ML20249B439
| ML20249B439 | |
| Person / Time | |
|---|---|
| Issue date: | 06/19/1998 |
| From: | Compton E NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | Camper L, Combs F, Piccone J NRC |
| References | |
| SSD, NUDOCS 9806230108 | |
| Download: ML20249B439 (58) | |
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! ?.i E NUCLEAR REGULATORY COMMISSION
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"**'** June 19, 1998
, 1 NOTE TO: Generic Assessment Panel Fred C. Combs LarryW. Camper Josepnine M.' Piccone -
Kevin M. Ramsey .
- FROM: Eric Compton, Engineering Aide Materials Safety Branch Difision ofIndustrial and A g
Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards
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SUBJECT:
REQUEST TO EVALUATE GENERIC IMPLEMENTATIONS OF STUCK IRRADIATOR SOURCE RACK The following information is provided to the Generic Assessment Panel in response to your request for analysis of the stuck source rack at the University of Michigan and additional
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information received from the University of Michigan in the letter dated Ma'y 12,1998. Based on <
review of the infomistion in the analysis, it does not appear that this is a generic design f
. problem Therefore, no further action is required.
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' The irradiator at the University of Michigan (see attachment) is a unique and custom design,-
buiit approximately forty years ago. Prior to the incident on April 8,1998, there had been no reports of similar incidents. The irradiator is used on a weekly basis to irradiate medical / bodily substances (i.e., bone, blood, etc.) and investigate radiation effects on materials. The facility had been last inspected in February 1997 (next nspect i on i n 0i 2 00), with no violations noted directly associated with the irradiator.
The irradiator is designed that in case of failure of the motor or of the interlock switches, the
- fixed end of the cable can be released thus allowing the elevator platform to lower into the pool under its own weight. The system had been tested a number of times the previous day and '
! used numerous times i , the 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> before the irradiator stuck. ' An imprecise platform j alignment in the guide cone of the cover (not shown on attachment), in addition to a low j< clearance between the linear bearings and guide rods, probably lead to the source rack becoming stuck and prevented it from dropping freely, in trying to move the source rack, once
. stuck, the motor continued to move which caused the cable to come off the motor side wheel spool and become tangled. Trying to lower the irradiator manually, the multi-strand cable was damaged.
As a result of this incident, the irradiator facility imposed numerous changes to the design.
g . After the design changes were completed, the refurbished irradiator was successfully tested on L April 23,1998, to insure proper operation of safety features. The tests included a ten second
[ loss of power drop to insure that the elevator platform would lower into the pool under its own j g toe voo619 1 mm ==
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2 Since 1993, there have been approximately 25 events involving pool type irradiators.- White, these events involved excessive pool water conductivity, warning alarm and source rack position indicator malfunction, hoist cable failure, stuck source rack in unshielded position, or
' other incidents, no major trends were evident.
Based on the fact, that the irradiator is unique in design and that corrective actions have been initiated, it does not appear that this is a generic design problem.
Attachment:
Diagram of irradiator I
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Distribution: Closes Ticket #lMNS-7021 IMNS r/f : NE02-SSD6% i CEstep {:
- DOCUMENT NAME
- H:\ERIC\ MISC \U_OF_MI. GAP T; reeelve e copy of thee document, Indicate in the boa: 'C' = Copy without ettschment/ enclosure "E" = Lopy with attachment / enclosure "N" = No copy -
OFFICE MSB: -lC MSB 4 l l l l NAME ECompton - A SBaggett DATE 06//fr/98 06//0 /98 OFFICIAL RECORD COPY 230019:
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' Attachment 1 F/xsd Annulus R
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Overflow Line
- l*' ""#***P Detontrer Line o ' a':. r fixed Cab /g Motor Sh/e/d ,
" # a Motor s M y r Platform Q 7 ,h r Water Deflector 7
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J/l }I Y Linear Bearings (4)
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to Pulley '
- ~~ Pulleys (2)
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F RG*d DATE F 4T DATE IE NO.
- TYPE OF DOCUMENT DA N TO MEMO DATd ANSWERED TH R Specify) BY:
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CLASSIFICATION FILE CODE / ACTION NECESSARY NO ACTION NECESSARY D ON ur W 3 REFERRED TO DATE RECEIVED BY DATE Ltc,e tS COC #YltCboth b cesida- nul & f- b 4 by, gg V
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ETS DATA ENTRY FORM Revised 3/3/98 ASSIGNED / REFERRED TO: IMOB ASSIGNMENT (REPORT) DATE: Y/9/N LICENSEE / VENDOR: dweesM S UkNMa EN NO: EN MCM TVENT DATE: 4/f/W MR NO: M R- -- -
_ EVENT TYPE: NMS PN NO: PN- - -
SPECIALTY CODE:
ACCESSION NO: (80 = TAR)
OTHER REPORT NO: (84 = P21 Repod)
EVENT / CONDITION DESCRIPTION (descriptive title):
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SPECIFIC FOLLOW-UP ASSIGNMENT:
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SAFETY SIGNIFICANCE: _ OTHER % EOl _ SIG _ AO CANDIDATE FOR OP EVENTS BRIEFING 7 INO _ YES, BRIEFING NO.
(YY-MM)
GENERIC FOLLOW-UP RECOMMENDED: _ NO _ YES TBD
_ IN _ BUL _ _ THER (specify below)
GENERIC SAFETY ISSUE':)( NO _ YES (refer to RES for tracking)
STATUS DUE DATE: // (TAR due date, insp. report target date, etc.)
OTHER INFORMATION:
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INITIAL SCREENING DATE: M //0 / f[_ (Regional Coordinator Briefing) l FINAL SCREENING DATE: V //5778 (Generic Assessment Panel review)
. CLOSEOUT DATE: / /
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REQUEST TO ADD OR' CHANGE SfATUS Of A ORAI i'CAE' pas D, . CodG RE TICKET NO. MOM / (Jo - 129- 98$z,
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'4/28/98 L I left message for John D. Jones, R-Ill.
5/4/98- 1J Jones returned my call.
He stated that every irradiator is different - this one had somewhat of a custom' design and in addition is older. Incident summary not received
- yet by region Ill.
~ 5/4/98 ' I receivsd a called from Geoffrey Wright, R-Ill He said that this irradiator was almost hand built by staff there. As of-now, stuck rack attributed to failure of bushing on transfer mechanism that hadn't been replace.
- 5/11 ' I sent an email message to Geoffrey Wright concerning status of-
' incident summary.' Received email back indicating that the University of.
Michigan has requested a couple of days extension and could expected a copy sometime this week.
- 5/26. I sent another email to G. Wright concerning status.
5/27/98 e I received fax of incident report from U of Michigan.
6/2/98 L 'l spoke with Mark Mitchell, Region lli concerning report. I had asked
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the date of last cable change and frequency of use He did not know flast cable' change but stated that facility has been used for 40+ years on
- a weekly basis for medical (blood, bone, etc) and to research effect of .
i radiation on materials. I then asked date of last routine inspected. He i personally inspected the _ facility last on Feb. 13,141997, next .l L inspection in 2000 (E31 priority). No incidents were noted. J l "
'6/16/98- I spoke _with Geoffrey Wright again (M. Mitchell was on AL) trying to clear-up info from last inspection, specifically what no incidents meant. ;
He called me back shortly afterwards and mentioned that during the Feb {
1997 inspection no violations directly associated with the irradiator were l
' noted. However, an improper shipping violation of Co-60 (71.12 l violation) was noted.' '
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E GENERAL INFORMATION or OTHER EVENT NUMBER: 34044 LICENSEE: UNIVERSITY OF MICHIGAN NOTIFICATION DATE: 04/09/98 CITY: REGION: 3 NOTIFICATION TIME: 15:37 [ET)
COUNTY: STATE: MI EVENT DATE: 04/08/98 LICENSE #: 21-00215-06 AGREEMENT: N EVENT TIME: 20 :15 (EDT]
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i kc NOTIFICATIONS yp 76g gf,y JIM MCCORMICKBARGER RDO MICHAEL WEBER, MNSS EO NRC NOTIFIED BY: BOB BLACKBURN JOSEPH GIITTER IRD HQ OPS OFFICER: DICK JOLLIFFE EMERGENCY CLASS: NOT APPLICABLE 10 CFR SECTION:
MAAA 3 6. 8 3 (a) (1) UNSHIELD STUCK SOURCE EVENT TEXT
- STUCK PANORAMIC WET SOURCE STORAGE TYPE IRRADIATOR SOURCE -
WHILE LOWERING A 20,000 CURIE Co-60 GAMMA EMITTING SOURCE, FOR A PANORAMIC WET SOURCE STORAGE TYPE IRRADIATOR, INTO THE SHIELDING WATER, THE SOURCE BECAME STUCK AT APPROXIMATELY 6 INCHES ABOVE THE TOP OF THE WATER. THE IRRADIATOR OPERATORS JOSTLED THE SOURCE TO UNSTICK IT AND LOWERED IT INTO THE SHIELDING WATER WHERE IT BECAME STUCK AGAIN AT APPROXIMATELY 8 FEET BELOW THE SURFACE OF THE WATER. TWO OPERATORS ENTERED THE HIGH RADIATION ROOM TO UNTWIST THE SOURCE CABLE AND OBSERVED SLIGHT DAMAGE TO THE CABLE.
THE OPERATORS THEN LOWERED THE SOURCE TO ITS LOWEST POSITION UNDER WATER APPROXIMATELY 13 FEET BELOW THE SURFACE OF THE WATER. THE OPERATORS ESTIMATED THAT THEY RECEIVED 3 MILLIREMS EACH WHILE INSIDE THE ROOM. NO PERSONNEL WERE INJURED OR CONTAMINATED. THE OPERATORS PLAN TO REPLACE THE SOURCE CABLE. THE OPERATORS ARE INVESTIGATING THIS EVENT AND PLAN TO SUDMIT A WRITTEN REPORT TO NRC REGION 3 WITHIN 30 DAYS.
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' On W 74 w U.S.HUCLEAR REGULATORY COMMISSION W Amendment No.
g M ATERI Al,S 1,ICENSE
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Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 93 438), an g federal Regulations, Chapter I. Paris 30,31,32,33. 34,35,36,39,40, a.id 70, and in reliance on statements a id representations heretofore made p l
4 by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, source, and special nuclear Fl rnalerial designaled below, to use such material for the purpose (s) and at the place (s) desir.nated below; to deliver or transfer nitch ms'"ial to y f persons author:r.cd to receive it in accordance with the regulations of the applicable Part(s).This license shall be deemed to conu a the conduio 7
3 specified in Section 183 of the Atomic Energy Act of 1954, as amended, and is subject in all appheable rules, regulations, and orders of the k 4 Nuclear Regulatory Commission now or hereafter in effect and to any conditions specified below.
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In accordance with application dated July 29, 1993 d I. The University of Michigan p<
- 3. License Number 21-00215-06 is renewed in Radiation Safety Service its entirety to read as follows:
3 2. 1101 North University Building 5 Ann Arbor, MI 48109-1057 A Expiration Date June 30, 2000 *!
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E 5 5. Docket or p Reference No. 030-06958 A -
F g 6. llyprmluct, Source, and/or 7. Chemical and/or Physical H. Maximum Amount that I.icensee $
g Special Nuclear Material Form May Possess at Any One Time p Under This 1,icense p
4 h y A. Cobalt-60 A. Sealed sources A. 18 sources not to y (Neutron Products, exceed 7500 curies (E 3 Inc. Model NPRP-330- each. Total E y 14-K) possession not to W y exceed 50,000 F
.j curies. k 4 Y H E 3 E g 9. Authorized Use: g 5 E q A. To be used in a wet storage irradiator facility for irradiation studies described j in application dated July 29, 1993 (excludin9 explosive and flammable materials).
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4 V 4 F y CONDITIONS g
- 10. Licensed material shall be used only at the licensee's facilities located at y the Phoenix Memorial Laboratory, Room 1069 C, 2301 Bonisteel Boulevard, Ann Arbor, h' Michin-- :
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g 11. Lices. . .naterial shall be used by, or under the supervision and in the physical g ,
y presence of, individuals designated by the Radiation Policy Committee, p y James E. Carey, Chairperson.
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! M ATERIALS LICENSE 21-00215-06
"" *" " l SUPPLEMENTARY SHEET 5
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- 12. A. The ton exchange resin filter system shall be monitored on a continuous basis fp in accordance with letters dated June 30, 1993 and August 25, 1993. Whenever p
{ an apparent increase in radiation levels twice that caused by normal background y at the filter system is detected, the licensee shall immediately cease L operations, determine the cause of the increase, and notify the U.S. Nuclear f Regulatory Commission, Region !!!, ATTN: Chief, Nuclear Materials Safety p Branch, 801 Warrenville Road, Lisle,4 IL 60532-4351. p
, ( fs p f B. If tne increase is caused (b .al p'eaking s'oUr e',,, the source shall be removed from >
< the pool and repaired' g g plan and Commissio6fe'phdisposed of in accordanch with gulations prior to resuming'p$erations, a increase if the Commission-app p
W is caused by another source of radiation or radioactf'ytty, then in accordance p 4 with a Commissio'nTapproved plan, that cause shall be Tcemoved and the pool p d water decontam.inated, if,necessary, prior to resuming dperations. If the F l apparent increase was' caused by an instruments fault, thd fault shall be >
a recelebrated prior to resuming >
W corrected operations. and"the
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C. For each actual increase.1.n radioactivity /jn p 8
radiation levels twice,thatidaused by normalyp. s col water background causing at~the an increase inF ion exchange
[ resin filterfsystem" h rep' ort *s 'all gbe, f,tlid'within 5 days)of the increase H
< with the U.S. Nucle icgulafor C6mmission, Region Ill,vATTN: Chief, Nuclear s Lisle,IL760532-4351, fp
$ Materials describing th'eSafsty Braneg,v801.
.results', War,r'enville" of' th'e determination re Road,Nuired above, the schedule p 5 removal and disposal of the source of the radioactivity, and the procedures >
l followed or to beffpilowed for the decontaniinhtion of'the pool water, and the >;
L results achieved to.date. .
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h 13. Scaled sources containing licegsed material shal,L* not be opened. p t r .
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- 14. ThelicenseoshallnotperformrepaT,,..rs o} alterations of the irradiator involving W !
