Information Notice 1987-29, Recent Safety-Related Incidents at Large Irradiators: Difference between revisions
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| issue date = 06/26/1987 | | issue date = 06/26/1987 | ||
| title = Recent Safety-Related Incidents at Large Irradiators | | title = Recent Safety-Related Incidents at Large Irradiators | ||
| author name = Cunningham R | | author name = Cunningham R | ||
| author affiliation = NRC/NMSS/IMNS | | author affiliation = NRC/NMSS/IMNS | ||
| addressee name = | | addressee name = | ||
Line 13: | Line 13: | ||
| document type = NRC Information Notice | | document type = NRC Information Notice | ||
| page count = 6 | | page count = 6 | ||
}} | }} | ||
{{#Wiki_filter:X, | {{#Wiki_filter:X, v tC | ||
Attachment 2 IN 89-82 December 7, 1989 UNITED STATES | |||
NUCLEAR REGULATORY COMMISSION | |||
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS | |||
WASHINGTON, D. C. 20555 June 26, 1987 NRC INFORMATION NOTICE NO. 87-29: RECENT SAFETY-RELATED INCIDENTS AT | |||
LARGE IRRADIATORS | |||
==Addressees== | ==Addressees== | ||
:All NRC licensees authorized to possess and use sealed sources in | : | ||
All NRC licensees authorized to possess and use sealed sources in large | |||
irradiators. | |||
==Purpose== | ==Purpose== | ||
i--This notice is being issued to inform recipients of recent safety- | i-- | ||
This notice is being issued to inform recipients of recent safety-related | |||
incidents at large irradiators, which could have been prevented by proper | |||
management aictions and attention to preventative maintenance programs. It: | |||
is suggested that recipients review this information and their procedures | |||
and consider actions, if appropriate, to ensure both proper preventative | |||
maintenance programs and proper management actions at their facilities.- | |||
However, suggestions contained In this Information Notice do not constitute | |||
NRC requirements; therefore, no specific action or written response is required. | |||
==Description of Circumstances== | ==Description of Circumstances== | ||
:A description of each of six events is provided in Attachment 1. In summary,these events included:o hose failure resulting in a leak, failure to report the incident to NRC,and deliberate cover-up of this incident when NRC tried to investigate,leading to company fines and personnel probation;o intentional bypass of safety interlocks, resulting in'license | : | ||
A description of each of six events is provided in Attachment 1. In summary, these events included: | |||
o hose failure resulting in a leak, failure to report the incident to NRC, | |||
and deliberate cover-up of this incident when NRC tried to investigate, leading to company fines and personnel probation; | |||
o intentional bypass of safety interlocks, resulting in'license suspension | |||
and other enforcement actions by NRC; | |||
o improper pipe routing and inadequate piping material, which broke and | |||
caused partial loss of pool water; | |||
o source unable to retract to its fully shielded position, due to a frozen | |||
solenoid valve; | |||
o a stuck source plaque, due to failure to promptly replace a frayed lift | |||
cable; and | |||
o a stuck source plaque, due to interference from the product carriers and | |||
shroud. | |||
8706220303 | |||
IN 87-29 June 26, 1987 Discussion: | |||
These incidents illustrate a failure by management to assure that proper | |||
safety and maintenance procedures are followed. It is suggested that super- visory personnel, particularly the Radiation Protection Officer and maintenance | |||
personnel, be reminded of their responsibilities to assure safe operation at | |||
their facilities. The incidents discussed in Attachment 1 demonstrate the | |||
importance of: | |||
1. prompt reporting of incidents to the NRC, as required by regulations or | |||
license conditions | |||
2. safety training and periodic retraining of personnel | |||
3. not bypassing interlock systems or other safety systems | |||
4. attention to proper plumbing installation and use of appropriate piping | |||
material | |||
5. proper maintenance of cables, carrier systems, and other components that | |||
*could prevent radioactive sources from being retracted to a shielded | |||
position. | |||
