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| NUREG-0940 Vol. 7, No. 4 o
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| I l
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| Enforcement Actions:
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| l Sigt.ficant Actions Resolved Quarterly Progress Report October - December 1988 l
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| U.S. Nuclear Regulatory Commission office of Enforcement jo acoq, l u ~'
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| t 8384 388!? "' PDR 0940 R 1
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| l Available from 1
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| 1 Superintendent of Documents U.S. Government Printing Office i
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| Post Office Box 37082
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| - Washington, D.C. 20013-7082 A year's subscription consists of 4 issues for this publication. 1 Single copies of this publication 'l are available from National Technical Information Service, Springfield, VA 22161 e
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| NUREG-0940 Vol. 7, No. 4 Enforcement Actions:
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| Significant Actions Resolved u
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| Quarterly Progress Report October - December 1988 Manuscript Completed: February 1989 Date Published: Fcbruary 1989 Office of Enforcement U.S. Nuclear Regulatory Commission Washington, D.C. 20555 f
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| p uaoq
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| % /
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| ABSTRACT This compilation summarizes significant enforcement actions that have been resolved during one quarterly period (October December 1988) and includes copies of letters, Notices, and Orders sent by the Nuclear Regulatory Commission to licensees with respect to these enforcement actions. It is anticipated that the information in this publication will be widely disseminated to managers and employees engaged in activities licensed by the NRC, so that actions can be taken to improve safety by avoiding future violations similar to those described in this publication.
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| NUREG-0940 jij
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| CONTENTS Pace ABSTRACT...................................... ........................... 111 INTRODUCTION................................................................ 1 SUMMARIES................................................................... 3 I. REACTOR LICENSEES A. Civil Penalties and Orders Baltimore Gas and Electric Company, Lusby, Maryland (Calvert Cliffs Nuclear Power Plant, Units 1 and 2)
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| EA 88-202......................................................I.A-1 l Boston Edison Company, Plymouth, Massachusetts I
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| (Pilgrim Nuclear Power Station)
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| EA 87-164......................................................I.A-7 i
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| Carolina Power and Light Company, Raleigh, North Carolina I (Brunswick Steam Electric Plant)
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| EA 88-131.....................................................I.A-11 Commonwealth Edison Coh:pany, Chicago, Illinois (Braidwood Station, Unit 1)
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| EA 68-91......................................................I.A-24 Commonwealth Edison Company, Chicago, Illinois (Braidwood Nuclear Power Station, Units 1 and 2)
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| EA 88-125.....................................................I.A-42 Commonwealth Edison Company, Chicago, Illinois (Braidwood Nuclear Power Station, Unit 2)
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| EA 88-174.....................................................I.A-46 Consolidated Edison Company of New York, Inc., Buchanan, New York (Indian Point 2)
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| EA 88-142.....................................................I.A-48 Consumers Power Company, Jackson, Michigan (Palisades Nuclear Plant)
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| EA 88-138.....................................................I.A-56 Duke Power Company, Charlotte, North Carolina (Catawba Nuclear Station, Units 1 and 2)
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| EA 88-132.....................................................I.A-65 Florida Power Corporation, Crystal River, Florida (Crystal River, Unit 3)
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| EA 87-216.....................................................I.A-74 NUREG-0940 y u
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| 1 l
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| CONTENTS (Continued) l REACTORLICENSEES(Continued) Page Florida Power Corporation, Crystal River, Florida (Crystal River Nuclear Plant)
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| EA 88-34......................................................I.A-93 Georgia Institute of Technology, Atlanta (Neely Nuclear Research Center) 1 EA 88-32.....................................................I.A-105
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| )
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| Illinois Power Company, Decatur, Illinois (Clinton Nuclear Station)
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| EA 88-90.....................................................I.A-128 Iowa Electric Light and Power Company, Cedar Rapids, Iowa (Duane Arnold Energy Center)
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| E A 8 7 - 8 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A - 14 3 1
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| Nebraska Public Power District, Columbus, Nebraska (Cooper Nuclear Statior,!
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| EA 88-159....................................................I.A-150 i Omaha Public Power District, Omaha, Nebraska (Fort Calhoun Station)
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| EA 88-145....................................................I.A-166 Pennsylvania Power and Light Company, Allentown, Pennsylvania (Susquehanna, Units 1 and 2)
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| EA 88-143....................................................I.A-173 i Philadelphia Electric Company, Philadelphia, Pennsylvania (Peach Bottom Atomic Power Station)
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| EA 88-237....................................................I.A-180 Power Authority of the State of New York, White Plains, New York (IndianPoint3)
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| EA 88-148....................................................I.A-183 I Toledo Edison Company, Toledo, Ohio (Davis-Besse Nuclear Power Station)
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| EA 88-234....................................................I.A-190 University of Utah, Salt Lake City, Utah EA 88-64......................................................I.A-201 Virginia Electric and Power Company, Richmond, Virginic (Surry Units 1 and 2)
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| EA 88-215....................................................I.A-212 I NUREG-0940 vi
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| i l
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| I CONTENTS (Continued)
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| REACTOR LICENSEES (Continued)
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| B. Severity Level III Violation, No Civil Penelty Commonwealth Edison Company, Chicago, Illinois (Zion Unit 1)
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| EA 88-199......................................................I.B-1 Commonwealth Edison Company, Chicago, Illinois (Quad Cities Nuclear Power Station, Units 1 and 2)
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| EA 88-217......................................................I.B-4 Gulf States Utilities, St. Francisv111e, Louisiana (River Bend Station)
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| EA 88-249......................................................I.B-9 Maine Ycnkee Atomic Power Company, Augusta, Maine (Maine Yankee)
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| E A 8 8 -2 0 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . 3 - 14 Omaha Public Power District, Omaha, Nebraska (Fort Calhoun Station)
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| EA 88-201............. .......................................I.0-18 System Energy Resources, Inc., Jackson, Mississippi (Grand Gulf Nuclear Station)
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| EA 88-286.....................................................I.B-23 II. MATERIALS LICENSEES A. Civil Penalties and Orders Babcock and Wilcox Company, Lynchburg, Virginia EA 88-225.................................................... 11.A-1 Combustion Engineering, Windsor, Connecticut EA 80-193....................................................II.A-10 Computalog, Inc., Drumright, Oklahoma EA 88-169....................................................II.A-19 ;
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| 1 E. L. Conwell & Company, Bridgeport, Pennsylvania EA 88-248....................................................II.A-27 Davis Great Guns Logging, Wichita, Kansas EA 88-231....................................................II.A-40 Ford Motor Company,
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| ==Dearborn,==
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| Michigan EA 88-255....................................................II.A-48 NUREG-0940 vii I
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| CONTENTS (Continued)
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| MATERIAL LICENSEES (Continued)
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| Payne and Payne, Inc., Shawnee, Oklahoma EA 87-205....................................................II.A-52 Penn Inspection Company, Chickasha, Oklahoma EA 88-189....................................................II.A-59 Shadyside Hospital, Pittsburgh, Pennsylvania EA 88-188....................................................II.A-69 Syncor International Corporation, Chotsworth, Ca'lifornia EA 88-194 and 88-242.........................................II.A-73 Veterans Administration, Hines, Illinois EA 87-150....................................................II.A-93 Wise Appalachian Regional Hospital, Wise, Virginia EA 88-204...................................................II.A-112 B. Severity Level III Violation, No Civil Penalty Syncor Corporation, Chatsworth, California EA 88-53......................................................II.8-1 Syncor Corporation, Chatsworth, California EA 88-269.................................................... 11.B-7 Trinity Lutheran Hospital, Kansas City, Missouri EA 88-244..............,.....................................II.B-10 l
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| NUREG-0940 viii
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| _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ - - _ _ _ _ - _ - _ J
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| ENFORCEMENT ACTIONS: SIGNIFICANT ACTIONS RESOLVED October - December 1988 )
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| INTRODUCTION This issue of NUREG-0940 is being published to inform NRC licensees about significant enforcement actions and their resolution for the fourth quarter of 1988. Enforcement actions are issued by the Deputy Excrutive Director for Regional Operations (DEDRO) and the Regional Administrator. The Director, ,
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| Office of Enforcement, may act for the DEDR0 in the absence of the DEDRO or as directed. The actions involved in this NUREG involve NRC's civil penalties as well as significant Notices of Violation.
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| An objective of the NRC Enforcement Program is to encourage licensees to improve their performance and, by example, the performance of the licensed industry. Therefore, it is anticipated that the information in this publication will be widely disseminated to managers and employees engoged in activities licensed by NRC, so all can learn from the errors of others, thus improving performance in the nuclear industry and promoting the public health and safety as well as the common defense and security.
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| A brief summary of each significant enforcement action that has been resolved in the fourth quarter of 1988 can be found in the section of this report entitled " Summaries." Each summary provides the enforcement oction (EA) number to identify the case for reference purposes. The supplement number refers to the activity area in which the violations are classified according to guidance furnished in the U.S. Nuclear Regulatory Commission's " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988). Violations are categorized in terms of five levels of severity to show their relative importance within each of the following activity areas:
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| Supplement I - Reactor Operations Supplement II - Facility Construction Sup p ment III - Safeguards Supplement IV - Health Physics Supplement V - Transportation Supplement VI - Fuel Cycle and Materials Operations Supplement VII - Miscellaneous Matters Supplement VIII - Emergency Preparedness Part I.A of this report consists of copies of completed civil penalty nr Order actions involving reactor licensees, arranged alphabetically. Part I.B includes copies of Notices of Violation that were issued to reactor licensees for a Severity Level III violation, but for which no civil penalties were assessed.
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| Part II.A contains civil penalty or Order actions involving materials licensees.
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| Part II.B includes copies of a Notices of Violation that has been issued to materials licensees for Severity Level III violations, but for which no civil penalty was assessed.
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| Actions still pending on December 31, 1988 will be included in future issues of this publication when they have been resolved.
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| NUREG-0940 1 E '
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| SUMMARIES
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| : 1. REACTOR LICENSEES A. Civil Penalties and Orders Baltimore Gas and Electric Company, Lusby, Maryland (Calvert Cliffs Nuclear Power Plant, Units 1 and 2), Supplement I, EA 88-202 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $150,000 was issued on September 20, 1988 to emphasize the need for better control of operations and better coordination both within the operations department and among the departments to assure the reactors are operated safely in accordance with the technical specifications. The action was based on two events in which Technical Specification Limiting Conditions for Operation were violated. In the first, one of the two emergency diesel generators required for Unit 2 was inoperable for approximately 48 hours because the voltage regulator was left in manual after testing. In the second, all the variable high level and axial offset Reactor Protective System instrumentation channels on Unit I were set less conservative than required. The base civil penalty was escalated by 50% for both violations, in the first, because of poor prior performance and in the second, because of prior notice of a similar problem. The licensee responded and paid the civil penalty on October 19, 1988.
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| Boston Edison Company, Plymooth, Massachusetts (Pilgrim Nuclear Power Station) Supplements III and VII, EA 87-164 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued November 1, 1988 to emphasize that the conduct of supervisors at issue cannot be tolerated. The action was based on an access control violation, the failure to take prompt corrective action to mitigate the consequences of the violation, and a deliberate material false statement by a security lieutenant concerning his knowledge of the vulnerability of the vital area barrier. The licensee responded and paid the civil penalty on November 28, 1988.
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| Carolina Power and Light Company, Raleigh, North Carolina (Brunswick Steam Electric Plant) Supplement I, EA 88-131 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $75,000 was issued July 25, 1988 to emphasize the importance of the operations staff to maintain the highest degree of awareness and attentiveness to all aspects of plant operation. The action was i based en three violations involving (I) leaving a control rod fully 1 withdrawn with the reactor protection system shorting links installed, (2) the f ailure to have required system alignments completed prior to a change in Operational Condition as required by the Technical Specifications, and (3) the failure to maintain a proper shutdown cooling alignment whi:h resulted in an unplanned 35 F rise in reactor NUREG-0940 3
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| temperature. The base civil penalty was escalated 50% for poor past performance. The licensee responded in letters dated August 24 and September 26, 1988 and paid $50,000 of the civil penalty, but took exception to the $25,000 escalation. After consideration of the responses, the staff concluded that the escalation was justified and an Order Imposing a Civil Penalty in the amount of $25,000 was issued October 17, 1988. The licensee paid the civil penalty on November 3, 1988.
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| Commonwealth Edison Company, Chicago, Illinois (Braiowood Station, Unit 1) Supplement I, EA 88-91 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued on May 6, 1988 to emphasize the I need for improving implementation of procedures for design changes ;
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| I to safety systems. The action was based on three design control deficiencies which resulted in the Control Room Ventilation System being in a degraded condition. The deficiencies included a failure to properly translate design information into instructions, a failure to adequately test a modification and a failure to follow design procedures. The licensee responded in letters dated June 20 and October 6, 1988. Aft-r consideration of the responses, an Order Imposing Civil Monetary Penalty was issued October 19, 1988. The licensee paid the civil penalty on November 18, 1988.
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| Commonwealth Edison Company, Chicago, Illinois (Braidwood Station, Units 1 and 2) Supplement III, EA 88-125 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued on June 17, 1988 to emphasize the need to ensure the integrity of all vital area boundaries. The action was based on the failure to maintain control of access to a vital area of the plant. The licensee responded in a letter l dated July 22, 1988. After consideration of the licensee's respcnse, the violation was reduced to Severity Level IV and the proposed civil penalty was withdrawn on October 17, 1988.
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| Commonwealth Edison Company, Chicago, Illinois (Braidwood Nuclear Power Station, Unit 2) Supplement III, EA 88-174 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued or. September 16, 1988 to emphasize the importance of posting effective compensatory measures and the need to ensure that security officers' performance does not impact on the adequacy of those measures. The action was based on two separate examples of inattentiveness on the part of security officers assigned as compensatory measures for an unlocked and unalarmed vital area door. The licensee responded and paid the civil penalty on October 14, 1988.
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| Consolidated Edison Company of New York, Inc., Buchanan, New York (Indian Point 2) Supplement I, EA 88-142 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $75,000 to emphasize the importance of environmental NUREG-0940 4
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| qualification and meeting regulatory deadlines. The action was based on violations of NRC requirements for the environmental qualification of certain items of electrical equipment. The licensee responded and paid the civil penalty on December 2,1988. J ConsumersPowerCompany,) Jackson, (Palisades Nuclear Plant Supplement Michigan I, EA 88-138 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $150,000 was issued on November 23, 1988 to emphasize the ir9ortance of environmental qualification of electrical equipment important to safety and meeting regulatory deadlines. The action was based violations of NRC requirements for environmental qualifi-cation of certain items of electrical equipment. The licensee responded and paid the civil penalty on December 23, 1988.
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| Duke Power Company, Charlotte, North Carolina (Catawba Nuclear Station, Units 1 and 2) Supplement I, EA 88-132 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued October 24, 1988 to emphasize the importance of environmental qualification of electrical equipment and that regulatory deadlines are met. The action was based on violations of the equipment qualification requirements. The licensee responded and paid the civil penalty on November 23, 1988.