? removal of shielding or access to the licensed material. Installation, relocation, > l removal, replacement, and disposal of sealed sources in the irradiator shall be hl I
( performed by, or under the supervision and in the physical presence of Reed Burn, h 1
Robert Blackburn, philip Simpson or other persons specifically licensed by the p Commission or an Agreement State to perform such services, p
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- 15. Af ter installation of additional cobalt-60 sources greater than the quantity for F j which a previous radiation survey has been conducted, and prior to initiation of k the irradiation program, a radiation survey shall be conducted to determine the maximum radiation levels in each area adjoining the irradiation room. A detailed j
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report, in duplicate, of the results of the surveys shall be sent to the U.S. p Nuclear Regulatory Commission, Region 111, ATTN: Chief, Materials Licensing Section, 801 Warrenville Road, Lisle, IL 60532-4351, not later than thirty (30) h>
days following installation of the sources, t I
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- 16. Written instructions entitled " Cobalt-60 Irradiator Operating Procedure" enclosed l with letter dated March 29, 1995, shall be followed and a copy of these instructions shall be made available to each individual using or having responsibility for the use of licensed material.
- 17. Notwithstanding the requirements of 10 CFR Part 36, Section 36.27(b), the licensee is not required to maintain an automatic. fire suppression system in the radiation
( room. ry(- Nhp ,,).
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- 10. Notwithstandingtherequirem'enisof10CFRPart36,bSection 36.33(d), the licensee is not required to maintal'n a high water level indicat'o @
~ r 4 19. Notwithst'anding the riqu,rements of 10 CFR Part 36, Section 36.63(b), the licensee !
H shall perform conduct.tvity me.asurements in accordance with T6tter dated June 30, r 4
1993andrecordth(resultson.sweeklybasis. A.
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- 20. ExceM as specifically provided'otherwise in thiff-ficense, the licensee shall conduct its progra(n in accordance with the statempnts, representations, and j procedures contained in the documents including /any enclosures,. listed below.
The Nuclear Regulifory Commission?s-regulation (,shall govern utiless the statements, representations an'd procedures in'th'o l more restrictive than the Regulations,.3'lik icensed's.4pplication and correspondence are
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A. ApplicationdaiedJuly"29,1993 rand '
/, e B. ' etters dated J0na 30,1993, August 25,199N/ October' 26,1993, and March 29, 4 1795 (with attachnients). -
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05/y,7/98 16:03 FAI 630 513 1239 l'SNRC Region III/DNMS 1d001 1 l _00 D i- 0 b Nl N '
Y SN MICHIGAN MEMORIAL-PHOEfslX PROJECT PHOENIX MEMORIAL LABORATORY FORD NUCLtAR REACTOR ANN ARSOR. MICHICAN 48109-2100 Document Control Desk United States Nuclear Regulatory Commission -
Washington, D.C. 20555 -
OPTIONAL FORM 99 p-93)
F AX TR ANSMITT AL esma d May 12,1998 TAlO Cem4M '
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Subject:
Event #34044 ff a 41 -5 5 M
$tN he.01-317 7%e SC&101 CfNERA; $ERVICES ADVIN16TRATION Summary of Event On Wednesday, April 8,1998, at 20:15 our Cobalt-60 panoramic wet source storage irradiator lowered from the upper limit but didn't move more than six inches below the upper limit. The operator continued running the irradiator in the down direction for a total of 1.5 minutes and then -
switched the direction of tie motor in the up direction for 1.5 minutes trying to return the irradiator to the original position.
I received a call at home from the operator at approximately 20:20 regarding the problem. I instructed the operator to try to lower the irradiator manually with the cable release.
I arrived at PML at 20:48 and unsuccessfully tried to lower the irradiator manually. In doing so, I partially broke the 1/8" stainless steel multistrand cable. I requested that the Assistant Reactor Manager and the Assistant Manager for Research Support come in; they arrived at 21:49. We discussed causes, options, and NRC notification. We also repaired the cable using copper clamps.
We ran the cable back and forth using the irradiator raise and lower controls and detennined that the cable was free to move and therefore was not preventing the platform from dropping. We were able to wind up much of the cable on the manual winch side but it appeared to get to a point where it would not move any further. The cut out switch, which engages when the cable is wound on the cable drum opposite ofits normal dimetion, would engage and disengage at various positions so we believed the cable was probably wound around the drum incorrectly.
At 02:15 Thursday, April 9 we decided there was nothing more we could do to save the samples in the itradiator. Instead, we planned to observe the irradiator in the morning through the transfer chute, and if necessary, observe through one of the wall ports or with a robot.
I returned home at 03:00 and I left a phone message instructing our health physicist to inform the Radiation Safety Officer first thing in the morning. At approximately 09:00 April 9 I called the RSO myself; he had already heard from the HP.
First we shook the platform slide poles via the transfer chute without success. Next, at about 13:00, we used a borascope from the University of Michigan Plant Department and an extra flood l light to examine the irradiator from below, but the platform and slide poles looked normal. We decided that the irradiator must be bound by torque on the top guide pole or the brass sleeves
- (bushings) and that the cable must be wrapped around the motor shaft and drum.
( Q2d& N 18 $?8 Phone:(734! 7644220 Fax:(734) 941571 www umich edu/-mmpp/
05/27/98 16:03 FAI 630 915 1259 t'SNRC Region III/DNMS 16002 r
r We then tried to move the platform using the " lower" controls. Each time we " lowered the irradiator," (paid out cable in the direction that normally lowers the irradiatcr) I retrieved more cable with the manual winch than I had before. The irradiator didn't move, as seen with the j borascope. But a short time after the last lower, the irradiator dropped, without waming, until the j j
cable was taut. I continued lowering the irradiator manually. We withdrew the borascope and '
measured 0.3 mrem /hr as the irradiator passed the transfer chute. However, we couldn't lower the irradiator more than approximately eight feet below the surface-three feet above its usual depth-because the copper clamps we used to repair the cable would not pass through the entire conduit leading to the irradiator room.
The RSO and I slowly entered the irradiator room while watching two dose rate meters. Radiation was at background level until we reached the edge of the room, where the dose rate was 0.4 mrem /hr at approximately 2.5 meters from the irradiator. The maximum dose rate was 35 mrem /hr at the sample holder.
After a discussion outside the itTadiator room, I quickly removed the holder and raised the pool cover to examine the cable. As I expected, the cable was wrapped around the shaft. After further discussion with the RSO, I unwound the cable and the irradiator eventually dropped to the lower limit at approximately 15:30 April 9. The irradiator room was then closed.
The NRC was notified at 15:37 April 9,1998 and the event was given # 34044.
The irmdiator was unloaded Friday morning, April 10. The cable from the retention tank area was brought in to temporarily replace the cable that was in the irradiator room. New cable was ordered as replacement.
Root Cause On April 13, we began the process of determining the cause, options, and repairs.
On April 15. at approximately 16:00, we were visited by Darrel Wiedeman, Senior Health Physicist NRC, and Susan Woods to discuss the event in more detail.
The root cause was a combination of the platform alignment in the guide cone of the cover, which was never precise, and the very low clearance (0.040") of the brass sleeves / collars on the slide poles, This put excessive torgue on the platform and prevented it from dropping freely. A contributing factor as to why it took so long to retum the irradiator to the shielded position was that the cable came off the motor side wheel spool and became tangled when the motor continued to move with the irradiator platform stuck. We had tested the system a number of times the previous day and even used the irradiator a number of times in the 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> before the irradiator stuck.
Corrective Actions First we machined a new set of brass sleeves / collars made from hollow bearing bronze. The previous sleeves were made from an unknown type of brass and we determined that dezincification could be a problem in the future unless we used bronze with tin in it. We increased the clearance to 0.075". We rifled the internal surface to allow for more lubrication.
In conjunction with the sleeve change, we aligned the platform with the cover more precisely and added a linear bearing on top of the guide cone to eliminate friction on the guide pole. We also i
added bearings to the idler pulleys of the elevator platform to eliminate friction on the cable as it moves under the platform, we changed the aluminum block on the stationary cable side of the platform by adding a pulley to decrease friction on the cable when there is a ten second loss of
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! power drop, and we added four stainless steel stops on the stationary beams at the bottom of the
- f. plationn poles to prevent the bronze sleeves from hitting the beams during a ten second loss of
( power drop. Finally, to prevent the cable fromjumping off the spool we enlarged the block that covers the wheel spool.
.We successfully tested the refurbished platform, including a satisfactory ten second loss of power
. test, on Thursday, April 23,1998.
l Since e y,
! Robert Blackburn
' Assistant Manager Laboratory Operations xc: RegionIII 80;, Warrenville Road Lisle,IL ' 60532-4351 ATIN: MarkMitchell h-i_..___________ _ _ _ _ _ _ _ _ _
Lhnne21-00215-06 Phoenix Memorial Laboratory
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University of Michigan a.
,/ APPENDIX A APPLICATION FOR MATERIAL LICENSE tcontinued)
Notet Please add approved exemptions from NRC Control 8395388 to 1 this application for ronewal.
- 5. Radioactive Materini f
- The Phoenix Memorial Laboratory's cobnit-60 source consists of nine rods. Each rod is a doubic scaled, stainless-steel tube
,' approximately one-half inch in diameter by +hirteen inches .
i long that. contains cobnit-60. The nine rods are arranged in a seven-inch-outer-diameter cylindrieni array.
The cobalt-fiO sealed source rods are produced and supplied by !
Neutron Product.s. Inc. INPII Catalog No. NPRP-330-11-K ns specified in drnwing No. A200007 Revision B. (Attachment all.
The maximum cobalt-60 netivity on site is 50,000 curies during source replenishing /tran';fer operations; and 25.000 curies at all other times with no more t.hnn 7.500 curies in any single source rod. Individual source act.ivities are engraved on each rod by NPI. The entrance to the cot nit-60 irradiator room ts labeled as a high radiation aren (Attachment r9).
- 6. dilthori*cd Cue The i r rad i a t.o r is used in the laboratory's trradiator room for sterillantion and irradiation studies, excluding
- 9. plosive materials. Irradinted food will be used only in
.esearch involving universit.y npproved animal and human studies. It wiil not be used for human consumption on a commer ini hasis.
7 The irradiator is used by or under the supervision of the responsible individuals designated by the enatrman of the Radiation Policy Commit'ee. Un t ve rs i t y of Michigan. The current ehnirman is James E. rarey.
7.l The current responsible individuals are:
Robert B. Blackburn. Resen ren .\ssoc ia te II. Nuclear Henetor I.ni, oratory Reed R. Durn. Manager. Nuclear Henctor !.nboratory Philip \. Simpson, .\ssistant Manager for Research : uppo rt
\ct ivi t ies . Nuclear Reactor I.noo rn t o ry 7 . '.' it a t ement 8 o t'-trn11.1nu and experience tor the : nd ;' t if un i y current 1y tn these poMLtione . i r e- a t t nchest.
- 4. The ope rnt o rs of the tiUnittutor are t r n 1 n eet in the arens outlined o tt tha e nc l o sett Non i t.-tiO o pe rn t s on arid trradtattois t raining record t \t t tenment *2). Prior t o . rrad ia t o r PAGE 1' 1
A A ,lh L w nse 21-00215-06 phoenix Hemorial Laboratory University of Michigan training, trainees receive a mandatory two-hour orientation course through the University of Michigan's Radiation Safety Service. The course covers the principles and fundamentals of radiation safety and good safety practices, and the use of radiation detection instruments. Trainees receive approximately four hours of operational training covering the o pe r n t. i o na l procedures and emergency response taught by the responsible individuals. This training is followed by a written and oral practical exam given by one of the responsible individuals (Attachment #31. The training record is i n i t. i a l ed and signed by the trainee and signed by one of the responsible individuals. The written exam is signed by the trainee and by one of the responsible individuals.
Approval by the university's Rac i a t. i o n policy Committee is o b t.n t n ed before permission to use the i r r ad i a t.o r is grinted to an individual. The training records and exams of operators are maintained while thay are employed at the facility and for a period of three years after termination of employment.
Operntor training is conducted by the research associate who is assigned responsibility for the irradiator. The research asscelate is initially trained by one of the Nuclear ite nc t o r I. abo r a to ry managers. The latoratory managers are 1icensed sentor react.or operators with at. least four years of reactor o pe ra t. i n g experience and bachelor's degrees in
<nginenring or sc:ence.
- 9. Enti.LLUn_anLEuuMTELL The c o ba l t - tiO i r rad i a t.o r room, room 1069C of the phoent.s
't e mo r i a l Laboratory, is 10 feet by 12 feet with 30 inch thick, ba rv t es-conc re te walls and ceiling. The room has a double m n ?. e ont rance . In the center of the floor is a 1-feet ill ame t o r bv 10 - f e e t. deep, stainless-steel tank filled with temineralired watar. The cobalt-60 irradiator is l owe red int o the t. n t o r to pe* t entrance into 1. h e room.
\ hoast mechani m in the pool raises the coba i t -fio 1 r rad t a t o r so that the t ot al room volume can be used as a high-level, gamma irradiation fac1)ity.
The onclosed ' Schematic of P M I.
' o hn i t - +iG Irradiator' pr ovides thn layout of the olevator mechanism and the pooi I.\t t.n c h m e n t :l). The cobalt-60 irruitator it within a source holder i a s t.e ne d t. o a plat t orm 4 nich in turn is fasioned by wat.cr deflectors and beams te two pullrys. \ stainless-steel cable fixed on one side of the pool loops under the pulleys and up to a reversible electric winch on the other si<tn o f ' t he pool. When the cabie it ounit an the wioch drum by in alect rie motor, tho elevator platiorm rises to the pool surface, and the vource holder <nter' i r . .ed annulus nn ' h <'
- op cos a r of the poo1 in tippe r : imit t'tl' -wttUh bIOpN 'ip h 4 r's t r a \ P l . Io l o w" t' 'he I t' rad 1 llO r * *h
- tuif o r i. t Inh I fin i ti'J 'he ahje :q tid p o p m 3 t. t ; n g' t 3p
,'i" o vnaui<m nFMeil. wrr
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_r h Lhnse 21-00215-0'6 Phoenix Hemorial-Laboratory University of Michigan
~ lower,l'imit .the platform strikes a lever, lifting a plunger, which in' turn activates a. lower limit trip switch to stop winch rotation in.the down direction.
On?the far corner of the platform is a guidance system not shown on the schematic. This guidance system' consists of a -
solid stainless-steel centering rod, one inch in diameter and several feet long, projecting upward from a corner of the platform. The rod enters an inverted funnel on the: cover plate as the elevator approaches the pool surface to ensure proper source and platform orientation during the last few feet of. travel.
The entire platform mechanism is constructed of stainless l
steel with the exception of brass linear beorings identified I. on.the schematic. Each bearing consists of three brass wheels evenly space around the guido rods.
\ photograph of.the irradiator pool is included (Attachment r51. The. cover plat.c on the pool was removed for the photograph.
A lead shield for the reversible winch drive motor and the winch's cable feed-and-take-up drum can be'seen in the bottom center of the photograph.
The upper and lower 1imit microswitches can be seen at the t op of t. h e photograph. Benent.h them is the emergency reicase cable. In case.'of-failure of t.he' winch-or of the i n t.e r l oc k switchen..the fixed end of the cable can be. released thus allowing the elevat.or plat. form to lowe r . int.o . the pool under i t. s n ow n we i g h t. .~
Above'the limit switches is another microswitch nor.mally held closed by the pool cover'over the. pool. This stops the motor drivo l' f t he pool cover should be displaced unintentionally or i n t.c n L i o n n i l y tn an emergency.
