procedures covering processes which involve greater than 15 grams of'special nuclear material and failure to control those -l procedures in accordance with written administrative i requirements were identified as an apparent violation of l 4

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Section 2.7 of the NRC-approved license application.

Paragraphs 5.d. and 5.j.(1).

-- Failure to use raschig rings, in bottles containing uranium bearing solutions, in accordance with Section 4.2.5 (1)(b) of the NRC-approved license application is an apparent violation. ,

Paragraph 5.j.(1). l i

Failure to maintain the exhaust fan room free of combustible materials was identified as an apparent violation of Section 3.2.5.5 of the NRC-approved license application.

Paragraph 5.j.(2)(a).

-- Failure to conduct biennial reviews of the Radiological Contingency Plan (RCP) and procedures since 1983, failure to annually verify the emergency roster and telephone listing in the RCP since 1983 and failure to initiate or update Letters of Agreement with all applicable agencies since 1976 constitutes an apparent violation of Section 10.5 of the RCP. Paragraph 6.a. and 6.d.

-- Failure to maintain a back-up power source or alternate emergency communications system was identified as an apparent violation of 10 CFR 50 Appendix E, Section IV.E.9. Paragraph 6.c.

4. Process Review Cintichem, Incorporated owns and operates the Sterling Forest Reactor Facility under Nuclear Regulatory Commission License No. R-81, and possesses and uses special nuclear material under NRC License No.

SNM-639. The reactor is a 5 megawatt pool type research reactor utilizing MTR type fuel elements. The reactor and its adjoining hot laboratory facility is used in producing radiochemical primarily for use in nuclear medicine. The reactor is operated, in general, on a 24-hour day, 7-day week cycle with refueling and maintenance shutdowns approximately every 14 days,

a. Radiopharmaceutical Production The general process of making radiochemical involves preparation of targets for irradiation by neutrons in the reactor core, processing the irradiated targets to obtain pure chemicals that are suitable for incorporation into drug products, and processing waste and effluents for safe disposal. The major product from this facility is molybdenum-99 which is chemically separated from the fission products of uranium-235. Currently, this is the only process which utilizes SNM at the facility.

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The targets or irradiation capsules are prepared by depositing i uranium (93 percent enriched) on the inner' surface of a suitable tubing in the hot laboratory facility.

Following sealing and Quality Assurance tests of the targets to assure that they are sealed and contain the proper quantity of  ;

uranium, the targets are transferred to the reactor facility for irradiation.

.The technical specifications for conducting fueled irradiations in the' reactor define the limits for this part of the process. Typi-cally, the . irradiation time and flux is limited to achieve less than 1 percent "burnup" of the original U-235, and therefore relatively i small quantities of the long-lived fission products are present when irradiation is discontinued.

After irradiation, the targets are held in the reactor pool for a .l specified minimum period of time to allow the very short-lived is-otopes to decay prior to commencement of the chemical separation }

process. The targets are then brought into the hot cells through a i water filled canal that is connected to the reactor pool. The  !

uranium is dissolved in acid inside the irradiation target capsule.

. Gaseous fission products are condensed at -200 C in a cold trap to which the irradiation target capsule is connected subsequent to the dissolution of the uranium. ,

Several carriers are added.to the uranium and mixed fission product solution to enhance separation from the Mo-99. The Mo-99 is pre-cipitated with a-benzoinoxine and.is filtered out of the solution.

The' filtrate containing the uranium is considered a waste byproduct and is stored inside the hot cells as uranyl sulfate in aqueous solutions of about 15 g of U-235 per batch.

Several batches of decayed uranium wash solutions- (less than 200 g U-235 per batch) are combined and the uranyl sulfate is converted to uranyl acetate by the addition of barium acetate. Sulfates are precipitated as barium sulfate and the uranyl acetate remains in so- i lution. The uranyl acetate is decanted, dried, and calcined to form  !

uranium oxide. The uranium oxide is stored for several weeks and shipped to a reprocessing facility to recover the uranium-235. Some of the uranium is trapped in the barium sulfate precipitate which is l~

slurried with water, mixed with cement, solidified, and shipped to an approved radioactive disposal facility.

During a review of the process, the inspectors determined that only small quantities of acids and flammable liquids are used. In add-ition, the inspectors determined that most of the processes were i.

conducted either in the reactor pool or inside hot cells. Because of the protection afforded by the reactor pool and the hot cell L

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walls l during l normal operation, 'no .significant concerns for. the.

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safety of;the workers or the.public:were identified. Hazards identified duringLoff-normal operation of those facilities are i' discussed :in- Paragraphs 4.b. and 4.c. The equipment for those portions of the processes conducted outside the reactor pool or the hot cells did not consist of components which, if failure occurred, could- significantly affect the health and safety of workers or the public..

b. Hazardous Material Storage and Use The inspectors. observed that the licensee has large quantities of flammable and combustible hazardous chemicals stored at the Tuxedo site for use at the site' or atLother Cintichem facilities' located in

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New Jersey.' Those chemicals include lubricating oils, paint,-

acetylene, trichlorethylene, acetone, and other organic solvents.

Although no significant problems were identified, the inspectors determined that the licensee does.not have an' administrative control program with respect:to the handling, storage, or dispensing of flammable and combustible liquids at the Tuxedo site.

The inspectors also observed that the majority of the combustible i liquid dispensing devices were not Underwriters' Laboratories (UL)

or Factory Mutual (FM) approved (i.e., plastic dispensing valves on 55-gallon drums of lube oil 'in the boiler house); and,' that the incidental storage and use'of flammable and combustible liquids on the site did not appear to comply with NFPA 30, " Flammable and Com-bustible Liquids Code." In addition, the licensee does not currently use UL/FM approved. flammable / combustible liquid safety cans for the handling and dispensing of these liquids.throughout the site. However, it was noted by the inspectors that the licensee initiated the purchase and installation of flammable / combustible liquid storage cabinets on site, prior to this inspection, and.that the licensee recognized the need to. control these liquids. The ';

inspectors recommended that the licensee implement a flammable / combustible liquid control program which utilizes the .

