ML21362A766

Armed Forces Radiobiology Research Institute Routine Inspection Report No. 05000170_2021203

ML21362A766
Person / Time
Site:	Armed Forces Radiobiology Research Institute
Issue date:	01/14/2022
From:	Travis Tate NRC/NRR/DANU/UNPO
To:	Naaem M US Dept of Defense, Armed Forces Radiobiology Research Institute
O'Bryan P
References
IR 2021003
Download: ML21362A766 (13)

Text

F January 14, 2022 Colonel M. Naaem, Director Armed Forces Radiobiology Research Institute 4301 Jones Bridge Road, Building 42 Bethesda, MD 20889-5648

SUBJECT:

ARMED FORCES RADIOBIOLOGY RESEARCH INSTITUTE - U.S. NUCLEAR REGULATORY COMMISSION ROUTINE INSPECTION REPORT NO. 05000170/2021203

Dear Colonel Naeem:

From November 29-30, 2021, the U.S. Nuclear Regulatory Commission (NRC) conducted an inspection at the Armed Forces Radiobiology Research Institute (AFRRI) reactor facility. The enclosed report documents the inspection results which were discussed on November 30, 2021, with LTC J. Brown and members of the AFRRI staff.

The inspection examined activities conducted under your license as they relate to safety and compliance with the Commissions rules and regulations and with the conditions of your license.

The inspectors reviewed selected procedures and records, and interviewed personnel. Based on the results of this inspection, no findings of significance were identified. No response to this letter is required.

In accordance with Title 10 of the Code of Federal Regulations, Section 2.390, Public inspections, exemptions, requests for withholding, a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records component NRCs document system (Agencywide Documents Access and Management System (ADAMS)). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

A. Cook If you have any questions concerning this inspection, please contact Mr. Phil OBryan at 301-415-0266, or by electronic mail at Phil.OBryan@nrc.gov.

Sincerely, Signed by Tate, Travis on 01/14/22 Travis L. Tate, Chief Non-Power Production and Utilization Facility Oversight Branch Division of Advanced Reactors and Non-Power Production and Utilization Facilities Office of Nuclear Reactor Regulation Docket No. 50-170 License No. R-84

Enclosure:

As stated cc: See next page

Armed Forces Radiobiology Research Institute Docket No. 50-170 cc:

Director, Maryland Office of Planning 301 West Preston Street Baltimore, MD 21201 Montgomery County Executive 101 Monroe Street, 2nd Floor Rockville, MD 20850 Environmental Program Manager III Radiological Health Program Air & Radiation Management Adm.

Maryland Dept of the Environment 1800 Washington Blvd., Suite 750 Baltimore, MD 21230-1724 Director Air & Radiation Management Adm.

Maryland Dept of the Environment 1800 Washington Blvd., Suite 710 Baltimore, MD 21230 Test, Research and Training Reactor Newsletter Attention: Ms. Amber Johnson Dept of Materials Science and Engineering University of Maryland 4418 Stadium Drive College Park, MD 20742-2115 Manager Nuclear Programs Maryland Department of Natural Resources Tawes B-3 Annapolis, MD 21401 Colonel Mohammad Naeem, Director Armed Forces Radiobiology Research Institute 4301 Jones Bridge Road, Building 42 Bethesda, MD 20889-5648

ML21362A766 NRC-002 OFFICE NRR/DANU/UNPO NRR/DANU/UNPO OE/CRB NAME POBryan NParker NColeman DATE 12/29/2021 12/29/2021 1/4/2022 OFFICE OE/AT NRR/DRO/IRAB NRR/DANU/UNPO/BC NAME DWillis MKeefe-Forsyth TTate DATE 1/5/2022 1/5/2022 1/14/2022 U.S. NUCLEAR REGULATORY COMMISSION OFFICE OF NUCLEAR REACTOR REGULATION Docket No.: 50-170 License No.: R-84 Report No.: 05000170/2021203 Licensee: Armed Forces Radiobiology Research Institute Facility: Armed Forces Radiobiology Research Institute TRIGA Reactor Location: Bethesda, MD Dates: November 29-30, 2021 Inspectors: Phil OBryan Dori Willis Molly Keefe-Forsyth Nicole Coleman Approved by: Travis L. Tate, Chief Non-Power Production and Utilization Facility Oversight Branch Division of Advanced Reactors and Non-Power Production and Utilization Facilities Office of Nuclear Reactor Regulation Enclosure