\t the top of the p h o t o r.t r a p h , to the right of the limit sw i t ches . pipes to nnd : rom the demineraliser, a drain line.
l and a' fili pipe can be seen.
The "onditions which must be met before the wanch motor an he ope ra t ert to raise or . lower the irradiator are shown in the wirint diaurams at.tached I \t t achments v6 and ri' fo ratse
_the irradtator, the RAISE, switch is actuated. If any of the L I l tollowing conditions are not met, the electric winch motor will notL he' activated: the irradiator must not be at the Lupper Itmit;.the backup' access control gate must he closed:
the -i rrad ia to r access <1oor mus t be closed; the pool cover int eriock <w t t eh must tm "losed: 'and the raise "antrol key mu's t , ho an tho enntrol atie I and ttarned on. wimilarly. to ,
.loker 1he ! r t'ad illi o r , t ne' l.OhER.vw1rch'ts actuated. The e s ncn mot or w i1 l' not te se t t va t.ett if the irradiator is at-i
'he ower ~!tmtt, shon 'he <* l e v a t o t- w i nc h 'tio t o r i s " tie r ;: i n eet
. /
L_L ___ . . "'
- Phoenix M Eorial Laboratory g y University of Michigan for either the raise or lower operation, an alarm bell rings within the irradiator room and our staff is adding a light in the irradiator room that will indicate irradiator-movement simultaneous with the bell. The wiring-diagram is attached (Attachment #8).
There are primary and independent backup access control systems (Attachment e6) to automatically lower the cobalt-60 irradiator if there.is entry when the irradiator is above-the lower l i m i t. . When the access door or backup access control gate.nre open, the access control systems'(ll-prevent the irradiator from moving from its shielded position and (2) automatically returns the irradiator to the shicided position if the door or gate are opened while the irradiator is in the unshicided position. Both access control systems act.ivate audibic and visible alarms on the control panel at the ent rance to the irradiator. In addition, our staff is adding an alarm to alert security and one of the responsible individunis of entry when the irradiator is exposed.
The elevntor winch motor is energized by a dual raise / lower swi t.ch which can be act.unted manun11y or actuated nutomnLically to lower. This switch is on the control panel at the e n t. r n n c e to the i r rad i n t.o r room adjacent to the access door (Attachment 89). There is a delay switch integrated into t.he raise / lower switch so the mo'.or can not be run in the opposite direction before i t. has come to a complete stop.
The entrance to t. h e irradiator room is held closed by a solenoid netuated door latch as well as by an ordinary lock.
To enter the irradiator room, the door must be unlocked and the door intch solenoid opernt.ed by a push button on the control panel. The key for the door is held by the
" responsible individuals' and also secured in locked Phoents
'le mo r i a l 1.nboratory and Ford Nuclear Reactor key boxes. If the door but. ton is pushed. t.he door latch solenoid ope rn t.e s i f all the following conait, ions are true: the rndintion level in the irradintor room is less than 100 mrem / hour; the irradinter lower l i m i t. switch is activated; and the water intel in the trradintor pool is not below the low level I s mi t . It is an cperntionni requirement for the operator to "arry n properly operating survey instrument during intttal ent ry into the irradintor room.
. Illuminated signs over 'ne a r rad i a t.o r room "ntrance indicate whether the trradiator ia up or down. These signs are activated by the lower and upper 1imit switches. In addition, our staff will be adding an irradintor 'in t rans i t '
ponitton i ruf i ca t o r. t o the c o n t. ro l console. .\ tPt t u. e is mounted in the treadinter room maze.
This tube is i rit e r ' ar ed 4tth i t ud e nt ton moni t or t he device and n'high rad 1nt t en sicht i ha t - is *isIble in ?ho . "rt"l i n t o r mnw tbrough a po r t tn the loor, t he r.- te t i <o i n:gh rrut i a l i on light in 'he irradintor .
t ' e t i m .~ f h e \' . Ir" ! nI e r ! O' 1:od wath the door latch 'ti c i e n o t d t ri een s ! a%n ti n $
IA { ' D r' 1 1 1 the Operalton of the soleonid (Ohdii, l { ' l * ; ~ ~, ( i **
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h 1 't ff.I {f L(fnse21-00215-06 Phoenix Hemorial Laboratory D?i University of Michigan g,C only when the radiation level is less than 100 mrem / hour.
f; If the detector fails, it defaults to high radiation and agi prevents entry to the irradictor room. The raise control
'( key for activating the elevator winch motor is attached to
>g?; the survey instrument. The physical location of the units 4
mentioned above is attached (Attachment #10 and #11).
Y,.
?n . Except for short periods of maintenance, the water in the pool
^" is recirculated through a disposable. ion exchange resin filter system. The conductivity of the pool water is Q measured with a standard conductivity cell and is maintained b at the levels indicated in Attachment #17. The water is circulated by means of a recirculating pump located at the output of the ion exchange tank. pool water level is f, monitored by a float switch that is wired to a relay outside 6 the irradiator room. This float switch can be seen on the J right side of Attachment s5 photograph. When the water level is approximately two feet below the top of the tank and one foot below the high water level, the float switch activates a relay and. low level indicator light that simultaneously turns off the pump motor and stops flow through the ion exchanger. j An indicator light on the control panel and a light on a remote relay box are turned on if the water 1cvel is low. Make up water is added to the pool by opening a deionized water valve located outside of the irradiater room. Also, the amount of water added to the pool is monitored. A maximum of 35 gallons per minute can be added to the pool. A low water icvel in the pool prohibits entry to the room by deenergizing the solenoid activated door Intch. The pipe that removes water from the pool to the deionizer is approximately 16 inches below the high water icvel and the deionizer return pipe is approximately 1.75 inches below the high level.
Venti 1ation tbrough.the gaseous effluent system of the Phoenix Memorini Laboratory is shown in the attached drawings (Attachments =12 and 13). Air from the irradiator room (500 CFM) is released from stack 2 (9,464 CFM). Air enters the irradiator room t.hrough both an air conditioner and as ordinary building supply. Ozone measurements were taken by the Occupational Safety and Env i ro nme n t.n l llealth Department of the l'niversity of Michigan, and the result.s are included in this report (Attachment *141. The l eve l o f c::one in the irradiator room immediately after the irradiator is lowered is leHH than the permissible 1imat set by the Federal Occupational Fafet y and llealth \ administration.
The locat ion of the cobalt-60 irradiator room (Room 106Wl :s givan in the attached Iloor plans ( A t. tac hmen t 15). Walls, floors and ceiltngs are conrt ruc ted of barytes concrete. No
- 'ombu s t i b l e mat erials were ised in any of the c o n s t. r u c t i o n . A minimal amount at combust ible matertal may he brought into ihe room for mperiment at :on.
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r Irradiator Events--Possible Correlations Licensee - Name Date Event 37 17860 Permagrain Products, Inc 6/1/93 Excessive Water Conductivity, Microorganism Control 4/22/94 Excessive Water Conductivity, Ion Exchanqer Broke 19-08330 Defense Nuclear Agency 6/16/93 Personnel Warning System inoperable 52-21175-01 Baxter Healthcare 11/13/96 Entry Alarm Malfunction 37 17860-01 Not Working
$2-2499441 Abbott Health Products 10/19/93 Rack Post. Indic:: tor Malfunction 52 24994-01 Abbott Health Products 5/12/94 Source Rack Indicator. Short Circuit SC-267 isomedix Operations 5/5/95 Broken Cable Strand, Damage of Cylinder NC-001-0701-1 RTI Process Tech 11/13/95 Broken Cable, Rack Fell NR Ethicon 6/30/95 Boxes Moved Rack Stuck I
29-1361342 RTI 8/1/95 Tote Door Open, Rack Stuck NR Ethicon 4/8/96 Boxes Shrft, Rack Stuck 29-20900-01 South Jersey Process Tech 12/2/94 Boxes Shrft, Rack Stuck 45-11496-01 Applied Radiant Energy 1/10/96. Mechanical Fault in Drive Mechanisin 19-08310-03 Defense Nuclear Agency 6/22/93 Op. Console Lost Power, Not Resetting after upgrading 19-00296-12 Health and Human Serv. 10/7/93 Interlock Failure 19-1725 % 5 Army, Department of the 10/26/93 Overflow / Spill, Pool Pres. Level Switch Failure 52-24994-01 Abbott Health Products 4/15/94 Pneumatic Bleed Off Failed 54-28275-01 Nordion International 9/20/94 Shipping Paper Violation - ft#"V
]
29-20900-01 South Jersey Proc. Tech 4/5/95 Module Bent. Door Stuck 48-09843-28 Wisc (Madison), Univ 9/12/95 Interlocks Circumvented IL-01220 01 Sterigenics 10/3/96 Worn Bushing in Lift Mech, Rack Stuck 30-02405 10 Army (White Sands) 4/23/96 Leak Test Failure l
52-24994-01 Abbott Health Products 4/16/95 Radiation Detector Cable Embrittled
'9-17520 Army Departmentof the 2/2/94 Drive Mech Failure, Elevator Valve 37-00134-06 Pittsburgh, Univ. of 1/5/95- Hydraulic System Lacked Pressure
Conclusions:
1, The first block includes two incidents of excessive pool water conductivity. Although due in part to different causes the potential for corrosion increases.
- 2. The second block includes three incidents in which warning alarm malfunctioned.
- 3. The third block includes two incidents by the same licensee in which the source rack indicator had failed.
- 4. ' The four block included two incidents in which the hoist cable had failed.
- 5. The five block includes four incidents in which boxes had moves causing sourm rack to become shuck.
- 6. The last block includes incidents or vkilations in which there appears to be no direct correlation.
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THE RSO REPOHT THAT THE SOURCE ROD ON CESIUM IRRADIATOR WOULO NOT TRACT BY GRAVITY AS 3 9 FAST AS IT SHOULD. IE UFACTURER SUGGESTED USING A GRAPHITE O NT WHICH WORKED. d 4 W T q?
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- s DLicense1' 3717860-02 llPERMAGRAIN PRODUCTS, INC. . .. .==-
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THE LICENSEE REPORTED POOL WATER CONDUCilVITY EXCEEDING 100 MICROSIEMENS/CM. THE POOL [
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> WATER MEASURED 340 MICROSIEMENS/CM. THE MICROORGANISM CONTROL ISSUE IS LINKED TO HIGH 0 POOL WATER CONDUCTIVITY. CORRECTIVE ACTIONS HAVE BEEN TAKEN TO REDUCE THE CONDUCTIVITY. M '
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_ , ! tem No:,j940229 @ Class. Event:;lEOP jp %# % Event Date: l6/16/93 QReport Date:l5/17/93 .
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l 2 j ' License ll19 08330-03 l DEFENSE NUCLEAR AGENCY THE PERSONNEL WARNING SYSTEM FOR THE WET POOL IRRADIATIONS WAS FOUND INOPERABLE fPRIOR /W) TO M AN IRRADIATION PROCEDURE. THE PROCEDURE WAS STOPPED AND THE WARNING SYSTEM REPAIRED. THE Ci; W ft IRRADIATOR USES RADIOACTIVE COBALT AS ITS SOURCE. THE SOURCE WAS NEVER OUT OF ITS FULLY f N'
l SHIELDED POSITION. THE CAUSE WAS MODIFICATIONS TO THE SYSTEMS TO COMPLY WITH NEW a l
[ A i REQUIREMENTS IN 10CFR36. .
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0228 , EQP 6/22/93 3/93 l OTHER l Mk1h 08330-03 jjoEFENSE,NUC_ LEAR AG_ENCY J THE OPERATING CONSOLE FOR THE WET POOL 1RRADIATOR LOST POWC.R UNEXPECTEDLY PPIOR TO AN IRRADIATION SESSION. THE OPERATION WAS STOPPED AND THE CONSOLE RESET. THE IRRADIATOR USES
. RADIOACTIVE COBALT AS ITS SOURCE. THE SOURCE WAS NEVER OUT OF ITS FULLY SHIELDED POSITION. hjM
- THE CAUSE WAS POSSOLY NOT RESETTING THE CONSOLE CORRECTLY FOLLOWING UPGRADES TO COMPLY
. WITH THE NEW 10CFR36. .s l
~
l ETHESDA MD NOJ 3521 N_A____, ,_ , . , _
- 50 EQP 8/27/93 l 8/27/93 l DEF ECTivE OR FAILED PARIS l J MIL-0050s-03]l CHICAGO UNIVERSITY OF
}
1HEL NSEE REPORTED THAT A J.L. SHEPHERD 1RRADIATOR, CONTAINING 5 CS-137, MALFUNCTIONED AND WI SELQ ERVICE FOR MORE THAN ONE DAY.
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] CHICAGO , IL
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- __, ,+.--- .r 940687 ! EQP l 9/24/93 l ,s m m :_ t_0/27/93 l
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DEF ECTIVE OR F AILED PARTS ll 19-00296-12 JHEALTH & HUMAN SERVICES, DEPARTMENT OF _]
Dunng routine quarterly 'nspection both safety interlocks failed on a Co-60 IrradWor operated under License #12-00296- p
. 12. Regulations 10CFR30.60 21.21 were reviewed, and it v;as determi d that a substantial safety hazard, as defined j Q i n the regulations, did not exist. ji ffp$ '
g Update: Licensee rephes to Notice of Volation iting to not e NRC of the defect of the safety device within two y days as stipulated in 10CFR2.1.21.(C)(3)(1) due to a i n n interpretaten of the regulations. g 3
b la Update: The NRC conducted another routine unannou inspe i The inspector learned that the defective irradiator l will.be transferred to an authorized recipient and di sed of _ _ , _ _ _ : y 5BETHESQA- j MD Y (
. _ _ , _ . _ _ . . . _ _#[ f_ . _ . . . _
. { NA ,Jg; 94 r3 gm . - FA rigiaWl'AMefj03510 P j l
@ 0625 _ . h, , gflEOP 4T Event Date' l10/7/93 kReport Deloj l10/7/93j _
s, L.a d%n;jDUECTWE OR F AILED PARTS
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PUCGflSFEl19-00296-12 u.l.__..____,_,__f HEALTH & HUMAN SERVICES, DEPARTMENT OF. . . . _ . . . ,
a . _ .
BOTH INTERLOCKS ON A CO-60 CUSTOM IRRADIATOR FAILED. THE INTERLOCKS FAILED WHILE THE SOURCE '
WAS IN A RELATIVELY SAFE POSITION AND QUICK RESPONSE PREVENTED ANY OVEREXPOSURE.
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. . ~ _ . _ _ _ .
