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| | issue date = 06/11/1996 | | | issue date = 06/11/1996 |
| | title = Failure of Safety Systems on Self-Shielded Irradiators Because of Inadequate Maintenance and Training | | | title = Failure of Safety Systems on Self-Shielded Irradiators Because of Inadequate Maintenance and Training |
| | author name = Cool D A | | | author name = Cool D |
| | author affiliation = NRC/NMSS/IMNS | | | author affiliation = NRC/NMSS/IMNS |
| | addressee name = | | | addressee name = |
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| | document type = NRC Information Notice | | | document type = NRC Information Notice |
| | page count = 8 | | | page count = 8 |
| | revision = 0
| |
| }} | | }} |
| {{#Wiki_filter:UNITED STATESNUCLEAR REGULATORY COMMISSIONOFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDSWASHINGTON, D.C. 20555June 11, 1996NRC INFORMATION NOTICE 96-35: FAILURE OF SAFETY SYSTEMS ON SELF-SHIELDEDIRRADIATORS BECAUSE OF INADEQUATE MAINTENANCEAND TRAINING | | {{#Wiki_filter:UNITED STATES |
| | |
| | NUCLEAR REGULATORY COMMISSION |
| | |
| | OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS |
| | |
| | WASHINGTON, D.C. 20555 June 11, 1996 NRC INFORMATION NOTICE 96-35: FAILURE OF SAFETY SYSTEMS ON SELF-SHIELDED |
| | |
| | IRRADIATORS BECAUSE OF INADEQUATE MAINTENANCE |
| | |
| | AND TRAINING |
|
| |
|
| ==Addressees== | | ==Addressees== |
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| |
|
| ==Purpose== | | ==Purpose== |
| The U.S. Nuclear Regulatory Commission (NRC) is issuing this informationnotice (IN) to alert addressees to two incidents where safety interlocks onself-shielded irradiators (Category I) failed to prevent inadvertent exposure.The causes of these exposures stemmed from a lack of appropriate maintenanceand/or worker training. The incidents include a broken spring -- possiblycausing malfunction of the safety interlock -- and a worker who intentionallybypassed a safety interlock. It is expected that recipients will review theinformation for applicability to their facilities and consider actions, asappropriate, to avoid similar problems. However, suggestions contained inthis information notice are not NRC requirements; therefore, no specificaction nor written response is required. | | The U.S. Nuclear Regulatory Commission (NRC) is issuing this information |
| | |
| | notice (IN)to alert addressees to two incidents where safety interlocks on |
| | |
| | self-shielded irradiators (Category I) failed to prevent inadvertent exposure. |
| | |
| | The causes of these exposures stemmed from a lack of appropriate maintenance |
| | |
| | and/or worker training. The incidents include a broken spring -- possibly |
| | |
| | causing malfunction of the safety interlock -- and a worker who intentionally |
| | |
| | bypassed a safety interlock. It is expected that recipients will review the |
| | |
| | information for applicability to their facilities and consider actions, as |
| | |
| | appropriate, to avoid similar problems. However, suggestions contained in |
| | |
| | this information notice are not NRC requirements; therefore, no specific |
| | |
| | action nor written response is required. |
|
| |
|
| ==Description of Circumstances== | | ==Description of Circumstances== |
| The first incident occurred when an operator may have been able to open theshielded door of an irradiator with the sources in the exposed position.After irradiation of several pocket dosimeters, the operator opened theshielded door of the irradiator to retrieve the dosimeters, but did notperform a radiation survey, as required by the facility's internal procedures,before opening the door. Twice, the operator placed one hand inside theirradiator to retrieve the dosimeters. Subsequently, the operator observedthat the unit timer continued to count, indicating that the sources remainedin the exposed position. The operator checked his personal pocket dosimeter,but did not note an unusual reading. However, the operator did not report theincident until questioned by the radiation safety officer, who had noted anunusually high dosimetry report of 3.55 millisievert (355 mrem) deep doseequivalent for the worker. The dose to the right hand was calculated to be amaximum of 12.5 millisievert (1.25 rem).The design of the irradiator includes two interconnected interlock systems,intended to prevent unshielded exposure of the sources. These include a doorinterlock system -- designed to allow opening of the shielded door only afterthe sources are placed in the fully shielded position -- and a source exposure-.interlock system -- designed to secure the sources in the fully shieldedtDR FE E NO r/C9 03 ?C 0t, II kk JIIN 96-35June 11, 1996 position whenever the shielded door is open or unlocked. The manufacturer ofthe irradiator indicated that under normal operations, either systemindividually wouldiprevent inadvertent access to the unshielded sources.Following the incident, the manufacturer of the irradiator was requested toperform an onsite inspection of the irradiator and facilities. During theinspection, the manufacturer noted:(1) the irradiator was located in an area that was not climate-controlled;(2) internal components of the irradiator were in a degraded state;(3) maintenance of the irradiator had last been performed approximately10 years ago; and(4) a return spring, integral to the source exposure safety interlocksystem, was broken. The manufacturer indicated that the lack ofenvironmental control may have accelerated the degradation of theinternal components of the irradiator, and that the lack of periodicmaintenance of the irradiator may have contributed to the failure ofthe return spring.The broken return spring may have caused the source securing mechanism of thesource exposure interlock system to malfunction, possibly allowing exposure ofthe sources after the shielded door was unlocked and opened. However, duringthe post-incident investigation, neither the manufacturer nor the licenseewere able to identify a failed component of either interlock system that couldhave allowed the shielded door to be opened with the sources in the exposedposition. The manufacturer indicated that the design of the source exposuremechanism -- the operator must manually move the sources from the shielded tothe exposed position with a lever -- would have provided the operator with apositive indication of source position even if the interlock systems failed.Source position would have been further provided by a series of green and redsource position lights on the irradiator.The operator's actions indicate either a lack of training on the properfunctioning and use of the irradiator, a lack of understanding of the trainingprovided, and/or a disregard for following the established operating andsafety procedures. The operator indicated that the timer continued to countwhen the shielded door was opened. However, the manufacturer reported thatthe timer automatically activates whenever the source lever is manually movedto one of the two source exposed positions and the lever is fully engaged inthe source slot, and stops counting as soon as the lever is moved from thefully engaged position. The fact that the timer continued to count indicatesthat the operator had not moved the sources from the fully exposed and engagedposition. The licensee reported that the operator had been trained in theoperation of the irradiator and was listed as an authorized user, but that theirradiator was used infrequently and that this was only the operator's seconduse of the irradiator since being trained.The second incident occurred when a maintenance worker preparing to performmaintenance on an irradiator bypassed the irradiator door interlock system toobserve movement of the inner irradiation chamber. The maintenance was being K>IN 96-35June 11, 1996 performed to correct previous maintenance that resulted in the irradiator notfunctioning properly. The maintenance worker was unaware that, although thesources remained shielded during movement of the irradiation chamber from theload to irradiate position, high levels of radiation scatter would be present.The maintenance worker, upon hearing the in-room monitor alarm, immediatelyreturned the