EXECUTIVE

SUMMARY

Armed Forces Radiobiology Research Institute Research Reactor Facility U.S. Nuclear Regulatory Commission Inspection Report No. 05000170/2021203 The primary focus of this follow-up inspection included the onsite review of the Armed Forces Radiobiology Research Institute (AFRRI) safety culture and safety-conscious work environment (SCWE) in response to the Chilled Environment Letter issued to AFRRI on March 18, 2020. In addition, the inspectors reviewed the implementation of the AFRRIs actions taken as required by Confirmatory Order EA-20-056 (Order), which was issued November 19, 2020, in response to an AFRRI employee placed on a 2-day suspension without pay, in part, for engaging in protected activity. The inspectors found that the elements of the Order were implemented within the time constraints specified in the Order.

REPORT DETAILS The AFRRI Training, Research, Isotopes, General Atomics (TRIGA) research reactor normally operates in support of research, experiments, education, reactor operator training and periodic equipment surveillance. However, since March of 2018, the reactor has been shut down pending a reactor console modification.

1. Confirmatory Order EA-2020-056

a. Inspection Scope On March 18, 2020, the U.S. Nuclear Regulatory Commission (NRC) issued a letter informing AFRRI about concerns with the SCWE at AFRRI (Chilled Work Environment for Raising Concerns at the Armed Forces Radiobiology Research Institute EA-20-015, ADAMS Accession Number ML20070K841). The NRC concluded that AFRRI staff members were hesitant to raise nuclear safety concerns or regulatory issues to upper management at AFRRI because of their belief that AFRRI staff were retaliated against by upper management for raising these concerns. During the current inspection, the inspectors conducted SCWE interviews of fifteen employees from AFRRI, including a mix of military and civilian personnel, and managers, to determine (1) the willingness of the employees to raise nuclear concern to management at AFRRI; (2) whether they received training on SCWE; and (3) whether they were aware of the Employee Concerns Program. Inspectors also reviewed documents related to the Order.

On November 19, 2020, the NRC issued Confirmatory Order EA-2020-056 as a result of an agreement reached during an alternate dispute resolution (ADR) mediation session conducted in September 2020. The Order was issued in response to an NRC Office of Investigation that substantiated that an AFRRI employee was subjected to a 2-day suspension without pay, in part, for engaging in protected activity. As part of the ADR settlement agreement, the licensee committed to implement several actions associated with SCWE at the site.

b. Observations The inspectors reviewed the agreed upon elements of the Order and found them to be implemented as required by the Order and the elements were completed within the time constraints specified in the Order. The inspection included several documents associated with these elements, including a review of the AFRRI Nuclear Safety Culture (NSC) Policy Statement dated October 14, 2021, AFRRI Employee Concerns Program dated September 15, 2021, and the SCWE Program dated October 14, 2021.

The following is a description of those elements and a summary of the verifications that were performed by the inspectors.

Communication Within 60 calendar days of issuance of the Order, the Uniformed Services University (USU) President shall issue a written statement communicating the specific strategy to improve AFRRIs NSC.

The communication is to include (1) a brief summary regarding the employee protection regulations, (2) the NRCs concerns expressed in its March 18, 2020, chilling effect letter, (3) specific lessons learned from previously applied corrective actions, and (4) corrective actions both taken and planned.

USU shall provide a copy of this communication to the NRC for prior review.

NRC shall provide comments within 1 week of receipt of the draft communication.