I guidance provided in NFPA 30. While the handling of hazardous materials pose potential hazards to employees, there is little potential for exposure of the general public to those hazards.

c. Emergency Generators l During examination of the electrical equipment room containing the site electrical transformer, switchgear, and motor control center, the inspectors observed that one of two emergency generators at the '

site was located in the same room. That emergency generator was gasoline fired. The other natural gas fired emergency generator, j although not located in this room, is interconnected with the electrical equipment located in the room through the power output i

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13-cables. As a result of.these observations, the inspectors, determined that a serious fire risk with radiological implications on the health and safety of the public exists in the' electrical equipment room, in that a fire in this room, which destroys the '

electrical equipment, could cause a loss of power. distribution. to I all hot laboratory and reactor building exhaust fans, reactor l 1 circulating water pump and nuclear instrumentation. This condition was. previously, but. i. independently, identified by the licensee's-insurance carrier American Nuclear' Insurers (ANI) during a 1984 audit. The licensee has been working with ANI since then to resolve this problem. The loss of the exhaust air flow from the reactor building and the hot laboratory would allow the containments to approach ambient or positive pressure. Since the hot cells in the hot laboratory are not sealed units, a loss of exhaust air flow would allow release of. fission gases and fission products into the-facility. In addition, the loss _of air flow through the hot cell

. charcoal filter beds could cause degradation of the filter media resulting in spontaneous heating of the charcoal and release of fission products to the environment.

.The inspectors recommended that the licensee improve fire protection in the electrical equipment room by-installing a 2-hour fire rated

. seismically qualified wall separating the gasoline fired emergency, generator from the electrical equipment. The door to the generator room should be curbed.in order to prevent flammable liquid flow into the electrical equipment room. The licensee should also consider installing'an automatic halon fire suppression system in the electrical equipment room and the recommended emergency generator

' room. Actuation of the~halon system in both the electrical equipment' room and the emergency generator room should be alarmed and annunciated in the reactor control room and remotely annunciated at the main entrance to Buildings 1 and 2. The licensee should also install'a flammable vapor detection and a dedicated vapor exhaust system in the proposed generator room,

d. Reactor Operations The inspectors examined the reactor facility and transfer tunnel; witnessed the removal and insertion of a target from and into the reactor core; reviewed several reactor operating procedures and  ;

checklists; examined the licensee's surveillance test program; and, interviewed several operators to identify any potential safety l concerns. With the exception of the fire hazard in the electrical  ;

equipment room previously discussed in paragraph 4.c., the l inspectof s did not identify any significant potential safety {

concerns in the reactor facilities. The operators appeared to be [

knowledgeable of their duties and responsibilities and the target l removal and insertion operation was conducted in accordance with '

approved procedures. ,

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5.. Management Controls a.. Organization Cintichem, Inc., the. licensee, is a wholly-owned subsidiary of Medi-Physics,-Inc. which, in turn, is.a wholly-owned subsidiary.of Hoffmann-LaRoche, Inc. The Plant. Manager /Vice' President (Cintichem) directly oversees the day-to-day site' activities and reports to the President.of Cintichem/Vice President'(Medi-Physics). The. manager of Health, Safety, and Environment Affairs (HSEA) reports .to' the Plant Manager, has a group of seven individuals in his organization,

.and is responsible for industrial safety and radiation protection at-the site.

b. ' Safety Program ' Implementation The responsibility for ' implementation of the safety program at the site has been assigned to the Manager, HSEA. One individual

. reporting'to the Manager, HSEA has been assigned. general safety, as opposed to radiation safety, responsibility at the site and. spends approximately forty percent of his time addressing industrial safety considerations. Through a review of licensee' records and discussions with licensee representatives, the inspectors determined that the licensee has. established a written safety policy,' defined a hazardous material communication program and implemented the use of a safety indoctrination. checklist for employees. However, the.

available_ policy and safety programs were not sufficiently developed to provide adequate direction for the establishment and execution of a safety program. Elements of an industrial safety program not fully addressed included: assignment of responsibility and authority; initial and periodic industrial safety training for supervisors and workers; program enforcement; corrective action on inspection / audit findings; identification and evaluation of hazards of new/ altered equipment, processes; and facilities; inspection and o monitoring-programs; and housekeeping. 2

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Based on these findings, the inspectors recommended that the licensee evaluate and revise, as necessary, the site industrial safety program to assure that the program contains all required elements.

c. Quality Assurance / Quality Control Programs The licensee has a Quality Assurance / Quality Control (QA/QC)

Department to assure that the radiochemical have been purified in accordance with customer or U. S. Federal Drug Administration requirements. A QA manual has been developed and extensive QA specifications exist to ensure the quality of the product. The QA organization is independent and reports to the Plant Manager. The .

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15 i emphasis of the facility-QA/QC program is on product quality. QA personnel perform no audits or overview of health physics or ,

industrial safety. The inspectors recommended that an i audit / surveillance. program be established by QA, or some other independent organization, to provide periodic overview in these areas.

d. Document Control Through a review of licensee records and discussions with licensee representatives, the inspectors determined that procedures are generally written, reviewed, approved, and maintained in accordance with the techniques specified in administrative procedure, No.

AD-01. In addition, the facility License No. SNM-639 in Section 2.7 requires that all processes which involve greater than 15 grams of special nuclear material (SNM) which have pertinent criticality or radiation safety issues shall be covered by written procedures.

Those procedures shall be reviewed by the Nuclear Safeguards Committee (NSC) and approved by Level II Management. The date of NSC approval shall be written on the procedure. During an NSC audit conducted on November 4,1986, it was recommended that the following procedures be added to those procedures controlled by procedure AD-01 since the processes involved handling in excess of 15 grams of ,

SNM: l

-- Precipitation of Sulfates with Barium Acetate, dated 10/14/86

-- Filtration of Supernatant, dated 10/14/86 I

-- Distillation of Uranyl Acetate, dated 10/14/86

-- Drying Phase,' dated 10/14/86

-- Manual Calcination Procedure, dated 10/14/86 l

-- Fission Product Mo-99 Production Process, dated 12/17/86, Rev 3 i

-- Procedure for. Receipt and Dissolution of SNM (Enriched U-235)

Feed Material, undated.

Corrective actions had not been initiated by the licensee between November 4, 1986 and the conclusion of this review on May 22, 1987.

Therefore, failure to have the Nuclear Safeguards Comittee review those procedures and failure to control the procedures in accordance with written adrainistrative procedures were identified as an apparent violation of Section 2.7 of the facility license.

e. Maintenance The inspectors reviewed the licensee's preventive and corrective maintenance programs. During the review, the inspectors held i discussions with operations, engineering and technical sales l personnel, and examined maintenance procedures, shop orders, '

computer print-outs, completed work orders, and the work order log.