radiation chamber to the 'load' position (maximum shielding).Although the maintenance worker was familiar with the operation of theirradiator and had been responsible for its maintenance for nearly 15 years,the worker apparently had not been given formal training on radiation safetyor the operation and maintenance of the irradiator. The maintenance workerwas not aware of the scatter radiation and assumed that since the sources werenot directly exposed, radiation from the sources would be contained within thedevice.During this incident, another worker, hired to perform contract maintenance onthe irradiator, was also in the room near the irradiator. Neither worker woredosimetry nor had any documented training in radiation safety. Therefore,their doses could only be calculated based on their recollection and wereestimated to both be approximately 4 microsievert (0.4 mrem) whole body.DiscussionAlthough neither incident resulted in doses in excess of regulatory limits,the doses received in both incidents were unnecessary and possibly could havebeen avoided with proper training and routine equipment maintenance. Asimilar incident in 1984, where a door interlock failed, resulted in theoperator being exposed to 222 terabequerel (6000 curies) of cesium-137.The first incident clearly demonstrates the need to perform appropriatemaintenance on these types of units. Even though these units are designedwith interlocks and safety features intended to prevent inadvertent exposures,the components of these systems depend on adequate maintenance to functionproperly. Failure to properly maintain these systems and provide appropriatetraining could result in unnecessary exposures. Manufacturers of these typesof irradiators frequently provide initial and periodic training on theoperation of their units and, in some cases, training on other manufacturers'units, as well. Initial training is typically a condition of the license and,therefore, must be provided to all irradiator users and maintenance personnel.Periodic refresher training is also beneficial as a reminder for workingsafely around the irradiator and provides for a means to receive ordisseminate additional or updated information.In addition, most manufacturers have a recommended schedule of maintenanceand/or recommended preventative/periodic maintenance that should be performed.Users of these types of irradiators should evaluate their usage to determinethe applicability of the recommended maintenance to their situation and usage.Users who operate their unit more than usual or who use their units underharsh conditions should consider the need for stepped-up maintenance or | | The first incident occurred when an operator may have been able to open the |
| '-> IN 96-35June 11, 1996 shortened maintenance intervals. In addition, each manufacturer's recommendedmaintenance may vary according to the specific unit or type of use.Therefore, personis performing maintenance on their unit may require specificmaintenance training for their unit.Users who are not aware of the required training for their unit, or who wishto receive information concerning training in general, should consult theirlicense, licensing authority, or the manufacturer of the unit. RegulatoryGuide 10.9, provides additional guidance in this area and may assist personswho wish to develop a training and maintenance program. Users who wish toreceive additional information concerning recommended maintenance for theirunit should contact the manufacturer of the unit. In addition, third-partyservice companies may also be available for training and maintenance servicesfor these types of irradiators.This information notice requires no specific action nor written response. Ifyou have any questions about the information in this notice, please contactone of the technical contacts listed below or the appropriate regional office.I3W¶flstn8by9WWstIADonald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand SafeguardsTechnical contacts: Douglas Broaddus, NMSS(301) 415-5847Internet:dab~nrc.govAnthony Kirkwood, NMSS(301) 415-6140Internet:ask~nrc.gov | | |
| | shielded door of an irradiator with the sources in the exposed position. |
| | |
| | After irradiation of several pocket dosimeters, the operator opened the |
| | |
| | shielded door of the irradiator to retrieve the dosimeters, but did not |
| | |
| | perform a radiation survey, as required by the facility's internal procedures, before opening the door. Twice, the operator placed one hand inside the |
| | |
| | irradiator to retrieve the dosimeters. Subsequently, the operator observed |
| | |
| | that the unit timer continued to count, indicating that the sources remained |
| | |
| | in the exposed position. The operator checked his personal pocket dosimeter, but did not note an unusual reading. However, the operator did not report the |
| | |
| | incident until questioned by the radiation safety officer, who had noted an |
| | |
| | unusually high dosimetry report of 3.55 millisievert (355 mrem) deep dose |
| | |
| | equivalent for the worker. The dose to the right hand was calculated to be a |
| | |
| | maximum of 12.5 millisievert (1.25 rem). |
| | |
| | The design of the irradiator includes two interconnected interlock systems, intended to prevent unshielded exposure of the sources. These include a door |
| | |
| | interlock system -- designed to allow opening of the shielded door only after |
| | |
| | the sources are placed in the fully shielded position -- and a source exposure-. |
| | |
| | interlock system -- designed to secure the sources in the fully shielded |
| | |
| | tDR FEE NOr/C9 03 ?C 0t, II |
| | |
| | k k JI |
| | |
| | IN 96-35 June 11, 1996 position whenever the shielded door is open or unlocked. The manufacturer of |
| | |
| | the irradiator indicated that under normal operations, either system |
| | |
| | individually wouldiprevent inadvertent access to the unshielded sources. |
| | |
| | Following the incident, the manufacturer of the irradiator was requested to |
| | |
| | perform an onsite inspection of the irradiator and facilities. During the |
| | |
| | inspection, the manufacturer noted: |
| | (1) the irradiator was located in an area that was not climate- controlled; |
| | (2) internal components of the irradiator were in a degraded state; |
| | (3) maintenance of the irradiator had last been performed approximately |
| | |
| | 10 years ago; and |
| | |
| | (4) a return spring, integral to the source exposure safety interlock |
| | |
| | system, was broken. The manufacturer indicated that the lack of |
| | |
| | environmental control may have accelerated the degradation of the |
| | |
| | internal components of the irradiator, and that the lack of periodic |
| | |
| | maintenance of the irradiator may have contributed to the failure of |
| | |
| | the return spring. |
| | |
| | The broken return spring may have caused the source securing mechanism of the |
| | |
| | source exposure interlock system to malfunction, possibly allowing exposure of |
| | |
| | the sources after the shielded door was unlocked and opened. However, during |
| | |
| | the post-incident investigation, neither the manufacturer nor the licensee |
| | |
| | were able to identify a failed component of either interlock system that could |
| | |
| | have allowed the shielded door to be opened with the sources in the exposed |
| | |
| | position. The manufacturer indicated that the design of the source exposure |
| | |
| | mechanism -- the operator must manually move the sources from the shielded to |
| | |
| | the exposed position with a lever -- would have provided the operator with a |
| | |
| | positive indication of source position even if the interlock systems failed. |
| | |
| | Source position would have been further provided by a series of green and red |
| | |
| | source position lights on the irradiator. |
| | |
| | The operator's actions indicate either a lack of training on the proper |
| | |
| | functioning and use of the irradiator, a lack of understanding of the training |
| | |
| | provided, and/or a disregard for following the established operating and |
| | |
| | safety procedures. The operator indicated that the timer continued to count |
| | |