Within 90 calendar days of the USU Presidents statement, AFRRI shall hold all-hands meetings for management to discuss the importance of the communication, described in the section above, with AFRRI employees.

AFRRI shall conduct the all-hands meetings on multiple levels of management (i.e., AFRRI Director, Department Heads), with current employees. AFRRI employees must attend at least one of the all-hands meetings.

AFRRI shall require participants to sign-in, confirming their attendance.

Employees unable to attend an in-person/virtual meeting, shall confirm their receipt of the communication by completing a Read and Sign.

Future AFRRI employees shall complete this requirement via a Read and Sign.

To verify proper implementation of the Order requirements related to communication, the inspectors: (1) reviewed the related written communications and their distribution, (2) reviewed minutes and attendance from AFRRIs all-hands meetings, (3) reviewed Read and Sign records, and (4) interviewed AFRRI employees. The inspectors determined that the agreed upon elements of the Order related to communication were implemented as required by the Order and all elements were completed within the time constraints specified in the Order.

Nuclear Safety Culture Within 150 calendar days of issuance of the Order, AFRRI shall ensure its NSC policy, guidance, and related materials are in place and updated.

AFRRI shall ensure that a distinct and comprehensive NSC Policy is updated and maintained, and is consistent with the NRCs June 14, 2011, Safety Culture Policy Statement and associated traits.

The NSC Policy shall include specific definitions for key safety culture terms, including examples of what constitutes a protected activity and safety/security concern(s).

The NSC Policy shall incorporate guidance from NUREG-2165, Safety Culture Common Language, and the industrys common language initiative (i.e., INPO 12-012, Revision 1, April 2013).

Copies of NSC Policy, guidance, and related materials shall be provided to the NRC for review at least 60 calendar days prior to issuance.

NRC will provide comments to AFRRI within 2 weeks of receipt of the document(s)/material(s).

Within 45 days of receiving communication that NRCs review is complete, AFRRI will either incorporate NRCs comments or provide acknowledgement of NRCs comments and state why NRCs comments were not incorporated.

AFRRI will distribute copies of the NSC Policy, guidance, and related materials to AFRRI employees and inform AFRRI employees how to access the documents and materials. These materials shall be maintained and provided to all new AFRRI employees during initial employee orientation.

AFRRI shall require both current and new AFRRI employees to confirm their receipt of the NSC Policy, guidance, and related materials by completing a Read and Sign.

SCWE Program Within 180 calendar days of issuance of the Order, AFRRI shall establish a nuclear SCWE program.

AFRRI shall ensure that the SCWE program is consistent with the NRC Safety Conscious Work Environment Policy Statement and associated guidance (i.e., NRCs May 14, 1996, policy statement Freedom of Employees in the Nuclear Industry to Raise Safety Concerns Without Fear of Retaliation, and the NRCs Regulatory Issue Summary 2005-18, Guidance for Establishing and Maintaining a Safety Conscious Work Environment).

Initial SCWE program documents (guidance and related materials) shall be provided to the NRC for review at 60 calendar days prior to issuance.

NRC will provide comments to AFRRI, within 2 weeks of receipt of the documents.

Within 45 days of receiving communication that NRCs review is complete, AFRRI will either incorporate NRCs comments or provide acknowledgement of NRCs comments and state why NRCs comments were not incorporated.

AFRRI will distribute copies of the SCWE program documents and materials to AFRRI employees and inform AFRRI employees how to access the documents and materials. These materials shall be maintained and provided to all new AFRRI employees during initial employee orientation.

AFRRI shall require both current and future AFRRI employees to confirm their receipt of the materials by completing a Read and Sign. Within the SCWE program, AFRRI shall document the requirements related to the Safety Culture Program Officer (Program Officer) to include the following:

1. The Program Officer function will report directly to the AFRRI Director.

2. The Program Officer shall complete specific training addressing topics such as intake of allegations/safety concerns and trending of concerns (e.g., National Association of Employee Concerns Professionals Employee Concerns Program basics course, or similar training). This training shall be completed within 180 days of designation as the Program Officer.