No specific actions or written response is required by this Information | |||
Notice. If you have any questions about this matter, please contact the | |||
Regional Administrator of the appropriate NRC regional office or this office. | |||
Richard E. Cunningham, Director | |||
Division of Fuel Cycle, Medical, Academic, and Commercial Use Safety | |||
Office of Nuclear Material Safety | |||
and Safeguards | |||
===Technical Contact:=== | ===Technical Contact:=== | ||
=== | ===Bruce Carrico, K1SS=== | ||
1. Events That Occurred at Large Irradiator | (301) 427-4280 | ||
$ | Attachments: | ||
* Operating | 1. Events That Occurred at Large Irradiator Facilities | ||
* Construction | |||
2. List of Recently Issued NRC Information Notices | |||
Attachment 2 IN 89-82 December 7, 1989 Attachment I | |||
IN 87-29 June 26, 1987 EVENTS THAT OCCURRED AT LARGE IRRADIATOR FACILITIES | |||
1. While the licensee was attempting to decontaminate pool water because of | |||
a leaking source, a hose on a filtration system ruptured. Contaminated | |||
pool water was then pumped onto the facility floor and leaked outside into | |||
the surrounding soil. The licensee failed to report the incident to NRC, | |||
and made deliberate efforts to prevent NRC's discovery of this incident. | |||
"Subsequently, the licensee was indicted by a Federal Court. *Aconviction | |||
resulted in a $35,000 fine for the company and two years probation for a | |||
management employee. Licensee failure to make required reports prevents | |||
the HRC from performing its radiological health and safety function and | |||
from making a timely assessment of the nature and severity of an incident. | |||
2. A licensee deliberately bypassed the safety interlock systems. The NRC | |||
subsequently learned that licensee personnel had willfully violated | |||
requirements, and that senior licensee management knew, or should have | |||
known, of these violations. When NRC attempted to inspect and investigate | |||
these suspected violations, senior licensee management knowingly provided | |||
false information to the NRC. Subsequent enforcement action included | |||
suspension of the license. | |||
3. A water line fractured in the pool circulation system which resulted in | |||
the loss of 5 feet of pool water. The line break led to a loss of | |||
shielding water because the intake and outlet pipes were misaligned | |||
during maintenance. The pipe break appears to have occurred because | |||
the pipe was made of polyvinyl chloride, designed for cold water, rather | |||
than for the heated water temperatures typical for the irradiator. The | |||
piping was replaced with polypropylene pipe. | |||
4. A night shift operator noticed that the travel time for the source to | |||
reach the fully unshielded position was excessive. After completing | |||
the next phase of irradiation, the source would not retract to the fully | |||
shielded position, even using emergency equipment. The operator discovered | |||
that the solenoid valve, that was supposed to retract the source to a | |||
shielded position, was frozen due to weather conditions. The valve was | |||
in a room above the irradiator facility. The operator went there and | |||
turned on a room heater to thaw out the valve so that it would operate. | |||
The operator violated license requirements to (1) notify the Radiation | |||
Safety Officer (RSO) that the source had not returned to Its shielded | |||
position because of the frozen valve, and (2)obtain RSO permission to | |||
enter and heat the room housing the valve. | |||
5. A licensee had identified a frayed lift cable a few days previously, but | |||
instead of immediately replacing the cable, the licensee decided to wait | |||
for scheduled maintenance. The cable Jammed and froze the source plaque | |||
in a less than fully shielded position. Employees cut the cables and let | |||
the source plaque free-fall into the pool. The incident could have been | |||
prevented by replacing the frayed cable imuediately, and selecting cable | |||
material with fray-resistant qualities. | |||
Attachment 2 IN 89-82 December 7, 1989 6. A source plaque became stuck In the exposed position. Conveyors stopped, | |||
'.A :ojirce DOWN 'ight came on, but cell radiation levels remained high. | |||