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The inspectors determined that maintenance activities are divided between three groups, Nuclear Operations, Site Operations and ,

Engineering. However, the lines of authority and responsibilities within each group and between the groups are not~ clearly defined and administrative controls vary between the groups. The Nuclear Operations group performs both preventive maintenance (PM) and corrective maintenance (CM) on most of the equipment associated with reactor operations. The Site Operations group performs maintenance activities on equipment associated with the Boiler House. The Engineering' group is responsible for all PM and . corrective maintenance activities associated with heating, ventilation and air conditioning (HVAC)equipmentusedthroughoutthesite. Maintenance activities performed by the Nuclear Operations group on the reactor facilities are controlled by.means of reviewed and approved procedures. However, the inspectors determined that maintenance activities conducted by the other groups are not accomplished by means of reviewed and approved procedures. Instead, the licensee depends on the experience of each individual. Maintenance personnel were found to'have between 10 and 30 years experience. Although the i majority of the maintenance activities should be well within the capabilities of experienced personnel, the licensee has not estab-lished a system for certifying that maintenance personnel have demonstrated the skills and knowledge to perform those activities.

The inspectors recommended that the licensee should either require j the use of approved procedures for the maintenance of safety related l equipment or should establish a certification program which ident-ifies and tests the skills and knowledge of the maintenance personnel to perform maintenance on safety related equipment.

f. Inspections and Audits l

The inspectors examined licensee records of internal audits of  ;

operations conducted since the facility SNM license was renewed on

~

October 19, 1984. The records indicated that five audits of trans-portation activities, hot laboratory operations and the Health, Safety, and Environmental program were performed. The inspectors noted that audits of activities, other than those identified in the facility NRC license were not conducted. The inspectors recommended that the licensee should evaluate all activities at the site and conduct periodic audits to assure that all activities were being conducted in a safe manner.

The inspectors also examined records of internal audits of the industrial safety program conducted by the General Safety Committee, and external audits conducted by the State of New York in 1974; the U. S. Operational Safety and Health Administration in 1982; a Medi-Physics Safety Audit team in 1984; and insurance company audits since 1984. l 1

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f>'li-l Onthebasisofthisreview,theinspectorsdeterminedthat@ed')

licensee's industrial safety program had not received c s t' y comprehensive independent review since 1984. Therefore, the' /

inspectors recommended that the licensee arrange to have an '

independent and comprehensive industrial safety program audit >

performed to identify areas for improvement. t =

g. Safety Committees /

I _ .

e-(1) Nuclear Safeguards Committee i i \l . ;\ y-l*

The inspectors examined minutes of the Nuclear Safeguards  ! i J I

Committee. From this examination, the inspectcrs determined t that the committee meets frequently and actions taken or items discussed at those meetings are well documented. However, the ,s inspectors determined that one member of the committee, thq ,.

nuclear criticality safety consultant, only attends one meetingd ,

each year. Any questions relating to criticality safety, that +f arise during the year, are either answered by the Plant'  ;

Manager, a Nuclear Engineer, or the questions, with avslable documentation are sent to the consultant for review. The A' '

inspectors recommended that the criticality safety censultar*. \q should be required to attend meetings of the Safeguards- 1 's ,

Committee more frequently so that he can maintain cognizance of' Y activities taking place at the facility. , (( f

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(2) General Safety Committee n ..p The licensee has established a General Safety Committee that is chaired by a part-time industrial safety professional and is j comprised of on-site managers. The committee meets regularly, reviews the results of safety inspections and audits bnd site accident and in,iury statistics, designates personnel- to perforn monthly safety audits, and records the minutes of meetings. J' '

j The inspectors examined the General Safety Committee meeting minutes and several monthly safety audit reports. The N inspectors determined that the committee has been meeting every two months, as required, and that actions taken or items discussed at those meetings are well documented. Howeverz i audit reports were available for only five monthly safety audits conducted in 1986 and those audits were performed sN without the benefit of documented plans and checklists. In I addition, records of verification of the corrective actions 4 recommended in those reports indicated that this verification /,

was not always timely. As a result of these observations, the e inspectors recommended that the licensee evaluate the need for ,{

a documented system for following up on inspection / audit find- > '

ings, that the monthly safety audits be performed at the proper '

frequency, and that the monthly safety audits should be ,_

conducted in accordance with documented plans ar,d checklists s l

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h. Training ,

q The,licep ee provides'each neu employee a copy of a booklet entitled

, 'Tnb rtth ding Radiation." This booklet is v.ied to indoctrinate f ebeh mw employee with information concerning radiation, its hazards ar/T cor. trol . Industdal safety infor; nation is also provided to each l new employee. That ir. formation _is contained in two documents, the l "?mpry of Safbty Proceparest and the " Hazard Communication l  ? / F @grav . The first do d ment. consists of a statement on safety l l Jolicy and a short para @aph br twa on a number of specific safety l

practices. The'second dacunwnt includes a one page description of

<  ? the hazard communication program, a safety indoctrination form with

> ,diecklist and $tgrlotur% : paces, four pages of forms for ordering s

y, 'i right-to-know Pinted materials and chemical fact sheets, and two j pages of samp1h chemical fact sheets. The " Hazard Communication I Program" also includes u safety indoctrination form.

includes a signature block for the safety office to indicate that That form t' the workers havE been provided with the following information: site

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j < safety rules, emergency procedures, injury reporting, use of safety 0

and emergency equipment, and the hazard communication Taw. The form

' als6 has a signature block for the worker to indicate"that those items had been explained to him and that he understood them. A

) t third portion of the form lists the safety orientation ena instructions which the worker's supervisor / manager is required to provide to'the worker. The safety orientation and instructions to be provided' include those pertinent to' the worker's specific work tasks and work locations, such as: safe operating methods, location ,

of emergency equipment, protective equipment to be used, and i precautions' icr the use of specif'4 azardous h chemicals. However,,

I the fy;n did rbt :ontain any mechanism to record the completion of this tv41nirg, ,

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s s The inspet; ors iiso determined, during discussions Win licensee  !