| | when the shielded door was opened. However, the manufacturer reported that |
| | |
| | the timer automatically activates whenever the source lever is manually moved |
| | |
| | to one of the two source exposed positions and the lever is fully engaged in |
| | |
| | the source slot, and stops counting as soon as the lever is moved from the |
| | |
| | fully engaged position. The fact that the timer continued to count indicates |
| | |
| | that the operator had not moved the sources from the fully exposed and engaged |
| | |
| | position. The licensee reported that the operator had been trained in the |
| | |
| | operation of the irradiator and was listed as an authorized user, but that the |
| | |
| | irradiator was used infrequently and that this was only the operator's second |
| | |
| | use of the irradiator since being trained. |
| | |
| | The second incident occurred when a maintenance worker preparing to perform |
| | |
| | maintenance on an irradiator bypassed the irradiator door interlock system to |
| | |
| | observe movement of the inner irradiation chamber. The maintenance was being |
| | |
| | K> |
| | IN 96-35 June 11, 1996 performed to correct previous maintenance that resulted in the irradiator not |
| | |
| | functioning properly. The maintenance worker was unaware that, although the |
| | |
| | sources remained shielded during movement of the irradiation chamber from the |
| | |
| | load to irradiate position, high levels of radiation scatter would be present. |
| | |
| | The maintenance worker, upon hearing the in-room monitor alarm, immediately |
| | |
| | returned the radiation chamber to the 'load' position (maximum shielding). |
| | |
| | Although the maintenance worker was familiar with the operation of the |
| | |
| | irradiator and had been responsible for its maintenance for nearly 15 years, the worker apparently had not been given formal training on radiation safety |
| | |
| | or the operation and maintenance of the irradiator. The maintenance worker |
| | |
| | was not aware of the scatter radiation and assumed that since the sources were |
| | |
| | not directly exposed, radiation from the sources would be contained within the |
| | |
| | device. |
| | |
| | During this incident, another worker, hired to perform contract maintenance on |
| | |
| | the irradiator, was also in the room near the irradiator. Neither worker wore |
| | |
| | dosimetry nor had any documented training in radiation safety. Therefore, their doses could only be calculated based on their recollection and were |
| | |
| | estimated to both be approximately 4 microsievert (0.4 mrem) whole body. |
| | |
| | Discussion |
| | |
| | Although neither incident resulted in doses in excess of regulatory limits, the doses received in both incidents were unnecessary and possibly could have |
| | |
| | been avoided with proper training and routine equipment maintenance. A |
| | |
| | similar incident in 1984, where a door interlock failed, resulted in the |
| | |
| | operator being exposed to 222 terabequerel (6000 curies) of cesium-137. |
| | |
| | The first incident clearly demonstrates the need to perform appropriate |
| | |
| | maintenance on these types of units. Even though these units are designed |
| | |
| | with interlocks and safety features intended to prevent inadvertent exposures, the components of these systems depend on adequate maintenance to function |
| | |
| | properly. Failure to properly maintain these systems and provide appropriate |
| | |
| | training could result in unnecessary exposures. Manufacturers of these types |
| | |
| | of irradiators frequently provide initial and periodic training on the |
| | |
| | operation of their units and, in some cases, training on other manufacturers' |
| | units, as well. Initial training is typically a condition of the license and, therefore, must be provided to all irradiator users and maintenance personnel. |
| | |
| | Periodic refresher training is also beneficial as a reminder for working |
| | |
| | safely around the irradiator and provides for a means to receive or |
| | |
| | disseminate additional or updated information. |
| | |
| | In addition, most manufacturers have a recommended schedule of maintenance |
| | |
| | and/or recommended preventative/periodic maintenance that should be performed. |
| | |
| | Users of these types of irradiators should evaluate their usage to determine |
| | |
| | the applicability of the recommended maintenance to their situation and usage. |
| | |
| | Users who operate their unit more than usual or who use their units under |
| | |
| | harsh conditions should consider the need for stepped-up maintenance or |
| | |
| | '-> IN 96-35 June 11, 1996 shortened maintenance intervals. In addition, each manufacturer's recommended |
| | |
| | maintenance may vary according to the specific unit or type of use. |
| | |
| | Therefore, personis performing maintenance on their unit may require specific |
| | |
| | maintenance training for their unit. |
| | |
| | Users who are not aware of the required training for their unit, or who wish |
| | |
| | to receive information concerning training in general, should consult their |
| | |
| | license, licensing authority, or the manufacturer of the unit. Regulatory |
| | |
| | Guide 10.9, provides additional guidance in this area and may assist persons |
| | |
| | who wish to develop a training and maintenance program. Users who wish to |
| | |
| | receive additional information concerning recommended maintenance for their |
| | |
| | unit should contact the manufacturer of the unit. In addition, third-party |
| | |
| | service companies may also be available for training and maintenance services |
| | |
| | for these types of irradiators. |
| | |
| | This information notice requires no specific action nor written response. If |
| | |
| | you have any questions about the information in this notice, please contact |
| | |
| | one of the technical contacts listed below or the appropriate regional office. |
| | |
| | I3W¶flstn 8 by9WWstIA |
| | |
| | Donald A. Cool, Director |
| | |
| | Division of Industrial and |
| | |
| | Medical Nuclear Safety |
| | |
| | Office of Nuclear Material Safety |
| | |
| | and Safeguards |
| | |
| | Technical contacts: Douglas Broaddus, NMSS |
| | |
| | (301) 415-5847 Internet:dab~nrc.gov |
| | |
| | Anthony Kirkwood, NMSS |
| | |
| | (301) 415-6140 |
| | Internet:ask~nrc.gov |
| | |
| | Attachments: |
| | 1. List of Recently issued NMSS Information Notices |
| | |
| | 2. List of Recently issued NRC Information Notices |
| | |
| | DOCUMENT NAME: 96-35.IN |
| | |
| | To receive a copy of this document, Indicate In the box: C' = Copy without attachment/enclosure *E' - Copy with attachmentjendosure N |
| | |
| | * No copy |
| | |
| | * See previous concurrence |
| | |
| | OFFICE IIMAB* [ClIMAB* [C Tech Editor* l IMOB* [C IMNS* I C, |
| | NAME IDBroaddus* LCamper lEKraus _KRamsey jDCof' |
| | DATE 14/17/96 5/28/96 4/01/96 5/31/96 6/4 96 11 OFFICIAL RECORD COPY |
| | |
| | j; |
| | IN 96-XX |
| | |
| | May XX, 1996 Users who are not aware of the required training for their unit, or who wish |
| | |
| | to receive information concerning training in general, should consult their |
| | |
| | license, licensing authority, or the manufacturer of the unit. Regulatory |
| | |
| | Guide 10.9, provides additional guidance in this area and may assist persons |
| | |
| | who wish to develop a training and maintenance program. Users who wish to |
| | |
| | receive additional information concerning recommended maintenance for their |
| | |
| | unit should contact the manufacturer of the unit. In addition, third-party |
| | |
| | service companies may also be available for training and maintenance services |
| | |
| | for these types of irradiators. |
| | |
| | This information notice requires no specific action nor written response. If |
| | |
| | you have any questions about the information in this notice, please contact |
| | |
| | one of the technical contacts listed below or the appropriate regional office. |
| | |
| | Donald A. Cool, Director |
| | |
| | Division of Industrial and |
| | |
| | Medical Nuclear Safety |
| | |
| | Office of Nuclear Material Safety |
| | |
| | and Safeguards |
| | |