ETHESDA DJ NOI 3510 J l 10/19/93 0591 EOP 10/19/93 l FECTIVE OR FAILED MATERIAL
. 994-01 l ABBOTT HEALTH PRODUCTS,INC. J ,
HE BOTTOM SOURCE RACK POSITION INDICATOR SWITCH MALFUNCTIONED AND INDICATED THAT ONE SOURCE RACK HAD NOT RETURNED TO THE STORED POSITION IN THE STORAGE POOL AFTER PRODUCT gf IRRADIATION. THE SOURCE RACK WAS FOUND TO BE IN A FULLY STORED POSITION. THE LICENSEE [,,f REPLACED SWITCH.
EGA ALTA R NOI 3521 l l
EOP ,L W26/93 ggg, gpj, g (0/26/93J w
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i (UCellSS'il19-17250-05 . ._J.h. RMY, DEPARTMENT
- . . ~ _ . . _ .OF
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_ . . . . _ . . . _ . . . ~ . . . .~ __ - - . _ . _ . . , , ,
WORKERS DISCOVERED THAT A SPILL OF 1RRADIATOR POOL WATER HAD OCCURRED OWRNIGHT. A POOLn PRESSURE LEVEL SWITCH FAILED WHICH RESULTED IN A SIGNAL CALLING FOR MAKE-UP WATER ADDITION TO THE POOL. ABOUT 5000 GALLONS OF WATER WAS ADDED TO THE POOL THE FIRST 500 GALLONS FILLED
) THE POOL TO THE TOP, RESULTING IN THE REMAINING 4500 GALLONS SPILLING OVER THE SIDES. SPILLED WATER WAS COLLECTED IN FLOOR DRAINS WHICH ARE ROUTED TO A HOLDING TANK OF 4000 GALLONS CAPACITY. THE REMAINING WATER APPROXIMATELY 500 GALLONS, FLOODED ONTO THE FLOOR OF THE i g
POOL ROOM AND THE RADWASTE STORAGE ROOM AND RAN OUT UNDER A DOOR OF ANALYZING CURRENT !
POOL WATER SAMPLES. THERE IS AN ALARM DEVICE THAT INDICATES WHEN WATEf
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Causea DEF ECTIVE OR F AILED PARIS
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[ LiC8RSGll19-0029617 j HEALTH &_H,U_ MAN _ SERVICES, DEPARTME_NT OF _ _ _ _ _
I A CS-137 SELF-CQNTAINED IRRADIATOR IS NONOPERATIONAL. A E INVOLVED IN MOVING THE TARGET 4 IRRADIATOR ROOM AND IRRADIATOR q.
. HAS BROKEN PREWNTING IT FROM LOWERING. THE DOOR T ,
ITSELF HAVE BEEN PMTED WITH OUT OF-ORDER SIGNS.
I BETHESDA MD NA 03510 OP 12/15/93 2/16/93 940819
.Y.I. __ /
l 19-00296-17 j HEALTH & HUMAN ERVICES, DEPARTMENT OF DURING A ROUTINEINSPECTION, THE ELECJMICAL INTERLOCK ON DOOR TO THE IRRADIATOR CHAMBER -(
HOUT ENGAGING THE DOOR RELEASE BUTTON AND COULD BE /; f )
FAILED. THE DOOR C00tosc OPEhED '
OPENED EVEN WHEN THE POWEM-T E IRRADIATOR WAS TURNED OFF. THE 1RRADIATOR WAS TAKEN OUT OF SERVICE AND WILL REMAI T Y UNTIL THE ELECTRICAL INTERLOCK HAS BEEN REPAIRED.
UPDATE:AN NRC LETTER DlS SSES THE FAILURE E LICENSEE TO NOTIFY THE NRC OF THE 1-
!RRADIATOR FAILURE.
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] l PUMP f ALLURE OR DAMAGE f j7 WRSe%19 296-1_7_, ,jl HEALTH & HUMAN SER,VlC DEPARTMENT OF ,
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A RESEARCHER FINIS %D USING THE IRRADIATOR A WENT TO RETRIEVE HER SAMPLE WHEN THE 1s
/
' OPEN THE RES HER ATTEMPTED TO RETRIEVE HER SAMPLE ON A FEW lg h~
IRRADIATOR DOOR FAILEDT(LE T0QPERATE T DEVICE SUCH THAT THE SOURC
- OCCASIONS, BUT WAS UNAB g' IRRADIATE POSITION AND THEN RET T. JANUARY 5,1994 THE RADIATION SAFETY BRANCH WAS
" Y REPORTED TO THE IRRADIATOR. APPARENTLY, THE TOP NOTIFIED OF THE PROBLEM AND IMMEDI l SOURCE ROD HAD NOT COMPLETELY TRACTEQ4ND CONSEQUENTLY, THE DOOR COULD NOT BE 7 OPENED. THE MECHANICAL AND E TRICAL INTERLOCKS WORKED ACCORDING TO THEIR DESIGN. THE l AREA HEALTH PHYSICIST OPENEp HE SIDE PANEL AND PllSHED THE SOURCE ROD SLIGHTLY WITH A METAL j '
ROD SO THAT THE SOURCE RF,MACTEDJNTO THE SHIELDED POSITION _WITH THE UNIT ON, THE " LOW AIR"._ j j
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-ltucense;ll19-0029617 j]H,EALT,H :.& HUMAN S.ERVICES, DE.P. ARTMENT OF-. . ;
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I A RESEARCHER FINISHED USING THE ARRADIATOR AND T TO RETRIEVE HER SAMPLE WHEN THE IRRADIATOft DOOR FAILED TO QPEN. THE RESEARCH ATTEMPTED TO RETRIEVE HER SAMPLE, BUT WAS UNABLE TO OPERATE THE DEVICQUCH THAT TH - OURCE WOULD MOVE INTO THE IRRADIATE POSITION AND THE RETRACT. THE RESEARCHE(t, THE IMMED ELY NOTIFIED THE RADIATION SAFETY BRANCH AND STAFF l TOP SOURCE ROD HAD NOT COMPLETELY RETRACTED ' PORTED TO THE IRRADIATOR. APPARE D CONSEQUEidTLY,THE DOOR COUL T BE OPENED. THE MECHANICAL AND ELECTRICAL INTERLOCKS RKED ACCORDING TO THEIR D . THDABEA HEALTH PHYSICIST OPENED THE SIDE PANEL AND SHED THE SOURCE ROD Y WITH A META (ROD SO THAT THE SOURCE RETRACTED INTO THE HIELDED POSIIlON, W!T!L _ _ IT_ON,_THE " LOW AW IGHT_WAS ACTIVATED AND THE PUMP _COULD NOTA BETHESDA D NO TlONAL INST. OF HEALTH j 3510 l EQP /15/94 j 4/15/94 1489 DEFECTIVE OR FAILED PARTS 2-24994-01 l BBOTT HEALTH PRODUCTS, INC. ONE OF THE TWO CO40 RACKS FAILED TO DROP BACK INTO THE POOL IRRADIATOR, AS DESIGNED, AFTER OPERATORS DEPRESSED THE PUSHBUTTON. PNEUMATIC BLEED OFF OF THE LIFT HOIST HAD FAILED TO f OPERATE. THE PNEUMATIC LINE WAS BROKEN ALLOWING THE SOURCE RACK TO FALL INTO THE IRRADIATOR POOL. THE LICENSEE IS PREPARING FOR ROOM ENTRY TAKING APPROPRIATE MEASURE TO ( MONITOR FOR RADIATION. PRIOR TO RESTORING OPERATIONS THE LICENSEE HAS AGREED TO CONTACT REGION 2 WITH THE RESULTS OF THE INVESTIGATION INTO THE HOIST FAILURE. SOLENOIDS REPLACED. THE LICENSEE IS PREPARING TO RESUME OPERATION AND WILL PERFORM VERIFICATION TEST F_OR OPERABILITY ._ _. __ _ _ _ _ _ _ VEGA ALTA _ PRJ NOj EQP 2/94 J 4/22/94] 9_41469 J OTHER j o [ $$4lSASSill45 23645-01NA jl NAVY, DEPARTMENT OF THE MR. MALINOSKI OF THE NAVAL RESEARCH LABORATORY OF WASHINGTON, DC, REPORTED THAT THE CO40 POOL 1RRADIATOR WEEKLY CONDUCTIVITY MEASUREMENT WAS 400 MICROSIEMENS, ABOVE THE 100 MICROSIEMENS 10CFR36.83 LIMIT. g'h/ g THIS CONDITION WAS ATTRIBUTED TO A SPENT ION-EXCHANGE RESIN COLUMN USED TO FILTER THE POOL h j WATER. IRRADIATOR ACTIVITIES WERE SECURED AND PROCUREMENT OF A NEW ION-EXCHANGE RESIN g COLUMN WAS INITIATED. A POOL SAMPLE WAS TAKEN FOR A RADIATION SURVEY AND THE RESULTS 4 INDICATE ACTMTY LEVELS BELOW THE MINIMUM DETECTABLE ACTIVITY LEVEL OF 1E-8 UCl/ML. FEGIONW Nll
< PERSONNEL HAVE BEEN NOTIFIED.
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7 Cause: OlHLH OPERATIONAL PROBLEM Ai , i g:' ie a . . _ . _ _ . . _ _ . - _ _ . _ . _ . . _ . . _ _ _ . . . . _ _ _ _ . _ _ JfM Ig h UCSRSS -ll52 24994-01 jlABBOTY_ HEALTH PRODUCTS,INC.. - . - . . _ - _ - 3 t
- - - . - __. ~ _ . . . _ _ _ _ .
_ __._._____ _____ _ g
( THE LICENSEE EXPERIENCED A
- SOURCE UP" INDICATION ON THk CONTROL CONSOLE FOR A POOL IRRADIATOR. THE INDICATION WAS FOR THE SOURCE RACK POSITION, AND IT INDICATED THAT THE SOURCE f RACK HAD NOT PROPERLY RETURNED TO ITS SHIELDED POSITION IN THE POOL. THE CAUSE OF THE (g f by
" SOURCE UP' INDICATION WAS A SHORT CIRCUlT WHICH HAD BEEN CAUSED BY WEAR ON THE ELECTRICAL WIRE INSULATION. THE DAMAGED WIRE WILL BE REPLACED AND PROTECTED BY WRAPPING IT WITH l I
CONDutT TO REDUCE THE POSSIBILITY OF RECURRENCE. 3_GA ALJ,A J, . PR i NOJ 2j YJ NA _ _, J 03[21 J Y NJ J NJ \ ' 9/20/94 l i 942103_J TRS _j 9/20/94 l LOSS OF ADMINISTRATIVE CONTROL l ;g i 54-28275-01 jjNORDION INTERNATIONAL, INC. , Dunng an NRC inspection, the following violation was identified: The Licensee failed to include the letters "RQ" on the shipping papers. , CM Update: The Licensee responds to the Notice of Violation and the Licensee has revised its shipping documer't preparation procedure. I
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950099 EQP l 1/11/9 1/19/95 l 01HER y ... b , r [f A Type A shipment left J.L. Shegrd and Astociates on 01/1 5 on a nation wida transportaten truck. The Type A - container was mounted on a heavy ot4y 48" X 48" skid, w blocking to prevent movement, surrounded by a heavy duty ; box. The box was marked with White I mond label abels containing the Container No., gross weight, " USA DOT 7A, l 6Y Type A, (RO) Rad 4 active Matenals Specia rm. S., UN2974 (Inside container complies with prescribed ,d regulations);" Fragile
- stickers;"This side uo"la ' and "Tip-N-Tell" indicator. The shipment was delivered by Kerr Freight Lines to Roschester Gas and Electricy och r Gas and Electric reported that the shipment was received 1
without either the box or the skid, that the fpe A contain was damaged and that there was no indication that it was a radioact;ve material sh'pment, except f he receiver. Prelim ry reports show damage to the devices operating and Qj f interlock systems; . howe fer the sour .cannot be rnoved to the e position .Both Rochester Gas and Electrj and ._.jf . d*f1SANtERNANDO _ . -. . -
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During an NRC inspection the following violation was plentified: The Licensee transported a self-shielded irradiator without j ensunng, by examination or appr ' to test, that e emal radiation levels were within allowable limits. [e
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Update: The Licensee replies to a Not' f lation statmg that the reason for the event was that a former employee l t
' e a refresher course to all employees. ;
misplaced paperwork. The Licensee plans
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BORDENTOWN J! O NA_ __ _, _ _ j 3320 _j . OP 1/95 3/21/95 _50335_ ' DEFECTIVE OR F AJLED PARTS j ] 2-23539-01AFj IR FORCE. DEPARTMENJ THE l
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The Licensee reported a broken retur nng on a Cs-137 sator. The condition was discovered dunng a routine ,
*nspection, while the irradiator was not in u The Licen has ruled out any possiblisty of an inadvertent personnef #
xposure. The spring is used to retum the sour y ided position in case of a power failure. There are two springs , vailable for this purpose and only one of the two was be broken The Licensee believes that one of the springs - lone would be able to fulfill the function of retuming i source the stowed position. Repairs are being pursued. The icensee will be evaluating the possible deportability this evpnt under Part 21, l
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_ ~ . . . - - _ . . . . - _ . . . . - . _ _ _ . . . , . _ . _ . . . _ . . . - - . . . . . _ _y-BROOKS AFB j _._ O!
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J 1 n EQP 4/5/95 l 4/5/95 50757 j l E ECTIVE OR FAILED PANTS ] h h?El29-2090041 Jl SOUTH JERSEY PROCESS TECHNOLOGY, INC. . . . .. , ._ _ _.-js _ . ~ . . . . . , .
; The NRC conducted an inspection, no violations were noted. But, dunng the loading of the new sources, the Licensee 4 experienced difficulty in opening the latches for two of the 16 modules The inspector examined both modules and noted ',
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that the entire module was bent at the comers where the pieces of module weie welded. Both damaged modules were removed from service and replaced. Tne cause of the damage to these modules was not immediately apparent. The Commission is concemed that longer use of these modules in this position could have resulted in damage to the sealed - sources. i j %. @meeM
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jlS.=O_M_EDIX. OPERATIONS, INC. t 1 l f
p The Licensee reported that one of the three source racks containing Co-60 failed to retum to its fully shielded posttion. The malfunction was a result of a broken cable strand within the cable hoist tube, further resulting in damage to the hoist fn j i cylinder and cable within the cylinder. On 05/07/95, the rack was placed in its fully shielded position. The hoist cable was i f replaced and repairs were made to the hoist cylinder. As a precaution, the other two hoist cylinders were disassembled (# # for a detailed inspection and the cables were replaced with new cables. PARTANBURG SC 1 YSJ
.,j 3521 _l NA _ _ _ _._
51152 EQP j 6121/95 1 9/15/95 l OT REPORTED l j 19-08330-02 j DEFENSE NUCLEAR AGENCY n July 28,1995, the Ucensee received higher than norrual dosame results for an individual who had performed ' libration of pocket chambers on June 21,1 5. Exposures for iduals who perform this activity normally range from I to 2 mrem, and this individual received 361 mr shallow do uivalent and 355 mrem deep dose equivalent. gf The Licensee's investigation revealed that there was a rent failure of an interlock on a cabinet irradiator which was used for calibrating pocket chambers. This J. L. Shephe odel-89 Irradiator utilized a 100 Ci Cs-137 source, and the run time for calibrating pocket ci ambers was 20 min with ource approximately 2 feet away. Apparently, the { individual opened a small door located on the side o he cabinet ir tator after the last of multiple calibration runs, reached in to removed the pocket chambers, and _ ggd1bgUbg tirder was still runn.ing This indicated that the source __ j
# # i BETHESDA _
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.oj j ll MSS 499All19-08330-03_ __jl DEFENSE NUCLEAR AG [CY. . , , .