, t representee.ives, training i'n hut laboratory process operations is p

i conducted cnetha-jeb. In general, a mew employee, in the hot t

, laboratory, observes as an experierlcm-0perator performs a routine task. At som undetermined time during the new employee's y

'ti on-the-job ,?. raining, the cognizant Department Manager and a lead N l egrator reach an agreement that the new employee is trained and is j j ready to perform the essigned task unassisted. Review of the ,

[z 3 processirs procedures written for the tasks may or may not be ' .) ' ,

i required er the new employee during on-the-job training.

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s In addition, the inspectors reviewed the annual requalification program for employees handling SNM and determined that completed requalification' checklists were available for each applicable employee. The checklists rated each employee as excellent, satis-factory, or needs improvement in a variety of SNM related areas.

The rating was made by supervisor observation and questioning of the employee. Any employee found to be needing improvement in an area '

was given oral instruction and more on-the-job training.

The inspectors recommended that the safety indoctrination form com-pleted for each new employee should be modified to indicate when safety training was completed and which subjects were covered during  ;

training. The training program for hot laboratory operators should i be formalized and should also include review of operating procedures by the new employees. This training program should also be documen-ted. In addition records should be maintained to indicate when each employee satisfactorily completed required requalification training.

Those employees should also sign the requalification checklists in order to acknowledge areas in which additional training is required.

i.. Calibration Program The inspectors examined the licensee's calibration /recalibration program which is divided among four groups. Nuclear Operations has assigned one individual, who is also a qualified Senior Reactor Operator (SRO), to perform all corrective maintenance and required cal 1brations on electronic equipment used in the control and monitoring of the reactor. Through a review of the equipment log, the inspectnrs determined that calibrations were being performed on the required schedule. The Health Physics department is responsible for calibration of all radiation monitoring / measuring equipment used throughout the plant. The instrument maintenance shop, under the Engineering Services Group, performs initial calibration of new equipment and corrective maintenance of all electronic equipment, except that used by Reactor Operations. The Pharmaceutical praduction group performs calibrations of all equipment used in the production of radiopharmaceuticals. No inadequacies were identified.

j. Operational Safety (D Nuclear Criticality Safety Contro.;

Du-ing examination of the licensee's nuclear criticality safety controls, the inspectors determined that yearly and bimonthly criticality audits were performed in conformance with license e ditions. For the criticality alarm system, it was found that cally operability checks, weekly alarm chetks, and annual calibrations are also being made in accordance with license requirements. Criticality emergency drills were conducted as required and criticality safety signs, which indicate the SNM l

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20 quantity limits and current inventory are posted in each appropriate area of the facility. However, during examination of the hot laboratory facilities, the inspectors observed that the licensee initiated use of raschig rings in glass bottles containing uranium bearing solutions. The raschig rings were vendor certified and verified by the licensee as containing 12.6 weight percent B 03 . Through examination of licensee records,theinspectobsdeterminedthatalthoughtheraschig rings were being used, operating procedures'for their use were not written and there was no documented evaluation to cover their use in the facility as required by license conditions.

During discussions with licensee representatives, the 1 inspectors determined that the required evaluation was conducted but was not documented. In addition, the inspectors noted that the bottles were filled with uranium bearing solutions approximately one inch over the top of the raschig rings. This was found to be contrary to Section 4.2.5(1)(b) of the NRC-approved license application and constituted an apparent violation of NRC requirements.

(2) Fire Protection In order to assess the licensee's fire protection program, the inspectors evaluated the potential for fire in the Reactor Building (Building No. 1) and the Hot Laboratory Building (Building No. 2), assessed the adequacy of administrative fire prevention control procedures, assessed the adequacy of the fire protection system maintenance and surveillance training program, evaluated the potential for a fire induced nuclear criticality safety accident or a major release of radioactive material which might result in the event of a fire or an explosion, and, assessed the licensee's response capabilities to mitigate fire conditions.

(a) Assessment of Fire Protection / Prevention Administrative Control Procedures The inspectors reviewed the fire prevention /adminis-trative procedures contained in the facility " Fire Control Program", dated October 9, 1984. Based on the inspectors' review of this program, it appears that the licensee's fire prevention administrative control program is weak with respect to the control of combustibles (housekeeping), storage, handling and dispensing of flammable and combustible liquids, and welding and cutting. The licensee's procedure does not restrict the use of the non-fire retardant treated wood and uncontrolled plastics in Buildings 1, (reactor) and 2 (hot laboratory). These materials were identified on the lower level of Building 1, on the reactor operating floor, and throughout portions of Building 2. The licensee has not I

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21 l

established a program which restricts or limits the amount i of combustible materials stored in Building Nos. I and 2.

In addition, the licensee has no formal fire prevention / housekeeping inspection program which assures 1 that Buildings 1 and 2, are periodically inspected for l concentrations of combustible materials. The licensee's I inspection program, as a minimum, shouli iJentify potential fire hazards and accumulation ',f combustible materials to upper plant management. In addition, upper management should take the appropriate c;rrective actions '

which will eliminate fire hazard conditions identified by the inspection program. Failure to have a fire prevention l inspection program to control fire hazards and combustibles in Buildings 1 and 2 was identified as an area needing improvement.

During a tour of the facilities, the inspectors examined the hot laboratory and reactor building exhaust fan room.

The door to this room is marked with a sign which states that no combustible storage is allowed. However, the inspectors found combustibles stored in this area (i.e.,

two wood ladders, a combustible chair, rubber gloses, plastic bagged contaminated items). This was identified as an apparent violation of license requirements for '

failure to maintain the exhaust fan room free of combustibles.

In addition, the licensee does not have an administrative control program with respect to the handling, storage, and dispensing of flammable and combustible liquids in Buildings 1 and 2. The inspectors noted that the majority of the combustible liquid dispensing devices are not Underwriters Laboratories (UL) or Factory Mutual (FM) approved (i.e. installation of plastic dispensing valves on 55-gallon drums of lubricating oil in the Boiler House) and that the incidental storage and use of flammable and l combustible liquids on the site does not appear to comply with NFPA 30, " Flammable and Combustible Liquids Code." '

Currently, the licensee does not utilize UL/FM approved flammable / combustible liquid safety cans for the handling j and dispensing of these liquids throughout the site.