| | Technical contacts: Douglas Broaddus, NMSS |
| | |
| | (301) 415-5847 Anthony Kirkwood, NMSS |
| | |
| | (301) 415-6140 |
| | Attachments: |
| | 1. List of Recently issued NMSS Information Notices |
| | |
| | 2. List of Recently issued NRC Information Notices |
| | |
| | DOCUMENT NAME: A:\IRADIATR.FIN |
| | |
| | To receive a copy of this docunent, Indicate hI the box: 'C Copy without attachmentlenclosure WE-= Copy with attachmentlenclosure ONE copY |
| | |
| | * See previous concurrence a |
| | |
| | OFFICE IMAB I INAB 15 /HTech Editor I IMOB IMN h |
| | |
| | NAME DBroaddus* LCam er' 1EKraus* KRamse Kmfl Co |
| | |
| | DATE 4/17/96 L/46/96 14/01/96 5-13j /96 / |
| | OFFICIAL RECORD COPY |
| | |
| | IN 96-XX |
| | |
| | May XX, 1996 Users who are not aware of the required training for their unit, or who wish |
| | |
| | to receive information concerning training in general, should consult their |
| | |
| | license, licensing authority, or the manufacturer of the unit. Regulatory |
| | |
| | Guide 10.9, provides additional guidance in this area and may assist persons |
| | |
| | who wish to develop a training and maintenance program. Users who wish to |
| | |
| | receive additional information concerning recommended maintenance for their |
| | |
| | unit should contact the manufacturer of the unit. In addition, third-party |
| | |
| | service companies may also be available for training and maintenance services |
| | |
| | for these types of irradiators. |
| | |
| | This information notice requires no specific action nor written response. If |
| | |
| | you have any questions about the information in this notice, please contact |
| | |
| | one of the technical contacts listed below or the appropriate regional office. |
| | |
| | Donald A. Cool, Director |
| | |
| | Division of Industrial and |
| | |
| | Medical Nuclear Safety |
| | |
| | Office of Nuclear Material Safety |
| | |
| | and Safeguards |
| | |
| | Technical contacts: Douglas Broaddus, NMSS |
| | |
| | 301-415-5847 Anthony Kirkwood, RI |
| | |
| | 610-337-5050 |
| | Attachments: |
| | 1. List of Recently issued NMSS Information Notices |
| | |
| | 2. List of Recently issued NRC Information Notices |
| | |
| | DOCUMENT NAME: A:\IRADIATR.FIN |
| | |
| | To receiv a copy of this document, Indicate In the box: C' = Copy without attachmentlenclosure 'E' = Copy with aftachment/enclosure *'N - No copy |
| | |
| | lOFFICE IMAB [ IMAB LJTech Editor LAL IMOB LJIMNS |
| | |
| | INAME DBroaddus LCamper EKraus wa KRamsey DCool |
| | |
| | DMTE 4//f/96 4/ /96 4/W /96 4/ /96 4/ /96 OFFICIAL RECORD COPY |
| | |
| | KUJ KU |
| | |
| | Attachment 1 IN 96-35 June 11, 1996 LIST OF RECENTLY ISSUED |
| | |
| | NMSS INFORMATION NOTICES |
| | |
| | Information ' Date of |
| | |
| | Notice No. Subject Issuance Issued to |
| | |
| | 96-33 Erroneous Data from Defec- 05/224/96 All material and fuel cycle |
| | |
| | tive Thermocouple Results licensees that monitor tem- in a Fire perature with thermocouples |
| | |
| | 96-28 Suggested Guidance Relat- 05/01/96 All material and fuel cycle |
| | |
| | ing to Development and licensees |
| | |
| | Implementation of Correc- tive Action |
| | |
| | 96-21 Safety Concerns Related 04/10/96 All NRC Medical Licensees |
| | |
| | to the Design of the Door authorized to use brachy- Interlock Circuit on therapy sources in high- Nucletron High-Dose Rate and pulsed-dose-rate remote |
| | |
| | and Pulsed Dose Rate |
| | |
| | Remote Afterloading Brachy- therapy Devices |
| | |
| | 96-20 Demonstration of Associ- 04/04/96 All industrial radiography |
| | |
| | ated Equipment Compliance licensees and radiography |
| | |
| | with 10 CFR 34.20 equipment manufacturers |
| | |
| | 96-18 Compliance With 10 CFR 03/25/96 All material licensees |
| | |
| | Part 20 for Airborne authorized to possess and |
| | |
| | Thorium use thorium in unsealed form |
| | |
| | 96-04 Incident Reporting 01/10/96 All Radiography Licensees |
| | |
| | Requirements for and Manufacturers of |
| | |
| | Radiography Licensees Radiography Equipment |
| | |
| | 95-58 10 CFR 34.20; Final 12/18/95 Industrial Radiography |
| | |
| | Effective Date Licensees. |
| | |
| | 95-55 Handling Uncontained 12/6/95 All Uranium Recovery |
| | |
| | Yellowcake Outside of a Licensees. |
| | |
| | Facility Processing Circuit |
| | |
| | 95-51 Recent Incidents Involving 10/27/95 All material and fuel cycle |
| | |
| | Potential Loss of Control licensees. |
| | |
| | of Licensed Material |
| | |
| | K>- iKJ |
| | |
| | Attachment 2 IN 96-35 June 11, 1996 LIST OF RECENTLY ISSUED |
| | |
| | NRC INFORMATION NOTICES |
| | |
| | Information Date of |
| | |
| | Notice No. Subject Issuance Issued to |
| | |
| | 96-34 Hydrogen Gas Ignition 05/31/96 All holders of OLs or CPs |
| | |
| | during Closure Welding for nuclear power reactors |
| | |
| | of a VSC-24 Multi-Assembly |
| | |
| | Sealed Basket |
| | |
| | 96-33 Erroneous Data From 05/24/96 All material and fuel cycle |
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| | Defective Thermocouple licensees that monitor tem- Results in a Fire perature with thermocouples |
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| | 96-32 Implementation of 10 CFR 06/05/96 All holders of OLs or CPs |
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| | 50.55a(g)(6)(ii)(A), for nuclear power reactors |
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| | "Augmented Examination |
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| | of Reactor Vessel" |
| | 96-31 Cross-Tied Safety Injec- 05/22/96 All holders of OLs or CPs |
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| | tion Accumulators for pressurized water |
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| | reactors |
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| | 96-30 Inaccuracy of Diagnostic 05/21/96 All holders of OLs or CPs |
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| | Equipment for Motor- for nuclear power reactors |
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| | Operated Butterfly Valves |
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| | 96-29 Requirements in 10 CFR 05/20/96 All holders of OLs or CPs |
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| | Part 21 for Reporting and for nuclear power reactors |
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| | Evaluating Software Errors |
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| | 96-28 Suggested Guidance Relating 05/01/96 All material and fuel cycle |
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| | to Development and Imple- licensees |
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| | mentation of Corrective |
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| | Action |
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| | 96-27 Potential Clogging of High 05/01/96 All holders of OLs or CPs |
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| | Pressure Safety Injection for pressurized water |
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| | Throttle Valves During reactors |
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| | Recirculation |
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| | 96-26 Recent Problems with Over- 04/30/96 All holders of OLs or CPs |
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| | head Cranes for nuclear power reactors |
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| | 96-25 Transversing In-Core Probe 04/30/96 All holders of OLs or CPs |
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| |
|
| ===Attachments:===
| | Overwithdrawn at LaSalle for nuclear power reactors |
| 1. List of Recently issued NMSS Information Notices2. List of Recently issued NRC Information NoticesDOCUMENT NAME: 96-35.INTo receive a copy of this document, Indicate In the box: C' = Copy without attachment/enclosure *E' -Copy with attachmentjendosure N