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| Florida Power Corporation, Crystal River, Florida (Crystal River, Unit 3) Supplement IV, EA 87-216 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $100,000 was issued March 17, 1988 to emphasize the serious nature of these events and the need for improvements in the administra-tion and control of the licensee's Radiation Safety Program and training program to ensure the safe performance of licensed activities and adherence to NRC requirements. The action was based on violations involving the failure to (1) lock, post, barricade, and issue a Radiation Work Permit to control access to a high radiation area, (2)provideade w ate instruction and training to employees working in a restricted area, (3) establish adequate procedures for radiation protection and refueling operations, (4) provide a radiation monitoring device to an individual inside a posted High Radiation Area as required by your Technical Specifications, and (5) follow radiation control procedures. The base civil penalty was escalated by 100% because of
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| , the licensee's prior notice of similar events and similar violations l
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| occurring in 1986. The licensee responded on May 16, 1988. After consideration of the licensee's response, one violation was withdrawn and the penalty was mitigated by 50%. An Order Imposing Civil Monetary Penalty in the amount of $50,000 was issued November 17, 1986. The licensee paid the civil penalty on December 15, 1988. ;
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| Florida Power Corporation, Crystal River, Florida (Crystal River Nuclear Plant) Supplement I, EA 88-34 i A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued May 4,1988 to emphasize the importance NUREG-0940 5 e
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| I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .
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| ._._2
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| of the identification and correction of problems in the area of design and incorporation of design changes into Technical Specifications and procedures. The action was based on the failure to take appropriate i corrective action to resolve a deficiency regarding the electrical '
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| loads placed on one of two plant emergency diesel generators (EDG).
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| The EDG overload was caused by errors made by the licensee in the interpretation of the EDG vendor's load ratings, and in the assess-ment of equipment electrical loads in incorporating a design change in May 1980, which added the emergency feedwater pump as an automatic load. The licensee responded in a {{letter dated|date=June 2, 1988|text=letter dated June 2, 1988}}. After )
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| consideration of the licensee's response, the civil penalty was J mitigated by 50% because of the licensee's identification of the violation. An Order Imposing $25,000 was issued October 31, 1988.
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| The licensee paid the imposed civil penalty on November 22, 1988.
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| Georgia Institute of Technology, Atlanta, Georgia (Neely Nuclear Research Center) Supplements I and IV, EA 88-32 An Order Modifying License, Effective Immediately, was issued January 20, 1988 requiring the licensee to immediately suspend certain activities until requirements of the Order were satisfied which included: (1) an assessment of management controls, (2) an assessment of personnel exposures from an August 1987 incident, and (3) a review of health physics and operating procedures. A Confirmatory Order Modifying License (Effective Immediately) was issued March 17, 1988 based en commitments by the licensee at an enforcement conference. A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $5,000 was issued November 15, 1988 to emphasize the importance of the licensee's managers of the necessity of assuring lasting and effective compliance with NRC requirements. The action was based on tne failure of management to assure that procedures were followed and i to have adequate procedures for the conduct and control of experi- )
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| ments and radiological safety activities, and the failure to conouct i adequate surveys to evaluate the extent of radiological hazards. '
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| The base civil penalty was increased by 100% because of the licensee's prior poor performance and failure to take prompt corrective actions.
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| The licensee paid the civil penalty on December 20, 1988.
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| Illinois Power Company, Decatur, Illinois (Clinton Nuclear Station) Supplement I, EA 88-90 A Notice of Violation and Proposed Imposition of Civil Penalty was issued June 1, 1988 in the amount of $75,000 to emphasize the importance of adequate engineering control of installation instructions to ensure qualification of electrical equipment important to safety. The action was bosed on the failure of the l licensee to assure that electrical equipment important to safety, l involving electrical connectors and junction boxes, were environ- !
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| mentally qualified resulting in a significant deficiency which could have led to equipment failures during postulated accider:t conditions in mu't'ple safety systems. The licensee responded on June 29, 1968. After consideration of the licensee's response, NUREG-0940 6
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| the staff concluded that one example of a violation should be withdrawn. However, the withdrawal did not affect the civil penalty.
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| An Order Imposing a Civil Penalty was i'ssued October 20, 1988. The licensee paid the civil penalty on November 14, 1988.
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| Iowa Electric Light and Power Company, Cedar Rapids, Iowa (Duane Arnold Energy Center) Supplement I, EA 87-83 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued on October 21, 1988 to emphasize the importance of environmental qualification and meeting regulatory deadlines. The action was based on a violation of the equipment qualification requirements of 10 CFR. 50.49. The licensee responded and paid the civil penalty on November 21, 1988.
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| Nebraska Public Power District, Columbus, Nebraska (Cooper Nuclear Station) Supplement I, EA 88-159 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $150,000 was issued on October 25, 1988 to emphasize the need to place greater attention on ensuring that equipment impcrtant to safety will perform its intenaed function in harsh environments and that regulatory deadlines are met. The action was based on violations of the equipment qualification requirements of 10 CFR 50.49. The base civil penalty was escalated by 100%
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| because of the licensee's failure to take corrective actions for the violations of the equipment qualification requirements of 10 CFR 50.49. The licensee responded and paid the civil penalty on December 8, 1988.
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| l Omaha Public Power District, Omaha, Nebraska l (Fort Calhoun Station) Supplement I, EA 88-145 i
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| A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued on October 12, 1988 to emphasize the importance of promptly correcting deficiencies that have been brought to the licensee's attention. The action was based on two violations (1) the installation of improper check valves in instrument air accumulator lines to level instruments, and (2) the failure of plant personnel to install a test cap on a containment pressure sensing line after testing. The licensee responded and paid the civil penalty on November 15, 1988.
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| Pennsylvania Power and Light Company, Allentown, Pennsylvania (Susquehanna Units 1 and 2) Supplement I, EA 88-143 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued on September 19, 1988 to emphasize sufficient attention was not provided to the EQ program as evidenced by inadequate engineering review, inadequate consideration of vendor installation information, and inadequate quality control of these activities. The action was based on a violation of the equipment qualification requirements of 10 CFR 50.49. The licensee responded and paid the civil penalty on October 19, 1988.
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| NUREG-0940 7 l
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| l L- - ----------_----
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| 1 Philadelphia Electric Company, Philadelphia, Pennsylvania j (Peach Bottom Atomic Power Station) Supplement III, EA 88-237 A Notice of Violation and Proposed Imposition of Civil Penalty in l the amount of $50,000 was issued to emphasize the importance of a strong utility oversight and appropriate management attention to ,
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| the program, as well as thorough analysis of root causes whenever '
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| deficiencies in the program are identified, so that effective corrective actions are taken to prevent recurrence. The action was based on two Severity Level III violations involving numerous examples of failure to take appropriate compensatory measures for cegraded vital area barriers, issuance of a vital area key to an 1 unauthorized person, and failure to maintain adequate assessment capability of two protected area barriers. The base civil penalty was mitigated by 50% because of unusually prompt and extensive ;
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| corrective actions and the licensee's identification and reporting of the events. The licensee responded and paid the civil penalty '
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| on December 15, 1968.
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| Power (Indian Authority)of the State Point 3 Supplement of New I, EA York, Khite Plains, New York 88-148 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $75,000 was issued September 21, 1988 to emphasize ;
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| that sufficient attention should be given to the EQ program and to assure that the program is completely in compliance with NRC requirements. The acticn was based on a violation of the equipment qualification requirements of 10 CFR 50.49. The licensee r.:sponded and paid the civil penalty on October 21, 1988.
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| Toledo Edison Company, Toledo, Ohio (Davis-Besse Nuclear Power Station) Supplement VII, EA 88-234 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $80,000 and an Order Modifying License were 1: sued November 21, 1988 to emphasize the need: (1) to ensure that the lictnsee's supervisors and managers do not take discriminatory actions against ;
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| employees for bringing forward safety concerns, and (2) to ensure that the licensee's employees feel free to bring safety concerns to managements attention. The violation was based on the actions of a former QC supervisor who deliberately laid off a QC inspector for raising a safety issue. The Order Modifying License directed the '
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| licensee to provide NRC with notice should the former supervisor be reinvolved in safety-related activities authorized by the Davis-Besse license. The licensee responded and paid the civil penalty on Decer.5er 21,1988.
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| University of Utah, Salt Lake City, Utah Supplements I and IV, EA 88-64 An Order Modifying Licence and Notices of Violation and Deviation were issued July 8, 1988. The action was based on findings of numerous violations and the licensee's failure to take prompt corrective actions to correct a number of audit findings. The Order NUREG-0940 8
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| confirms the licensee's commitment to retain an additional professor who will perform the duties of the facility's reactor supervisor.
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| The licensee responded in letters dated August 4 and 25, 1988.
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| Virginia Electric and Power Company, Richmond, Virginia (Surry Powcr Station) Supplement I, EA 88-215 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued November 10, 1988 to emphasize the concerns with regard to the licensee's inadequate implementation of a program which could affect operability of safety-related systems and the period of time in which adequate controls were not in place.
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| The action was based on the failure of the licensee to adequately implement cleanliness and foreign material exclusion controls which allowed a substantial amount of debris to accumulate in the portion of the containment sumps which supply water to the safety-related inside recirculation pumps. The licensee responded and paid the civil penalty on December 9,1988.
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| 8, Severity Level III Violation, No Civil Penalty Commonwealth Edison Company, Chicago, Illinois (Zion Unit 1) Supplement I, EA 88-199 A Notice of Violation was issued October 19, 1988 based on the installation of two Rosemount transmitters and one Barton transmitter with leads landed on unqualified terminal blocks rather than spliced utilizing environmentally qualified splices. A civil penalty was not proposed because the licensee had satisfied the five criteria of the Modified Enforcement Policy; (1) the violation was isolated and affected a limited number of systems, (2) the licensee identified the violation, (3) the violation was promptly reported, (4) the violation was corrected and full compliance was achieved within a reasonable time, and (5) the licensee demonstrated best efforts to complete EQ within the deadline.
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| Commonwealth Edison Company, Chicago, Illinois (Quad Cities Nuclear Power Station, Units I and 2) Supplement I, EA 88-217 A Notice of Violation was issued October 21, 1988 based on a licensee identified event where the automatic transfer function of a motor contral center failed during modification testing. A civil penalty was not proposed because the licensee identified the problem and promptly reported it and because of the licensee's extensive corrective actions to prevent recurrence.
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| Gulf States Utilities, St. Francisville, Louisiana (River Bend Station) Supplement I, EA 88-F49 A Notice of Violation was issued November 15, 1988 based on the discovery that heaters in both divisions of the fuel building venti-lation charcoal filtration system had been deenergized at a time when the plant's technical specifications required them to be available.
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| A civil penalty wbs not proposed because the licensee initiated short and long-term corrective actions and good regulatory performance in identifying and correcting deficiencies.
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| NUREG-0940 9
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| i l
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| Maine Yankee Atomic Power Company, Augusta, Maine (Maine Yankee) Supplement I, EA 88-206 A Notice of Violation was issued October 17, 1988 based on violations involving the lack of qualification of certain items of electric equipment. A civil penalty was not proposed because (1) the violations affected only a few systems, (2) the violations were identified by the licensee's staff and promptly reported, (3) the violations were corrected within a reasonable amount of time, and (4) the licensee made best efforts using external groups to support, audit, and upgrade the plant EQ program within the 1985 deadline.
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| Omaha Public Power District, Omaha, Nebraska (Fort Calhoun Station) Supplement I, EA 88-201 A Notice of Violation was issued October 12, 1988 based on violations involving the failure of the licensee M verify the adequacy of design, to perform design analyses in a correct manner, and to provide accurate information to the NRC regarding a setpoint A ange to the thermal Margin / Low Pressure reactor trip. A civil per.alty was not proposed because the licensee identified the problem and reported it promptly to the NRC, took immediate actions to address the safety implications, and developed long-term actions to minimize the possibility of such a calculational error being made in the future.
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| System Energy Resources, Inc., Jackson, Mississippi l (Grand Gulf Nuclear Station) Supplement III, EA 88-286 l A Notice of Violation was issued December 16, 1988 based on a violation involving a failure of the licensee's site security to conduct an adequate search of packages received. As a result two handgcns were subsequently brought into the protected area. A civil penalty was not proposed because the event was identified and immediately reported by the licensee, prompt and extensive corrective action was initiated, and the licensee had a good record of performance.
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| II. MATERIALS LICENSEES A. Civil Penalties and Orders Babcock and Wilcox Company, Lynchburg, Virginia Supplement VI, EA 88-225 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $6,250 was issued November 18, 1988 to emphasize the need for improvement in the licensee's nuclear criticality sefety program.
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| The violations involved the failure to (1) follow the nuclear criticality safety double-contingency policy, (2) carefully control moderating materials, (3) post certain areas with nuclear criticality limits, (4) conduct activities in accordance with operating procedures and posted nuclear criticality safety limits, (5) obtain required reviews and approvals by 'che Nuclear Licensing Board, (6) perform interpretations of nuclear safety limits and controls in acccrdance with license requirements, and (7) conduct activities in accordance with approved procedures. The licensee responded and paid the civil penalty on December 16, 1988.
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| NUREG-0940 10
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| 1 l
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| Combustion Engineering, Inc., Windsor, Connecticut 1 Supplements IV and VI, EA 88-193 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $12,500 was issued October 7, 1988 to emphasize the need to upgrade and more effectively manage the facility. The action was based on (1) the failure to perform adequate surveys at the l licensee's facility, (2) the failure by certain individuals to wear i gloves while handling certain contaminated equipment, (3) shipment l of radioactive waste to a burial ground without meeting all of the l shipping requirements, and (4) the failure to properly measure the l uranium-235 content of certain waste materials. The licensee responded and paid the civil penalty on November 4, 1988.
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| Computalog, Inc., Drumright, Oklahoma i Supplements IV, V, and VI A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $1,000 was issued August 25, 1988 to emphasize the need to improve management controls over licensed activiti: The action was based on numerous violations, several that were r oeat violations from a 1985 inspection. They included failure to (1) calibrate radiation survey instrument every six months, (2)accountforall1;censedmaterialandhaverecordsavailable, (3) test sealed sources every six months, and (4) follow required shipping instructions for hazardous material. The base civil penalty was increaseo by 100% because of poor past performance and some of the violations had been identified in the 1985 inspection. The licensee responded and paid the civil penalty on November 27, 1988.
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| E. L. Conwell and Company, Bridgeport, Pennsylvania Supplements IV, V, VI, and VII, EA 88-248 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $1,950 and an Order to Show Cause why License Should not be Modified was issued November 18, 1988 to emphasize the need for increased and improved management attention to activities authorized by the license. The action was based on violations involving (1) failure to secure, or maintain constant surveillance
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| ! of a nuclear gauge (2) failure to secure the source lock on a gauge when not in use, (3) transport of a gauge without the gauge being accompanied by adequate shipping papers, and (4) transmittal of inaccurate information to the NRC. The Order was issued to prescribe additional requirements to ensure that acthities are conducted safely and in accordance with the terms of the license. The licensee responded and paid the civil penalty December 16, 1988.