However, tre inspectors determined that the licensee is j presently purchasing and installing flammable / combustible liquid storage cabinets on site and that the licensee recognizes that they need to control these liquids. As a result of these observations, the inspectors recommended  !

that the licensee implement a flammable / combustible liquid control program which utilizes the guidance provided in NFPA 30.

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The' inspectors also conducted a review of.the licensee's welding, cutting,-and grinding program, and determined I that the licensee does/not have a formal program in this 1 area.- The inspectors recommended that the licensee should evaluate and improve the welding, cutting and grinding .,

program. through the implementation of. controls that- i requires..those operations to be conducted.by permit. The i permit should.be approved by the supervisor performing the' ^

work and authorired by.the site safety / fire. protection specialist. The welding, grinding, and cutting work authorized under a specific permit should be completed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the issuance of the permit. The-program should also ensure that. combustibles have been  !

moved at least 35 feet away from such operations and a f trained fire watch, with the appropriate fire j extinguisher, should be posted during the work and for 30 minutes'thereafter to ensure that sparks or drops of hot metal do not start fires. In addition, if welding or cutting is being done on metal structures which penetrates walls, floors, or ceilings, a fire watch should be established on the opposite side of the partition. The program should also include fire watch training for personnel involved in welding, cutting and grinding operations.

With regard-to fire hazards associated with oil in the hot cell windows, the inspectors recommended that the licensee should investigate utilizing a non-combustible media in the windows (i.e., zinc bromide solution).

(b) Assessment of the Licensee's Fire Protection / Prevention Organization (1) Site Personnel Fire Prevention / Control Training Through examination of licensee records and discussions with licensee representatives, the inspectors determined that the licensee.does not have a formal, established,. site-wide, fire prevention /

control training program which provides instruction to site and contractor personnel on: selection, use and handling of fire extinguishers and proper use of combustible materials. Establishment of such a program was recommended by the inspectors.

(2) Site Fire Prevention / Control Personnel Qualifications and Responsibilities Through examination of licensee records and discussions with licensee representatives, the inspectors determined that the licensee has not

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established the qualifications or the responsibilities of site fire prevention / control (lossprevention) personnel. The fire prevention specialist should be at a level in the organization which permits communications with persons in direct charge of production, engineering, health and safety and other staff units. The fire prevention specialist's qualifications should be consistent with j the requirements of the position. The following qualifications are considered'to be appropriate:

an engineering degree or equivalent experience fire protection / prevention engineering experience successful performance of responsibility in fire protection and prevention programs.

The fire protection specialist should be responsible for establishing a fire protection and prevention program which, as a minimum, should include:

interpretation of applicable codes, regulations and standards .

1 engineering design review, including changes of process and material selection, as necessary inspection of facility and equipment for fire hazards administration of the hot work (welding, cutting and grinding) permit program inspection, testing and maintenance of fire protection equipment fire brigade training including interface with local fire departments to ensure equipment compatibility fire damage investigation and reports recovery planning for minimizing effects of fire damage preparation of emergency fire procedures.

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24 The inspectors recommended that the licensee formally establish qualifications and responsibilities for fire prevention and control personnel' as described above.

(c) Fire Protection System Inspection and Maintenance Program  !

The inspectors conducted a review of the licensee's fire i' suppression system inspection program to determine if the inspection / test instructions followed general industry fire i protection practices and the guidelines of the NFPA fire codes.

Based on this review, it appears that the hot laboratory carbon filter bank carbon dioxide (C09 ) fire suppre-ssion/ detection system, yard mains, hydrants, valves, hose house equipment, automatic sprinkler systems, hose stations and hose are not being adequately tested and maintained in accordance with the NFPA fire codes and the manufacturer's recommendations.

The thermal detection system on the hot laboratory HEPA/ charcoal filter banks activates the CO,, suppression system in the filter banks. The licensee d6es not conduct detector sensitivity testing, does not clean the detectors and does not test the detector activation circuits. In addition, the licensee presently does not have an ,

established maintenance and testing program for the CO 2 i suppression system.

It should also be noted that the inspectors were concerned that the C0 system would not adequately extinguish a charcoal fi$ter bed fire since the normal fire suppression medium for extinguishing charcoal bed fires is water which was not present. As a result the inspectors recommended that the licensee consider the installation of a backup, manually actuated, water spray suppression system on the charcoal filter banks. In addition, the inspectors recommended that the fire detection circuitry in the filter banks be reevaluated to assure that it is environmentally qualified for use in high radiation fields.

The inspectors determined that the licensee does not perform periodic fire hydrant maintenance such as, i inspecting the operating nut packing, verifying that the barrel drain is properly working, cycling the foot valve and lubricating the hose connections. In  !

addition, the licensee does not periodically flush  !

the underground fire main or flow test fire hydrants.

25 With regard to fire sprinklers, the inspectors determined that the only maintenance conducted by the licensee involved verification that the outside stem and yoke (OS&Y) valves which isolate the main water supply to the various plant sprinkler systems are open. The licensee does not have an established maintenance, inspection or test program which requiresthe performance of sprinkler system test connection flow tests, inspection of sprinkler heads and piping for corrosion and/or mechanical damage, and maintenance of OS&Y and sprinkler alarm and trim valves.

During the plant tour, the inspectors noted that some of the sprinkler piping supports for the site wood air i conditioning cooling tower, which is locat. behind the boiler building, were not properly instal u : or had been ,

removed and not reinstalled. In addition, tae reactor j building cooling tower sprinkler valve and it's '

attachments along with the OS&Y sprinkler control valve are severely rusted and should be appropriately protected against corrosion.

With respect to hose stations inside buildings 3 and 4,-at the site, it appears that the licensee has not established a maintenance, inspection and test program which requires the hose angle valve to be periodically cycled, hydrostatic testing of the fire hose, inspection of nozzles, hose coupling and hose for damage and flow testing of the hose stations.

Based on the observations indicated above, the inspectors recommended that the licensee reevaluate the site fire {

protection system maintenance, testing and inspection {

programs to assure operability of the fire detection, j suppression and control systems, i (d) Site Fire Brigade (1) Fire Brigade Organization The licensee does not have an established fire l brigade organization or the proper manual fire l fighting equipment for the protection of the i radioactive material processing areas. j Therefore, the inspectors recommended that the licensee consider formation of a fire brigade consisting, as a minimum, of a team leader and l two other members who have sufficient training or knowledge of the plant process related l l

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26 systems to understand the effects of fire and fire suppressants on nuclear criticality safety in the manufacturing process.