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| * No copy* See previous concurrenceOFFICE IIMAB* [ClIMAB* [C Tech Editor* l IMOB* [C IMNS* I C,NAME IDBroaddus* LCamper lEKraus _KRamsey jDCof'DATE 14/17/96 5/28/96 4/01/96 5/31/96 6/4 96 11OFFICIAL RECORD COPY j;IN 96-XXMay XX, 1996 Users who are not aware of the required training for their unit, or who wishto receive information concerning training in general, should consult theirlicense, licensing authority, or the manufacturer of the unit. RegulatoryGuide 10.9, provides additional guidance in this area and may assist personswho wish to develop a training and maintenance program. Users who wish toreceive additional information concerning recommended maintenance for theirunit should contact the manufacturer of the unit. In addition, third-partyservice companies may also be available for training and maintenance servicesfor these types of irradiators.This information notice requires no specific action nor written response. Ifyou have any questions about the information in this notice, please contactone of the technical contacts listed below or the appropriate regional office.Donald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand SafeguardsTechnical contacts: Douglas Broaddus, NMSS(301) 415-5847Anthony Kirkwood, NMSS(301) 415-6140
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| ===Attachments:===
| | County Station, Unit 1 OL - Operating License |
| 1. List of Recently issued NMSS Information Notices2. List of Recently issued NRC Information NoticesDOCUMENT NAME: A:\IRADIATR.FINTo receive a copy of this docunent, Indicate hI the box: 'C Copy without attachmentlenclosure WE- = Copy with attachmentlenclosure ONE copY* See previous concurrence aOFFICE IMAB I INAB 15 /HTech Editor I IMOB IMN hNAME DBroaddus* LCam er' 1EKraus* KRamse Kmfl CoDATE 4/17/96 L/46/96 14/01/96 5-13j /96 /OFFICIAL RECORD COPY IN 96-XXMay XX, 1996 Users who are not aware of the required training for their unit, or who wishto receive information concerning training in general, should consult theirlicense, licensing authority, or the manufacturer of the unit. RegulatoryGuide 10.9, provides additional guidance in this area and may assist personswho wish to develop a training and maintenance program. Users who wish toreceive additional information concerning recommended maintenance for theirunit should contact the manufacturer of the unit. In addition, third-partyservice companies may also be available for training and maintenance servicesfor these types of irradiators.This information notice requires no specific action nor written response. Ifyou have any questions about the information in this notice, please contactone of the technical contacts listed below or the appropriate regional office.Donald A. Cool, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand SafeguardsTechnical contacts: Douglas Broaddus, NMSS301-415-5847Anthony Kirkwood, RI610-337-5050 | |
|
| |
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| ===Attachments:===
| | CP - Construction Permit}} |
| 1. List of Recently issued NMSS Information Notices2. List of Recently issued NRC Information NoticesDOCUMENT NAME: A:\IRADIATR.FINTo receiv a copy of this document, Indicate In the box: C' = Copy without attachmentlenclosure 'E' = Copy with aftachment/enclosure *'N -No copylOFFICE IMAB [ IMAB LJTech Editor LAL IMOB LJIMNSINAME DBroaddus LCamper EKraus wa KRamsey DCoolDMTE 4//f/96 4/ /96 4/W /96 4/ /96 4/ /96OFFICIAL RECORD COPY KUJ KUAttachment 1IN 96-35June 11, 1996 LIST OF RECENTLY ISSUEDNMSS INFORMATION NOTICESInformation ' Date ofNotice No. Subject Issuance Issued to96-33Erroneous Data from Defec-tive Thermocouple Resultsin a Fire05/224/96All material and fuel cyclelicensees that monitor tem-perature with thermocouples96-2896-2196-2096-18Suggested Guidance Relat-ing to Development andImplementation of Correc-tive ActionSafety Concerns Relatedto the Design of the DoorInterlock Circuit onNucletron High-Dose Rateand Pulsed Dose RateRemote Afterloading Brachy-therapy DevicesDemonstration of Associ-ated Equipment Compliancewith 10 CFR 34.20Compliance With 10 CFRPart 20 for AirborneThoriumIncident ReportingRequirements forRadiography Licensees10 CFR 34.20; FinalEffective DateHandling UncontainedYellowcake Outside of aFacility Processing CircuitRecent Incidents InvolvingPotential Loss of Controlof Licensed Material05/01/9604/10/9604/04/9603/25/9601/10/9612/18/9512/6/9510/27/95All material and fuel cyclelicenseesAll NRC Medical Licenseesauthorized to use brachy-therapy sources in high-and pulsed-dose-rate remoteAll industrial radiographylicensees and radiographyequipment manufacturersAll material licenseesauthorized to possess anduse thorium in unsealed formAll Radiography Licenseesand Manufacturers ofRadiography EquipmentIndustrial RadiographyLicensees.All Uranium RecoveryLicensees.All material and fuel cyclelicensees.96-0495-5895-5595-51 K> -iKJAttachment 2IN 96-35June 11, 1996 LIST OF RECENTLY ISSUEDNRC INFORMATION NOTICESInformation Date ofNotice No. Subject Issuance Issued to96-3496-3396-3296-3196-30Hydrogen Gas Ignitionduring Closure Weldingof a VSC-24 Multi-AssemblySealed BasketErroneous Data FromDefective ThermocoupleResults in a FireImplementation of 10 CFR50.55a(g)(6)(ii)(A),"Augmented Examinationof Reactor Vessel"Cross-Tied Safety Injec-tion AccumulatorsInaccuracy of DiagnosticEquipment for Motor-Operated Butterfly ValvesRequirements in 10 CFRPart 21 for Reporting andEvaluating Software ErrorsSuggested Guidance Relatingto Development and Imple-mentation of CorrectiveActionPotential Clogging of HighPressure Safety InjectionThrottle Valves DuringRecirculationRecent Problems with Over-head CranesTransversing In-Core ProbeOverwithdrawn at LaSalleCounty Station, Unit 105/31/9605/24/9606/05/9605/22/9605/21/9605/20/9605/01/9605/01/9604/30/9604/30/96All holders of OLs or CPsfor nuclear power reactorsAll material and fuel cyclelicensees that monitor tem-perature with thermocouplesAll holders of OLs or CPsfor nuclear power reactorsAll holders of OLs or CPsfor pressurized waterreactorsAll holders of OLs or CPsfor nuclear power reactorsAll holders of OLs or CPsfor nuclear power reactorsAll material and fuel cyclelicenseesAll holders of OLs or CPsfor pressurized waterreactorsAll holders of OLs or CPsfor nuclear power reactorsAll holders of OLs or CPsfor nuclear power reactors96-2996-2896-2796-2696-25OL -Operating LicenseCP -Construction Permit}}
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| {{Information notice-Nav}} | | {{Information notice-Nav}} |
Failure of Safety Systems on Self-Shielded Irradiators Because of Inadequate Maintenance and TrainingML031060046 |
Person / Time |
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Site: |
Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000442, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant ![Entergy icon.png](/w/images/7/79/Entergy_icon.png) |
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Issue date: |
06/11/1996 |
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From: |
Cool D NRC/NMSS/IMNS |
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To: |
|
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References |
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IN-96-035, NUDOCS 9606060078 |
Download: ML031060046 (8) |
|
Similar Documents at Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000442, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant |
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Category:NRC Information Notice
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Mclaughlin on NRC, Regarding NRC Information Notice 2006-13: Groundwater Contamination2006-07-13013 July 2006 E-mail from M. Mclaughlin on NRC, Regarding NRC Information Notice 2006-13: Groundwater Contamination 2020-09-03 The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:05000442]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] </code>.
[Table view]The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:05000442]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] </code>. |
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, D.C. 20555 June 11, 1996 NRC INFORMATION NOTICE 96-35: FAILURE OF SAFETY SYSTEMS ON SELF-SHIELDED
IRRADIATORS BECAUSE OF INADEQUATE MAINTENANCE
AND TRAINING
Addressees
All U.S. Nuclear Regulatory Commission irradiator licensees and vendors.
Purpose
The U.S. Nuclear Regulatory Commission (NRC) is issuing this information
notice (IN)to alert addressees to two incidents where safety interlocks on
self-shielded irradiators (Category I) failed to prevent inadvertent exposure.