- . . . .s. , . .
On June 21,1995 at approximately 1300 hours, a health sics technician was calibrating high range (200 rem) pocket chambers in the Radioactive Waste Facility (rm #101 of RRt. He was using a 100 Curie Cs-137 source contained in a - l" , J L. Shepard Calibrator (model 89-130). The cket ch bets were being exposed for 20 minutes at a dose rate of 5 rem l . 6 f. , per minute. At the end of the 20 minutes, the te ici opened the door of the calibrator. At this point he failed to l I perform the required radiation survey and extended ht hand inside the calibrator twice to retrieve the pocket M C chambers. He then realized that the interlock had f iled a dttlat the source was exposed. He immediately closed the door and secured the calibrator. He did not notify e Radiat M received from the Naval Dosimetry Center on Jul 28J993.pafety Officer until questioned about the dosimetry results l g$- !4 j BETHESDA __. - - - D ff,
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. _ _. _ . . . _ __ _ _ _ _ _ _ (ym e' I d'
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' The agreement state licensee reported the inabihty to retract an arradiator source rack to the fully shielded position. The source rack and carrier were manually manipulated until the source rack returned to the shielded position. The licensee h f determined that boxes had shifted in the carrier and did not allow the source rack to retum to the shielded position. All g safety systems worked correctly and all internal procedures were correctly followed. No personnel exposure was received as a result of the incident. Equipment changes and product changes were made to prevent a recurrence of the incident *i p
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4\ m 51036 . OP 1/95 j 8/2/95 OU ECTIVE OR F AILE.D PARTS 9-13613 02 T1, INC. l t The Director of Operations of RTI, Inc., notified the NRC Region i office staff that licensed by-product material possessed g at the Licensee's commercial pool-type irradiator facility had become stuck in the unshielded position. The Licensee is 7 ylV c authorized to possess 3 million Cl of Co-60 to sterilize a variety of products in their tote-type irradiator. The source rack
- had stuck on a tote door and the open door prevented the source elevator from descending to the pool. The elevator was ~
freed at 4:30 a.m. on August 2,1995, by reshuffling the totes from the control room. The NRC was concemed that operations would be resumed without a full understanding of the causes involved and i necessary corrective action irnplemented. A Confirmatory Action Letter (CAL) was issued on August 2,1995, requiring the i
. Licensee to remain shutdown until NRC authorizes resurnption of operations, investigate causes and take corrective __._j Q
@OCKAWAY __ f hlN_OJ 3520
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( QP 9/1_2y/9 9/12/95 { x.951114_j
~ =e.-n 7 ]3 9 4 .% JiNAOLOUATE TRAINING l l jl WISCONSIN, UNIVERSITY OF, AT MADISON f IUCGnSSNl4_B-09843-28
! The Licensee reported that two individuals circumvented an interlock on an inclosed rradiator. I I _/k
( 7 { HUP f The individuals intentionally disabled and interlock which prevents the sample chamber from dropping while the doors of the irradiator are open. When they did this, it resulted in the two individuals getting an exposure of 12-20 mrem for a four 6 second period This occurred during an unapproved maintenance activity which involved repair work to the sample kj chamber. When the sample chamber dropped with the irradiator doors open, the area radiation monitor alarms went off 9 l
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l and the individuals received a four second exposure from the Sample. h 5 p l l MADISON 5 WI k tatehNO
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.f Q!f@nM"%3%g}@'p&&h Datef ]11/13/95 % Report Date:
)l11/14/95 [ .
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-j FCguee; lNOI REPORlLD. - - - . - - . , . , - _ . - _ . . . . - . _ }{4 w- e .... - . - . . . . -
i 11tcense]lNC-001-0701-1 lRTI PROCESS TECHNOLOGY .. --.
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' The RSO (Bonnie Bishop) for RTI Process Technology, Haw Rrver, NC. reported that on 11/13/95 at 2300 hours a source d rack cable in their Panoramic trradiator broke and the source rack fell three feet to the bottom of the irradntor pool None {
; of the sources in lne source rack were damaged and nobody received any exposure form this event.
ly / ( The State of North Carolina requested RTI Process Technology to perform a metallurgical test of the broken cable to find j L4 b/ / out why the cable broke. RTI Process Technology is taking the sources out of the rack and inspecting each source 1 d individually for damage. After the inspection of the sources is completed, they will place the sources back in the rack. j The cable that broke is being replaced.
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"^ lPERMAbRAIN PRODUCTS,INC. l 37-17860-01 _ _ . - _ _ _ . _ . _ . , . . _ _ _ . j fhe underwater irradiator's intrusion alarm does not detect unauthonzed entry into the pool area when the personnel
- 1 access barrier is locked. Specifically, the intrusion alarm only detects unauthorized entry at the personnel access barrier y
; gates and not at any other point along the perimeter of the pool. ,
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/10/96 j 1/11/96 J _
; Cause:JoEF EciiVE OR F AILED PARIS g]
h $ES.I.1N! .._.jlAPPLl_ED RAQlANT EN3RGY, CORP,__~ . _ _ _ , , _ _ Mechanical fault in drive mechanism at Appl d Rabant energy Corp (an underwater, Category til, Gamma irradiator fh Facelsty located in Lynchburg, Va). h 4 1p This underwater irradiator facility utilizes 25 WESF (Waste Encapsulated Storage Facihty) capsules of Cs 137 with a current activity of 900,000 to 1,000,000 Cl it also utilizes approximately 15,000 Ci Co40 The Cs-137 materialis focated W ' [4 in a plaque frame which moves laterally underwater.
) At approximately 1645, or' January 10,1996, the Licensee identified a failure of the dnve mechanism that moves the Cs-hW 137 plaque frame laterally at_the bottom of the pool.. This prevented the free lateral movement of the plaque frame flLYNCHBURG [ STY lVA [b f 8 NO Rhok k f[Ab$ h j H
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f L.lCG11SG'llNR JHEALTH & HUMAN SERVICES, DEPARTMENT OF
At the end of an irradiation wrth a J.L Shepherd and Associates Mark i erradiator. the 4,476 Ci Cs-137 source (strength as i of 09/04/92) failed t fully retum to its shielded position and stopped approximately 2 inches before reaching the "off' . position. Personne omptly retumed the r the shielded position using manual procedures. This permitted the . [
= chamber to be accessed and the samp to be safehremoved. There were no exposures incurred as a result of this g incident, and the irradia has bee ken out of servich ntil prooer operation ca ted by an authorized J.L $
Shepherd and Associates ntative. [ i l' J,
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n .. gqlgDEF ECTIVE OR FMLED PARTS l v- n _ lRA.MSDSSENR JETHICON, INC. , The agreement state licensee reported an equipment malfunct n. A p duct box jarnmed a source rack and w r allow a Co-60 source to retum to the shielded position. The RSO successfully lowered the source. The Co40 remained
- under the water level of the storage pool. No personnel received exposure. .. [e y h
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0-j,i th CauselBlDEF kw -. ECilVE OR FAILED PARTS _ _ . _ . _ _ . _ _ _ _ . _ _ _ _ _ _ _ . ___ Jf kll License lltL-01220-01 jlSTERIGENICS h The agreement state licensee reported a stuck source rack in a category IV irradiator. Source rack #2 did not return to the
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fully shielded position, but stopped at an intermediate point. The licenseu determined a worn bushing caused the rack to stick in a partially raised position. To minimize the potential for any future similar incident, the source rack guide cables d$ h i I and bushings are on a routine inspection, maintenance, and change-out program.
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${ JW 4 Event.Date: l11/13/96 p ReportDate;,l11/13/96 h qj
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i tlf license:ll52-21175-01!l8AXTER HEALTHCARE CORP. - Q;
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[ The licensee reported an inoperable safety device at an irradiator facility. The facility uses 144300 TBq (3.9 MCl) of Co-60 n an underwater rack-type irradiator. The licensee uses floor mats composed of a couple of cells. The function of this floor mat is to detect attempted entry and to protect the individual attempting entry. When an in5idual steps on the mat, p3 {M - alarms a;d annunciated, and the source is lowered to protect the individual. In this case, one e ta floor mats was l9 damaged when one of the carriers hit it. The cell has been fixed. k ' g# l3 iw
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j, k4 .t:J - Datef 11/13/96 i m.m iR 3 960719 1E EQP 4w ww ,w a - - -
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.wsAa NOT REPORTED .. . . . - . .
l 'l IBAXTER HEALTHCARE CORK --. l
. . - . ~ .- ~ - . - .
The hcensee reported an anoperable safety device at an irradiator facihty. The facihty uses 144300 TBq (3.9 mci) of Co-00 in an underwater rack-type irradiator. The licensee uses floor mats composed of a couple of cells. The function of this l I floor mat is to detect attempted entry and to protect the individual attempting entry. When an individual steps on the mat, alarms are annunciated, and the source is lowered to protect the individual. In this case, one of the floor mats was f q damaged when one of the carriers hit it. The cell has been fixed?. l1 i r l ' .; l n...-._ ;
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An tradator heensee reported that a 74 TBq (2000 Ci) Co-60 source that failed a leak test. The bcensee reported results of 3.7 KBq (0.1 uCI) of removable activity on a 74 TBq (2000 Ci) triple encapsulated cobalt slug. The licensee began to suspect that the source was leaking after detecting increased activity in the tube which is used to move the source. No contaminations were reported. No information was provide on disposition of the source. l ITE SANDS NM NA , l 03521 PRpttJteamnts stem non 1 1
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950614 J E0P J 16/95 l __m_._ __4/17/95 J OLF LC IIVE OR FAILLD PARIS E l52-24994-01 ll ABBOTT HEALTH PRODUCTS, INC.
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The Licensee reported a malfunction of the rad:ation monitonng system which dened personnal access to the irradiation room following retum of the radioactive sources to the shielded position. The cause of the malfunction was determined fa [4
/ be an 'embrittled cable which connected the radiation detector to the L-118 monitor, i( , . .
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EGA ALTA PR NO NA _j 03521 960719 J FCP l 11/13/96J 11/13/96 [_' M o'"'vo"o _ __
\E l^^ _ d 52-21175-01 jlBAXTER HEALTHCARE CORP. l ihe licensee reported an inoperable safety device at an irradiator facility. e facility uses 149300' TBq (3.9 ' ) of Co-60 in an underw rr -type irradiator. The hcensee uses floor mats coryi$o of a couple offells. he fun n of this
(_ / floor mat is dete attempted entry and to protect the individual atte pting e alarms are nnuncia d, and the source is)cMred to protect the ind idual. In t s case, one of the oor mats w
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CORP. [ j T e hcensee reported an sno etable safety device at an irrad(ator facility. The Iacility uses 144300 TBq (3.9 mci) of Co-60 . in n underwater rack-type ir adiator. The licensee uses floorgats composed of a couple of cellk The functidn nf this % flog mat is to detect attemp entry and to protect the individual attempting eptry. When an indisdual steps of the mat, [ y alarrys are annunciated, an the source is lowered to protect the k)dividual. I this case, one of the.floof mats v'as b dama ed when one of the triers hit it. The cell has been fixed, n i N p _JV
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RACKS AND OTHLH PHYS CAL / MECHANICAL CONTROLS ]
\ $lCORSSll19-17250-05 _-
jl ARM _Y, DEPARTMENT OF THE_ . . _ _ _, _ . . .
.. . . . ___].._
__Dunng an NRC inspection it was discovered that a failure of the dnve mechanism used to move the source racks / f][l/ occurred. The NRC was not notified of this failure until 07/29/94, a penod of time greater than 24 hours and also greater 9 than 30 days. The Licensee was issued a Notice of Violation for this event. The Licensee replied to the Notice of t Violation, and prepared a written report of the incident. The Licensee contested the issuance of the violation because they h f s t beheve the filure of the elevator control valve did not constitute the " failure of the cable or dnve mechanisms used to P move the source racks." and the Licensee also stated that at no time did the cable, pulley, or pneumatic drive cylinder s that constitutes the drive mechanism fail. The Licensee's corrective steps to avoid further violation will be to include a k reminder in annual operator training of all occurrences that are now reportabka to the NRC under the new 10CFR36. h d' DELPH) j MDJ N_O..j 1_J YJ NA l 03521 l
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. . _ . _ . .. . .- ~ . . . . . _ , , _._- ~ - ,_- ___
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- Dunng an NRC inspection, the authonzed user indicated that the source en the irrad6ator failed to leave its shelded I position during a second irradiation f '
He attempted to diagnose the problem by placing tape over the microswitch (door interlock). The authorized user , j
; determined the cause of the problem was lack of pressure in the hydrauhc system which drives the source out of its [i shielded p .sition. The unit will be shutdown until completion of necessary maintenance on the hydraulic system; and l co c M y and issuing a letter of reprimand to the user. l..