Cable slack data indicated that the plaque was stuck about five and a half | |||
feet down from its full-up position. The RSO attempted some raising and | |||
lowering maneuvers, but the plaque then stuck in a full-up position. The | |||
RSO, able to run the product containers out of the cell, saw some were | |||
misaligned on the carrier. The RSO notified a State Inspector, who arrived | |||
in the afternoon. It was determined that the plaque cable was off its pulley. | |||
The bottom of a splice in the cable was resting on the lip of the tube | |||
leading to the cell. After the cable was set on its pulley, the cable was | |||
guided through the tube, and the plaque was lowered, until it caught again. | |||
--A borrowed radiation-resistant camera arrived the next morning. An adequate | |||
view of the plaque was obtained by midnight. Apparently the stationary | |||
aluminum shroud between product containers and plaque had been deflected | |||
and caught on the plaque frame. The plaque was carefully raised and dropped | |||
to break the Jam. On the second try, the plaque broke free and dropped | |||
into the pool. Analysis revealed that a product container had probably | |||
tipped onto the shroud, causing interference with the plaque. | |||
This incident was apparently caused by inadequate design of the shroud. | |||
This led to the shroud deforming, which interfered with plaque motion. | |||
Inadequate maintenance contributed to the problem. The cable should | |||
have been replaced instead of spliced. A few months later, the entire | |||
source hoist mechanism failed and had to be replaced. This failure oc- | |||
*curred when the source plaque was submerged. | |||
Attachment 2 IN 89-82 December 7, 1989 -2- | |||
$ I | |||
Attachment 3 IN 89-82 December 7, 1989 LIST OF RECENTLY ISSUED | |||
NMSS INFORMATION NOTICES | |||
Information Date of | |||
Notice No. Subject Issuance Issued to | |||
89-78 Failure of Packing Nuts on 11/22/89 All U.S. NRC licensees | |||
One-Inch Uranium Hexafluoride authorized to possess | |||
Cylinder Valves and use source material | |||
and/or special nuclear | |||
material for the heating, emptying, filling, or | |||
shipping of uranium | |||
hexafluoride in 30- and | |||
48-inch diameter cylinders. | |||
89-60 Maintenance of Teletherapy 08/18/89 All U.S. NRC Medical | |||
Units Teletherapy Licensees. | |||
89-47 Potential Problems with 05/18/89 All holders of operating | |||
Worn or Distorted Hose licenses or construction | |||
Clamps on Self-Contained permits for nuclear power | |||
Breathing Apparatus reactors and fuel | |||
facilities. | |||
89-46 Confidentiality of 05/11/89 All holders of licenses | |||
Exercise Scenarios for fuel cycle facilities | |||
and byproduct material | |||
licensees having an | |||
approved emergency | |||
response plan. | |||
89-37 Proposed Amendments to 40 04/04/89 All U.S. NRC licensees. | |||
CFR Part 61, Air Emission | |||
Standards for Radionuclides | |||
89-35 Loss and Theft of Unsecured 03/30/89 All U.S. NRC byproduct, Licensed Material source and special | |||
nuclear material licensees. | |||
89-34 Disposal of Americium 03/30/89 All holders of U.S. NRC | |||
Wel1-Logging Sources specific licenses | |||
authorizing well-logging | |||
activities. | |||
89-25 Unauthorized Transfer of 03/07/89 All NRC source, byproduct, Ownership or Control of and special nuclear | |||
Licensed Activities material licensees. | |||
t . a | |||
4 Attachment 4 IN 89-82 December 7, 1989 Page 1 of I | |||
LIST OF RECENTLY ISSUED | |||
NRC INFORMATION NOTICES | |||
--- e -- | |||
DJAWOf | |||
Inrormaliw | |||
001_____. <_ | |||
Subject Issuance Issued to | |||
Notice No. | |||
89-59, Suppliers of Potentially 12/6/89 All holders of OLs | |||
Supp. I Misrepresented Fasteners or CPs for nuclear | |||
power reactors. | |||
899C1 Inadequate Control af 12/6/89 All holders of OLs | |||
Temporary Modifications or CPs for nuclear | |||
to Safety-Related Systems power reactors. | |||
89-80 Potential for Wdater Hanmre 12/1/89 All holders of OLs | |||
Thermal Stratification, and or CPs for nuclear | |||
Steam Sinding in High- power reactors. | |||
Pressure Coolant Injection | |||
Piping | |||
89-79 Degraded Coatings and 12/1/89 All holders of OLs | |||
Corrosion of Steel or CPs for LkRs. | |||
Containment Vessels | |||