(2) Fire Brigade Training If the licensee establishes a fire brigade as recommended above, the inspectors recommended that the licensee implement a fire brigade training program that includes the following:

preparation of a fire fighting plan with specific identification of each individual's responsibilities identification of the type and location of fire  !

hazards and associated types of fires that could occur at the site I

the toxic and corrosive characteristics of expected products of combustion

~

• identification of the location of fire fighting equipment in each fire area and familiarization with the layout of the plant, including access and egress routes to each area the proper use of available fire fighting equipment and the correct method of fighting each type of fire. The types of fires should include fires in energized electrical equipment, fires in cables and cable trays, hydrogen fires, fires involving chemicals, and fires resulting from construction or modifications (welding) the proper use of communication, lighting, ventilation and emergency breathing equipment the proper methods for fighting fires inside '

buildings and confined spaces the direction and coordination of the fire fighting activities (fire brigade leaders only) detailed review of fire fighting strategies and procedures l review of the latest plant modifications and corresponding changes in fire fighting plans.

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s 27 In addition to an initial fire' brigade training ..

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program which. satisfies the above and is providedsto new fire brigade members prior. to:their assignment' to

'the plant fire brigade, the licensee should conduct quarterly refresher training and practice fire

. fighting drills w!iich simulate emergency fire ,

conditions:inside the plant. The licensee's fire brigade drill program should assure-that'

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' drills are conducted on each operating shift at regular intervals, not to exceed 3 months each brigade member participates in at least'two'

.(2) drills-the fire. brigade on each shift should participate in at least one unannounced drill all drills are pre-planned

.all drills are critiqued unsatisfactory drills'should be repeated within 30 days.

(3) Fire Emergency Plans (Fire Fig,hting Strategies)-

Through discussions with licensee representatives, the-inspectors determined'that.the licensee had not developed fire emergency plans for process' areas.

Under complex fire fighting conditions, such as those

.whicn could be experienced at the licensee's facility, a fire emergency plan would provide fire fighting strategy which the fire brigade. leader and the local Fire. Chief can use to mitigate fires.

The inspectors recommended that the licensee develop fire emergency plans for various areas of the site that address:

fire hazards in the areas extinguishing agents to be used direction of attack systems to be managed to reduce loss

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heat sensitive systems l

specific fire brigade duties ]

1 smoke control capabilities criticality concerns.

(E) Inspection of Fire Protection In Plant Areas Impcetant To Safety 4

'l The inspectors' performed an evaluation of the' fire l protection equipment provided to mitigate the consequences I af a fire in Buildings 1 and 2. The inspectors observed j tMt, the only fire protection equipment provided inz the reactor' building (Building 1).was portable fire j

)

extinguishers.: In the hot _ laboratory facility (Building j

2) a C0 suppression system was.provided for the carbon )

filter banks, sprinkler protection (wet' pipe) was provided .j in.the storage / warehouse. area adjacent to the carbon 1 filter banks, and, portable fire extinguishers of various .

types were located throughout the building.  !

As a result of the inspectors assessment of the fire.

protection equipment provided in Buildings.l.and 2, it appears that protection is weak with respect to detecting j and quickly suppressing fires that occur. The following recommended fire protection equipment modifications, if implemented, would enhance the probabilities that a fire 1

'in either building would not create a radiological event: 1 1

the licensee should evaluate the worst case fire in '{

the hot cell, determine its affect on radiological .j safety, and consider installing a manually operated 3 halon fire suppression system in the hot cells with nozzles distributed in such a manner that they would )j discharge the extinguishing agent onto the work surface the licensee should consider installing early warning )

fire detection capabilities in the reactor pump room, various office spaces around the reactor, inside the main control board / panels in the control room, j the Building 2 maintenance shop and electrical 1 transformer room, the area of the natural gas fired 1 generator, the building area outside the maintenance shop and electrical transformer room, the target welding shop, the areas in front and behind the hot I cells, the laboratory areas in Building 2, the hazardous material and combustible storage areas above the hot cells and in the exhaust and supply fan rooms.  !

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these fire detection devises should be '

alarmed and annunciated in the main control room and remotely annunciated at the main entrance to Buildings 1 and 2 additional manual fire hose stations with current state-of-the-art fire hose and nozzles should be installed in Buildings 1 and 2. The layout of those hose stations should allow an effective hose (water) stream to reach all areas of the facility the licensee should evaluate the adequacy of the fire extinguishers in Buildings 1 and 2 and assure that the fire extinguishers installed are capable of extinguishing incipient stage class A, B, and C fires activation of the sprinkler system in the Building 2 storage area should be electrically supervised, alarmed and annunciated in the main control room and remotely annunciated at the entrance to Buildings 1 and 2 on the previously recommended remote fire al .tn panel the licensee should add a fire department pumper connection to the Building 2 sprinkler system the fire hydrants outside Buildings 1 and 2 should be replaced with hydrants which have 4t" fire department pumper truck connections in addition to the two 21" hose connections; the natural gas lines in Building 2 should be coded and the emergency shutoff valves appropriately identified.

(3) Radiation Protection and Industrial Safety (a) Radiation Protection During a review of licensee records concerning the  !

calibration of personnel radiation and radioactive contamination monitoring equipment, the inspectors determined that the calibration of hand and foot counters, every three months, may actually be an operational check since there is no recorded comparison between the output of the source and the detection capability of the equipment. It was also noted, during examination of the ,

hand and foot counters located at the facility exits, that i the background radiation levels were so high that the  !

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equipment will not detect low levels of radioactive contamination on hands and shoes of individuals leaving the restricted area of the facility.

During examination of the exhaust stack ventilation room.-

the inspectors noted that the stack measuring devices may not be providing accurate sample results. .The tubing between the stack sampler and the measuring devices was improperly installed.

The inspectors recommended that the licensee reevaluate the. hand and' foot monitor' calibration procedure to assure that the instruments were actually being calibrated, reduce the background radiation levels in'the vicinity of.

the hand and foot counters to as ore low levels of contamination can be detected on personnel, and assure that the exhaust stack radioactive material measuring devices are recording accurate values for releases from the stack.

