ML23062A707
| ML23062A707 | |
| Person / Time | |
|---|---|
| Issue date: | 10/02/2000 |
| From: | Charlton M, Emery R, Hernandez M, Orders A Office of Nuclear Material Safety and Safeguards, Univ of Texas |
| To: | |
| Shared Package | |
| ML23062A719 | List: |
| References | |
| Download: ML23062A707 (25) | |
Text
Getting to the Root Causes of Non-Compliance:
A Prescription for Prevention Robert Emery, Dr.P.H., CHP, CIH, CSP, RBP University of Texas-Houston Health Science Center Michael Charlton, MS, MPH, CHP, CHMM University of Texas Health Science Center-San Antonio Amy Orders, MS, RT University of Texas-Houston Health Science Center Mike Hernandez, Graduate Biometry Student University of Texas-Houston School of Public Health
Objectives To emphasize how stakeholders really evaluate radiation safety programs and the important role compliance plays in this assessment To objectively identify the common violations issued to permit holders in Texas Show how this data can be put to use for prevention by identifying the root causes of non-compliance Make you an offer you cant refuse!
Health and Safety Outcome Measures Systemic: ultimate program outcomes number of injuries, illnesses, fatalities OSHA 200 log or equivalent Organic: indicators of program design and implementation numbers of unsafe conditions, practices, behaviors, attitudes regulatory compliance
A Word About Inspections (to the regulated community)
The public and the radiation safety profession benefit from the compliance inspection process.
These works are intended to make permit holders aware of the common deficiencies, so they can be avoided.
This should not be done to the exclusion of other important safety tasks!
Licensees: Top Ten Violations 1988-1997 Procedures 11% Inventories 6%
Absent surveys 10% Transfer records 6%
Leak testing 8% Disposal records 4%
Personnel monitoring 7% Main program 4%
Instrument calibration 7% Training 2%
Total 65%
Annual Top Ten Varied from 55% to 75% of all NOVs
15.0%
Percent of All Violations Issued 10.0%
20.0% 25.0%
0.0% 5.0%
Procedures Surveys Not Done Leak Tests Not Done Monitoring Records Licensee: Top Ten Violations By Year Calibration Exceeded Inventory/Use Log Transfer Records Surveys/Disposal Records Insp./Main. Not Done Training 1997 1994 1991 1988 Year 1988-1997
Licensee NOVs by Regulatory Citation: 25 TAC 289 202(e) Radiation protection program 17%
201(g) Sealed source leak test 16%
202(p) Surveys and monitoring 11%
201(o) General public dose limits 8%
201(d) Receipt, transfer,disposal records 8%
Top five account for 60% of total, based on 1999 data.
Licensee Violations Severity Level Distribution 1988-1997 Severity Level I Severity Level II 1%
4%
Educational Value Figure 2: Summary of overexposure and total incidents reported to the Texas Department of Health, Bureau of Radiation Control from 1988 to 1997.
300 279 264 267 256 1994 - Revision of 250 regulations (10CFR20).
206 Number of Events 200 201 190 168 164 Overexposure 150 131 Total Incidents 100 100 101 78 83 78 73 50 39 16 10 15 0
1986 1988 1990 1992 1994 1996 1998 Year
Educational Value Educational Value Educational Value What Does All This Cost?
Estimating the administrative cost to the BRC associated with the issuance of violations:
baseline cost of inspection process some added cost to issue and resolve NOVs if this added cost could be estimated, then reductions through education could be quantified Cost to the permit holders not included, but equally important
Estimating the Cost
$100,000.00 2
R = 0.8014
$90,000.00
$80,000.00 Derived Administrative Costs
$70,000.00
$60,000.00 Registrants
$50,000.00
$40,000.00
$30,000.00
$20,000.00 Licensees
$10,000.00
$0.00 0 2000 4000 6000 8000 10000 12000 14000 16000 Number of Violations
The EU (Emery Unit)!
Administrative dollars per NOV saved, at STP
The Next Step: Root Cause Analysis Ex: Sealed Source Leak Test NOV Problem Root Cause Done or not done Failure to execute Ever? Or not at proscribed frequency? Frequency Time frame based on Violation of regulation permit condition or or permit condition regulation?
Documentation Completeness incomplete?