The causes of these exposures stemmed from a lack of appropriate maintenance
and/or worker training. The incidents include a broken spring -- possibly
causing malfunction of the safety interlock -- and a worker who intentionally
bypassed a safety interlock. It is expected that recipients will review the
information for applicability to their facilities and consider actions, as
appropriate, to avoid similar problems. However, suggestions contained in
this information notice are not NRC requirements; therefore, no specific
action nor written response is required.
Description of Circumstances
The first incident occurred when an operator may have been able to open the
shielded door of an irradiator with the sources in the exposed position.
After irradiation of several pocket dosimeters, the operator opened the
shielded door of the irradiator to retrieve the dosimeters, but did not
perform a radiation survey, as required by the facility's internal procedures, before opening the door. Twice, the operator placed one hand inside the
irradiator to retrieve the dosimeters. Subsequently, the operator observed
that the unit timer continued to count, indicating that the sources remained
in the exposed position. The operator checked his personal pocket dosimeter, but did not note an unusual reading. However, the operator did not report the
incident until questioned by the radiation safety officer, who had noted an
unusually high dosimetry report of 3.55 millisievert (355 mrem) deep dose
equivalent for the worker. The dose to the right hand was calculated to be a
maximum of 12.5 millisievert (1.25 rem).
The design of the irradiator includes two interconnected interlock systems, intended to prevent unshielded exposure of the sources. These include a door
interlock system -- designed to allow opening of the shielded door only after
the sources are placed in the fully shielded position -- and a source exposure-.
interlock system -- designed to secure the sources in the fully shielded
tDR FEE NOr/C9 03 ?C 0t, II
k k JI
IN 96-35 June 11, 1996 position whenever the shielded door is open or unlocked. The manufacturer of
the irradiator indicated that under normal operations, either system
individually wouldiprevent inadvertent access to the unshielded sources.
Following the incident, the manufacturer of the irradiator was requested to
perform an onsite inspection of the irradiator and facilities. During the
inspection, the manufacturer noted:
(1) the irradiator was located in an area that was not climate- controlled;
(2) internal components of the irradiator were in a degraded state;
(3) maintenance of the irradiator had last been performed approximately
10 years ago; and
(4) a return spring, integral to the source exposure safety interlock
system, was broken. The manufacturer indicated that the lack of
environmental control may have accelerated the degradation of the
internal components of the irradiator, and that the lack of periodic
maintenance of the irradiator may have contributed to the failure of
the return spring.
The broken return spring may have caused the source securing mechanism of the
source exposure interlock system to malfunction, possibly allowing exposure of
the sources after the shielded door was unlocked and opened. However, during
the post-incident investigation, neither the manufacturer nor the licensee
were able to identify a failed component of either interlock system that could
have allowed the shielded door to be opened with the sources in the exposed
position. The manufacturer indicated that the design of the source exposure
mechanism -- the operator must manually move the sources from the shielded to
the exposed position with a lever -- would have provided the operator with a
positive indication of source position even if the interlock systems failed.
Source position would have been further provided by a series of green and red
source position lights on the irradiator.
The operator's actions indicate either a lack of training on the proper
functioning and use of the irradiator, a lack of understanding of the training
provided, and/or a disregard for following the established operating and
safety procedures. The operator indicated that the timer continued to count
when the shielded door was opened. However, the manufacturer reported that
the timer automatically activates whenever the source lever is manually moved
to one of the two source exposed positions and the lever is fully engaged in
the source slot, and stops counting as soon as the lever is moved from the
fully engaged position. The fact that the timer continued to count indicates
that the operator had not moved the sources from the fully exposed and engaged
position. The licensee reported that the operator had been trained in the
operation of the irradiator and was listed as an authorized user, but that the
irradiator was used infrequently and that this was only the operator's second
use of the irradiator since being trained.
The second incident occurred when a maintenance worker preparing to perform
maintenance on an irradiator bypassed the irradiator door interlock system to
observe movement of the inner irradiation chamber. The maintenance was being
K>
IN 96-35 June 11, 1996 performed to correct previous maintenance that resulted in the irradiator not
functioning properly. The maintenance worker was unaware that, although the
sources remained shielded during movement of the irradiation chamber from the
load to irradiate position, high levels of radiation scatter would be present.
The maintenance worker, upon hearing the in-room monitor alarm, immediately
returned the radiation chamber to the 'load' position (maximum shielding).
Although the maintenance worker was familiar with the operation of the
irradiator and had been responsible for its maintenance for nearly 15 years, the worker apparently had not been given formal training on radiation safety
or the operation and maintenance of the irradiator. The maintenance worker
was not aware of the scatter radiation and assumed that since the sources were
not directly exposed, radiation from the sources would be contained within the
device.
During this incident, another worker, hired to perform contract maintenance on
the irradiator, was also in the room near the irradiator. Neither worker wore
dosimetry nor had any documented training in radiation safety. Therefore, their doses could only be calculated based on their recollection and were
estimated to both be approximately 4 microsievert (0.4 mrem) whole body.
Discussion
Although neither incident resulted in doses in excess of regulatory limits, the doses received in both incidents were unnecessary and possibly could have
been avoided with proper training and routine equipment maintenance. A
similar incident in 1984, where a door interlock failed, resulted in the
operator being exposed to 222 terabequerel (6000 curies) of cesium-137.
The first incident clearly demonstrates the need to perform appropriate
maintenance on these types of units. Even though these units are designed
with interlocks and safety features intended to prevent inadvertent exposures, the components of these systems depend on adequate maintenance to function
properly. Failure to properly maintain these systems and provide appropriate
training could result in unnecessary exposures. Manufacturers of these types
of irradiators frequently provide initial and periodic training on the
operation of their units and, in some cases, training on other manufacturers'
units, as well. Initial training is typically a condition of the license and, therefore, must be provided to all irradiator users and maintenance personnel.
Periodic refresher training is also beneficial as a reminder for working
safely around the irradiator and provides for a means to receive or
disseminate additional or updated information.
In addition, most manufacturers have a recommended schedule of maintenance
and/or recommended preventative/periodic maintenance that should be performed.
Users of these types of irradiators should evaluate their usage to determine
the applicability of the recommended maintenance to their situation and usage.
Users who operate their unit more than usual or who use their units under
harsh conditions should consider the need for stepped-up maintenance or
'-> IN 96-35 June 11, 1996 shortened maintenance intervals. In addition, each manufacturer's recommended
maintenance may vary according to the specific unit or type of use.
Therefore, personis performing maintenance on their unit may require specific
maintenance training for their unit.
Users who are not aware of the required training for their unit, or who wish
to receive information concerning training in general, should consult their
license, licensing authority, or the manufacturer of the unit. Regulatory
Guide 10.9, provides additional guidance in this area and may assist persons
who wish to develop a training and maintenance program. Users who wish to
receive additional information concerning recommended maintenance for their
unit should contact the manufacturer of the unit. In addition, third-party
service companies may also be available for training and maintenance services
for these types of irradiators.
This information notice requires no specific action nor written response. If
you have any questions about the information in this notice, please contact
one of the technical contacts listed below or the appropriate regional office.