(b) Industrial Safety During examination of the licensee's facilities, the inspectors reviewed hazardous chemical storage, use and disposal;~ material handling equipment such as cranes, hoists, slings, and fork lifts; and, machine shop equipment. As a result of this examination the inspectors observed that:

there are no centralized storage locations for hazardous chemicals (organic solvents, acids or bases) there are no centralized storage locations for waste containing hazardous materials incompatible chemicals and gases (oxidizers and flammable) were being stored together in an area located above the reactor offices in Building machine shcp machines (lathes, drill presses, etc.)

are not securely anchored not all of the slings used with cranes to lift equipment were labeled with rated capacity as required.

The inspectors reconnended that the licensee evaluate each of the observations identified above and take the required corrective action.

l 31

6. Emergency Planning The licensee owns and operates the Sterling Forest Reactor Facility under Nuclear Regulatory Comission License No. R-81, possesses and uses special nuclear material under NRC License No. SNM-639, and possesses and use byproduct materia 1'under the State , 7 New York License No. 729-0322. s The reactor is a 5 megawatt pool type research reactor utilizing MTR type fuel elements. The reactor and its adjoining hot laboratory facility are used in producing radiochemical primarily for use in nuclear medicine.

The inspectors initiated a review of emergency planning at this facility by examining the contents of the Radiological Contingency Plan'(RCP) and its associated implementing procedures. Since the facilities for handling radioactive materials are contiguous (adjoining buildings), the RCP was written to provide integrated site-wide instructions for i emergency planning purposes,

a. Radiological Contingency Plan (RCP) and Implementing Procedures ,

H The Emergency Response Coordinator is required by the RCP to ensure that the RCP, the implementing procedures and emergency equipment and supplies are maintained up-to-date. The licensee is also required to conduct biennial reviews of the RCP and procedures. In addition, the emergency roster and telephone listing shall be verified annually. The inspectors could not find evidence that the j RCP and procedures had been reviewed biennially or that the j' emergency roster and telephone lists had been verified annually since 1983. Therefore, this was identified as an apparent violation of Section 10.5 of the RCP.

On July 23-26, 1984 an Emergency Preparedness Implementing Appraisal (EPIA) (Report No. 50-54/84-03) of the licensee's emergency response facilities, Radiological Contingency Plan (RCP), and implementing procedures was conducted. During that inspection, the inspectors identified fourteen (14) inspector follow-up items, for licensee action. During this inspection, the inspectors determined that only three of the follow-up items were adequately addressed. The inspectors also used the 65 emergency planning criteria contained in NUREG-0849 as guidance for the inspection. The inspectors determined that only 14 of the 65 criteria could be satisfied during this inspection. Therefore, the inspectors recommended that the licensee conduct a reevaluation of the site emergency planning activities using the guidance given in the NUREG document, ANS/ ANSI 15.16, and the previous inspection report.

A description of the emergency response organization duties and lines of authority including those of the Emergency Director (ED) is provided in Section 3.0 of the RCP. The succession of alternates as Emergency Director is also provided. The individuals who would become E.D.'s during backshifts are also identified.

However, the RCP does not provide a mechanism for a level 1 or

32 level 2 manager to take over as the E.D. upon arrival at the site.

From discussions with licensee personnel and review of the RCP, the inspectors determined that the role of the licensee's corporate personnel, above the position of Plant Manager, is not clearly defined with respect to emergency planning. Therefore, the inspectors expressed concern that unknowledgeable corporate personnel could attempt to take over control of emergency actions during a site emergency. The effect of such an action should be evaluated and guarded against, if appropriate. Supporting offsite police, fire, ambulance and hospital organizations are listed in Section 3.6. However, as discussed further in Paragraph 6.d, two of the organizations identified, the Tuxedo Hospital and the Tuxedo Ambulance Corp, are no longer involved in providing support to the licensee and one new organization, the Good Samariten Hospital located in Suffern, is not identified in the RCP. As a result of this review, the inspectors recommended that the RCP be revised to reflect the current status of all offsite support groups.

A description of the three classes of emergencies, Unusual Event, Alert and Site Area Emergency is provided in Section 4.0 and the action levels, along with the appropriate actions to be taken for each emergency class are provided in Tables 5.1, 5.2 and 5.3 of the RCP, respectively. The events described include radiological releases, natural phenomena, fire, security threats, injured and/or contaminated individuals, fuel damage and reactor pool water loss. The Emergency Planning Zone (EPZ) is defined in Section 6.0. Assessment actions are treated in Section 7.2.

Assessment actions will include the use of high volume air samplers, off site monitoring and counting of filters taken from a near site monitoring station shared with the State of New York, as necessary.

Procedure EP-01 provides additional detail regarding the emergency action levels and actions which are correlated to each classification. The RCP also identifies actions to be taken with regard to a General Emergency as required by Appendix E Section 4.

However, the inspectors recommended that the licensee provide the reasons for not identifying a General Emergency as a class of emergency in the RCP since offsite radiological releases are not expected to exceed EPA Protective Action Guidelines (PAG).

b. Facilities and Equipment The inspectors toured the facilities to examine those areas that i will be used for energency response purposes. During the tours of these areas, the inspectors examined emergency kits and lockers, communications equipment, criticality monitoring equipment, radio-logical survey instruments, and first aid supplies. The facilities and equipment are as described in the RCP and appear adequate for response to criticality and other potential nuclear related incidents at the Tuxedo site. Eyewash fountains and acid showers were also inspected and found to be in working order.

33 W

The primary emergency control center, (ECC) for the reactor or hot .

laboratory will be set up in Building 2 just outside the upper personnel air lock to the Reactor Building. The secondary (alternate) emergency control center for reactor and hot laboratory and the primary emergency control center for site emergencies will -

be set up in the lobby of Building 4. The inspectors examined both .

areas and determined that the Building 2 area was an assembly area rather than a control center in that copies of the RCP implementation procedures were not available, there were no tables or desks, and only one wall phone was found. It was also noted that copies of the RCP and implementing procedures were not available at _

the Building 4 control center. However, it was noted that some emergency equipment was located in Building 2, just outside the .t upper personnel air lock to the Reactor Building, and in Building 4. L.,

The equipment maintained in Building 2 consisted of first aid and decontamination materials and no dedicated radiological survey or dosimetry equipment was maintained. The inspectors noted that the Building 4 secondary emergency control center was adequately equipped to handle all aspects of an emergency. Therefore, the inspectors recommended that the licensee ensure that adequate ,

primary and alternate emergency control centers are established and adequately equipped to enable response actions to be carried out efficiently.