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SC-267 llSOMEDIX OPERATIONS, INC .~~ ;{ hLlC981 f[ The Licensee The malfunction rtea that one of the three source racks containing Co failgMc return to its fully shleided~ sittoa. a result of a broken cable strand within the cable tTube, further resulting in damage the hoist [l p cylinder and cable wi q the cylinder. On 05/07/95, the rack waps d in its fully shielded position. The hoi cable wa f' I } ( ; replaced and repairs wer ade to the hoist cylinder. As apecadffon, the other two hoist cylinders were disa emble( j for a detailed inspection and . ables were replaced 'n cables [ k, f[v ( 7;
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']DU LCitVE 08 .. FAILED
- . . =PARTd - - -. q .,
_ ff:=:Y The Licensee reported that at their commercial pool-
,, $fstradiatorY cility (RTI, Inc.) in Salem, NJ, a Co-60 source, used
* - N for Gamma Radiation Sterihzation of rnedical devices a the nsumer goods, could not be placed in its shielded position for approximately 40 minutes. The RSO said that an object on a carrier shifted in its carrier and somehow'was able to lean against the shroud which protects the Co-60 source and prevented it from going into its shielded position. The h
RSO t,uid that they were able to exteraally activate the motor that moved the camer and were able to move the carrier far enough so that the source was able to go back into its shielded position. Nobody was exposed to the unshielded source. A Confirmatory Action Letter (CAL) was negotiated with the Licensee and requires the Licensee to: W RemairlshutdowrLuntiLRR_C_authorizesjesumption pf ppg. rations. I ROCKAWAY j NJ_j NOi i 1j ,JY SALEM 03521 l l ) Yj a ,- h currence WNyt6 bimondanNos. NJ
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1 ) i',,[ y... g - . . se 8/1/95 1 . mm,e,d/l8/2/95 pNba 951036 j ve wmm mlEOP .- e+, - -? e.. l Cause:][DU LCilVE OR F AlLED PARIS
$4CGilS01h29-13613-02 ]lRTI, INC.- _ . -
. . _ _ . ._ _._m . _ . _ _ _ . . . _ _ . _ _ _ _ . . . . . _ . . _ - -- ._
l irector of Operstions of RTI, Inc., notifed the NRC Region i office staff that licensed by-product matenal possessed The at th Licensee's commercial pool-type irradiator fachity had become stuck in the unshelded position. The Licensee is i autho ed to possess 3 million Ci of Co-60 to sterilize a variety of products in their tote-type irradiator. ffe so ce rack i hadst on a tote door and the open door preva the rce elevator from descending to the p The ele tor was j-freed at .30 a m. on August 2,1995, t'y res ing the totes f the control room. The NRC as concerned that operatio would be resumed witho full understanding of t causes involved and l[ necessary rrective action impleme ed. A Confirmatory Action Le (CAL) was issued August 2,1995, requinng e'f' Licensee $ remain. shutdown until RC authorizes resurnption of oper 'or)s, investigate use.s and take. corrective.
]ROCKgWAY
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%, e:7 lNOT REPOR1ED ..
_ . . _ ,_____.J, f lllicel180 ~ hNR , ] HEALTH & HUMAN SERVICES, DEPARTMENT OF L i At the end of arpttr istion with a J L. Shepherd and A ociates Mark I arradiator, the 76 C Cs- 37 source (strength as ! $ of 09/04/92)f%d to fly retum to its shie!d position an stopped approximately ches before aching the "off* 4 d .A q position. Perponnel promptly returned the ource to the shi ed position using ual procedures. his permstted the l' charriber to p accessed d the sampi to be safety remov There were nyerposures incurred as result of this W- . incidekt, and the irradiator h beejnen out of service until pr r operajiefi can be validated by an aut ed J.L. Shephed$nd Associates re(preventative. '
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;lNR _ M '3 THE RSO REPORTED THAT THE SOURCE ROD ON CESIUM IRRADIATOR WOULD NOT RETRACT BY GRAVITY AS d
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S L400nOS1l3717860-02 _ lPERMAGRAIN PRODUCTS, INC. jfj-j THE LICENSEE REPORTED POOL WATER CONDUCTIVITY EXCEEDING 100 MICROSIEMENS/CM. THE POOL B 1 - 1 WATER MEASURED 340 MICROSIEMENS/CM. THE MICROORGANISM CONTROL ISSUE IS LINKER TO HIGH d I POOL WATER CONDUCTIVITY. CORRECTIVE ACTIONS HAVE BEEN TAKEN TO REDUCE THE CONDUCTIVITY. hj
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- l DEFENSE NUCLEAR AGENCY Oj THE PERSONNEL WARNING SYSTEM FOR THE WET POOL 1 IRRADIATIONS WAS FOUND INOPERABLE PRIOR TO d. .
AN IRRADIATOR IRRADIATIONUSES RADIOACTIVE PROCEDURE. COBALT AS ITS SOURCE. THE THE SOURCE PROCEDURE WAS NEVER OUT WAS OF ITS STOPPED FULLY AND THE SHIELDED POSITION. THE CAUSE WAS MODIFICATIONS TO THE SYSTEMS TO COMPLY WITH NEW h REQUIREMENTS IN 10CFR36. .M q r 8 _a ; 9
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; THE OPERAT CONSOLE FbR THE WET POOL IRRADIATOR LOST POWER UNEXPECTEDLY PRIOR TO AN IRRADIATION SESSION. THE OPERATION WAS STOPPED AND THE CONSOLE RESET. THE IRRADIATOR USES l(
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d [ h1EIL-0050943 _ jlCHICA_GO. UNIVERSITY OF, _ _ , _ . - _ _ _ __ __ J_ &'*,9 l THE LICENSEE REPORTED THAT A JL. SHEPHERD IRRADIATOR, CONTAINING 550 Cl CS 137, MALFUNCTIONED t AND WILL BE OUT OF SERVICE FOR MORE THAN ONE DAY. y [
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g y q; ih119 0029612 . j jHEALTH & HUMAN SERVICES, DEPARTMENT OF M e i Dunng routsne quarterty inspection teoth safety interlocks failed on a Co-60 Irradiator operated under License #12-00296-
- 12. Regulations 10CFR30 50 and 21.21 were reviewed. and it was determinedg that a substan in the regulations. did not exist, p
'( 4 Update' Licensee replies to Notice of Violation for faAng to notify the NRC of the defect of the safety device within two b M
days as stipulated in 10CFR2121 (CX3Xf) due to a difference in interpretation of the regulations v p A Update: The NRC conducted another routine unannounced inspection. The inspector learned that the defective irradiator will be. transferred to an authonzedfecipipnt and disposed of; _ i._ _ _ _ _ _ _.. _ _,_, _ _.jf__ _.__, _ p y e ( BETHESDA . < g" M,;lMD "y-h ts, n, ,g/,_00de:%gn p* gA Regiget -nnkm_ASA:f W $$
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[ IM519 0029612_- llHEALTHf HUMAN SERVICES, DEPART _ MENT OF, _ _ _ _ , _ _ l [ BOTH INTERLOCKS ON A C040 CUSTOM IRRADIATOR FAILED THE INTERLOCKS FAILED WHILE THE SOURC l , WAS IN A RELATIVELY SAFE POSITION AND QUICK RESPONSE PREVENTED ANY OVEREXPOSURE. !1. l1 i !, . l
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p. th]191 250 05,J_ jl ARMY, DEPA,RTMENT OF THE . _ _ _ _ . _ , _.__ j k. WORKERS DISCOVERED THAT A SPILL OF IRRADIATOR POOL WATER HAD OCCURRED OVERNIGHT, A POOL I~ PRESSURE LEVEL GWITCH FAILED WHICH RESULTED IN A SIGNAL CALLING FOR MAKE-UP WATER ADDITION i- , i TO THE POOL. ABOUT 5000 GALLONS OF WATER WAS ADDED TO THE POOL. THE FIRST 500 GALLONS FILLED : I L THE POOL TO THE TOP, RESULTING IN THE REMAINING 4500 GALLONS SPILLING OVER THE SIDES. SPILLED I I WATER WAS COLLECTED IN FLOOR DRAINS WHICH ARE ROUTED TO A HOLDING TANK OF 4000 GALLONS ! y; I l CAPACITY. THE REMAINING WATER, APPROXIMATELY 500 GALLONS, FLOODED ONTO THE FLOOR OF THE i9 POOL ROOM AND THE RADWASTE STORAGE ROOM AND RAN OUT UNDER A DOOR OF ANALYZING CURRENT iN POOL WATER SAMPLES. >THERE IS AN ALARM DEVICE THAT INDICATES WHEN WATER LEVEL IN HOLDING !! TANK REACHES 2000 OAl,.LONS. THIS. ALARM SOUNDED, BUT THE SECURIT.Y GUARD MISUNDERSTOOD.THE_ j j n, ,- wnnnn, an .n,
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~.A DURING A ROUTINE INSPECTION, THE ELECTRICAL INTERLOCK ON DOOR TO THE IRRADIATOR CHAMBER l N FAILED. THE DOOR COULD BE OPENED WITHOUT ENGAGING THE DOOR RELEASE BUTTON AND COULD BE '
4 OPENED EVEN WHEN THE POWER TO THE IRRADIATOR WAS TURNED OFF. THE 1RRADIATOR WAS TAKEN l OUT OF SERVICE AND WILL REMAIN THAT WAY UNTIL THE ELECTRICAL INTERLOCK HAS BEEN REPAIRED. lQ
;g y UPDATE: AN NRC LETTER DISCUSSES THE FAILURE OF THE LICENSEE TO NOTIFY THE NRC OF THE lj IRRADIATOR FAILURE.
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I Th'E19-0029617 j jHEAL,TH_& HUMAN SERVICES, DEPARTMENT OF_ ___ _ A RESEARCHER FINISHED USING THE IRRADIATOR AND WENT TO RETRIEVE HER SAMPLE WHEN THE 1 IRRADIATOR DOOR FAILED TO OPEN. THE RESEARCHER ATTEMPTED TO RETRIEVE HER SAMPLE ON A FEW j j c OCCASIONS. BUT WAS UNABLE TO OPERATE THE DEVICE SUCH THAT THE SOURCES WOULD MOVE INTO THE i ?, IRRADIATE POSITION AND THEN RETRACT, ON JANUARY 5,1994. THE RADIATION SAFETY BRANCH WAS B NOTIFIED OF THE PROBLEM AND IMMEDIATELY REPORTED TO THE IRRADIATOR. APPARENTLY, THE TOP SOURCE ROD HAD NOT COMPLETELY RETRACTED AND CONSEQUENTLY, THE DOOR COULD NOT BE [ OPENED. THE MECHANICAL AND ELECTRICAL INTERLOCKS WORKED ACCORDING TO THEIR DESIGN. THE h e AREA HEALTH PHYSICIST OPENED THE SIDE PANEL AND PUSHED THE S T ROD.SO THAT THE SOURCE RETRACTED INTO THE SHIELDED POSITION._WITH THE UNIT..ON,THE " LOW AIR"_ d km en.mm wumen m{-- Sy-~~gkpgl Aggggesent9m g Q /, $ RAWen: lfQASA:
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1 I A RESEARCHER FINISHED USING THE IRRADIATOR AND WENT TO RETRIEVE HER SAMPLE WHEN THE Y IRRADIATOR DOOR FAILED TO OPEN. THE RESEARCHER ATTEMPTED TO RETRIEVE HER SAMPLE, BUT WAS h UNABLE TO OPERATE THE DEVICE SUCH THAT THE SOURCE WOULD MOVE INTO THE IRRADIATE POSITION Y ' I AND THE RETRACT. THE RESEARCHER IMMEDIATELY NOTIFIED THE RADIATION SAFETY BRANCH A b REPORTED TO THE IRRADIATOR. APPARENTLY, THE TOP SOURCE ROD HAD NOT COMPLETELY RETRACTED p AND CONSEQUENTLY. THE DOOR COULD NOT BE OPENED. THE MECHANICAL AND ELECTRICAL INTERLOCKS I (I WORKED ACCORDING TO THEIR DESIGN. THE AREA HEALTH PHYSICIST OPENED THE SIDE PANEL AND I PUSHED THE SOURCE ROD SLIGHTLY WITH A METAL ROD SO THAT THE SOURCE RETRACTED INTO THE ! :b 4( SHIELDED POSITION, WITH THE UNIT ONJHE ". LOW AIR" LIGHT.WAS ACTIVATED
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1 ONE OF THE TWO C040 RACKS FAILED TO DROP BACK INTO THE POOL IRRADIATOR, AS DESIGNED, AFTER (y i OPERATORS DEPRESSED THE PUSHBUTTON: PNEUMATIC BLEED OFF OF THE LIFT HOIST HAD FAILED TO {i )
.' : OPERATE. THE PNEUMATIC LINE WAS BROKEN ALLOWING THE SOURCE RACK TO FALL INTO THE i[ l h IRRADIATOR POOL. THE LICENSEE IS PREPARING FOR ROOM ENTRY TAK'NG APPROPRIATE MEASURE TO jf MONITOR FOR RADIATION PRIOR TO RESTORING OPERATIONS THE LICENSEE HAS AGREED TO CONTACT Ly REGION 2 WITH THE RESULTS OF THE INVESTIGATION INTO THE HOIST FAILURE. l1 i
[ !M ij SOLENOIDS REPLACED. THE LICENSEE IS PREPARING TO RESUME OPERATION AND WILL PERCORM
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5 *an= P'"'a b I0sNSllSS 545-23645 01NA jl NAVY, DEPARTMENT OF THE . . . f g MR. MALINOSKI OF THE NAVAL RESEARCH LABORATORY OF WASHINGTON, DC, REPORTED THAT THE CO-60 : t
; POOL IRRADIATOR WEEKLY CONDUCTIVITY MEASUREMENT WAS l1 400 MICROSIEMENS, ABOVE THE 100 MICROSIEMENS 10CFR36.83 LIMIT. lj
!i THIS CONDITION WAS ATTRIBUTED TO A SPENT ION-EXCHANGE RESIN COLUMN USED TO FILTER THE POOL id WATER. IRRADIATOR ACTIVITIES WERE SECURED AND PROCUREMENT OF A NEW ION-EXCHANGE RESIN W
- COLUMN WAS INITIATED. A POOL SAMPLE WAS TAKEN FOR A RADIATION SURVEY AND THE RESULTS 1 INDICATE ACTIVITY LEVELS BELOW THE MINIMUM DETECTABLE ACTIVITY LEVEL OF 1E-8 UCl/ML. REGION 11 1 PERSONNEL HAVE BEERNOTIFIED. _ __.___.._________j.
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4 s l E 'THE LICENSEE EXPERIENCED A" SOURCE UP" INDICATION ON THE CONTROL CONSOLE FOR A ISOL IRRADIATOR. THE INDICATION WAS FOR THE SOURCE RACK POSITION, AND IT IND
' 4 RACK HAD NOT PROPERLY RETURNED TO ITS SHIELDED POSITION IN THE POOL. THE CAUSE OF THE
" SOURCE UP* INDICATION WAS A SHORT CIRCUIT, WHICH HAD BEEN CAUSED BY WEAR ON THE ELECTRICAL M c
WIRE INSULATION. THE DAMAGED WIRE WILL BE REPl. ACED AND PROTECTED BY WRAPPING IT WITH CONDUlT TO REDUCE THE POSSIBILITY OF RECURRENCE. h P h
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< During an NRC inspection, the following violation was identrhed: The Licensee failed to include the letters "RQ" on the l s shipping papers. -
l1 l}$ Updata: The Licensee responds to the Notice of Violation and the Licensee has revised its shipping document preparation j j procedure. ; y 8
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} A Type A shipment left J.L. Shepherd and Associates on 01/11/95 on a nation wide transportation truck The Type A jq F container was mounted on a heavy duty 48" X 48" skid, with blocking to prevent movement, surrounded by a heavy duty !
box. The box was marked with White l Diamond labels; labels containing the Container No., gross weight, " USA DOT 7A, l 1 Type A, (RO) Radioactive Materials Special Form, N.O S., UN2974 (Inside container complies with prescribed j regulations);" Fragile" stickers;"This side up" labels; and 'Tip-N-Tell" iiidisator. The shipment was delivered by Kerr Freight Lines to Roschester Gas and Electric. Rochester Gas and Electric reported that the shipment was received ;%j without either the box of the skid, that the Type A container was damaged and that there was no indication that it was a
! radioactive material shipment, except for the receiver. Preliminary reports show damage to the devices operating and h@I nterlock systems; however the sources ~~ cannot.bepoved to the exposed positiorLBoth Rochester Gas and Electric an y[ wjSAN FERNANDO .