89-56, Questionable Certification 11/22/89 All holders of OLs | |||
Supp. 1 of Material Supplied to or CPs for nuclear | |||
the Defense Department power reactors. | |||
by Nuclear Suppliers | |||
89-78 Failure of Packing Nuts 11/22/89 All NRClicensees | |||
on One-Inch Uranium authorized to possess | |||
Hexafluoride Cylinder and use source material | |||
Valves and/or special nuclear | |||
material for the heating, emptying, filling, or | |||
shipping of uranium | |||
hexafluoride In 30- | |||
and 48-inch diameter | |||
cylinders. | |||
89-77 Debris in Containment 11/21/89 All holders of OLs | |||
Emergency Sumps and or CPs for PURs. | |||
Incorrect Screen | |||
Configurations | |||
89-76 Biofouling Agent: Zebra 11/21/89 All holders of OLs | |||
1Nussel or CPs for nuclear | |||
power reactors. | |||
OL | |||
* Operating License | |||
CP | |||
* Construction Permit | |||
UNITED STATES PIRST CLASS MAIL | |||
IPOSTAGE & FEES PAID | |||
NUCLEAR REGULATORY COMMISSION USNAC | |||
WASHINGTON, D.C. 20555 PERMIT No. 0 p | |||
OFFICIAL BUSINESS | |||
PENALTY FOR PRIVATE USE, 5300 | |||
-U Sup SvCs -' -. 4 1 A HVCS SVCS SECT | |||
OC 20555}} | |||
{{Information notice-Nav}} | {{Information notice-Nav}} |
Latest revision as of 03:30, 24 November 2019
ML031190114 | |
Person / Time | |
---|---|
Issue date: | 06/26/1987 |
From: | Cunningham R NRC/NMSS/IMNS |
To: | |
References | |
IN-87-029, NUDOCS 8706220303 | |
Download: ML031190114 (6) | |
X, v tC
Attachment 2 IN 89-82 December 7, 1989 UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, D. C. 20555 June 26, 1987 NRC INFORMATION NOTICE NO. 87-29: RECENT SAFETY-RELATED INCIDENTS AT
LARGE IRRADIATORS
Addressees
All NRC licensees authorized to possess and use sealed sources in large
irradiators.
Purpose
i--
This notice is being issued to inform recipients of recent safety-related
incidents at large irradiators, which could have been prevented by proper
management aictions and attention to preventative maintenance programs. It:
is suggested that recipients review this information and their procedures
and consider actions, if appropriate, to ensure both proper preventative
maintenance programs and proper management actions at their facilities.-
However, suggestions contained In this Information Notice do not constitute
NRC requirements; therefore, no specific action or written response is required.
Description of Circumstances
A description of each of six events is provided in Attachment 1. In summary, these events included:
o hose failure resulting in a leak, failure to report the incident to NRC,
and deliberate cover-up of this incident when NRC tried to investigate, leading to company fines and personnel probation;
o intentional bypass of safety interlocks, resulting in'license suspension
and other enforcement actions by NRC;
o improper pipe routing and inadequate piping material, which broke and
caused partial loss of pool water;
o source unable to retract to its fully shielded position, due to a frozen
solenoid valve;
o a stuck source plaque, due to failure to promptly replace a frayed lift
cable; and
o a stuck source plaque, due to interference from the product carriers and
shroud.
8706220303
IN 87-29 June 26, 1987 Discussion:
These incidents illustrate a failure by management to assure that proper
safety and maintenance procedures are followed. It is suggested that super- visory personnel, particularly the Radiation Protection Officer and maintenance
personnel, be reminded of their responsibilities to assure safe operation at
their facilities. The incidents discussed in Attachment 1 demonstrate the
importance of:
1. prompt reporting of incidents to the NRC, as required by regulations or
license conditions
2. safety training and periodic retraining of personnel
3. not bypassing interlock systems or other safety systems
4. attention to proper plumbing installation and use of appropriate piping
material
5. proper maintenance of cables, carrier systems, and other components that
- could prevent radioactive sources from being retracted to a shielded
position.
No specific actions or written response is required by this Information
Notice. If you have any questions about this matter, please contact the
Regional Administrator of the appropriate NRC regional office or this office.