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| Davis Great Guns Logging, Wichita, Kansas Supplements TV, V, and VI, EA 88-231 A Notice of Violation and Proposed Imposition of Civil Penalty in the amcunt of $500 was issued October 27, 1988 to emphasize the importance of conducting licensed activities in accordance with NRC's radiation safety requirements. The action was based on inadequate control of NUREG-0940 11 L_. .
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| h licensed material, failure to identify and post radiation areas, failure to conduct semiannual equipment inspections and conduct visual checks, tailure to conduct semiannual equipment inspections and conduct visual checks of logging equipment, and failure to maintain records of the use of licensed material and training. The licensee responded.
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| and paid the civil penalty on November 25, 1988. .After considering the licensee's response, one of the violations was withdrawn and a refund of $56 was made to the licensee.
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| Ford Motor Company,
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| ==Dearborn,==
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| Michigan Supplement IV, EA 88-255 A Notice of Violation and Proposed Imposition of Civil Penalty in the i amount of $500 was issued October 27, 1988 to emphasize the importance of maintaining adequate control over gauges containing radioactive material. The action was based on the' improper disposal of a generally licensed device containing byproduct material. The licensee responded and.paic the civil penalty on November 23, 1988.
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| Payne and Payne, Inc. , Shawnee, Oklahoma Supplements V.and VI, EA 87-205 A Notice of Violation end Proposed Imposition of Civil Penalty in the amount of $1,600 was issued September 20, 1988 to emphasize the t significance in which the NRC views deliberate violations, the importance of an effective radiation control program and the need for lasting improvements in management controls over licensed activities. The action was based on failures to calibrate, perform surveys, evaluate personnel dosinetry, leak test and inventory sealed i sources, enter into an agreement with well operators as owners or to j responsibilities in event of a down-hole irretrievable source, and l follow DOT regulations. The base civil' penalty was increased by 100% ;
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| because of multiple examples of some violations and duration. The i licensee responded and paid the civil penalty on October 14, 1988.
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| Penn Inspection Company, Chickasha, Oklahoma i Supplement VI, EA 88-189 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $2,500 and an Order Modifying License was issued October 6, 1988-to emphasize the importance of ensuring that individuals in the licensee's employ who use radioactive materials understand their responsibilities to meet all radiation safety requirements. The action was based on a source hang-up incident during radiography operations which included failure to utilize personnel monitoring devices, to have access to and follow emergency procedures, to straighten the source transfer tube prior to conducting radiography and to observe and record the performance of a radiographer who had not participated in radiographic operations in more than 3 months. The Order Modifying License prohibits the radiographer involved from acting as a radiographer for the licensee without specific NRC approval. The base civil penalty was reduced by 50% because of good prior compliance. The licensee responded and paio the civil penalty on December 12, 1988.
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| - NUREG-0940 12
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| m Shadysidd Hospital, Pittsburgh, Pennsylvania Supplement IV, EA 88-188 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $2,500 was issued October 28, 1988 to emphasize the !
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| importance of maintaining adequate management control of all 1 licensed naterials and activities. The action was based on a violation involving the failure to recover and return a nuclear pacemaker to the manufacturer upon the death of an individual. As a result of the failure to recover and return the nuclear pacemaker to the manufacturer, the pacemaker was disposed of by the funeral home in the normal trash, a method not authorized by NRC regulations.
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| The licensee responded and paid the civil penalty on November 11, 1988.
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| Syncor International Corporation, Chatsworth, California EAs 88-194 and 88-242 An Order Modifying Licenses, Effective Immediately, was issued October 12, 1988. The action was based on an unacceptably large number of improperly tagged or labeled radiopharmaceuticals distributed
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| -from the two Ohio facilities. The Order required the provisions of the Confirmatory Action Letters issued September 2 and 9,1988 to each facility be maintained and that the licenses perform at the corporate level an assessment of the licensed activities at the two Ohio facilities and at least 50% of the other Syncor facilities licensed by the NRC. The licensee responded in letters dated October 19 and November 1, 1988.
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| Veterans Administration, Hines, Illinois EA 87-150 An Order to Show Cause why Licensee Should not be Modified (Effective Immediately) was issued August 24, 1987 based on a physician's failure to report a diagnostic misadministration, subsequent actions to conceal the misadministration, and actions to impede the NRC investigation.
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| The Order (1) removed the physician's authority to independently use or supervise the use of licensed material at the Medical Center,.
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| (2) required independent quarterly aucits of the licensee's Radiation Safety Program, (3) required the licensee to take and reprt corrective i actions for identified deficiencies, and (4) implemented the provisions of the Confirmatory Action Lett - issued on January 12, 1987. The physician requested a hearing, but on June 13, 1988 the NRC was notified that the physician had resigned from the Hospital. An Agreement to terminate the hearing proceeding was signed October 1, 1988.
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| Wise Appalachian Regional Hospital, Wise Virginia Supplements IV and VI, EA 88-204 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $1,250 was issued September 30, 1988 to emphasize the need for proper management control over the radiation safety ro The action was based on violations involving failure to p(1) gram. label syringes or syringe shields containing radiopharmaceuticals, (E) usue written permission to a visiting authorized user, (3) post FUREG-0940 13
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| l a restricted area, (4) ccnduct a quarterly Radiation Safety Committee meeting, (5) perform a formal annual review of the radiation safety program, (6) provide in-service and initial training to ancillary personnel, ans (7) perform quarterly dose calibratcr linearity tests, l The base civil penalty was mitigated by 50% because of the licensee's i prolapt and extensive corrective actions. The licensee responded and paid the civil penalty on October 24, 1988.
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| B. Severity Level III Violation, No Civil Penalty Syncor Corporation, Chatsworth, Californic ,
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| Supplements IV and VI, EA 88-53 l A Notice of Violation was issued June 22, 1988 based on actions involving (1) a cumulative radiation exposure in excess of the regulatcry limit to the right hand of one of the radiopharmacists during the fourth calendar quarter of 1987, (2) failure to perform !
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| required bioassays on at least 10 occasions, (3) failure to perform !
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| d required Calibration check of the dose calibrator, and (4) labelling of containers of radioactive material with the wrong radiopharmaceutical name. A civil penalty was not proposed because (1) prompt notification of clients to prevent further administration of the mislabeled ,
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| product, (2) the licensee informed the NRC of the mislabeling i incident, (3) good prior enforcement history at the Allentown facility, and (4) because of the reconsideration of the violation.
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| 1 Syncor Corporation, Chatsworth, California Supplement VI, EA 88-269 l
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| A Notice of Violation was issued November 2, 1988 based on four misadministration at the Fairfield, New Jersey facility. These were caused by mislabeling of radiopharmaceuticals at the Fairfield, Pennsylvania facility. A civil penalty was not proposed because (1) the mislabeling occurred prior to the issuance of an Information Notice which communicated to all licensees that, in the future, any '
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| such violations would be categorized at a Severity Level III, and (2) the licensee's comprehensive corrective actions.
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| Trinity Lutheran Hospital, Kansas City, Missouri Supplement VI. EA 88-244 l
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| A Notice of Violation was issued December 14, 1988 based on actions involving a therapeutic misadministration which resulted from a ,
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| failure to compare the assayed dose to the prescribed physician's dose which was in excess of 10% of that prescribed. A civil penalty was osedbecauseofthelicensee's(1)identificationand not prop (2) prior good performance, and (3) prompt and extensive I
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| reporting, corrective actions which included disciplinary action, revision of procedures, and instructions to the nuclear pharmacy to limit doses sent to the hospital to within i 5% of the prescribed dose, h
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| l NUREG-0940 14 l
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| 4 l
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| I l
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| I i
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| J.A. REACTOR LICENSEES, CIVIL PENALTIES AND ORDERS f
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| l l
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| NUREG-0940
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| g Itj UNITED STATES NUCLEAR REGULATORY COMMISSION W pe i REGION I E .
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| 475 ALLENDALE ROAD
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| *I KING OF PRUSSI A, PENNSYLVANIA A 194o6
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| ,y
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| ....* 1 September 20, 1988 Docket Nos. 50-317; 50-318 License Nos. DRP-53; OPR-69 EA 88-202 Baltimore Gas and Electric Ccmpany ATTN: Mr. J. A. Tiernan Vice President, Nuclear Energy Calvert Cliffs Nuclear Power Plant Md. Rts. 2 and 4, Post Office Box 1535 Lusby, Maryland i Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC Inspection Report No. 50-317/88-17; 50-318/88-17)
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| This refers to the special NRC safety inspection conducted between June 27 and July 13, 1988 at Calvert Cliffs Nuclear Power Plant, Units 1 and 2, to review two operational events which occurred at your facility in June and July, 1988.
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| The report of this inspection was sent to you on July 21, 1988. The two events, both of which were identified by members of your staff and reported to the NRC, involved violations of technical specification limiting conditions for opera-tion (LCO). In one case, the LCO was violated in that certain technical specification limiting safety system settings were set at values less conser-vative than required. The violations are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penelty. On August 8, 1988 an enforcement conference was conducted with you and members of your staff to discuss the violations, their causes, and your corrective action.
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| The first violation involved the inoperability of one of the emergency diesel generators (EDG) for Unit 2, for approximately 48 hours in June 1988, while the reactor was at 100% power. During surveillance testing, Operations personnel assumed a malfunction in the diesel generator's automatic voltage regulator and they placed the voltage regulator in manual mode in order to complete the test. However, the voltage regulator was not returned to the automatic mode upon completion of the test. As a result, the violation occurred in that the diesel generator was rendered inoperable because it would not successfully power essential loads as required.
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| The second violation involved operation of the Unit I reactor at power in July 1988 while all the variable high level and axial offset Reactor Protective System instrumentation channels were inoperable for approximately 12 hours because their trip setpoints were less conservative than the limiting safety system settings described in the technical specifications. The violation occurred when operations personnel noted a 5% mismatch between nuclear instrumentation (NI) power indication at 17% and reactor coolant system (RCS)
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| Delta T power indication at 22%, and the control room operator lowered the RCS Delta T power indication to coincide with the NI power indication. This is of particular concern because prior to taking this action, the operator was NUREG-0940 1.A-1
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| Baltimore Gas and Electric Company )
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| not aware nor made any attempt to determine which power indication was correct.
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| This adjustment was made with the supervisor's approval but without his realizing the magnitude of the change or the effect of this change or. the I limiting safety system settings, and without formal and administrative approval of what, in fact, constituted a temporary change to a procedure.
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| i The NRC is particularly concerned that, in each case, operations personnel made changes to safety related equipment without understanding or determining the effects of these changes on the operability of the equipment, and without coordinating with, or seeking assistance from, technical support personnel.
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| Furthermore, in making these changes, which were contrary to established procedures, operations personnel did not exhibit a proper safety attitude in that they were not sufficiently questioning or technically inquisitive while seeking resolution of these problems.
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| l These events raise significant questions concerning the (1) the control of operations, and (2) the coordination and communication that exists between operations and technical support personnel. Furthermore, they provide another example of a continuing NRC concern, expressed during previous SALP evaluations, that your staff was, at times, slow to recognize the existence of potential safety issues and was not always effective in reviewing, evaluating, j and resolving potential safety problems.
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| l Accordingly, a need exists for better control of operations at Calvert Cliffs, and better coordination both within the operations department and among the departments to assure the reactors are operated safely in accordance with the the technical specifications. To emphasize these needs, I have been i authoMzed, after consultation with the Director, Office of Enforcemer.t, and l the Douty Executive Director for Regional Operations, to issue the enclosed l l
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| Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Hundred Fif ty Thousand Dollars ($150,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988)
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| (Enforcement Policy), the violations described in the enclosed Notice have been l individually categorized at Severity Level III.
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| Although the base civil penalty amount for a Severity Level III violation is I
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| 1 550,000, the base civil penalty amount has been increased by 50% to $75,000 in each case. With respect to the first violation, the penalty was increased by 50% because of your recent poor performance in the area of control of surveillance tests. For example, deficiencies in this area have caused (1) an event in 1987 in which all four sensor channels of the recirculation actuation systems were inoperable for 15 minutes due to improper isolation of all four switches during preparations for a surveillance test, .nd (2) problems encountered during testing of Auxiliary Feedwater pumps which resulted in a Confirmatory Action Letter being issued on November 2,1987. With respect to the second violation, the penalty was increased by 50% because your staff should have known of the reduced ex-core NI signals resulting from the lower leakage two year core design. A similar situation had previously occurred at Unit 2 following the i 1987 refueling and although your staff had been notified of the potential for l
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| NUREG-0940 1.A-2
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| Baltimore Gas and Electric Company this type of problem by the NSSS vendor, they failed to adequately disseminate and use this information.
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| The other escalation and nitigation factors were considered and no further adjustment was considered appropriate.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing you response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be place in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely.
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| William T. Russell Regional Administrator
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| ==Enclosure:==
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| Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enc 1:
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| M. Bowman, General Supervisor, Technical Services Engineering T. Magette, Administrator, Nuclear Evaluations Public Document Room (PDR)
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| Local Pub?ic Document Room (LPDR)
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| Nuclear Safety Information Center (NSIC)
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| NRC Resident Inspector State of Maryland (2)
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| NUREG-0940 I . A- 3
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES Baltimore Gas and Electric Company Docket Nos. 50-317; 50-318 Calvert Cliffs, Units 1 and 2 License Nos. OPR-53, OPR-69 EA 88-202 During an NRC inspection conducted between June 27 and July 13, 1988, a review of the circumstances associated with two violations of NRC requirements which were identified by the licensee and reported to the NRC was performed. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Action," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205.
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| ; The particular violations and associated civil penalties are set forth below:
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| A. Technical Specification Limiting Condition for Operation (LCO) 3.8.1.1.b requires that whenever the reactor is in modes 1, 2, 3 or 4, two separate and independent diesel generators shall be operable, one of which may be a swing diesel generator capable of serving either Unit 1 or Unit 2.
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| Technical Specification LC0 Action Statement 3.8.1.1.b permits one diesel generator to be inoperable for a maximum of 72 hours provided the oper-ability of the remaining A.C. power sources is demonstrated by performing Technical Specification Surveillance Requirement 4.8.1.1.1.a within one hour and at least once per 8 hours thereafter, and Technical Specification Surveillance Requirement 4.8.1.1.2.a.4 within 24 hours.
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| Contrary to the above, between 11:13 a.m. on June 4,1988 and 11:09 a.m.
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| on June 6,1988, while the Unit 2 reactor was in Mode 1 operating at 100%
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| power, Emergency Diesel Generator (EDG) No. 21, one of the two required diesel generators was inoperable, and during that time, Technical Specifi-cation Surveillance Requirements 4.8.1.1.1.a and 4.8.1.1.2.a.4 were not performed. The EDG was inoperable during that time period in that its voltage regulator was in the manual mode, and with the voltage regulator in that mode, the EDG would not successfully power essential loads as required during a loss of coolant accident concurrent with a loss of offsite power.