3. The Program Officer shall assist the AFRRI Director in management and execution of the SCWE program to include the intake and processing of reported safety concerns.

4. The Program Officer shall review AFRRI communications related to safety culture messaging and provide feedback.

5. The Program Officer shall encourage better communication between nuclear materials safety and security committees associated with AFRRI.

To verify proper implementation of the Order requirements related to AFRRIs NSC and SCWE program, the inspectors: (1) interviewed AFRRI employees, (2) reviewed AFRRIs NSC policy and SCWE program documents to verify content required by Order incorporated, (3) reviewed Read and Sign records, (4) reviewed training material completed by AFRRIs Safety Culture Program Officer, and (5) verified that that the Program Officer reports directly to the AFRRI Director. The inspectors determined that the agreed upon elements of the Order related to AFRRIs NSC policy and SCWE program were implemented as required by the Order and all elements were completed within the time constraints specified in the Order.

Training Within 210 calendar days of issuance of the Order, AFRRI shall develop and/or revise its employee protection, NSC and SCWE training for all AFRRI employees and supervisors.

Training shall include the following:

1. Case studies of discriminatory practices;

2. Definitions of key industry terms/common language;

3. Behavioral expectations with regard to each NSC trait as defined in NRCs June 14, 2011, Safety Culture Policy Statement;

4. Expectations for demonstrating support for raising nuclear safety concerns without fear of retaliation; and

5. A statement that all employees have the right to raise nuclear safety concerns to USU/AFRRI, the NRC and Congress, or engage in any other type of protected activity without disciplinary action or retaliation, as well as, providing a list of available reporting avenues.

Supervisory Training: In addition to the content areas described within the paragraph above, supervisory training shall also include expectations specific to the role of management and include discussion on (1) effectively managing safety concerns and (2) ensuring employees feel comfortable raising concerns. Additional supervisory training requirements include:

1. The supervisory training shall be conducted by either the independent third party organization hired to assist AFRRI, or AFFRI employees trained by the independent third-party organization.

2. The initial supervisory training shall be completed within 210 calendar days after the issuance of the Order.

3. AFRRI shall conduct instructor-led training for any new supervisors hired after the initial training, as part of the supervisors initial training.

4. Training records shall be retained for 4 years after the completion of applicable training and made available to the NRC upon request.

5. All training material shall be made available to the NRC upon request.

Employee (Non-Supervisory) Training: The initial AFRRI employee training described in the paragraph above shall be conducted by AFRRI employees trained by the team who developed the training. Additional non-supervisory training requirements include:

1. The initial AFRRI employee training shall be primarily instructor-led and all AFRRI employee training shall commence within 180 calendar days after the issuance of the Order.

2. All initial AFRRI employee training must be completed within 330 calendar days of the issuance of the Order.

3. All training material shall be made available to the NRC upon request.

The training described in the paragraphs above is applicable to all AFRRI employees and management who are engaged in work associated with NRC-regulated activities.

AFRRI shall provide all initial training materials to the NRC for review at least 60 calendar days prior to conducting training.

NRC will provide comments to AFRRI within 2 weeks of receipt of the documents.

Within 45 days of receiving communication that NRCs review is complete, AFRRI will either incorporate NRCs comments or provide acknowledgement of NRCs comments and state why NRCs comments were not incorporated.

To verify proper implementation of the Order requirements related to training, the inspectors: (1) reviewed the related training materials for content as required by the Order, (2) reviewed associated attendance records, and (3) interviewed AFRRI employees. The inspectors determined that the agreed upon elements of the Order related to the training requirements described within this document was implemented as required by the Order and all elements were completed within the time constraints specified in the Order.