Richard E. Cunningham, Director
Division of Fuel Cycle, Medical, Academic, and Commercial Use Safety
Office of Nuclear Material Safety
and Safeguards
Technical Contact:
Bruce Carrico, K1SS
(301) 427-4280
Attachments:
1. Events That Occurred at Large Irradiator Facilities
2. List of Recently Issued NRC Information Notices
Attachment 2 IN 89-82 December 7, 1989 Attachment I
IN 87-29 June 26, 1987 EVENTS THAT OCCURRED AT LARGE IRRADIATOR FACILITIES
1. While the licensee was attempting to decontaminate pool water because of
a leaking source, a hose on a filtration system ruptured. Contaminated
pool water was then pumped onto the facility floor and leaked outside into
the surrounding soil. The licensee failed to report the incident to NRC,
and made deliberate efforts to prevent NRC's discovery of this incident.
"Subsequently, the licensee was indicted by a Federal Court. *Aconviction
resulted in a $35,000 fine for the company and two years probation for a
management employee. Licensee failure to make required reports prevents
the HRC from performing its radiological health and safety function and
from making a timely assessment of the nature and severity of an incident.
2. A licensee deliberately bypassed the safety interlock systems. The NRC
subsequently learned that licensee personnel had willfully violated
requirements, and that senior licensee management knew, or should have
known, of these violations. When NRC attempted to inspect and investigate
these suspected violations, senior licensee management knowingly provided
false information to the NRC. Subsequent enforcement action included
suspension of the license.
3. A water line fractured in the pool circulation system which resulted in
the loss of 5 feet of pool water. The line break led to a loss of
shielding water because the intake and outlet pipes were misaligned
during maintenance. The pipe break appears to have occurred because
the pipe was made of polyvinyl chloride, designed for cold water, rather
than for the heated water temperatures typical for the irradiator. The
piping was replaced with polypropylene pipe.
4. A night shift operator noticed that the travel time for the source to
reach the fully unshielded position was excessive. After completing
the next phase of irradiation, the source would not retract to the fully
shielded position, even using emergency equipment. The operator discovered
that the solenoid valve, that was supposed to retract the source to a
shielded position, was frozen due to weather conditions. The valve was
in a room above the irradiator facility. The operator went there and
turned on a room heater to thaw out the valve so that it would operate.
The operator violated license requirements to (1) notify the Radiation
Safety Officer (RSO) that the source had not returned to Its shielded
position because of the frozen valve, and (2)obtain RSO permission to
enter and heat the room housing the valve.
5. A licensee had identified a frayed lift cable a few days previously, but
instead of immediately replacing the cable, the licensee decided to wait
for scheduled maintenance. The cable Jammed and froze the source plaque
in a less than fully shielded position. Employees cut the cables and let
the source plaque free-fall into the pool. The incident could have been
prevented by replacing the frayed cable imuediately, and selecting cable
material with fray-resistant qualities.
Attachment 2 IN 89-82 December 7, 1989 6. A source plaque became stuck In the exposed position. Conveyors stopped,
'.A :ojirce DOWN 'ight came on, but cell radiation levels remained high.
Cable slack data indicated that the plaque was stuck about five and a half
feet down from its full-up position. The RSO attempted some raising and
lowering maneuvers, but the plaque then stuck in a full-up position. The
RSO, able to run the product containers out of the cell, saw some were
misaligned on the carrier. The RSO notified a State Inspector, who arrived
in the afternoon. It was determined that the plaque cable was off its pulley.
The bottom of a splice in the cable was resting on the lip of the tube
leading to the cell. After the cable was set on its pulley, the cable was
guided through the tube, and the plaque was lowered, until it caught again.
--A borrowed radiation-resistant camera arrived the next morning. An adequate
view of the plaque was obtained by midnight. Apparently the stationary
aluminum shroud between product containers and plaque had been deflected
and caught on the plaque frame. The plaque was carefully raised and dropped
to break the Jam. On the second try, the plaque broke free and dropped
into the pool. Analysis revealed that a product container had probably
tipped onto the shroud, causing interference with the plaque.