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| I This is a Severity Level III violation (Supplement 1).
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| l l Civil Penalty - 575,000 l B. Technical Specification (TS) LCO 3.3.1.1 requires a minimum of three l channels of the Reactor Protective System (RPS) instrumentation to be operable whenever the reactor is operating in Mode 1. With two channels operable TS 3.3.1.1 specifies that operations may continue provided the requirements of Table 3.3-1 Action 2 are met. If less than two channels are operable, TS 3.0.3 requires action to be initiated within one hour to place the unit in at least hot standby within the next 6 hours.
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| NUREG-0940 I.A-4
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| 1 1
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| L l
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| Notice of Violation For channel operability, TS 2.2.1 requires that RPS instrumentation setpoir'ts shall be set consistent with the trip setpoint values contained in TS Table 2.2-1. . Table 2.2-1 states that the high power level trip l setpcint must be less than or equal to 10% above thermal power, with a minimem setpoint of 30% of rated thermal power and a maximum of 107% of j rated ther.nl power. Table 2.2-1 also states that the axial flux offset trip setpoint must be adjusted to not exceed the limit lines of TS figure 2.2-1.
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| l Co ttrary to the above, between 10:25 a.m. and 10:00 p.m. on July 4,1988, l whd e Wi+ 1 was operated in Mode I at power levels up to 44%, all of the l high power level and axial flux offset RPS channels were inoperable and the unit was not placed in hot standby as required. The channels were inoperable in that improper adjustments were made to all RPS delta T power indications which caused the setpoints for the above RPS channels to be less conservative than the setpoint values in TS Table 2.2-1.
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| This is a Severity Level III violation (Supplement 1)
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| Civil Penalty - $75,000.
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| l Pursuant to the provisions of 10 CFR 2.201, Baitimore Gas and Electric Company is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation:
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| (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will b? achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not S taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFQ 2.201, the Licensee may pay the civil penalties by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer -f the United States in the cumulative l amount of the civil penalties proposed above, or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fa1.1 to answer within the time specified, an order imposing the i
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| civil penalties will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violation (s) listed in this Notice in whole er in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or NUREG-0940 I.A-5
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| Notice of Violation l (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provision of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the pnalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Directo , Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) sho::1d be addressed to: Director, Office of Enforcement U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406 and a copy to the NRC Resident Inspector, at Calvert Cliffs.
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| FOR THE NUCLEAR REGULATORY COMMISSION William T. Russell Regional Administrator l
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| l Dated at King of Prussia, Pennsylvania I
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| thisJdkayofSeptember1988 l
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| NUREG-0940 1.A-6
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| f, ,4 UNiitU blAltb '
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| {*' ' ,j NUCt. EAR BEGULATORY COMMISSION r REGION 1 e 475 ALLENDALE ROAD
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| ***** KING OF PRUSSIA. PENNSYLVANIA 19406 l November 1, 1988 Docket No. 50-293 License No. DPR-35 '
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| EA 87-164 Boston Edison Company ATTN: Mr. Ralph G. Bird Senior Vice President - Nuclear Pilgrim Nuclear Power Station RFD #1 Rocky Hill Road Plymouth, Massachusetts 02360 Gentlemen:
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| ==Subject:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection Reports Nos. 50-293/87-30 and 50-293/87-50; and NRC Office of Investigation Report Synopsis No. 1-87-009)
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| This refers to the NRC physical security inspections conducted on July 13 - 17, 1987, and October 27 - December 6,1987, as well as an investigation conducted by the NRC Office of Investigations (01). The inspections and investigation were conducted in response to (1) an allegation received by the NRC concerning a degradation of a vital area barrier, and (2) violations identified by your staff and reported to the NRC concerning other degradations of vital area barri rs. The inspection reports were sent to you on August 19, 1987, and February 11, 1988. The synopsis of the OI report is enclosed. As a result of the inspections and investigation, numerous violations of NRC requirements were identified.
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| The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty, include three examples of degradations of vital area barriers, two of which were discussed with you and members of your staff during an enforcement conference on September 9, 1987. In addition to these three degradations, the NRC has also found that (1) in the case of one of the degradations, although two security lieutenants were made aware of the degraded concition by the security guard who identified the condition, neither of the lieutenants took action to report or compensate for the condition; therefore, the condition went uncorrected for an additional two months at which time the NRC received the allegation; and (2) one of the two security lieutenants made a deliberate material false statement concerning his knowledge of the degraded condition when questioned by an NRC inspector in July 1987.
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| The specific degradation for which compensatory measures were not taken involved the existence of a deadbolt on the outside of the left section of a two section vital area door which permitted the door to be opened from the outside. That condition was recognized by a member of the contract security force in May 1987, .
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| and he informed a security lieutenant who in turn discussed the matter with i NUREG-0940 I.A-7
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| 1 l
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| j Boston Edison Company 2 another security lieutenant, who was in charge of the shift The two security lieutenants did not take appropriate action to correct the condition. These failures constitute, at a minimum, careless disregard for NRC requirements.
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| l Furthermore, one of those lieutenants, when initially questioned by an NRC l inspector concerning the degraded condition, made a deliberate material false statement in that he stated that he could not remember if he was told of this condition when, in fact, he did _ the time know that the door was degraded.
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| The failure by the two contractor security lieutenants to t'ake appropriate action to correct this degraded condition, and the material false statement by one of the lieutenants when questioned by an NRC inspector, was indicative of significant inadequacies in BEC0's control of the contract security force at Pilgrim at that time. Further, these failures raised additional concerns regarding the training provided to, and the qualifications of, personnel implementing the security program. As you know, the security program at Pilgrim has exhibited weaknesses, as evidenced by (1) a Category 3 rating in this area during the Systematic Assessment of Licensee Performance conducted prior to l identification of these violations; and (2) a S25,000 civil penalty that was imposed by the NRC on February 25, 1986 for other problems with the security program.
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| Normally, the violation involving this degradation, which is described in Section I.A.1 of the enclosed Natice, would be classified at Severity Level IV in accordance with Section 0.3 of Supplement III of the " General Statement of Policy and Procedure for NRC Enforcement Actions",10 CFR Part 2, Appendix C, (Enforcement Policy) (1988), since only the barrier was inadequate and monitoring and response were adequate. However, when viewed in conjunction with the other violations set forth in Section I of the Notice, namely, (1) the failure to take appropriate corrective actions when the condition was initially identified, and (2) the deliberate material f alse statement made by the former lieutenant, the violations have been classified in the aggreg&te s a Severity level Ill problem.
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| The conditions which existed in July 1987 for which enforcemer.t is being proposed have been corrected. Corrective actions for these violations were prompt and extensive and have been verified to be effective by subsequent inspections. Prior to the plant shutdown in April 1986, NRC had identified serious concerns regarding the implementation and management support of the security program at Pilgrim. The licensee has been aggressively pursuing a cceprehensive course of action to identify and correct the root cause of the programmatic weaknesses in physical security. The most recent SALP (50-293/87-99) covering the period February 1, 1987 to May 15, 1988, determined that the licensee has demonstrated a commitment to implement an effective secu*ity program. The licensee's security organization has been expanded with the addition of experienced personnel in key positions, significant capital I
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| resources have been expended to upgrade security hardware, and equipment and program plans have been in, proved.
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| NUREG-0940 I.A-8
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| Boston Edison Company 3 The most recent inspection conducted at Pilgrim was the Integrated Assessment Team (IAT) inspection to verify the readiness for restart. During the IAT inspection, all phases of the security program, including management support, staffing, organization, and hardware maintenance were reviewed to assess the effectiveness of the program implementation. The conclusion of the IAT inspection is that the licensee has established and is implementing a signi-ficantly improved security program over that which existed when the station was shut down in April 1986. Upgrades to the security program include a greatly expanded security organization, major installation of state-of-the-art equipment, improved security maintenance support, and upgrades to plans and procedures.
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| Notwithstanding improvements which you have made in the security area, I have been authorized, after consultation with the Commission, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fif ty Thousand Dollars ($50,000) for the three violations described in Section I of the enclosed Notice. This action is being taken to emphasize that the conduct by supervisors at issue here cannot be tolerated. If it were not for the improvements in the security area, the civil penalty in this case would have been 'arger.
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| The base civil peralty amount for a Severity Level III violation or problem is
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| $50,000. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment to the amount of the civil penalty is warranted.
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| Although the licensee's corrective actions in response to this event would warrant mitigation, in light of its prior poor performance in the security area, the staff determined that, on balance, no adjustment to the civii penalty amount is appropriate.
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| The violation set forth in Section II of the enclosed Notice, involving two additional degradations of vital area barriers, is classified at Severity Level IV since both of these degradations were not readily apparent or easily exploitable. Both examples were identified by your staff, promptly reported to the NRC, and compensatory measures we.e taken.
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| We note that you have already respcnded to the technical issues involved in this case during meetings with the NRC staff and we have reviewed your corrective actions for the technical issues. In responding to this letter, you may .4eference the previous meetings and correspondence. A direct response is required, however, to the findings presented in the synopsis of the OI report and the violation involving the material false statement and you should follow the instructions specified in the i.otice when preparing your response. Further, all Safeguards Information (as defined in 10 CFR 73.21) necessary for your response should be provided in enclosures, so as to allow your lettar (without enclosures) to be placed in the Public Document Room.
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| Portions of the enclosed Notice contain details of your security program that have been determined to be exempt from public disclosure in accordance with 10 CFR 73.21 (Safeguards Information). Therefore, those portions will not be placed in the NRC Public Document Raom and will receive limited distribution.
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| NUREG-0940 1.A-9
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| Boston Edison Company 4 The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Managemerit and Budget as required by the Paperwork Reduction Act of 1980, P. L. No. 96-511.
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| Sincerely, b.) . 7. /YO Villiam 1. Russell Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Imposition of Civil Penalty (Contains Safeguards Information (SGI))
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| : 2. Synopsis of 01 Repoct 1-87-009 (contains Safeguards Information (SGI))
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| cc w/encls (w/o Safeguards Information):
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| K. Highfill, Station Director R. Anderson, Plant Manager J. Keyes, Licensing Division Manager E. Robinson, Nuclear Information Manager R. Swanson, Nuclear Engineering Department Manager The Honorable Edward J. Markey The Honorable Edward P. Kirby The Honorable Peter V. Forman B. McIntyre, Chairman, Department of Public Utilities Chairman, Plymouth Board of Selectmen Chairman, Duxbury Board of Selectmen Plymouth Civil Defense Director P. Agnes, Assistant 'ecretary of Public Safety, Commonwealth of )
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| Massachusetts S. Pollard, Massachusetts Secretary of Energy Resources R. Shimshak, MASSPIRG Public Document Room (POR) local Pub;ic Document Room (LPOR) .
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| Nuclear Safety Information Center (NSIC)
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| NRC Resident Inspector (w/ Safeguards Information)
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| Commonwealth of Massachusetts (2) 4 I
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| l NUREG-0940 I.A-10
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| UNITED STATES
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| /pa afcg% NUCLE AR REGULATORY COMMisslON
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| ; REGION ti
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| ~y j 101 MARIETTA STREET.N W.
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| ATLANT A. GEORGI A 30323
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| %, - /
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| ....- JU'. 2 51988 Docket No. 50-324 License No. DPR-62 EA 88-131 Carolina Power & Light Company ATTN: Mr. E. E Utley Senior Executive Vice President Power Supply and Engineering and Construction P.O. Box 1551 Raleigh, NC 27602 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT kOS. 50-325, 324/88-15 AND 50-325, 324/88-18)
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| This refers to the Nuclear Regulatory Commission (NRC) inspections conducted on April 1-30, and May 1-June 3, 1988, at the Brunswick Steam Electric Plant. The inspections included a review of several operational events involving operator error and less than adequate attention to detail which are discussed below.
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| The reports-documenting these inspections were sent to you by {{letter dated|date=May 23, 1988|text=letter dated May 23, 1988}} and June 29, 1988. As a result of these inspections, failures to comply with NRC regulatory requirements were identified. The NRC concerns relative to the inspection findings were discussed in ar Enforcement
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| ' Conference held on May 27, 1988, and a sumary of this conference was sent to you by {{letter dated|date=June 17, 1988|text=letter dated June 17, 1988}}.
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| The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involve several events which resulted in Technical Specification (TS) noncompliance. Individually, the violations do not have serious safety significance. The significant issue manifested by the collective violations is operator error and inattention to detail, an issue of critical importance to the safe operation of your plant. The operations staff must be aware of the operational status of plant equipment at all times.
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| Violation A in the enclosed Notice involved Unit 2 entering into Operational Condition 2 without Division II of the residual heat removal (RHR) system being aligned for automatic low pressure coolant injection (LPCI) initiation and without primary containment being established. This evolution appeared to have been handled in a confused atmosphere. The violation was caused, in part, by an incorrect verbal verification of LPCI alignment, an alignment that had been performed many times before by the operations staff, which raises a concern about the degree of attention to detail being practiced by the operations staff on shift. In this regard, Division II RHR may not have been NUREG-0940 1.A-11 l
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| Carolina Power & Light Company 2 g,j _ 2 5 T.
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| l aligned for automatic LPCI initiation but for questioning from the NRC inspector who was in the control room at the t1me.
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| Violation B in the enclosed Notice involved a second occurrence within a four month period where shutdown cooling was inadvertently interrupted and plant heatup went unnoticed by the operations staff. This Unit 2 occurrence continued for four and a half hours, and revealed a lack of adherence to a procedure whereby a valve, that by procedure had to be either fully opened or fully closed, was used as a throttle valve to maintain reactor temperature control. This error notwithstanding, the operations staff should have been alerted sooner had appropriate attention been used in monitoring other available temperature indications. Taken in its entirety, it is evident that a major cause of this incident was the inadequate attention to plant status by the operations staff.
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| Violation C in the enclosed Notice involved an incident in Unit 2 wtare control rod 10-39 was in the fully withdrawn position with the shorting links installed in violation of the TS. Aside from the lack of attention to the status of a shutdown plant by the operations staff in neglecting to reinsert the control rod after testing, the lack of attention is further highlighted by the fact that no one on the operations staff recognized that the green " full-in" light for cDntrol rod 10-39 was not illuminated to indicate that the control rod was fully inserted, as assumed by the operations staff for 17 hours. This is especially significant because the red light which would have indicated the control rod was fully withdrawn was known to be inoperable and should have caused the operators involved, in the two shift-turnovers which occurred during this event, to be especially sensitive to the position of this particular ccntrol rod.
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| These three events occurred during a three month period from March to May 1988. .
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| In January 1988, there had been an event similar to that described in Viola- l l
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| tion B. The NRC staff's concern is that the indications of lack of attention to detail are not restricted to an isolated incident or to one individual, but appear to be permeating the operations staff and possibly other plant organi-zations interfacing with that staff. Each event could have been prevented had your staff properly monitored plant conditions. The NRC staff considers the lack of attention to detail by the licensed operators during these events to have significant safety implications which must be corrected immediately.