Through inspection of emergency lockers and review of emergency locker inventory records, the inspectors determined that adequate emergency monitoring equipment was available, maintained and was in operable condition. However, the inspectors found that the portable flow rate meter had not been calibrated since purchase and that the iodine collection cartridges for the measurement of iodine, were not stored in containers that were properly sealed. The inspectors recommended that the licensee calibrate the portable flow rate meter for flow and collection efficiency at an established interval and that the iodine collection cartridges are stored in sealed containers to prevent inadvertent contamination.

c. Notifications and Communications Activation of the response organization during the day shift is '

accomplished by dialing extension 200 and requesting that an emergency announcement be made. During backshifts, weekends and I holidays, personnel onsite and offsite are notified using commercial phones. Conditions which cause the response organization to be activated are given in Tables 5.1, 5.2 and 5.3 of the RCP. An emergency call list and an emergency roster telephone listing is given in Procedure EP-01. The inspectors noted that some personnel listed in the call list were no longer identified in the current phone directory. The licensee provided the inspectors with a current phone list, a copy of which is posted in the control room area. The inspectors recommended that the licensee should ensure v that the notification list is maintained current.

l

\ . .

r 34 The licensee maintains onsite to onsite, onsite to offsite and offsite to onsite communications by means of commercial telephones.

There is no backup power source for the telephone system available and no alternative communication system has been installed. Failure to maintain a back-up power source or alternate communication system was identified as an apparent violation of 10 CFR 50 Appendix E, Section IV.E.9.

d. Coordination with Offsite Groups The inspectors reviewed the RCP and Letters of Agreement with offsite agencies and support personnel and then contacted representatives of six of these agencies to verify their understanding of the agency's role and responsibilities in response to an incident at the Tuxedo site. Offsite support groups contacted by the inspectors and their primary emergency function, were: New York State Police (Middletown Barracks) - traffic control of interstate highways around the site; Tuxedo Police Department -

traffic control on local roads around the site; Tuxedo Fire District  !

- firefighting; Greenwood Lake Volunteer Ambulance Corps - ambulance services; Good Samaritan and St. Anthony's Hospitals - treatment of chemical, nonradiological and radiological accident victims. Each representative expressed a clear understanding of the agency's respective role and responsibilities and described the assistance to the licensee that would be provided in an emergency. However, the inspectors found that with the exception of outdated Letters of Agreement with St. Anthony's and the Tuxedo Hospitals, there were no Letters of Agreement with the other agencies. The available Letters of Agreement with hospitals did not address actions to be taken by the hospitals if a criticality accident should occur at the licensee's facilities. The Order to Modify Licenses to Incorporate New or Upgraded Radiological Contingency Plans dated February 11, ,

1987 requires, in part, in Section 4.3 that the licensee describe i provisions and arrangements for assistance to onsite personnel during and after radiological emergencies and identify ...the type of agreements that are in place for, medical treatment facilities, ambulance services, police assistance and firefighting backup. As stated above, the licensee has not initiated Letters of Agreement f with all of the applicable agencies. This was identified as an apparent violation.

The inspectors also determined during interviews with offsite agency representatives that close working relationships with offsite support groups has not been established by the licensee. Support group representatives interviewed by the inspectors, were generally aware of the licensee's operations but had not been provided with site orientation or training tours which identify licensed or hazardous materials. Only one agency, the Tuxedo Police, indicated that they had been provided with a tour of the facility but that tour took place several years ago. The inspectors recommended that i

4

. 35 the licensee provide applicable offsite support groups with copies of the facility RCP and invite support groups to attend site orientations.

e. Training, Drills and Exercises Section 10 of the RCP specifies the required training and .

maintenance activities for the emergency preparedness program.

Section 10.1 designates the Manager of Health, Safety and Environmental Affairs as the Emergency Planning Coordinator (EPC) and the Health Physics Department is responsible for training. .'

Through an examination of licensee records and discussions with licensee representatives, the inspectors determined that the licensee has not developed a comprehensive emergency planning training matrix, or a set of lesson plans, requalification and testing procedures. As stated in Paragraph 6.d there has been no training or site familiarization tours provided to offsite agencies.

In addition, copies of the RCP and emergency procedures have not been given to offsite agencies even though they have requested copies from the licensee.

Although there is no formal emergency planning training program, the licensee provides employees with general emergency response training, as necessary. Specialized training is provided to ,

individuals assigned specific duties in the emergency organization  ;

(reactor operators, public information officers, health physics d teams,etc.) However, most emergency training is conducted by providing personnel with procedures to read and acknowledge. Very few lectures or practical training is provided except for and during routine emergency drills. New hires are trained by the health physics department in health physics, emergency planning and the handling of special nuclear material. Knowledge of the subjects provided is then measured by means of an examination.

During the course of this inspection, the inspectors conducted emergency planning walk-throughs with several managers and reactor operators, using a predetermined scenario of events. Based on the responses of those individuals to accident / emergency oriented questions, the inspector determined that the site emergency plan could be implemented. However, employee training appeared to be minimally effective. Therefore, the inspectors recommended that the licensee establish and implement a formal training program for .

licensee and offsite agency personnel that will include a training  !

matrix, lesson plans, requalification and testing procedures, as necessary.

Through a review of licensee records, the inspectors determined that !'

the licensee routinely conducts evacuation drills every six months as required by license conditions. Critiques of each drill were conducted following the drills and appeared to be adequate.

Corrective actions were taken, as required.

I 36 Those drills provide training in site evacuation procedures to personnel with respect to simulated incidents. However, a comprehensive exercise to simultaneously test all portions of the licensee's RCP and the emergency response capability.of offsite agencies has not been conducted. Drills or exercises should be held annually with State Police, local police, local fire departments, ambulance services and hospitals participating. The inspectors recommended those exercises simultaneously test as many areas of the RCP as possible to a variety of simulated accidents (radiological and nonradiological) having a potential for offsite impact. The exercises should provide for an integrated response by facility and offsite groups expected to be involved, l- 7. Exit Interview i

l The inspectors met with the licensee representatives indicated in

) Paragraph 1 at the end of the inspection on May 22, 1987. The inspector l summarized the scope and findings of the inspection.

No written information was supplied to the licensee by the inspector during this inspection.

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