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> 2 h Dunng an NRC inspection the following violation was 6dentifed. The Licensee transported a self-shelded irradiator without r k ensuring, by examination or appropriate test, tha' extemal radiation levels were within allowable hmits. (
4 Update: The Licensee rephes to a Notice of Violation staGng that the reason for the event was that a former employee [ mesplaced paperwork. The Licensee plans to give a refresher course to all employees. I f iM [ r i
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EFECTIVE OR FAILED PARTS _ l; (g - __ . _ , _ __ . _ . _ _ . _ . _ . . _ _ _ . --___ _ .- f, I 42-23539-0,1 A.F.-llA. IR,FO..~RCE, DEPA__RT.ME.,NT OF. TH. E .-.-_--
-. - - - - . . . -.--..--..-.---.h s The Licensee reported a broken retum spnng on a Cs-137 irradiator. The condition was discovered dunng a routine 'j
( inspection, while the irradiator was not in use. The Licensee has ruled out any possibihty of an inadvertent personnel a l exposure. The spring is used to return the source to e shielded position in case of a power failure. There are two springs j a available for this purpose and only oi ) of the two was found to be broken. The Licensee beheves that one of the springs ' j* f alone would be able to fulfill the function of returning the source to the stowed position. Repairs are being pursued. The 1 Licensee will be evaluating the possibla reportabihty of this event under Part 21. 0 . .. - . . . - . - ww BROOKS AF_B__ _ _ _. .. j $f[jTX . rpmwwwww[qh.pw" Q hwpw"iARA:. .-...... em -
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w The NRC conducted an inspection, no violations were noted. But, dunng the loading of tne new sources, the Licensee g experienced difficulty in opening the latches for two of the 16 modules. The inspector examined bc modules and noted p that the entire module was bent at the comers where the pieces of module were welded. Both damaged mndules were l{ removed from service and replaced. ,The cause of the damage to these modules was not immediately apparent. The {q
? Commission is concerned that longer use of these modules in this position could have resulted in damage to tne sealed !j sources. 4 h
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4 The Licensee reported that one of the three source racks containing Co-60 failed to retum to its fully shielded position. The malfunction was a result of a broken cable strand within the cable hoist tube, further resulting in damage to the hoist M h l l cylinder and cable within the cylinder, On 05/07/95, the rack was replaced and repairs were made to the hoist cylinder. As a precaution, the other two hoist cylinders were disassembled l placed in f for a detailed inspection and the cables wete replaced with new cables. j q t r p ! i a p wlbPARTANBURG- _ -[ST:_' y :s [~ "' hg.Ag q ;.gu.g;g & .u:;gQ[' : 3 ;A g p[ a p~47 h5 QpQ? M S ARAt W'f
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_ _ _.. _ _ _ _ . j j th'E19-0_8330-02 _ _ JDEFENSE_NUCL, EAR, AGENCY _ _ _ ___
,, h) g On Juty 28,1995, the L6censee received higher than normal dosimetry results for an individual who had performed p ,
calibration of pocket chambers on June 21,1995 Exposures for individuals who perform this activity normally range from M I
' I to 2 mrem, and this individual received 361 mrom shallow dose equivalent and 355 mrem deep dose equivalent. I The Licensee's investigation revealed that there was an apparent failure of an interlock on a cabinet irradiator which was I used for calibrating pocket chanfArs This J. L Shepherd Model-89 Irradiator utilized a 100 Cl Cs-137 source, and the ,
? I run time for calibrating pocket chembers was 20 minutes with the source approximately 2 feet away. Apparently, the i ndividual opened a small door located on the side of the cabinet irradiator after the last of multiple calibration runs, O reached in to removed the pocket chambers, and noticed that the timer was still running._ This indicated that the source _ _ . d -
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,l DEFENSE NUCL.EA_R_ AGE _NCY _ .- -
- - . - . - . - . . . . - - - __.lh On June 21,1995 at approximately 1300 hours, a health physics technician was cahorating high range (200 rem) pocket chambers in the Radioactive Waste Facility (rm #101) of AFRRI. He was using a 100 Curie Cs-137 source conteined in a i M@
J L. Shepard Cahbrator (model 89-130). The pocket chambers were being exposed for 20 minutes at a dose rate of 5 rem ipf per minute. At the end of the 20 minutes, the technician opened the door of the calibrator. At this point he failed to $~ p perform the required radiation survey and extended hic right h6nd inside the calibrator twice to retrieve the pocket chambers. He then realized that the interlock had fan and that the source was exposed. He immediately closed the ]h door and secured the calibrator. He did not notify the Radiation Safety Officer until questioned about the dosimetry results y received from the Naval Dosimetry Center on July 28,199'.,. kg
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t The agreement state hcensee reported the inability to retract an irradiator source rack to the fully shselded position. The
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. [{ source rack and carrier were manually manipulated until the source rack retumed l, to the sh O determined that boxes had shifted in the carrier and did not allow the sou" 1ck to retum to the shielded position. All >
f safety systems worked correctly anJ all internal procedures were correctly followed. No personnel expnsure was received g as a result of the incident. Equipment changes and product changes were made to prevent a recurrence of the incident.
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IWSESS129-13613-02_JRTI, INC.
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y The Drector af Operations of RTI, Inc., notified the NRC Region i office staff that hcensed by-product matenal possessed Ef t- at the Ucensee's commercial pool-type irradiator facility had become stuck in the unshielded position. The Licensee is y authorized to possess 3 million Ci of Co-60 to sterihze a variety of products in their tote-type irradiator. The sou ce rack ? had stuck on a tote door and the open door prevented the source elevator from descending to the pool. The elevator was
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- freed at 4.30 a m. on August 2,1995, by reshuffling the totes from the control room. jj f
i The NRC was concemed that operations would be resumed without a full understanding of the causes invotved and y necessary correctrve action implemented. A Confirmatory Action Letter (CAL) was issued on August 2,1995, requiring the jf r Ucensee to remain shutdown until NRC authorizes resumption of operations, investigate causes and take corrective _ _ . j an w- nmwmmen. -<-wwww ym t u e > y wwWnr ? .
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t i EQ09843-28 jWISCONSIN, UNIVERS_IT_Y OF, AT_ MADISON _ , _ __ _ _l [ The Licensee reported that two Individuals circumvented an interlock on an inclosed arradiator, ig iL s The individuals intentionally disabled and interlock which prevents the sample chamber from dropping while the doors of d i the irraciator are open. When they did this, it resulted in the two individuals getting an exposure of 12-20 mrem for a four l0
'[ second period. This occurred daring an unapproved maintenance activity which involved repair work to the sample {g chamber. When the samp e chamber dropped with the Irradiator doors open, the area radiation monitor alarms went off jM and the individuals received a four second exposure from the sample. ! jj
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l l l l [ rack The RSO (Bonnie Bishop) for RTI Process Technology, Haw Rrver, NC. reported that on 11/13/95 at 2300 hours a source h cable in their Panoramic frradiator broke and the source rack fell three feet to the bottom of the irradiator pool. None d (Lof the sources in the source rack were damaged and nobody received any exposure form this event. %
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- The State of North Carolina requested RTI Process Technology to perform a metallurgical test of the broken cable to find l
; out why the cable broke. RTI Process Technology is taking the raurces out of the rack and inspecting each source !
.ndtvidually for damage. After the inspection of the sources is completed, they will place the sources back in the rack. .
The cable that broke is being replaced. w,; - - - - -
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I M 'E 37 11860-01 J IPERMA.GR. A.IN,P_RO. , DUCTS _, I.NC.- - . - -. - M 4p$ v:
, The underwater stradiator's intrusion alarm does not detect unauthonzed entry into the pool area when the personnet ;}
p access barrier is locked. Specifically, the intrusion alarm only detects unauthorized entry at the personnel: *ess bamor j0 t gates and not at any other point along the perimeter of the pool.
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Ih v Mechanical fault in dnve mechanism at Applied Radiant energy Corp. (an underwater, Category lit. Gamma irradiator Q f Facility located in Lynchburg, Va). 4 i1 k This underwater irradiator facility utilizes 25 WESF (Waste Encapsulated Storage Facility) capsules of Cs-137 with a I? g current activity of 900,000 to 1,000.000 Cl it also utilizes approximately 15,000 Cl Co-60. The Cs4137 materialis located h l in a plaque frame which moves laterally underwater.
, At approximately 1645, on January 10,1996, the Licensee idenhfied a failure of the drive mechanism that moves the Cs.
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F l At the end of an stradeauon with a J L. Shepherd and Associates Mark i irradiator, the 4,476 Ca C<,-137 source (strength as ,Q of 09/04/92) failed to fulty retum to its shielded position and stopped approximately 2 ;nches before reaching the "off" jq y position. Personnel promptly retumed the source to the shielded potition using manual procedures. This permitted the :a chamber to be accessed and the samples to be safely removed. There were no exposures incurred as a result of this jj incident, and the irradiator has been taken out of service until proper operation can be validated by an authorized J L. Shepheid and Associates representative. %g? ij 3 sgg;ig,w 3.g hp;:lBETHESDA
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- - - - - aj@j
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. - . . - . - .-.---.---y h K^
! The agreement state hcensee reported an equipment malfunction. A product box jammed a source rack and would not %"'
allow a Co-60 source to retum to the shieldeG position. The RSO successfully lowered the source. The Co-60 remained 9 under the water level of the storage pool. No personnel receiveo exposure. hl b-f ; # f
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y g; p,.: l DEFECTIVE OR F AILEO PARTS, _ . _ _ _ _ . . . _ _ _ . _ _ _
._.__.....__._.____._.p, .
h (W}EIL-01220-01 j jSTERH3ENICS __ _ __ _______j{ n The agreement state hcensee reported a stuck source rack in a category IV erradiator. Source rack #2 did not retum to the g fully shield 61 position, but s'opped at an intermediate point. The licensee determined a wom bushing caused the rack to g 5 stick in a partially raised position. To minimize the potential fer any future similar incbnt, the source rack guide cables % and buchings are on a routine inspection, maintenance, and change-out program d M M ) M ! lM l
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N g p t - . {h NOT NEPORTED - _ _ . . . . _ _ _ _ ._ _ _ __ __ ._ _s, r
.y f nMh' E S2-211_75-0.1 - !lBAXTER HEALTHC_ARE _CO_RP.
- _ _---- -- _ -_ ,h t
L , - l I The hcenses reported an inoperable safety devic 4 at an irradiator facekty. The facihty uses 144300 TBq (3 9 MCl) of Co-60 l l t . < in an underwater rack-type irradiatar. The licensee uses floor mats composed of a couple of cells. The function of this !l p floor mat is to detect attempted entry and to protect the kdvidual attempting entry. When an individual steps on the mat, iDl
, ;: alarms are annunciated, and the purce is lowered to protect the 4.1dividual. In this case, one of the floor mats was l is((
{ damaged when one of the carriers hit it. The cell has been fund. m (% l3 s 3
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. l11/13/96, j LWJNOT m ~ REPORTED . - . -
. . - - . .-. .- --. . .- f E N152{1175-01_ JBAXTER HEALTHCARE CORP,. . _ ,_ __ . __
The hcensee reported an inoperable safety device at an irradiator facility. The facahty uses 144300 TBq (3.9 mci) of Co-60 R in an underwater rack-type irradiator. The licensee uses floor mats composed of a couple of cells. The function of this $ floor mat is to detect attempted entry and to ptotect the individual attempteg entry. When an individual steps on the mat, t l alarms ara annunciated, and the source is lowared to protect the individual. In this case, one of the floor mats was , damaged when one of the carriers hit l' The cell has been fixed. l b
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[! !UCSWdDQ]52 24994-01 JABBOTT HEALTH PRODUCTS, INC. M g w d [ 1he Licensee reported a malfunction of the radiation monitonng system which denied personnel access to :he irradiation R room following return of the radioactive sources to the shielded position. The cause of the malfunction was determined to Q]
,f be an embnttled cable which connected the radiation detector to the L-118 monitor. M a, a
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{ p;Causeg lNOT REPOHILD gr-g y q g{h!USSRS$jl52 jMXTER 21175-01 HEALTHCARE CORP. j y The ricensae reported :en snoperable safety devic at an irradiator facility The facility uses 144300 TBq (3 9 MCs) of Co-60 9
~n i,g j- in an underwater rack-type irradiator. The licensee uses floor nats composed of a couple of cells. The function of this a/ & floor mat is to detect attempted entry and to protect the individual attempting entry When an individual steps or 'he mat, p]
(/ ' h alarms are annunciated, and the source is lowered to protect the individual in this case, one of the floor mats wa:. f damaged when one of the carriers hit it. The cell has been fixed. p
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j (t.Where occurfect; > qs lNA mm-. ,g J.- > d b [ Program code: l03521, , M[ Reportable: fYj {6Atmormed occurrenceiks lr C "on:@, Consultent?' -[tQL "
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f p Cause: lNOT Hr.POHILD W s- - f!) h WC8HSS ~lh21175-01 j jBAXTER - HEALTHCARE CORP. The licensee repcrted an inoperable safety device at an irradiator facility. The facility uses 144300 TBq (3.9 MCl) of Co-60j @a a in an underwater rack-type irradiator. The licens:e uses floor mats composed of a couple of cells. The function of this fj l floor mat is to detect attempted entry and to protect the individual attempting entry. When an individual steps on the mat, id j alarms are annunciated, and the source is lowered to protect the individual. In this case. one of the floor mats was % damaged when one of the camers hit it. The cell has been fixed. A r <d e @ l dv Y)
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.a No: j960300 .pl L Class Evert: jLKS
.. f: 3 Ewent Dete: l4/23/96 7.f Report Date: j4/24/% ;-
[!,; Cageek lNOT REPORTED . _jj
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~ ll3042405-10 . l ARMY, DEPARTMENT OF THE - WHITE SANDS MISSLE RANGE !f1 An irradiator licensee reported that a 74 TBq (2000 Cl) Co40 source that failed a leak test. The licensee reported results M!
f
$ of 3.7 KBq (0.1 uCi) of ternovable activity on a 74 TBq (2000 Ci) triple encapsulated cobalt slug. The licensee began to 13 j suspect that the source was leaking after detec'ing increased activity in the tube which is used to move the source. No ;[d y contaminations were reported. No information was provide on d'sposition of the source.