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| Management must evaluate this apparent trend, identify the root cause, and implement corrective action.
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| To emphasize the importance of the operations staff to maintain the highest !
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| degree of awareness and attentiveness to all aspects of plant operation, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Seventy-five Thousand Dollars ($75,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," in 10 CFR Part 2, Appendix C (1988)
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| (Enforcement Policy), the violations described in the enclosed Notice hau been NUREG-0940 1.A-12
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| Carolina Power & Light Company 3 p .5 gg categorized in the aggregate as a Severity level IIL problem. The base value of a civil penalty for a Severity Level III problem is $50,000. The escalation and mitigation factors were considered, and the 'uase civil penalty amount has been increased by 50 percent because of poor past performance. Specifically, the lack of attention to detail on the part of the operations staff has allowed inadvertent heatups to occur twice in a four month period. The operations staff did not learn from the first event. Having a technical problem with the same type valve, whose inadvertent closure resulted in the January 1988 heatup, should have caused the operations staff to focus on that valve again in May 1988.
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| In addition, the throttling of the valve, which contributed to the inadvertent closure in January 1988, was in violation of the applicable operating procedure.
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| This earlier event should have motivated your staff to aggressively pursue plant design or procedural changes so as to preclude recurrence. Thus, the similar event which occurred in May 1988 could have been avoided. Additional escalation for past performance was considered but, because of the plant's generally acceptable performance in the operations area and the relatively short period during which the violations occurred, escalation was found not to be appropriate.
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| You are requircd to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter ard the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Should you have any questions concerning this letter, please contact us.
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| Sincerely,
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| .D, /M
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| )J.NelsonGrace
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| / Regional Administrator j
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| ==Enclosures:==
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| Notice of Violation and Proposed
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| ( Imposition of Civil Penalty cc w/encis:
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| P. W. Howe, Vice President Brunswick Nuclear Project C. R. Dietz, Plant General Manager NUREG-0940 I.A-13
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| i l JUL 2 5 E3 l
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| NOTICE OF VIOLATION AND PROPOSED IhPOSITION OF CIVIL PENALTY Carolina Power & Light Company Docket No. 50-324 Brunswick Steam Electric Plant License No. DPR-62 Unit 2 EA 88-131 During the Nuclear Regulatory Comission (NRC) inspection conducted on April 1-30 and May 1 - June 3, 1988, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforce-ment Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commis-sion proposes to impose a civil pena''v pursuant to Section 23? if the Atomic Energj Act.of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFn 2.205. The violations and associated civil penalty are ?t forth below:
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| A. Technical Specification (TS) 3.0.4 states that entry into an OPERATIONAL CONDITION or other specified applicability state shall not be made unless the conditions of the Limiting Condition for Operation are met without reliance on provisions contained in the ACTION statements unless otherwise excepted.
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| TS 3.5.3.2 requires in Operational Conditions 1, 2, and 3 that two indepen-dent low pressure coolant injection (LPCI) subsystems of the residual heat removal (RHR) system be OPERABLE with each subsystem comprised of two pumps and an OPERABLE flow path capable of taking suction from the suppres-sion pool and transferring the water to the reactor pressure vessel.
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| TS 3.6.1.1 requires in Operational Conditions 1, 2 and 3 that primary containment integrity be maintained.
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| TS 3.6.1.3 requires in Operational Conditions 1, 2 and 3 that the primary containment air lock be OPERABLE with: (1) both doors closed except when the air lock is being used for normal transit entry and exit through the containment, then at least one air lock door shall be closed; and (2) r.
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| overall air lock leakage rate of less than or equal to 0.05 La at P '
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| a 49 psig.
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| Contrary to the above, at 4:35 a.m. on April 26, 1988, Unit 2 entered Operational Condition ? when the unit's mode switch was placed in the "startup/ hot standby" .vithout RHR Division II being aligned for automatic LPCI initiation, without primary containment integrity being established, and with the primary containment air lock doors open.
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| B. Technical Specification 6.8.1.a requires that written procedures shall be implemented for applicable procedures recommended in Appendix A of Regulatory Guide 1.33, November 1972. Appendix A requires operating l procedures for the RHR system. Operating Procedure, OP-17, RHR System Operating Procedure, Revision 76, implements this requirement and requires that the RMR heat axchanger outlet valve (E11-F003A) be either in the fully open or closed position during the shutdown cooling mode.
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| I NUREG-0940 I.A-14
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| Notice of Violation 2 Jk 2 3 iM Contrary to the above, OP-17 was not fully implemented on May 11, 1988, in that valve EN-F003A was used in a throttled position during the shutdown cooling mode on Unit 2.
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| C. TS 3.3.1 requires, as a minimum, that the reactor protection system (RPS) instrumentation channels shown in TS Table 3.3.1-1 be operable. Accord-ingly, notation "b" of TS Table 3.3.1-1 requires that while in Operational Condition 5, " shorting links" be removed from the RPS circuitry prior to and during the time any control rod is withdrawn.
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| Contrary to the above, from 3:50 a.m. until 7:48 p.U., on March 8, 1988, with the reactor in Operational Condition 5, Unit 2 contro? rod 10-39 was in the fully withdrawn position and the shorting links were not removed from the RPS circuitry.
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| Collectively, these violations have been categorized as a Severity Level III problem (Supplement I).
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| Cumulative Civil Penalty - $75,000 (Assessed equally amoung the violation).
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| Pursuant to the provisions of 10 CFR 2.201, Carolina Power and Light Company (licensee) is hereby required to submit a written statement or examination to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked cs a
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| " Reply to a Notice of Violation" and should include [for each violation]:
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| (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps dich will be taken to avoid further viola-tions, and (5) the date when full con.pliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Con-sideration may be given to extending the response time for good cause shown.
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| Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United Stater, in the amount of the civil penalty proposed above or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole NUREG-0940 I.A-15
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| Notice of Violation 3 JUL 2 51988 or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205'regarding the procedure for imposing a civil penalty.
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| Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the
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| 'Act, 42 U.S.C. 2282.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, Region II and a copy to the NRC Resident Inspector at the Brunswick Steam Electric Plant.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| -~
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| J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia this#dday of July 1988 i
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| NUREG-0940 I.A-16
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| ~
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| i j .nasous,k.
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| UNITED STATES NUCLEAR REGULATORY COMMISSION g 7, WASHINGTON, D. C. 20555 r,, -l
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| [ %. .. ]
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| **"* OCT 17 !983 Docket No. 50-324 License No. DPR-62 EA 88-131 Carolina Power & Light Company
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| ~
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| A1TN: Mr. E. E. Utley Senior Executive Vice President Power Supply and Engineering and Construction-Post Office Box 1551 Raleigh, North Carolina 27602 lientlemen:
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| ==SUBJECT:==
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| ORDER IMPOSING A CIVIL MONETARY PENALTY This refers:to your letters of August 24 and September 26, 1988, in response to the Notice of Violation and Proposed Imposition of Civil Penalty (Notice) sent to you on July 25, 1988. Our letter and Hotice described violations involving operator error and inattention to detail. A civil penalty in the amount of $75,000 was proposed to errphasize the importance of the operations staff to maintain the highest degree of awareness and attentiveness to all aspects of plant operation.
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| In your response, you admitted the violations, paid $50,000 of the proposed civil peralty, and took exception to the $26,000 escelation as inappropriate and not justified.
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| After careful consideration of your response, we have concluded, for the reasons giver, in the Apper. dix attachcd to the enclosed Order Ircposing Civil Monetary Penalty, that a sufficient basis was not provided for reduction of the civil penalty amount. Accordingly, we hereby serve the enclosed Order en Carolina Power and Light Company imposing the balance of the unpaid civil penalty in the amount of Twenty-five Thousar.d Collars ($25,000).
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| The effectiveness of your corrective actions, including your supplemental response which Region 11 requested by separate letter, will be reviewed during a subsequent faspection.
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| In accordance with Section 2.790 of the NRC's
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| * Rules of Practice," Part 2, l
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| Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be platied in the fiRC's Public Document Room.
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| Sincerely.
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| 7
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| /w f4
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| ' ujmes li. Tv r, Deputy Executive Director
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| ' 'or Operations v
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| Er. closure: See Next Page NUREG-0940 I.A-17
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| UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket No. 50-324 BRUNSWICK UNIT 2 ) License No. DPR-62 (Carolina Power & Light Co.) ) EA 88-131 ORDER IMPOSING CIVIL MONETARY PENALTY I
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| Carolina Power and Light Company, Raleigh, flor'" Carolina (licensee), is the holder of Operating License No. DPR-62 (license) issued by the Nuclear Regulatory Commission (Commission /NRC) on December 27, 1974. The license authorizes the licensee to operate Unit 2 of the Brunswick facility in accordance with the conditions specified therein.
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| II NRC inspections of the licensee's activities under the license were conducted on April 1-30 and May 1-June 3, 1988, respectively. The result of these inspections indicated that the licensee had not conducted its activitic. in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was served upon the licensee by {{letter dated|date=July 25, 1988|text=letter dated July 25, 1988}}. The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalty proposed for the violations. The licensee responded to the Notice by letters dated August 24 and September 26, 1988. In its response, the licensee admitted the violaticr,s but stated that escalation of the civil penalty under 10 CFR Part 2, Appendix C, is inappropriate. The licensee submitted a check for $50,000 and took exception to the $25,000 escalation.
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| NUREG-0940 I.A-18
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| I III After consideration of the licensee's response and the statements of fact, explanations, and argument for reduction contained therein, the Deputy Execu-tive Director for Regional Operations has determined, as set forth in the Appendix to this Order, that the violations occurred as stated and that the penalty proposed for the violations designated in the Notice should be imposed.
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| IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (ACT) 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT:
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| The licensee pay the remainder of the civil penalty in the amount of Twenty Five Thousand Collars ($25,000) within 30 days of the date of this Order, by check, draf t, or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555.
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| V The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing sijall be clearly marked as a "Pequest for an Enforcement Hearing" and shall be addressed to the Director, Office of Enforcement, NUREG-0940 1.A-19
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| U.S. Nuclear Regulatory Commission, ATTH: Document Control Desk, Washington,
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| ! D.C. 20555, with copi'es to the Assistant General Counsel for Enforcement,
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| ! U. S. Nuclear Regulatory Commission, Washington, D. C. 20555, the Regional Administrator, Region II, 101 Marietta Street, N.W., Atlanta, Georgia 30323, and the NRC Resident Inspector, Brunswick Steam Electric Plant.
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| l If a hearing is requested, the Commission will issue an Order designating the time and place of the hearing. If the licensee fails to request a hearing l l
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| within 30 days of the date of this Order, the provisions to this Order shall be effective without further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection.
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| i In the event the licensee requests a hearing as provided above, the issue to be considered at such hearing shall be whether t'ie unpaid remainder of the civil penalty should be imposed.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| - l TV s M. Taylor eputy Executive Director m/orRegionalperations Dated at Rockville, Maryland this (qMday of October 1988 NUREG-0940 I.A-20
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| APPENDIX EVALUATION AND CONCLUSION On July 25, 1988, a Notice of Violation and Proposed Imposition of Civil Penalty was issued for violations identified during routine NRC inspections.
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| CP&L responded to the Notice on August 24, 1988 and September 26, 1988. In .
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| its response, the licensee admitted the violations, paid $50,000 of the !
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| proposed $75,000 civil penalty, but took exception to the $25,000 escalation ,
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| as inappropriate and not justified. The NRC staff's evaluation and conclusion '
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| regarding CP&L's response is as follows:
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| I. Restatement of Violations A. Technical Specification (TS) 3.0.4 states that entry into an OPERA-TIONAL CONDITION or other specified applicability state shall not be made unless the conditions of the Limiting Condition for Operation are met without reliance on provisions contained in the ACTION statements unless otherwise excepted.
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| TS 3.5.3.2 requires in Operational Conditions 1, 2, and 3 that two independent low pressure coolant injection (LPCI) subsystems of the residual heat removal (RHR) system be OPERABLE with each subsystem comprised of two pumps and an OPERABLE flow path capable of taking suction.from the suppression pool and transferring the water to the reactor pressure vessel.
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| TS 3.6.1.1 requires in Operational Conditions 1, 2 and 3 that primary containment integrity be maintained.
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| TS 3.6.1.3 requires in Operational Conditions 1, 2 and 3 that the primary containment air lock be OPERABLE with: (1) both doors closed except when the air lock is being used for normal transit entry and exit through the containment, then at least one air lock door shall be closed; and (2) an overall air lock leakage rate of less than or equal to 0.05 La at P a' 49 PSI 9' Contrary to the above, at 4: 35 a.m. on April 26, 1988, Unit 2 entered Operational Condition 2 when the unit's mode switch was placed in the "startup/ hot standby" without RHR Division II being aligned for automatic LPCI initiation, without primary containment integrity being established, and with the primary containment air lock doors open.
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| B. Technical Specification 6.8.1.a requires that written procedures shall be implemented for applicable procedures recommended in Appendix A of Regulatory Guide 1.33, November 1972. Appendix A requires operating procedures for the RHR system. Operating Proce-dure, OP-17, RHR System Operating Procedure, Revision 76, ir:plements this requirement and requires that the RHR heat exchanger outlet l valve (E11-F003A) be either in the fully open or closed position during the shutdchn cooling mode.
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| Contrary to the above, OP-17 was not fully implemented on fiay 11, 1988, in that valve E11-F003A was used in a throttled position during the shutdown cooling mode on Unit 2.
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| NUREG-0940 I.A-21 o
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| t Appendix c. TS 3.3.1 requires, as a minimum, that the reactor protection system (RPS) instrumentation channels shewn in TS Table 3.3.1-1 be operable.
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| Accordingly, notati::n "b" of TS Table 3.3.1-1 requires that while in Operational Condition 5. " shorting links" be removed from the RPS circuitry prior to and during the time any control rod is withdrawn.
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| Contrary to the above, from 3:50 a.m. until 7:48 p.m., on March 8, 1988, with the. reactor in Operational Condition 5, Unit 2 control rod 10-39 was in the fully withdrawn position and the shorting links were not removed from the RPS circuitry.
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| II. Summary of Licensee Response The licensee, in its response, admits the violations and agrees that the violations, when viewed together, identify an issue of critical importance to the safe operation of the Brunswick Plant and meet the criteria for imposition of a civil penalty.
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| The licensee makes the following arguments relative to the 50*. escalation of the base civil penalty:
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| : a. Escalation of the civil penalty for an event lacking serious safety significance is not justified, simply because the event has been collectively incorporated with two other events.
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| : b. The three events were collectively categorized as Severity Level III.
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| Combination of such events allows the overall safety significance of similar issues to be put into proper perspective. However, once these events have been combined to represent a more significant concern, they lose their unique identity. Thus, considerations for escalation of the penalty must be evaluated against the violation as a whole (i.e., the combination of the three violations) since that is what provides the justification for the base civil penalty,
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| : c. The three violations cited individually do not have serious safety significance and, therefore, if cited individually, would not warrant a civil penalty. Considerations for escalation were basec solely on Violation B; not on the violation as a whole. Thus, the escalation of the civil penalty based on past performance is inappropriate.