Independent Third-Party Organization Within 120 calendar days of the issuance of the Order, AFRRI will hire an independent third-party organization to assist AFRRI with updates to its NSC Policy and the establishment of its SCWE program and associated tasks, as described within the Order. AFRRI may utilize the same organization as described in the paragraph above.

The independent third-party organization shall be unrelated to the proceedings at issue and experienced within NRC employee protection regulations, Section 211 of the Energy Reorganization Act, as amended, and NSC and SCWE policies/programs.

AFRRI shall receive assistance from the independent third-party organization for the following tasks:

1. Initial revisions/updates to AFRRIs NSC Policy to ensure that AFRRI guidance is consistent with NRC and industry guidance.

2. Establishment of AFRRIs SCWE program.

3. Development and implementation of AFRRIs initial NSC and SCWE program assessment.

AFRRI will ensure that the independent third-party organization is provided all materials to comprehensively assist AFRRI, including NRC inspection reports associated with AFRRIs SCWE and the March18, 2020, Chilling Effect Letter.

To verify proper implementation of the Order requirements related to an independent third-party organization, the inspectors: (1) reviewed acquisition documentation securing the independent third-party organization, (2) reviewed policy and program documents associated with the Order and supported by the independent third-party organization, and (3) interviewed AFRRI employees.

Work Process Within 270 calendar days of the issuance of the Order, AFRRI will develop a program for AFRRI employees to raise nuclear safety and security concerns.

The program shall include the following:

1. An electronic, telephonic or physical reporting mechanism for AFRRI employees to submit nuclear safety or security concerns.

This mechanism shall allow for both standard and anonymous submission capability.

2. A means to evaluate information collected through the available reporting mechanisms in order to analyze the data related to AFRRIs NSC over time.

3. A means to ensure AFRRIs NSC Policy, SCWE program, and associated guidance/materials are readily accessible for employee viewing.

4. The opportunity for departing AFRRI employees to participate in an exit interview/survey to facilitate identification of nuclear safety issues, resulting trends and conclusions.

To verify proper implementation of the Order requirements related to work processes, the inspectors: (1) interviewed AFRRI employees, (2) verified that AFRRI developed several reporting mechanisms for reporting nuclear safety or security concerns, and (3) reviewed documents and forms supporting the implementation of the Order requirements. The inspectors determined that AFRRI implemented an Employee Concerns Program and Safety Culture Committee in order to investigate employee concerns and develop actions to address the concerns, as required by the Order requirement Work Process.

The inspectors determined that AFRRI developed procedures for these programs and assigned a mix of military and civilian personnel to implement them to ensure that the programs were sustainable considering the turnover of the military personnel.

c. Conclusion The inspectors determined that all employees interviewed stated they would feel free to raise nuclear safety concerns through all avenues, and up and down the chain of command, without fear of retaliation. Based on AFRRIs progress to date in responding to the Order, inspectors found that AFRRIs actions to address existing SCWE issues have improved the environment for raising concerns, ensuring that individuals are permitted to pursue resolution of issues without fear of retaliation. Inspectors determined that AFRRI is implementing its SCWE program in accordance with the Order.

No findings of significance were identified and the conditions of the Order, inspected as described above, were met. The NRC will continue to monitor the work environment at AFRRI.

2. Exit Meeting The inspection scope and results were presented on November 30, 2021, to Lieutenant Colonel Brown and members of the AFRRI staff. No dissenting comments were received from the licensee.

PARTIAL LIST OF PERSONS CONTACTED Licensee Personnel COL M. Naeem Director, AFRRI LTC J. Brown AFRRI Chief of Staff LTC O. Makinde Director of AFRRI Radiation Science Department A. Cook Interim Reactor Facility Director INSPECTION PROCEDURES USED IP 93100 Safety-Conscious Work Environment Issue of Concern Follow-up IP 92702 Follow-Up on Traditional Enforcement Actions Including Violations, Deviations, Confirmatory Action Letters, and Orders ITEMS OPENED AND CLOSED None Attachment