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y _ L No:j940678 4 Claen Event: ylNPR
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Event Date: l11/23/93 p ReportDate:l11/23/93 j
): h ; lDLF LCTIVE OR F AILEO PARTS
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pll1 LICORet:llR-0120 - j jNORTH CAROLINA STATE UNIVERSITY k
-j LEAKAGE OF WATER FROM THE PULSTAR REACTOR COOLANT SYSTEM. OPERATIONS WERE CEASED WHEN
\y f THE LEAK RATE FROM THE SYSTEM REACHED 1 GALLON PER HOUR f4
} UPDATE: THE LICENSEE PROVIDES STATUS ON THE PULSTAR REACTOR COOLANT SYSTEM THE REACTOR d .[ FACILITY HAS COMPL 50 WITH ALL APPLICABLE ACTIONS OUTLINED AND THEY ARE CURRENTLY 9 g '! CONSTRUCTING AN UNDERGROUND VAULT TO ENCLOSE THE SUBTE7RANEOUS PULSTART REACTOR I PRIMARf SYSTEM COMPONENTS..
fi P 1 id V UPDATE. THE NRC CONDUCTED AN INSPECTION TO REVIEW THE LICENSEE'S PREPARATIONS TO RESUME s, , , - , , -, n,. .
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4 '4' Region: h. v ' (AEA:h,4 [ City:lRALEIGH
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item hio:'l940678 E ; CNEvent: lEOP f I l; Event Detof l11/23/93 y Report Date:l11/23/93 h 4; h.. Cause: lDLF LC11VL OR F AILLD PARIS 1m L[LICORSS llR-0120 lNORT H CAROLINA STATE UNIVERSITY j
+.
LEAKAGE OF WATER FROM THE PULST AR REACTOR COOLANT SYSTEM OPERATIONS WERE CEASED WHEN d f
, THE LEAK RATE FROM THE SYSTEM REACHED 1 GALLON PER HOUR. l t h I I
[ UPDATE. THE LICENSEE PROVIDES STATUS ON THE PULSTAR REACTOR COOLANT SYSTEM. THE REACTOR M FACILITY HAS COMPLIED WITH ALL APPLICABLE ACTIONS OUTLINED AND THEY ARE CURRENTLY y} [ CONSTRUCTING AN UNDERGROUND VAULT TO ENCLOSE THE SUBTERRANEOUS PULSTART REACTOR d PRIMARY SYSTEM COMPONENTS. )4.m
, , ;-g )
NUPDATE: THE NRC CONDUCTED AN INSPECTION TO REVIEW THE LICENSEE'S PREPARATIONS TO RESUME , , i .;a j t- , n. . , - ~ , , - - - [ City:jRALEIGH
- p. ,. .. ~7
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Reporteble:h.; Albormalocb [ [l$1vestigetloSh ..Conseltant? U d
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^% No: l941469 N IClass Eventi lEQP y. Event Date: l4/22/94 ' L Report Dete; l4/22/94 /) l
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h l! LICORSS -ll45-23645-01NA JNAVY, DEPARTMENT OF THE
- l t 1 ,
i MR. MALINOSKI OF THE NAVAL RESEARCH LABORATORY OF WASHINGTON, DC, REPORTED THAT THE CO-60 i I I f POOL IRRADIATOR WEEKLY CONDUCTIVITY MEASUREMENT WAS 400 MICROSIEMENS. ABOVE THE 100 MICROSIEMENS 10CFR36 83 LIMIT. ,
} THIE CONDITION WAS ATTRIBUTED TO A SPENT ION-EXCHANGE RESIN COLUMN llSED TO FILTER THE POOL 1 WATER. IRRADIATOR ACTIVITIES WERE SECURED AND PROCUREMENT OF A NEW ION-EXCHANGE RESIN ,
l li COLUMN WAS INITIATED. A POOL SAMPLE WAS TAKEN FOR A RADIATION SURVEY AND THE RESULTS lj : h INDICATE ACTIVITY LEVELS BELOW THE MINIMUM DETECTABLE ACTIVITY LEVEL OF 1E-8 UCl/ML. REGION 11 f f PERSONNEL HAVE BEEN NOTIFIED.. _ _ i), STilVA ..E [ Agreement [AEA:h
+
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'~
f;[Cause: l LOSS OF A CON 1 ROLLED PARAMETERj,, j N .- o g ilfl.IOGnOS ll37-17860-02 w
- lPERMAGRAIN PRODUCTS. INC.
L' THE LICENSEE REPORTED POOL WATER CONDUCTIVITY EXCEEDING 100 MICROSIEMENS/CM. THE POOL Ih ( WATER MEASURED 340 MICROSIEMENS/CM. THE MICROORGANISM CONTROL ISSUE IS LINKED TO HIGH fj i POOL WATER CONDUCTIVITY. CORRECTIVE ACTIONS HAVE BEEN TAKEN TO REDUCE THE CONDUCTIVITY. h M[p f r
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( . :. : , , ., pllemNo: j942082 - d) Cfase Event: lEQP
< . Event Date: l12/2/94 $ ReportDate:jl2/2/94 ,"'
I Cause: IDEF ECTIVE OR FA LED PARTS ._ fy
&, I ._ _ _ _
7 h!LICGHSG jl29-20900-01 - l SOUTH JERSEY PROCESS TECHNOLOGY, INC.
=
r .m i-i The Licensee reported that at their commercial pool-type irradiatorfacility (RTI, Inc.) in Salem, NJ, a Co-60 source, used d[1 f for Gamma Radiation Sterihzation of medical devices ahdothery,onsumer goods, could not be placed in its shielded O I positico for approximately 40 minutes. The RSO sad that an object on a carrier shifted in its carrier and somehow was , c 5 able to lean against it 3 shroud which protects the Co-60 source and prevented it from going into its shielded position. The ,! '
) RSO said that they were able to extemally activate the motor that moved the carrier and were able to move the carrier far
) enough so that the source was able to go back into Ms shielded positon. Nobody was exposed to the unshielded source. ps cf
; A Confirmatory Action Letter (CAL) was negotiated with the Licensee arid requires the Licensee to: D " ?;
i (1) Remain shutdown until NRC authonzes resumption of c% rations. . p -.-
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y CelyjlROCKAWAY ;{iST:lNJ <
- Agreement State:lNO [
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J/ b;Reportehle:k, Almormaloccurrencei k~ investigation:h? Consultant?.h.; v yE , < f, 9 e , w , + q
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1.--_ . . .. , ,. - - . . m [, Item Noh l951036 p Class Event:, lEQP ? Event Datei l8/1/95 t' Report Date:l8/2/95 .fy [Couse: jDEF EC11VE OR F AILEO PARTS h d i p LicGstee'll29-13613-02 . j RTI, INC. _ ,_ __ g The Director of Operations of RTl, Inc., notified the NRC Region 1 office staff that hcensed by-product matenal possessed e at the Licensee's commercial pool-type irradiator facihty had become stuck in the unshielded position. The Licensee is Th '
) authorized to possess 3 million Ci of Co-60 to stenlize a vanety of products in their tote-type irradiator. The source rack ,
f had stuck on a tote door and the open door prevented the source elevator from descending to the pool. The elevator was y
) freed at 4 30 a m on August 2,1995, by reshuffhng the totes from the control room M
[ 4 l The NRC was concerned that operations would be resumed without a full understanding of the causes involved and ;d
? necessary corrective action implemented. A Confirmatory Action Letter (CAL) was issued on August 2,1995, requiring the fg
?. Licensee to remain shutdown until NRC autnonzes resumption of operations,. investigate causes and take corrective :i L~ . . , - ,
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[ City:lROCKAWAY g ST: lNJ . . A,L._. _2 State:lNO y ::T Region: h ' =c .AEA:h ,< r <m . f Where occurve'd : jNA _[ ,
~ Program' code:l03520 j f ReportatN:h Atmormhl occurrence h I reetigation: . Cons 5 tant? k -
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.L..iNo: l96,0202 y IClase Eventi lEOP f ['ent Date! l3/22/96 b ~ Report Date: l3/22/96 p
P Cause: lNOT REPOHTED
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j At the end of an arradiaton with a J.L. Shepherd and Associates Mark i irradiator, the 4,476 Ci Cs-137 source (strength as e of 09/04/92) tailed to fully return to its shielded position and stopped approxima%y 2 inches before reaching the "off" 3 j, position Personnel promptly returned the source to the shiekied positien using manual procedures. This permitted the 1
} chamber to be accessed and the samples to be safely removed. There were no exposures incurred as a result of this i incident, and the irradiator has been taken out of service until proper operation can be vahdated by an authonzed JL. .i 1 Shepherd and Associates representative ,,l i> y
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__W g g "he agreement state licensee reported the inability to retract an irradiator source rack to the fully shielded position. The Q L source rack and carrier were manually manipulated until the source rack retumed to the shielded position. The licensee jJ f determined that boxes had shifted in the carrier and did not allow th6 Source rack to retum to the shielded position. All lj safety systems worked correctly and allinternal procedures were correctly followed. No personnel exposure was received j J f as a result of the incuent. Equipment changes and product changes were made to prevent a recurrence of the incsdent. ;M r i l6 l1 7.
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96 6 g lEQP tseeth l4/8/96 . Jg RgNtOW h/8/96_ j . DEFECTIVE OR FAILED PARTS . , l o j !-M]NR =- { lETHICON, INC. o .m ., . . . JJ ' I k [" The agreement state hcensee reported an equipment malfunction. A product box jammed a source rack and would not allow a Co-60 Source to return to the shielded position. The RSO successfully lowered the source. The Co-60 remained ) under the water level of the storage pool. No personnel received exposure. . A
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h l DEFECTIVE OR FAILED PARTS k, f WWISS' : IL-01220-01 llSTERIGENICS , mJ The agreement state bcensee reported a stuck source rack in a category IV arradiator. Source rack #2 did not retum to the h 4 fully shielded position, but stopped at an intermediate point. The licensee determined a wom bushing caused the rack to y l' stick in a partially raised position. To minimize the potential for any future similar incident, the source rack guide cables $ k and bushings are on a routine inspection, maintenance, and change-out program. M
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" .$10:. . ..l941880 lleen U Class Event::lEOP , f Event Oste: l2/2/94 jt Report Detsh l7/29/94 -h
-M V Cause; l RACKS AND 0 THLR PHYSICAUMLCHANiCAL CONTHOLS M'
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(4 i L400ftOS Jl19-17250 05 l ARMY, DFPARTMENT OF THE hm [ g Dunng an NRC inspection et was discovered that a failure of the dnve mechanism used to move the source racks ij y p occurred The NRC was not notified of this failure until 07/29/94, a period of time greater than 24 hours and also greater }, 4
} than 30 days. The Licensee was issued a Notice of Violation for this event. The Licensee replied to the Notice of f i Violation, and prepared a wntten 'eport of the incident. The Licensee contested the issuance of the violation because they j .
\ ! believe the failure of the elevator control valve did not constitute the " failure of the cable or dnve mechanisms tred to d I move the source racks." and the Licensee also stated that at no time did the cable, pulley, or pneumatic drive cylinder d I k that constitutes the drive mechanism fail. The Licensee's corrective steps to avoid further violation will be to include a 32 reminder in annual operator training of all occurrences that are now reportable to the NRC under the new 10CFR36. p h lh_
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Event Date: lI/5/95 f ReportDate:l1/13/95 %, , { Cause: lDU LC HVL OR F AllLD PANiS _ n h.lf LICGftSGjl37-00134-06 j lPITTSBURGH, UNIVI RSITY OF . dj j +J
- Dunng an NRC inspection, the authonzed user indicated that the source in the irradiator failed to leave its shielded N f position dunng a second irradiation. }[
y j< He attempted to diagnose the problem by placing tape over the microswitch (door interlock) The authorized user
& determined the cause of the problem was lack of pressure in the hydraulic system which dnves the source out of its Q@
{ shielded position. The un4 will be shutdown until completion of necessary maintenance on the hydraulic system; and bj
; counseling and issuing a letter of repnmand tv the user. Q I i f%+
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n-y' ", 3 ~v 3 < - h, - Bloh,l951033 QCleedEventf jEQP [ f Event Date: l$/5/95 [, Piport Dato: l5/30/95 h Em 3 iq [ Cause: g v- lDU LCilVL OR F AILLO PARIS. . _ . . _ Q v _. llSOMEDIX OPERATlONS, INC. fl L4COMSG'flSC-267 ,r The Licensee reported that one of the three source racks containing Co-60 failed to retum to its fully shielded position. j The malfunction was a result of a broken cable strand within the cable hoist tube, further resulting in damage to the hoist m i cylinder and cable within the cylinder On 05/07/95. the rack was placed in its fully shielded position. The hoist cable was %j [ replaced and repairs were rnade to the hoist cylinder, As a precaution, the other two hoist cylinders were disassembled j for a detailed inspection ar d the cables were replaced with new cables.
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.V 4 ai lNOI REPORTED ,, j l,
]!N" ENC-001-0701 1 ;)RTl_ PROCESS TECHNOLOGY h,. Q.
a The RSO (Bonnie Bishop) for RTI Process Technology, Haw Riv6r, NC. reported that on 11/13/95 at 2300 hours a source d. rack cable in their Panoramic Irradiator broke and the source rack fell three feet to the bottom of the irradiator pool None $ .l of the sources in the source rack were damaged and nobody received any exposure form this event. $
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( The State of North Carolina requested RTI Process Technology to perform a metallurgical test of the broken cable to find g.lj "kout why the cable broke. RTl Process Technology is taking the sources out of the rack and inspecting each source yd k individually for damage. 'After the inspection of the sources is completed, they will place the sources back in the rack. ! The cable that broke is being replaced. . ' f i pw 4 lJ i 4 , m .- ng pmwmm y@w-,jHAW RIVER tp 871 ffsj & 4 y. , M fmemmhm{ j UpReM j;[ASA:h, " -W
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[ IM'E45-11496-01 ,l APPLIED RADIANT ENERGY CORP. {y
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!j. Mechanical fault in dove mecnanism at Apphed Radiant energy Corp. (an underwater, Category lit, Gamma Irradiator p'P Facihty located in Lynchburg. Vs). M i
Thrs underwater irradiator facility utilizes 25 WESF (Waste Encapsulated Storage Facihty) capsules of Cs-137 with o J
@j l current activity of 900.000 to 1,000,000 CL lt also utikzes approximately 15.000 Ci Co-60. The Cs-137 materialis located d in a plaque frame which moves laterally underwater, y b
s.37. At approximately 1645, on January 10,1996, the Licensee identified a failure of the drive mechanism that moves tha Cs-
,1 plaque. frame laterally at the bottom of the pool. This prevented the -free lateral movement of the plaque fram h
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