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| III. NRC Staff's Evaluation of Licensee Response In asserting that the NRC staff is escalating the civil penalty based on one of the events cited in the flotice, the licensee demonstrates that basis for e'scalation was misunderstood. The civil penalty was escalated for past poor performance in the area of control of operations. This past poor performance was specifically illustrated by a January 1968 heatup event which was not cited in this fJotice but was similar to the May 11, 1988 event which was cited.
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| The fiRC staff agrees with the licensee that escalation of a civil penalty trust be considered in the context of the eserall problem. However, the NRC staff does not agree that such an overall evaluation was not rade in this case.
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| NUREG-0940 1.A-22
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| | |
| Appendix Based on an event from the recent pcst the NRC staff concluded that escalation for past poor performance was appropriate given that the licensee had not implemented earlier broad corrective actions to prevent future problems similar to those cited in the Notice. Further, though only onc example of past poor performance was specifically noted, other events such as the mispositionir., of an RHR minimum flow valve in February 1987 were considered when the NRC staff decided to escalate the civil penalty for past poor performance.
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| The licensee's argument that the considerations for escalation were based solely on violation B and not on the probleni as a whole is incorrect.
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| While Violat'on B is most similar to the previous event, each of the three violations were symptomatic of lack of awareness and attitude to detail for control room activities. The safety significance of the Severity Level III problem was derived from indications that lack of awareness and attenticn to detail for control room activities was not dn isolated problem in the operations staff. The escalation for poor past performance was based on a prior example of this problem, e.g., lack of attention to detail on the part of the operations staff, and NRC staff's conclusion that CP&L did not learn from the first event and aggressively pursue the underlying cause.
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| IV. NRC Staff's Conclusion The licensee did not provide a sufficient basis for reduction of the proposed 575,000 civil penalty. Therefore, the NRC staff concludes that the unpaid balance ($25,000) of the civil penalty should be imposed.
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| l t
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| NUREG-0940 1.A-23
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| l tme ntoo UNITED STATES
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| [p *g NUCLEAR REGutATORY COMMisstON i % nEcsON til t 'f 799 ROOSEVELT RO AD S GLEN ELLYN OLLINott 60037
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| ''' . . . . . *#[ MAY 6 1989 Docket No. 50-456 License No. NPF-72 EA 88-91 Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, Illinois 60690-0767 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-456/88007(DRSS))
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| This refers to the NRC inspection conducted during the period March 1-17, 1988, of activities authorized by NRC Operating License No. NPF-72, at the Braidwood Station, Unit 1. The inspection focused on problems associated with degraded control room ventilation systems and identified violations of NRC regulatory requirements. The details are presented in the subject inspection report which was sent to you by {{letter dated|date=March 25, 1988|text=letter dated March 25, 1988}}.
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| An enforcement conference was held on March 28, 1988, with Mr. T. J. Maiman and other members of your staff during which the violations, the causes, and your corrective actions were discussed. The enforcement conference was documented in Meeting Report No. 50-456/88012 which was sent to you by {{letter dated|date=April 4, 198|text=letter dated April 4,198}}%
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| The violations represent a failure to check the adequacy of a design change, failure to adequately demonstrate system operability, and tailure to modify system components in accort'ance with instruc+ ions or drawings. These violations resulted in a celay in identifying e initial design error. As a result of this delay, the plant operated with the Control Room Ventilation Systems in a degraded condition from May 29, 1987 until November 21, 1987.
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| Subsequent to the design error, which improperly altered the trip function of differential pressure switches, neither the independent design change review nor the pre-service tuting program detected the error before the systems were put into service. In addition, the failure to adjust the setpoints of the differential pressure switches masked the ability of routine surveillance testing to identify the design error. As discussed in the inspection report, potential violations of 10 CFR 50.59 and the applicable Technical Specifications were under consideration, but af ter further review it was concluded that any such violations were the direct results of the violations contained in the enclosed Notice.
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| We have considered your arguments concerning the ability of the Control Room Ventilation System to function without the proper preheating of makeup air.
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| However, our concerns with the violations are based not only on the degraded CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.A-24
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| Commonwealth Edison Company 2 MAY 6 1989 system but also, and more importantly, on the underlying design control and testing issues. These violations appear to be symptomatic of deficiencies that were identified during your last SALP period (Inspection Reports No. 50-456/88001(DRP); No. 50-457/88001(DRP)) and which resullied in rating declines from Category 1 to Category 2 in the functional areas of Quality Programs and Administrative Controls Affecting Quality and of Preoperational and Startup Testing.
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| To emphasize the need for improving implementation of ;.*ocedures for design changes to safety systems, I have been authorized, af ter consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars (550,000) for the violations described in the enclosed Notice. In accordan e with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR. Part 2, Appendix C (1988) ('.iforcement Policy), the violations described in the enclosed Notice have been categorized at a Severity Level III. The escalation and mitigation factors in the Enforcement Policy were' considered, and no adjustment has been deemed appropriate. Although you did make a timely report after the problem was identified, the plant operated for more than five months with the Control Room Ventilation Systems in a degraded condition.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, A. Bert Davis Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Imposition of Civil Penalty
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| : 2. Inspection Report l No. 50-456/88007(DRSS)
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| : 3. Meeting Report No. 50-456/88012(DRSS)
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| NUREG-0940 I.A-25 i o __- _ _ _ _ _
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| -1 NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Commonwealth Edison Company Docket No. 50-456 Braidwood Station, Unit 1 License No. NPF-72 EA 88-91 During a NRC inspection conducted during the period March 1-17, 1988, violations of NRC requirements were identified. In accordance with the
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| " General Statement of Policy and Procedure for NRC Enforcement Actions,"
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| 10 CFR, Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| A. 10 CFR, Part 50, Appendix B, Criterion III, " Design Control," requires that measures be established for the identification and control of design interfaces and for coordination among participating design organizations. Design control measures are required to provide for verifying or checki.ng the adequacy of design, such as by the performance of design reviews or by the performance of a suitable testing program.
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| Commonwealth Edison Company Quality Procedure No. 3-1, " Design Control,"
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| in part, implements 10 CFR Part 50, Appendix B, Criterion III.
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| Section 4.2 of Quality Procedure No. 3-1 requires that the capability of each item with respe:t to meeting design requirements be verified for each application.
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| Commonwealth Edison Company Quality Procedure No. 3-2, " Design Change Control," in part also implements 10 CFR 50, Appendix B, Criterion III.
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| Section 2.0 of Quality Procedure No. 3-1 requires that design reviews be conducted within the participating departments on each design change.
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| Further Section 3.6 defines an Engineering Change Notice (ECN) as a design change by the Architect Engineer (A/E) which documents and authorizes design changes engineered and issued by the A/E.
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| Contrary to the above, as of December 16, 1986, measures for coordination among design organizations participating in Design Change VC-041, to the Control Room Ventilation Systems' heater interlock control systems were inadequate in that, the measures failed to ensure that ECN No. 34272 was correctly incorporated into ECN 34446.
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| B. 10 CFR, Part 50, Appendix B, Criterion XI, " Test Control," requires in part, that a test program be established to demonstrate that systems and components will perform satisfactorily in service.
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| I I
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| NUREG-0940 1.A-26 l
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| l 1
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| Notice of Violation 2 Mg 6 1988 Commonwealth Edison Company Quality Procedure No. 11-2, " Development, Performance, Documentation, and Evaluation of Preoperational and Start-up Tests," in part implements 10 CFR Part 50, Appendix B, Criterion XI.
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| Section 3.2 of Quality Procedure No. 11-2 defines preoperational tests as tests to demonstrate the satisfactory mechanical and electrical operation of the systems involved including interlocks between systems.
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| Contrary to the above, the licensee's test program did not demonstrate that the Control Room Ventilation System would perform satisfactorily in that preoperational testing of the Control Room Ventilation Systems which was performed on March 4 and 11, 1987 on trains _ B and A respectively did not identify that heater interlock logic switches were wired incorrectly, that specified switch setpoints had not been adjusted, and that the Control Room Ventilation Systems were inoperable.
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| C. 10 CFR Part 50, Appendix B, Criterion V, " Instructions, Procedures, and .
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| Drawings," requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings and be accomplished in accordance with these instructions, procedures, or drawings.
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| Contrary to the above, as of November 6,1987, it was identified that activities affecting quality had not been accomplished in accordance-with prescribed instructions or drawings, in that:
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| : 1. The Architect Engineer did not perform the interdisciplinary review of ECN 34446, to verify or check the adequacy of the design information, as required by procedures.
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| : 2. The heater interlock logic switches for the Control Room Ventilation Systems had not been modified in accordance with the instructions or drawings of ECN No. 34272 which was issued December 16, 1986 or in accordance with the differential pressure switch setpoint specifica-tions for Switches OPDS-VC059 (Sheet No. PS631) and OPDS-VC060 (Sheet No. PS633) which were promulgated on February 9, 1987.
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| These violations have been categorized in the aggregate as a Severity Level III problem (Supplement I).
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| Cumulative Civil Penalty - 550,000 (assessed equally among the violations).
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| Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation; (2) the reasons for the violation if admitted; NUREG-0940 I.A-27
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| Notice of Violation 3 MAY 6 1989 (3) the corrective steps that have been taken and the results achieved; (4) the corrective steps that will be taken to avoid further violations; and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. I Within the same time as provided for the response required above under 10 CFR 2.201, Commonwealth Edison Company may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory ,
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| Commissien, with a check, draft, or money order payable to the Treasurer of i the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violation (s) listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g.,
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| citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control NUREG-0940 1.A-28
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| F-I
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| (.
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| Notice of Violation 4 MAY 6 1989 Desk, Washington D.C. 20555, with a copy to the Regional Administrator, i- U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137 and a copy to the NRC Resident Inspection at the Braidwood Station.
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| FOR THE NUCL AR REGULATORY COMMISSION h =
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| A. Bert Davis Regional Administrator DatedagGlenEllyn, this 6 Illinois day of May 1988 f
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| NUREG-0940 I.A-29
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| # \, UNITED STATES
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| [ g NUCLEAR REGULATORY COMMISSION j r, j m swiworou,o.c.aossa <
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| g,*****j OCT 191998 Docket No. 50-456 License No. NPF-72 EA 88-91 Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, Illinois 60690-0767 Gentlemen:
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| | |
| ==SUBJECT:==
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| ORDER IMPOSING CIVIL MONETARY PENALTY This refers.to your letters dated June 20, 1988 and October 6, 1988, in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you by our {{letter dated|date=May 6, 1988|text=letter dated May 6,1988}} and our September 7,1988 letter concerning Violation B of the Notice. Our letters and the Notice describe three violations
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| -identified by the NRC.
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| To emphasize the need for improving implementation of procedures for design changes to safety systems, a civil penalty of Fifty Thousand Dollars ($50,000) was proposed.
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| In your June 20, 1988 response, you admit that Violation A occurred as stated in the Notice of Violation, but deny Violations B, C.1, and part of 0.2. How-ever, you take issue with the proposed imposition of a Severity Level III 1 violation and the civil penalty. i After consideration of your responses, we have concluded, for the reasons given in the Appendix attached to the enclosed Order Imposing Civil Monetary Penalty, that Violations A and C occurred as stated in the Notice of Violation, that Violation B occurred as amended, and that a sufficient basis has not been provided to warrant; reduction of the Severity Level; or remission / mitigation of the proposed civil penalty. Accordingly, we hereby serve the enclosed Order on Commonwealth Edison Company imposing a civil penalty in the amount of Fifty ThousandDollars($50,000). We will review the effectiveness of your corrective actions during a subsequent inspection.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, l Title 10 Code of Federal Regulations, a copy of this letter and the enclosbre will be placed in the NRC's Public Document Room.
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| Sincerely, j K,, - -
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| Ja es M. Tay1 , Deputy Executive Director l for Regional Operations
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| ==Enclosure:==
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| Order Imposing Civil Monetary Penalty with Appendix cc w/ enclosure: See Next Page NUREG-0940 I.A-30 i
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| UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of Docket No. 50-456 Commonwealth Edison License No. NPF-72 Braidwood Station, Unit 1 EA 88-91 ORDER IMPOSING CIVIL MONETARY PENALTY I
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| Commonwealth Edison Company (licensee) is the holder of Operating License No. NPF-72 issued by the Nuclear Regulatory Commission (NRC/ Commission) on July 2,1987. The license authorizes the licensee to operate the Braidwood Station, Unit 1, in accordance with the conditions specified therein.
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| II An inspection of the licensee's activities was conducted during the period March 1-17 1988. The results of this inspection indicated that the licensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violaticn and Proposed Imposition of Civil Penalty was served upon the licensee by {{letter dated|date=May 6, 1988|text=letter dated May 6,1988}}.
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| The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalty proposed for the violations.
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| The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalty by {{letter dated|date=June 20, 1988|text=letter dated June 20, 1988}}. In its response, the licensee denies Violations B, C.1, and part of C.2 and admits Violation A.
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| In addition, the licensee takes issue with the proposed imposition of a Severity Level III violation and the civil penalty.
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| NUREG-0940 I.A-31
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| I After reviewing the licensee's response, the NRC staff concludes that with regard to Violation B the licensee was correct in arguing that the violation was incorrect as stated in that testing performed on March 4 and 11, 1987 could not have detected a problem in a design change that was not fully implemented until a few weeks after the testing. In a {{letter dated|date=September 7, 1988|text=letter dated September 7, 1988}} the NRC staff informed the licensee of that
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| , conclusion and provided the licensee with a modification of V %1ation B which properly identified the time period of testing which, by the licensee's admission, was inadequate to identify the heater interlock logic switch deficiency. The licensee responded to the September 7, 1988 letter in a {{letter dated|date=October 6, 1988|text=letter dated October 6,1988}}. In that response the licensee-did not take exception to the modified violation but rather provided additional information relative to system opera'bility.
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| III After consideration of the licensee's responses and the statements of fact, explanation, and argument for mitigation contained therein, the Deputy Executive Director for Regional Operations has determined, as set forth ir. the Appendix to this Order, that Violations A and C occurred as stated, that Violation B as amended in the NRC staff's letter of September 7, 1988 occurred as stated, that the violations are properly categorized at Severity Level III, and that the penalty proposed for the violations I designated in the Notice of Violation and Proposed Imposition of Civil 1 Penalty should be imposed.
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| NUREG-0940 I.A-32
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| IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended-(Act), 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT:
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| The licensee pay a civil penalty in the amount of Fifty Thousand Dollars ($50,000) within 30 days of the date of this Order, by check, draft, or money order, payable to the Treasurer of the United States and mailed to the Director of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555.
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| The licensee may request a hearing within 30 days of the date of this Urder. A request for a hearing shall be clearly marked as a " Request-for an Enforcement Hearing" and shall be addressed to the Director of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region III, 799 Roosevelt Road, Glen Ellyn, Illinois, 60137, and a copy to the NRC Resident Inspector, Braidwood Station.