Found leaking, but not reported? Inappropriate actions
Fault Tree Analysis:
Sealed Source Leak Test NOV SEALED SOURCE LEAK TEST NOTICE OF VIOLATION OR VIOLATION OF VIOLATION OF PERMIT REGULATION CONDITION OR OR FAILURE TO EXECUTE DOCUMENTATION FREQUENCY ACTIONS FAILURE TO EXECUTE DOCUMENTATION FREQUENCY ACTIONS OR OR OR OR PERFORMED FOUND PERFORMED FOUND PERFORMED BUT NOT FULLY PERFORMED LEAKING:NOT FOUND PERFORMED BUT NOT FULLY PERFORMED LEAKING:NOT FOUND TASK NOT BUT NOT AT LEAKING: TASK NOT BUT NOT AT LEAKING:
BUT NOT DOCUMENTED/ POSTED OR BUT NOT DOCUMENTED/ POSTED OR PERFORMED DOCUMENTED INCORRECTLY REQUIRED TAKEN OUT OF AUTHORITIES PERFORMED DOCUMENTED INCORRECTLY REQUIRED TAKEN OUT OF AUTHORITIES FREQUENCY NOT NOTIFIED FREQUENCY NOT NOTIFIED DOCUMENTED SERVICE DOCUMENTED SERVICE
Fault Tree Analysis:
Sealed Source Leak Test NOV VIOLATION OF REGULATION OR FAILURE TO EXECUTE DOCUMENTATION FREQUENCY ACTIONS OR OR PERFORMED FOUND PERFORMED FOUND PERFORMED BUT NOT FULLY LEAKING:NOT TASK NOT BUT NOT AT LEAKING:
BUT NOT DOCUMENTED/ POSTED OR PERFORMED REQUIRED AUTHORITIES DOCUMENTED INCORRECTLY TAKEN OUT OF FREQUENCY NOT NOTIFIED DOCUMENTED SERVICE
Results of Analysis INAPPROPRIATE OTHER ONLY ACTIONS ONLY 2% 5%
FAILURE TO EXECUTE FAILURE TO AND INAPPROPRIATE EXECUTE AND ACTIONS OTHER 7%
FAILURE TO EXECUTE AND COMPLETENESS 7%
FAILURE TO EXECUTE 34%
FAILURE TO EXECUTE FAILURE TO AND FREQUENCY EXECUTE 43%
TOTAL 93%
Implications Consider the findings within the context of the regulators common plea: read your permit!
Do the permit holders really know what they are supposed to do?
What can be done to improve compliance?
create summaries of requirements inherent to permits and their identified regulations?
modify the way RSOs are trained?
re-structure permit inspection process?
What About Other States?
Are the trends shown here consistent?
Are the root causes consistent?
Could there be some basic, simple interventions?
Proposal to OAS To facilitate comparisons, heres the deal:
identify number of licensees and average number of NOVs per permit inspection well calculate an appropriate sample size and sampling strategy you get the coding forms completed we (grad student) will summarize and analyze as their research project findings provided to you and OAS
We Need to Stress That Were All in the Same Pool!
By any measure, the radiation safety record is excellent!
This success is due in part to the inspection process:
hate it or love it, it benefits all.
NOV outcome data can be valuable for prevention Emphasize the common goal and work together to achieve it!
References Emery, R.J., Johnston, T.P., Sprau, D.D., "Simple Physical, Chemical, and Biological Safety Assessments as Part of a Routine Institutional Radiation Safety Survey Program" Health Physics , Vol. 69, No. 2, pp. 278-280, 1995.
Emery, R.J., Sawyer, R.L., Sprau, D.D., "Assessing the Service Provided by an Institutional Radiation Safety Survey Program" Health Physics , Vol.
70, No. 5, pp. 741-743, 1996.
Emery, R.J., Savely, S., "The Benefits of Actively Soliciting Worker Concerns During Routine Safety Inspections" Professional Safety, Vol. 42, No. 7, 36-38, 1997.
Emery, R.J., Pollock, J., Charlton, M., "Notices of Violation Issued to Texas Radioactive Material Licensees Inspected in 1995", Health Physics, Vol. 73, No. 4, 706-709, 1997.
References (cont)
Emery, R.J., "Adding Value to Your Radiation Protection Program", chapter in Management and Administration of Radiation Safety Programs, Medical Physics Publishing, Madison, WI. 1998.
Emery, R.J., Charlton, M.A., Assessing the Results of Receipt Monitoring Programs for Packages Containing Radioactive Materials Operational Radiation Safety, Vol. 77, (Health Physics Supplement 1) S5-S9, 1999.
Emery, R.J., Charlton, M.A., Goodman, G.R., Texas Radiation Safety Program Outcomes as Indicated by Regulatory Compliance Activities from 1988 to 1997 Health Physics, Vol. 78, No. 3, 335-342, 2000.
Emery, R.J., Charlton, M.A., Mathis, J.L, "Estimating the Administrative Cost of Regulatory Noncompliance: A Pilot Method for Quantifying the Value of Prevention", Operational Radiation Safety , Vol. 78 (Health Physics Supplement 2)S40-S47; 2000.