I3W¶flstn 8 by9WWstIA
Donald A. Cool, Director
Division of Industrial and
Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Technical contacts: Douglas Broaddus, NMSS
(301) 415-5847 Internet:dab~nrc.gov
Anthony Kirkwood, NMSS
(301) 415-6140
Internet:ask~nrc.gov
Attachments:
1. List of Recently issued NMSS Information Notices
2. List of Recently issued NRC Information Notices
DOCUMENT NAME: 96-35.IN
To receive a copy of this document, Indicate In the box: C' = Copy without attachment/enclosure *E' - Copy with attachmentjendosure N
OFFICE IIMAB* [ClIMAB* [C Tech Editor* l IMOB* [C IMNS* I C,
NAME IDBroaddus* LCamper lEKraus _KRamsey jDCof'
DATE 14/17/96 5/28/96 4/01/96 5/31/96 6/4 96 11 OFFICIAL RECORD COPY
j;
IN 96-XX
May XX, 1996 Users who are not aware of the required training for their unit, or who wish
to receive information concerning training in general, should consult their
license, licensing authority, or the manufacturer of the unit. Regulatory
Guide 10.9, provides additional guidance in this area and may assist persons
who wish to develop a training and maintenance program. Users who wish to
receive additional information concerning recommended maintenance for their
unit should contact the manufacturer of the unit. In addition, third-party
service companies may also be available for training and maintenance services
for these types of irradiators.
This information notice requires no specific action nor written response. If
you have any questions about the information in this notice, please contact
one of the technical contacts listed below or the appropriate regional office.
Donald A. Cool, Director
Division of Industrial and
Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Technical contacts: Douglas Broaddus, NMSS
(301) 415-5847 Anthony Kirkwood, NMSS
(301) 415-6140
Attachments:
1. List of Recently issued NMSS Information Notices
2. List of Recently issued NRC Information Notices
DOCUMENT NAME: A:\IRADIATR.FIN
To receive a copy of this docunent, Indicate hI the box: 'C Copy without attachmentlenclosure WE-= Copy with attachmentlenclosure ONE copY
- See previous concurrence a
OFFICE IMAB I INAB 15 /HTech Editor I IMOB IMN h
NAME DBroaddus* LCam er' 1EKraus* KRamse Kmfl Co
DATE 4/17/96 L/46/96 14/01/96 5-13j /96 /
OFFICIAL RECORD COPY
IN 96-XX
May XX, 1996 Users who are not aware of the required training for their unit, or who wish
to receive information concerning training in general, should consult their
license, licensing authority, or the manufacturer of the unit. Regulatory
Guide 10.9, provides additional guidance in this area and may assist persons
who wish to develop a training and maintenance program. Users who wish to
receive additional information concerning recommended maintenance for their
unit should contact the manufacturer of the unit. In addition, third-party
service companies may also be available for training and maintenance services
for these types of irradiators.
This information notice requires no specific action nor written response. If
you have any questions about the information in this notice, please contact
one of the technical contacts listed below or the appropriate regional office.
Donald A. Cool, Director
Division of Industrial and
Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Technical contacts: Douglas Broaddus, NMSS
301-415-5847 Anthony Kirkwood, RI
610-337-5050
Attachments:
1. List of Recently issued NMSS Information Notices
2. List of Recently issued NRC Information Notices
DOCUMENT NAME: A:\IRADIATR.FIN
To receiv a copy of this document, Indicate In the box: C' = Copy without attachmentlenclosure 'E' = Copy with aftachment/enclosure *'N - No copy
lOFFICE IMAB [ IMAB LJTech Editor LAL IMOB LJIMNS
INAME DBroaddus LCamper EKraus wa KRamsey DCool
DMTE 4//f/96 4/ /96 4/W /96 4/ /96 4/ /96 OFFICIAL RECORD COPY
KUJ KU
Attachment 1 IN 96-35 June 11, 1996 LIST OF RECENTLY ISSUED
NMSS INFORMATION NOTICES
Information ' Date of
Notice No. Subject Issuance Issued to
96-33 Erroneous Data from Defec- 05/224/96 All material and fuel cycle
tive Thermocouple Results licensees that monitor tem- in a Fire perature with thermocouples
96-28 Suggested Guidance Relat- 05/01/96 All material and fuel cycle
ing to Development and licensees
Implementation of Correc- tive Action
96-21 Safety Concerns Related 04/10/96 All NRC Medical Licensees
to the Design of the Door authorized to use brachy- Interlock Circuit on therapy sources in high- Nucletron High-Dose Rate and pulsed-dose-rate remote
and Pulsed Dose Rate
Remote Afterloading Brachy- therapy Devices
96-20 Demonstration of Associ- 04/04/96 All industrial radiography
ated Equipment Compliance licensees and radiography
with 10 CFR 34.20 equipment manufacturers
96-18 Compliance With 10 CFR 03/25/96 All material licensees
Part 20 for Airborne authorized to possess and
Thorium use thorium in unsealed form
96-04 Incident Reporting 01/10/96 All Radiography Licensees
Requirements for and Manufacturers of
Radiography Licensees Radiography Equipment
95-58 10 CFR 34.20; Final 12/18/95 Industrial Radiography
Effective Date Licensees.
95-55 Handling Uncontained 12/6/95 All Uranium Recovery
Yellowcake Outside of a Licensees.
Facility Processing Circuit
95-51 Recent Incidents Involving 10/27/95 All material and fuel cycle
Potential Loss of Control licensees.