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| If a hearing is requested, the Commission will issue an Order designating the time and place of the hearing. If the licensee fails to request a hearing within 30 days of the date of this Order, the provisions of this Order shall be effective without further proceedings. If payment has not been made at that time, the m:tter may be referred to the Attorney
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| . General for collection.
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| NUREG-0940 1.A-33 l
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| In the event the licensee requests a hearing'as provided above, the issue to be considered at such hearing shall be:
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| (a) whether the licensee was in violation of the-Commission's requirements as' set forth in the Notice of Violation and Proposed Imposition of Civil Penalty as amended referenced in Section II above, and (b) whether, on the basis of such violations, this Order should be sustained.
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| FOR THE NUCLEAR REGULATORY COMMISSION h
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| a es H. Tayl # , Deputy Executive Director for Regional Operations-Dated at Rockville, Maryland this / '/t' day of October 1988 NUREG-0940 I.A-34
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| - 4:m
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| l APPENDIX On May 6, 1988, a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for violations identified during an NRC inspection.
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| Commonwealth Edison Company (CECO) responded to the Notice on June 20, 1988.
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| In its initial response, the licensee admits that Violation A occurred as stated, but denies that Violations B, C.1, and part of C.2 occurred as stated in the Notice. In addition, the licensee takes issue with the proposed imposition of the Severity Level III violation and the civil penalty. The NRC staff's evaluation and conclusions regarding the licensee's arguments follows.
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| Restatement of Violation B B. 10 CFR, Part 50, Appendix B, Criterion XI, " Test Control," requires in part, that a test program be established to demonstrate that systems and components will perform satisfactorily in service.
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| Commonwealth Edison Company Quality Procedure No. 11-2, " Development, Performance, Documentation, and Evaluation of Preoperational and Start-Up Tests," in part implements 10 CFR, Part 50, Appendix B, Criterion XI.
| |
| Section 3.2 of Quality Procedure No. 11-2 defines preoperational tests as tests to demonstrate the satisfactory mechanical and electrical operation of the systems involved including interlocks between systems.
| |
| Contrcry to the above, the licensee's test program did not demonstrate that the Control Room Ventilation System would perform satisfactorily in that preoperational testing of the Control Room Ventilatica Systems which was performed on March 4 and 11, 1987 on trains B and A respectively did not identify that heater interlock logic switches were wired incorrectly, that specified switch setpoints had not been adjusted, and that the Control Room Ventilation Systems were inoperable.
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| Summary of Licensee's Response to Violation B The licensee denies the violation because the design error could not have been detected by initial preoperational testing of the Control Room Ventilation Systems (CRVS) performed on March 4 and 11, 1987. The design change was not completed until May 21, 1987. However; the licensee admits that testing required subsequent to the installation of the design change was incorrectly selected, It also points out that the Notice transmittal letter characterized the CRVS as a degraded system rather than an inoperable system as stated in Violation B.
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| NRC Evaluation of Licensee's Response The NRC staff agrees that the design change occu: red after the initial preoperational testing of the CRVS on March 4 and 11, 1987, and, therefore, the initial preoperational tests could not have detected the design error.
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| However, the licensae admits that testing required subsequent to the instal-lation of the design change was incorrectly se',ected. This testing is considered part of the required preoperational testing program and should have been adequate to identify the design error before the CRVS were declared operable at the time of initial criticality for Unit 1 on May 29,1987; however, the design error was not identified by the licensee until November 6, 1987, during a review of CRVS startup test results. The NRC staff agrees with the licensee's statement that, for consistency, the Notice transmittal letter NUREG-0940 I.A-35
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| | |
| )
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| Appendix l characterization of the CRVS as a degraded system rather than an inoperable i system is also appropriate for Violation B. In consideration of these comments, i Violation B was amended in a September 7, 1988 letter to the licensee to read as follows: 1 B. 10 CFR, Part 50, Appendix B, Criterion XI, " Test Control," requires in part, that a test program be established to demonstrate that systems and components will perform satisfactorily in service.
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| Commonwealth Edison Company Quality Procedure No.11-2, " Development, Performance, Documentation, and Evaluation of Preoperational and Start-up Tests," in part implements 10 CFR, Part 50, Appendix B, Criterion XI.
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| Section 3.2 of Quality Procedure No.11-2 def1res preoperational tests as tests to demonstrate the satisfactory mechanical and electrical operation of the systems involved including interlocks between systems.
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| Contrary to the above, the licensee's test program did not demonstrate that the Control Room Ventilation Systems (CRVS) would perform satisfactorily in that CRVS preoperational testing, which was completed before the CRVS were declared operable at the time of Unit 1 initial criticality on May 29, 1987, did not identify that heater interlock logic switches were wired incorrectly, that specified switch setpoints had not been adjusted, and that the CRVS were in a degraded condition.
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| The violation, as modified, focuses on the licensee's failure to adequately implement the CRVS preoperational test program, including tests required following system design changes but before the systems were declared operational, rather than the inability of the initial preoperational tests to identify the design error. The licensee responded to the September 7, 1988 I letter. However, that response dated October 6, 1988 only provided further )
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| information relative to system operability and did not take exception to the l modified violation. Therefore, the NRC staff has concluded that the violation, as rewritten for clarification, occurred.
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| Restatement of Violation C.1 C. 10 CFR, Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings and be accomplished in accordance with these instructions, precedures, or drawings.
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| Contrary to the above, es of November 6,1987, it was identified that activities affecting quality had not been accomplished in accordance with prescribed instructions or drawings, in that:
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| , 1. The Architect Engineer did not perform the interdisciplinary review I
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| of ECN 34446, to verify or check the adequacy of the design information, as required by procedures.
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| Summary of Licensee's Response to Violation C.1 The licensee denies the violation and contends that it is a restatement of Violation A. l NUREG-0940 1.A-36 l
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| | |
| i-Appendix NRC Evaluation of Licensee's Response The NRC staff maintains.that Violations C.1 and A are different. Violation A states that the licensee did not meet the requirements of 10 CFR Part 50, ,
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| Appendix B, Criterion III because measures for coordination among design I organizations were inadequate in that the measures failed to ensure that ECN No. 34272 was correctly incorporated into ECN No. 34446. The root cause of Violation A was ambiguous nomenclature used in the logic diagrams of ECN No. 34272. Violation C.1 states that the licensee did not meet the requirements of 10 CFR Part 50, Appendix B, Criterion V in that activities affecting quality had not been accomplished in accordance with prescribed procedural instructions. Specifically, the architect engineer did not follow the procedural requirement to perform the interdisciplinary review of ECN No. 34446 to verify or check the adequacy of the design information. The root cause of Violation C.1 was an individual's errnr which resulted in a procedural I instruction being improperly implemented. Sargent & Lundy General Quality i Assurance Procedure No. GQ-3.13. " Engineering Change Notices," states that the preparer shall forward the ECN for internal interfacing comments and if no interfacing comments are required, the ECN shall be forwarded directly to the reviewer. By incorrectly concluding that no internal interfacing comments were necessary, the preparer precluded the interdisciplinary review of ECN No. 34446.that could have caught the error that was made. This violation occurred independently of and in addition to Violation A.
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| Restatement of Violation C.2 C. 10 CFR, Part 50, Appendix B, Criterion V, " Instructions, Procedures, and Drawings," requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings and be accomplished in accordance with these instructions, procedures, or drawings.
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| Contrary to the above, as of November 6,1987, it was identified that activities affecting quality had not been accomplished in accordance with prescribed instructions or drawings, in that:
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| : 2. The heater interlock logic switches for the Control Room Ventilation Systems had not been modified in accordance with the instructions or drawings of ECN No. 34272 which was issued December 16, 1986 or in accordance with the differential pressure switch setpoint specifications for Switches OPDS-VC059 (Sheet No. PS631) and OPDS-VC060 (Sheet No.
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| PS633) which were promulgated on February 9, 1987.
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| Summary of Licensee's Response to Violation C.2 1
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| The licensee denies the first part of the violation because it contends that the l heater interlock logic switches for the Control Room Ventilation Systems (CRVS) had been modified in accordance with the instructions and drawings of ECN No. 34272 on May 20 and 21, 1987. The licensee admits t' the differential pressure switch setpoints specifications had not been i ented in a timely fashion, per the Station Peview Program, because of a wo. aacklog.
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| NRC Evaluation of Licensee's Response The NRC staff maintains its position that the CRVS had not been modified NUREG-0940 I.A-37
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| l I
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| Appendix 4 in accordance with the instructions or drawings of ECN No. 34272. The. 2 1
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| modifications which occurred in May 1987 were in accordance with ECN No. 34446, i not ECN No. 34272. The instructions and drawings of ECN No. 34272 correctly I specified the modifications to the CRYS heater interlock logic switches. Due, in part, to the licensee's failure to follow design control procedures ECN No. 34272 specifications were incorrectly incorporated into ECN No. 34446.
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| Sumary of Licensee's Arguments Regarding Severity Level The licensee acknowledges that there were specific deficiencies which required corrective action, but believes that no programmatic defects exist warranting the imposition of a Severity Level III violation and civil penalty. The licensee presents the following arguments to support this assertion: g
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| : 1. The failure to coordinate mechanical and electrical design requirements was an isolated occurrence resulting from one individual's misinterpretation ;'
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| of nomenclature.
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| : 2. A 100% review of safety-related differential pressure switch applications [
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| at the four Byron and Braidwood units revealed no similar discrepancies. -
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| thus demonstrating that adequate measures were established to control design interfaces.
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| : 3. The failure to conduct a proper test of the change in heater design resulted from an individual (rather than general) failure to judge accurately the complexity of the change.
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| 4 A *eview of 2,176 preoperational testing " deficiencies," resul6ing from changes in design after completion of preoperational testing but before the systems were released to plant operations, showed that the proper ,
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| tests had been conducted in all but five cases (only three in addition !
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| to CRVS tests for which licensee was cited). The licensee asserts this I demonstrates that the test control program was, in general, fundamentally sound and properly implemented.
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| : 5. A review of violations identified t ring the last SALP period indicated j that those items should not be considered symptomatic of the items ]
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| presented in the Notice. .
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| \
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| NRC Evaluation of Licensee's Response "
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| i The NRC staff maintains that the violations should be categorized collectively j l as a Severity Level III problem in accordance with 10 CFR Part 2, Supplement I.C.2, ;
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| in that the violations resulted in systems (CRVS) designed to prevent or mitigate a serious safety event not being able to perform their intended function under certain conditions. In Attachment C to its June 20, 1988 response, the licensee responds to NRC concerns regarding its safety significance assessments. The licensee provides additional information in its October 6, 1988 letter. The licensee concludes that while thyroid dose in an accident could be increased '
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| due to the degraded CRVS, that dose would remain below the design criterion of 10 CFR Part 50, Appendix A, GDC-19 (23.7 rem versus 30 rem). The NRC staff review of the licensee's submittals indicates that although some of the NRC concerns have been resolved, the 'icensee assessment remains speculative, especially the filter efficiency assumption for 100% relative humidity NUREG-0940 1.A-38
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| I Appendix i conditions. Moreover, although the staff and the licensee disagree on some assessment assumptions, there ie agreement that the Control Room Ventilation Systems were in a degraded conoition and the accident thyroid dose would be increased due to the degraded conditions. NRC's concerns are based not only on the degraded systems but also, and more importantly, on the underlying design control and testing problems which permitted a safety system to be operated for several months in a modified condition without appropriate verification to assure it met design requirements. Although the design and test control problems l appear to be primarily due to personnel errors, the failure to reset the heater !
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| interlock switch setpoints was due to a programmatic backlog problem which caused significant delays in making setpoint adjustments. The series of problems represented by the violations exacerbated the initial design error by delaying its discovery. As a result of this delay, the Control Room Ventilation Systems (CRVS) were & graded from May 29, 1987 until November 21, 1987.
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| The NRC staff nas reviewed the specific arguments made by the licensee and concludes that an argument may be made that no programmatic deficiencies existed. However, the fact remains that in this case a series of errors resulted in a safety related system being in a degraded mode and, as such, the violations most appropriately fit example C.2 of Supplement I of 10 CFR Part 2, Appendix C.
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| Summary of Request for Mitigation of Civil Penalty The licensee contends that an adequate basis exists for mitigation of the proposed Civil Penalty. In support of this position, it presents the following arguments which address the five civil penalty adjustment factors contained in Section V(B)of 10 CFR 2, Appendix C:
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| : 1. Prompt Identification and Reporting Summary of Licensee's Argument Under the circumstances, the length of time to discover the design error was not unreasonably long and, as'such, should not be the basis to discount the licensee's prompt reporting.
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| NRC Evaluation Under the NRC Enforcement Policy, the reasonableness of the length of time to discovery depends on the opportunities for discovery and ease of discovery. In this case, from the time ECN No. 34445 was prepared on December 16, 1986 until the design error was discovered, durisq a review of CRVS startup test results on November 6, 1987, the licensee missed numerous discovery opportunities, including: (1) interfacing comment reviews of ECN No. 34446, if the ECN preparer had properly followed the procedure; (2) the required review of the ECH by the reviewer and the approver; (3) the testing of the heater switch design change in May 1987, if the correct test type had been chosen; (4) switch setpoint verifica-tions, if the setpoint had been adjusted as required before the CRVS were declared operable on May 29, 1987; (5) various CRVS surveillance and startup tests between May 29 and November 6, 1987, if the setpoints had been adjusted as required; .ind (6) the CRVS startup test on October 2, 1987, if startup test personnel had been fully cognizant of the system NUREG-0940 I.A-39
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| \
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| {
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| l b
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| Appendix operability implications of the zero heater current measurements. It is ,
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| the NRC staff's position that it is reasonable to have expected the licensee to have discovered the design error earlier and, therefore, mitigation of the proposed civil peralty for prompt identification ano a reporting of the event is not warranted. l
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| : 2. Corrective Action to Prevent Recurrence 'f i
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| Summary of Licensee's Arguments l
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| The licensee contends that prompt and comprehensive corrective actions
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| ! have been taken.
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| i NRC Evaluation .
| |
| Although the design changes were quickly corrected after the errors were !
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| identified, it was 15 days before the heater interlock switch setpoints i' were corrected. Furthermore, although the licensee conh eted a review to '
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| verify no other safety-related errors were associated with design changes which occurred after completion of system preoperational testing but before the systems were released to the Operations Department, the review was conducted after concerns were raised by the NRC during the enforcement conference. It is the NRC staff's position that the licensee's corrective 3 actions were not sufficiently prompt to warrant mitigation of the proposed 1 civil penalty for corrective action to prevent recurrence. I
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| : 3. Past Performance Surmary of Licensee's Arguments The licensee believes that this incident is distinct from other issues addressed in the last Braidwood SALP. The licensee maintains that, although prior violations have occurred in the Braidwood Startup Test Program, and that this program is significant to the safe operation of Braidwood Station, the remedial review done of the results of the program, as they relate to detection of design errors, has identified no prior occurrence for which prior corrective action was either inadequate or ineffective.