This incident was apparently caused by inadequate design of the shroud.
This led to the shroud deforming, which interfered with plaque motion.
Inadequate maintenance contributed to the problem. The cable should
have been replaced instead of spliced. A few months later, the entire
source hoist mechanism failed and had to be replaced. This failure oc-
- curred when the source plaque was submerged.
Attachment 2 IN 89-82 December 7, 1989 -2-
$ I
Attachment 3 IN 89-82 December 7, 1989 LIST OF RECENTLY ISSUED
NMSS INFORMATION NOTICES
Information Date of
Notice No. Subject Issuance Issued to
89-78 Failure of Packing Nuts on 11/22/89 All U.S. NRC licensees
One-Inch Uranium Hexafluoride authorized to possess
Cylinder Valves and use source material
and/or special nuclear
material for the heating, emptying, filling, or
shipping of uranium
hexafluoride in 30- and
48-inch diameter cylinders.
89-60 Maintenance of Teletherapy 08/18/89 All U.S. NRC Medical
Units Teletherapy Licensees.
89-47 Potential Problems with 05/18/89 All holders of operating
Worn or Distorted Hose licenses or construction
Clamps on Self-Contained permits for nuclear power
Breathing Apparatus reactors and fuel
facilities.
89-46 Confidentiality of 05/11/89 All holders of licenses
Exercise Scenarios for fuel cycle facilities
and byproduct material
licensees having an
approved emergency
response plan.
89-37 Proposed Amendments to 40 04/04/89 All U.S. NRC licensees.
CFR Part 61, Air Emission
Standards for Radionuclides
89-35 Loss and Theft of Unsecured 03/30/89 All U.S. NRC byproduct, Licensed Material source and special
nuclear material licensees.
89-34 Disposal of Americium 03/30/89 All holders of U.S. NRC
Wel1-Logging Sources specific licenses
authorizing well-logging
activities.
89-25 Unauthorized Transfer of 03/07/89 All NRC source, byproduct, Ownership or Control of and special nuclear
Licensed Activities material licensees.
t . a
4 Attachment 4 IN 89-82 December 7, 1989 Page 1 of I
LIST OF RECENTLY ISSUED
NRC INFORMATION NOTICES
--- e --
DJAWOf
Inrormaliw
001_____. <_
Subject Issuance Issued to
Notice No.
89-59, Suppliers of Potentially 12/6/89 All holders of OLs
Supp. I Misrepresented Fasteners or CPs for nuclear
power reactors.
899C1 Inadequate Control af 12/6/89 All holders of OLs
Temporary Modifications or CPs for nuclear
to Safety-Related Systems power reactors.
89-80 Potential for Wdater Hanmre 12/1/89 All holders of OLs
Thermal Stratification, and or CPs for nuclear
Steam Sinding in High- power reactors.
Pressure Coolant Injection
Piping
89-79 Degraded Coatings and 12/1/89 All holders of OLs
Corrosion of Steel or CPs for LkRs.
Containment Vessels
89-56, Questionable Certification 11/22/89 All holders of OLs
Supp. 1 of Material Supplied to or CPs for nuclear
the Defense Department power reactors.
by Nuclear Suppliers
89-78 Failure of Packing Nuts 11/22/89 All NRClicensees
on One-Inch Uranium authorized to possess
Hexafluoride Cylinder and use source material
Valves and/or special nuclear
material for the heating, emptying, filling, or
shipping of uranium
hexafluoride In 30-
and 48-inch diameter
cylinders.
89-77 Debris in Containment 11/21/89 All holders of OLs
Emergency Sumps and or CPs for PURs.
Incorrect Screen
Configurations
89-76 Biofouling Agent: Zebra 11/21/89 All holders of OLs
1Nussel or CPs for nuclear
power reactors.
- Operating License
- Construction Permit
UNITED STATES PIRST CLASS MAIL
IPOSTAGE & FEES PAID
NUCLEAR REGULATORY COMMISSION USNAC
WASHINGTON, D.C. 20555 PERMIT No. 0 p
OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE, 5300
-U Sup SvCs -' -. 4 1 A HVCS SVCS SECT
OC 20555