of Licensed Material
K>- iKJ
Attachment 2 IN 96-35 June 11, 1996 LIST OF RECENTLY ISSUED
NRC INFORMATION NOTICES
Information Date of
Notice No. Subject Issuance Issued to
96-34 Hydrogen Gas Ignition 05/31/96 All holders of OLs or CPs
during Closure Welding for nuclear power reactors
of a VSC-24 Multi-Assembly
Sealed Basket
96-33 Erroneous Data From 05/24/96 All material and fuel cycle
Defective Thermocouple licensees that monitor tem- Results in a Fire perature with thermocouples
96-32 Implementation of 10 CFR 06/05/96 All holders of OLs or CPs
50.55a(g)(6)(ii)(A), for nuclear power reactors
"Augmented Examination
of Reactor Vessel"
96-31 Cross-Tied Safety Injec- 05/22/96 All holders of OLs or CPs
tion Accumulators for pressurized water
reactors
96-30 Inaccuracy of Diagnostic 05/21/96 All holders of OLs or CPs
Equipment for Motor- for nuclear power reactors
Operated Butterfly Valves
96-29 Requirements in 10 CFR 05/20/96 All holders of OLs or CPs
Part 21 for Reporting and for nuclear power reactors
Evaluating Software Errors
96-28 Suggested Guidance Relating 05/01/96 All material and fuel cycle
to Development and Imple- licensees
mentation of Corrective
Action
96-27 Potential Clogging of High 05/01/96 All holders of OLs or CPs
Pressure Safety Injection for pressurized water
Throttle Valves During reactors
Recirculation
96-26 Recent Problems with Over- 04/30/96 All holders of OLs or CPs
head Cranes for nuclear power reactors
96-25 Transversing In-Core Probe 04/30/96 All holders of OLs or CPs
Overwithdrawn at LaSalle for nuclear power reactors
County Station, Unit 1 OL - Operating License
CP - Construction Permit
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list | - Information Notice 1996-01, Potential For High Post-Accident Closed-Cycle Cooling Water Temperatures to Disable Equipment Important to Safety (3 January 1996)
- Information Notice 1996-01, Potential for High Post-Accident Closed-Cycle Cooling Water Temperatures to Disable Equipment Important to Safety (3 January 1996)
- Information Notice 1996-02, Inoperability of Power-Operated Relief Valves Masked by Downstream Indications During Testing (5 January 1996, Topic: Stroke time)
- Information Notice 1996-03, Main Steam Safety Valve Setpoint Variation as a Result of Thermal Effects (5 January 1996)
- Information Notice 1996-03, Main Steam Safety Valve Setpoint Variation As a Result of Thermal Effects (5 January 1996)
- Information Notice 1996-04, Incident Reporting Requirements for Radiography Licensees (10 January 1996, Topic: Brachytherapy, Overexposure, Depleted uranium)
- Information Notice 1996-05, Partial Bypass of Shutdown Cooling Flow from Reactor Vessel (18 January 1996, Topic: Reactor Vessel Water Level)
- Information Notice 1996-06, Design & Testing Deficiencies of Tornado Dampers at Nuclear Power Plants (25 January 1996)
- Information Notice 1996-07, Slow Five Percent Scram Insertion Times Caused by Viton Diaphragms in Scram Solenoid Pilot Valves (26 January 1996)
- Information Notice 1996-08, Thermally Induced Pressure Locking of a High Pressure Coolant Injection Gate Valve (5 February 1996, Topic: Anchor Darling, Cold shutdown justification)
- Information Notice 1996-09, Damage in Foreign Steam Generator Internals (12 February 1996, Topic: Earthquake)
- Information Notice 1996-10, Potential Blockage by Debris of Safety System Piping Which Is Not Used During Normal Operation or Tested During Surveillances (13 February 1996)
- Information Notice 1996-10, Potential Blockage by Debris of Safety System Piping Which is Not Used During Normal Operation or Tested During Surveillances (13 February 1996)
- Information Notice 1996-11, Ingress of Demineralizer Resins Increases Potential For Stress Corrosion Cracking of Control Rod Drive Mechanism Penetrations (14 February 1996)
- Information Notice 1996-11, Ingress of Demineralizer Resins Increases Potential for Stress Corrosion Cracking of Control Rod Drive Mechanism Penetrations (14 February 1996)
- Information Notice 1996-12, Control Rod Insertion Problems (15 February 1996)
- Information Notice 1996-13, Potential Containment Leak Paths Through Hydrogen Analysis (26 February 1996, Topic: Stress corrosion cracking, Integrated leak rate test)
- Information Notice 1996-14, Degradation of Radwaste Facility Equipment at Millstone Nuclear Power Station, Unit 1 (1 March 1996)
- Information Notice 1996-15, Unexpected Plant Performance During Performance of New Surveillance (8 March 1996)
- Information Notice 1996-16, BWR Operation with Indicated Flow Less than Natural Circulation (14 March 1996, Topic: Stress corrosion cracking)
- Information Notice 1996-17, Reactor Operation Inconsistent with the Updated Final Safety Analysis Report (18 March 1996)
- Information Notice 1996-18, Compliance with 10 CFR Part 20 for Airborne Thorium (25 March 1996, Topic: Stress corrosion cracking, Brachytherapy)
- Information Notice 1996-19, Failure of Tone Alert Radios to Activate When Receiving a Shortened Activation Signal (2 April 1996, Topic: Tone Alert Radio, Siren)
- Information Notice 1996-20, Demonstration of Associated Equipment Compliance with 10 CFR 34.20 (4 April 1996, Topic: Brachytherapy)
- Information Notice 1996-21, Safety Concerns Related to the Design of the Door Interlock Circuit on Nucletron High-Dose Rate and Pulsed Dose Rate Remote Afterloading Brachytherapy Devices (10 April 1996, Topic: Brachytherapy)
- Information Notice 1996-22, Improper Equipment Settings Due to Use of Nontemperature-Compensated Test Equipment (11 April 1996, Topic: Brachytherapy)
- Information Notice 1996-23, Fires in Emergency Diesel Generator Exciters During Operation Following Undetected Fuse Blowing (22 April 1996, Topic: Brachytherapy, Overspeed trip)
- Information Notice 1996-24, Preconditioning of Molded-Case Circuit Breakers Before Surveillance Testing (25 April 1996, Topic: Brachytherapy)
- Information Notice 1996-25, Traversing In-Core Probe Overwithdrawn at Lasalle County Station, Unit 1 (30 April 1996, Topic: Brachytherapy)
- Information Notice 1996-26, Recent Problems with Overhead Cranes (30 April 1996, Topic: Brachytherapy)
- Information Notice 1996-26, Recent Problems With Overhead Cranes (30 April 1996)
- Information Notice 1996-27, Potential Clogging of High Pressure Safety Injection Throttle Valves During Recirculation (1 May 1996, Topic: Brachytherapy)
- Information Notice 1996-28, Suggested Guidance Relating to Development and Implementation of Corrective Action (1 May 1996, Topic: Brachytherapy)
- Information Notice 1996-29, Requirements in 10 CFR Part 21 for Reporting and Evaluating Software Errors (20 May 1996, Topic: Brachytherapy)
- Information Notice 1996-30, Inaccuracy of Diagnostic Equipment for Motor-Operated Butterfly Valves (21 May 1996)
- Information Notice 1996-31, Cross-Tied Safety Injection Accumulators (22 May 1996)
- Information Notice 1996-32, Implementation of 10 CFR 50.55a(g) (6) (II) (A), Augmented Examination of Reactor Vessel (5 June 1996, Topic: Non-Destructive Examination)
- Information Notice 1996-32, Implementation of 10 CFR 50.55a(g) (6) (ii) (A), Augmented Examination of Reactor Vessel (5 June 1996, Topic: Non-Destructive Examination)
- Information Notice 1996-33, Erroneous Data From Defective Thermocouple Results in a Fire (24 May 1996, Topic: Reverse polarity)
- Information Notice 1996-33, Erroneous Data from Defective Thermocouple Results in a Fire (24 May 1996, Topic: Reverse polarity)
- Information Notice 1996-34, Hydrogen Gas Ignition During Closure Welding of a VSC-24 Multi-Assembly Sealed Basket (31 May 1996)
- Information Notice 1996-35, Failure of Safety Systems on Self-Shielded Irradiators Because of Inadequate Maintenance and Training (11 June 1996)
- Information Notice 1996-36, Degradation of Cooling Water Systems Due to Icing (12 June 1996, Topic: High winds, Ultimate heat sink, Frazil ice)
- Information Notice 1996-37, Inaccurate Reactor Water Level Indication and Inadvertent Draindown During Shutdown (18 June 1996, Topic: Reactor Vessel Water Level)
- Information Notice 1996-38, Results of Steam Generator Tube Examinations (21 June 1996, Topic: Stress corrosion cracking)
- Information Notice 1996-39, Estimates of Decay Heat Using ANS 5.1 Decay Heat Standard May Vary Significantly (5 July 1996)
- Information Notice 1996-40, Defciencies in Material Dedication and Procurement Practices and in Audits of Vendors (7 October 1996, Topic: Coatings, Troxler Moisture Density Gauge)
- Information Notice 1996-41, Effects of a Decrease in Feedwater Temperature on Nuclear Instrumentation (26 July 1996, Topic: Feedwater Heater)
- Information Notice 1996-42, Unexpected Opening of Multiple Safety Relief Valves (5 August 1996, Topic: Reactor Vessel Water Level)
- Information Notice 1996-43, Failures of General Electric Magne-Blast Circuit Breakers (2 August 1996)
... further results |
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