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| NRC Evaluation The NRC maintains that the design control problems are indicative of the previous performance problems identified during the SALP 7 assessment period. The SALP 7 Inspection Report (No. 50-456/8871(DRP);
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| No. 50-457/88001(DRP)) findings are symptomatic of the items presented in the Notice in that they are indicative of a need to reduce personnel errors by increasing personnel alertness and sensitivity to plant conditions and requirements and to improve design control, test control, and adherence to procedures.
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| NUREG-0940 I.A-40
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| T kr k
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| p Appendix -7 b 4. Prior Notice of Similar Events Sumary of Licensee's Arguimts j The licensee contends that ther.' was no prior notice of similar events.
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| ?
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| [ NRC Evaluation I
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| J The NRC staff agrees that the licensee had no prior notice. However, because a lack of prior notice does not serve as a basis for mitigation under the' Enforcement Policy, the base civil penalty is unaffected by
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| 'this factor.
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| 1
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| : 5. Multiple Occurrences f Sumary of Licensee's Arguments j .The licensee contends that comprehensive reviews of design changes did not identify multiple occurrences of the problems identified in the Notice.
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| F NRC Evaluation The NRC staff agrees that there were no multiple occurrences. However, because a lack of multiple occurrences does not serve as a basis for mitigation under the Enforcement Policy, the base civil penalty is unaffected by this factor.
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| NRC Conclusion The NRC staff concludes that the violations, as amended with respect to Violation B, occurred as stated in the Notice of Violation and Proposed Imposition of Civil Penalty. Moreover, the NRC concludes that the violations are a]oropriately classified as a Severity Level III problem.
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| Further, the NRC staff has also concluded that a sufficient basis has not-been provided by the licensee for the reduction of the Severity Level, or Accordingly, the remission, civil penaltyorinmitigation the amount of of theFifty proposed civil Dollars Thousand penalty$50,000)
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| (. should be imposed.
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| NUREG-0940 I.A-41
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| l p, etc UNITED STATES
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| / )e([g '
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| 7, NUCLEAR REGULt. TORY COMMISSION REGION 811
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| [
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| r,,
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| , y no aooseveu acao
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| .a, cu~ cava, iui~oi uin JUN 11 1988 1
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| Docket Nos. 50-456; 50-457 License Nos. NPF 72; NPF-75 EA 88-125 Commonwealth Edison Company ATTN: Mr. Cordell Reed Senior Vice President Post Office Eox 767 Chicago, IL 60690 Gentlemen:
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| 1
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROF 0 SED IMPOSITION OF CIVIL PENALTY I (NRC INSPECTION REPORT N05. 50-456/88015(DRSS); 50-457/38016(DRSS))
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| This refers to the inspection conducted t,n April 20-21, 1988, of activities at i Braidwood Nuclear Power Station, Units 1 and 2, authorized by NRC Operating {
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| Licenses No. NPF-72 and No. NPF-75. On April 19, 1988, your staff identified i an unprotected vital area tarrier opening, as described in the subject l Inspection Reports sent to you by {{letter dated|date=May 2, 1988|text=letter dated May 2, 1988}}. An enforcement I conference was held on May 19, 1988 between Mr. T. J. Maiman and members of l your staff and Mr. B. S. Mallatt and twmbers of my staff during which the I violation, its root cause and your corrective actions were discussed. The )
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| enforcement conference attendees are listed in Enclosure 2 to this letter. 1 In violation of your Security Plan, an opening has existed in a vital area I barrier since initial licensing of the plant. Upon discovery by your rtaff, it was posted with a guard as a compensatory measure and report *d to the NRC in accordance with 10 CFR 73.71. On April 23, 1988, the opening was modified to reduce the penetration size. This opening had not been ade y ately evaluated during previous vital area barrier walkdowns.
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| To emphasize the need to ensure the ihtegrity of all vital area boundaries, I i have been authorized, after consultation with the Director, Office of i Enforcement, and the Deputy Executive Dire.ctor for Regional Ope. tions, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988)
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| (Enforcement Policy), the violation described in the enclosed Notice har been !
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| categorized at a Severity Level III. The escalation and mitigation factors in the Enforcerant Policy were considered as were the unique characteristics of this security area, and no adjusteent has been deemed appropr' ate.
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| CERTIFIED RAIL RkTURN RECEIPT RE00ESTED NUREG-0940 I A-42
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| _ _ _ _ a
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| Commonwealth Edison Company 2 JUN 17 1988 You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. Af ter reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will detennine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| Areas discussed in this Notice concern subject matter which is exempt from disclosureaccordingto10CFR73.21(c)(2). Consequently, the enclosures to this letter will not be placed in the NRC Public Document Room. Your response to the violation identified in the enclosed Notice should be submitted in accordance with 10 CFR 73.21.
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| The responses directed by this letter and the enclosed Notice ere not subject to the clearance procedures of the Office of Management ar.d Budget, as required by the Paperwork Reduction Act of 1980, Pub. L., No. 96-511.
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| Sincerely,
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| [7 Mv W A. Bert Davis Regional Administrator i
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Impesition of Civil Penalty
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| : 2. Enforcement Conference Attendees
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| : 3. Inspection Reports No.50-456/88015(DRSS);
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| No. 50-457/88016(DRSS)
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| (UNCLASSIFIEDSAFEGUARDSINFORMATION) l l See Attached Distribution l
| |
| NUREG-0940 1.A-43
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| , 'o. UNITED STATES E $ NUCLEAR REGULATORY COMMISSION
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| ( WASHINGTON, D. C. 20666 s e
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| %,..... /
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| uCT J 71353 Docket Nos. 50-456; 50-457 .
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| License Nos. NPF-72; NPF-75 j EA 88-1?5 Commonwealth Edison Company S
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| ! ATTN: Mr. James J. O'Connor l l President j l
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| Post Office Box 767 i Chicago, Illinois 60690 j Gentlemen:
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| | |
| ==SUBJECT:==
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| RESPONSE TO NOTICE OF VIOLATION AND PROPOSED IPPOSITION OF CIVIL PENALTY (f.RC INSPECTION REPORT t105. 50-456/88015(DRSS);
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| 50-457/88016(CRSS))
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| i This is in response to your letter of July ??,1988 concerning the Notice of Violetion and Preposed Imposition of Civil Penalty (f'otice) forwarded by our letter of June 17, 1988. In your response to the Notice, you admitted that I an opening existed but stated that the deficiency was different from and of d Pluch lower significance than that CCT.templated by example 0.3 of Supple- j mert III of the NRC Enforcement Folicy, 10 CFR Part 2, Appendix C. In support >
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| of this conclusion, you emphasized the fact that (1) the structure in question was ir. side of a separate protected area, (F) all individuals granted access to this protected area are authorized access to the vital area and (3) for an unauthorized person to gain access to the vital area, there would have to be a failure of the protected area access control system or of the protected j area intrusion detection system, neither of which occurred, j J
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| l I
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| The vital area barrier deficiency lacked both barrier ard monitoring elements of access control. The absence of these two elements et the same point in a single barrier norraally constitutes a Severity Level !!I violation. However, special circumstances may be taken into consideration when assigning severity lavels to violations, particularly when access control violations include ouestions concerning the eese with which a deficiency L1ay be identified or exploited. In this case,.although the openirg was such that it could have allowed unauthorized anc undetected access from the protected area into a vital area, the ease with which a person could exploit this vulnerability is subject ,
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| to cuestion. We also note that it may have been difficult for a person outside I the protected area to have recognized that a vulnerability existed.
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| After careful consideration of the circumstances of thc present case, and due to the difficulty of identification of the pathway, the Severity Level of the violatien has been reduced to Severity Level IV cnd the proposed civil i penalty has been withdrawn.
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| This reduction of the Sever 1+3 level #re n e violaticr cited in the Notice does rot alter the licensee's respcnsitility to dett:ct vulnerabilities ir. O e physical protection systen of the plant. Tre licer:see is expecte.d to use roving cuerds, vital area barriu wa lkacwr 5, and sectrity-oriented QA NUREG-0940 I.A-44
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| {
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| L
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| | |
| 00717 !sse Commonwealth Edison Company -F-activities to uncover deficiencies in the plant physical protection system.
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| The failure to do so may allow violations to go undetected, and mcy in itself be considercJ a violation. Any similar violation in the future may result in ddditional enforcement action.
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| We note your argument that the significance of the vulnerability is lessened because all individuals granted access to the protected area are authcrized access to 'the vital area in question. While this is a consideration in this case because of the uniqueness of the protected area, it is not controlling.
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| The vital area boundary provides protection not only against the insider but also the outsider who defeats the protected area barrier. For this reason, the violation is of more than minor significance.
| |
| A response to this letter is not necessary since you have already provided the necessary details concerning the violation cited in the Notice. The corrective actions which you described in your response are considered adequate and will be examined during future inspections. If you have any questions about this action, please contact James Lieberman, Director, Office ci Enforcement.
| |
| Sincerely,
| |
| 'r_ i. f'a o Deputy Executive Director or Regional Operations i
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| l l
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| l NUREG-0940 I.A-45
| |
| | |
| [s****w,[o, ,
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| NUCLEAR REGULATORY COMMIS$10N y 3e 7, - noios m
| |
| ; a too noosevsLt noAo o oLsN eLLvN, sLLimots sonst SEP 161949 l
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| l Docket No. 50-457 ticense No. NPF-77 EA 88-174 Commonwealth Edison Company ATTN: Mr. Cordell Reed i Senior Vice President Post Office Box 767 Chicago, Illinois 60690 Gentlemen:
| |
| SL8 JECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL-PENALTY (NRC INSPECTION REPORTS NO. 50-456/88020(DRSS);
| |
| NO. 50-457/88020(DRSS))
| |
| This refers to the inspection conducted on June 20, 1988 of activities at the Braidwood Nuclear Power Station, Unit 2, authorized by NRC Operating License No. NPF-77. The inspection related to events on June 16, 1988 when the NRC Resident Inspector identified two instances of inattentiveness on the part of security officers, as described in the subject Inspection Report sent tt you by {{letter dated|date=July 1, 1988|text=letter dated July 1,1988}}. An enforcement conference-was held on July 18, 1988 in the Region III Office in which the violation, its root cause, and your corrective actions were discussed.
| |
| On June 16, 1988 two separate examples of security officers' inattentiveness were identified. The officers were posted as compensatory measures for an unlocked, unalarmed vital area door. When the resident inspector walked in the vicinity of the two officers, both of whom were noted with eyes closed, his presence was neither acknowledged nor challenged by them. We believe that access to the vital area could have been achieved while the officers were inattentive.
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| At the July 18, 1988 enforcement conference, it was your staff's position that the performance of the officers was not acceptable to CECO, but concluded that the officers were sufficiently attentive to control access for purposes of meeting regulatory requirements and, therefore, a violation had not occurred.
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| The two officers in question were posted to control access to a vital area, were observed at close range by NRC inspectors who waited to be acknowledged, and failed to respond to the presence of the inspectors for an unacceptably long period of time. In one case, the inspector actually walked past the guard and approa:hed and stood by the vital area door without challenge, the guard clearly falling to meet the requirements of positive access control. In view of these facts, it is difficult to understand and accept your staff's position.
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| Subsequently, we understand that position has been revised to acknowledge that a violation had occurred.
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| CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 1.A-46
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| | |
| Commonwealth Edison Company 2 SEP 161988 To emphasize the importance of posting effective compensatory measures and the need to ensure that security officers' performance does not impact en the adequacy of those measures, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violation described in the enclosed Notice. In accordance with the
| |
| " General Statement of Policy and Procedure for NRC Enforcement Actions,"
| |
| 10 CFR, Part 2, Appendix C (1988) (Enforcement Policy), the violation described in the enclosed Notice has been categorized at a Severity Level III. The escalation and mitigation factors in the Enforcement Policy were considered, and no adjustment has been deemed appropriate.
| |
| As a result of the Enforcement Conference, we have additional concerns. The position taken by your staff was not supported by the facts. We were surprised that this position was supported by corporate management at the meeting and concerned that it may provide the wrong message to plant personnel, specifically regarding the importance of maintaining effective compensatory measures and the appropriate standards for communicating with the Commission.
| |
| You are required to respond to this letter and should folic >w the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
| |
| Areas discussed in this Notice concern subject matter which is exempt from disclosure according to 10 CFR 73.21(c)(2). Consequently, the enclosure to this letter will not be placed in the NRC Public Document Room. Your response to the violations identified in the enclosed Notice should be submitted in accordance with 10 CFR 2.790(d) and 10 CFR 73.21.
| |
| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget, as required by the Paperwork Reduction Act of 1980, Pub. L., No. 96-511.
| |
| Sincerely, C Y l
| |
| 4 A. Bert Davi Regional Administrator
| |
| | |
| ==Enclosure:==
| |
| Notice of Violation and Proposed Imposition of Civil Penalty (UNCLASSIFIED SAFEGUARDS INFORMATION)
| |
| See Attached Distribution NUREG-0940 I.A-47
| |
| : f. .., v...6.,..m...
| |
| [ Ty # j
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| , t NUCLEAR REGULATORY COMMISSION REGION I j
| |
| ,o E 475 ALLENDALE ROAD
| |
| ***** KING OF PRusstA. PENNSYLVANIA 19404 I
| |
| {
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| November 3, 1988 l Docket No. 50-247 ]
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| 'icense No. OPR-26 EA 88-142 Consolidated Edison Company of New York, Inc.
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| J ATTN: Mr. Stephen Bram ?
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| Vice President, Nuclear Power Indian Point Station Broadway at Bleakley Avenue Buchanan, New York 10511 Gentlemen:
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| ==Subject:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY '
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| (NRC INSPECTION REPORTS NOS. 50-247/85-11; 50-247/87-38)
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| This refers to the NRC inspections conducted on May 12-16, 1986 and December 14-18, 1987 to review the program for the environmental qualification (EQ) of electrical equipment at Indian Point 2. The inspection reports were sent ;
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| to you on September 24, 1986 and February 11, 1988, respectively. During the :
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| inspections, violations of NRC requirements were identified involving the lack of qualification of certain items of electric equipment used at the facility.
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| Furthermore, the inspectors also reviewed several other EQ violations identi-fied by your staff. On June 16, 1988, an enforcement conference was conducted with you and members of your staff to (1) discuss the extent and significance 1 of the violations, causes of the violation, and the corrective actions taken or planned, and (2) discuss the factors of the Modified Enforcement Policy for EQ ' requirements which are described in the enclosure to NRC Generic letter 88-07. l The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), included the failure to maintain, for certain items of electric equipment, a complete file of documentation to demonstrate that the items were qualified to perform their intended function (s) during the postulated environmental conditions, and the failure to ensure that the equipment was installed in a qualified configuration. These items, the majority of which were identified by your staff, included two types of terminal blocis (Weidmuller & Westinghouse), ASCO solenoid valves and NAMCO limit switches, two types of cable splices (Raychem and UE&C), and lead connections used in resistance temperature detectors (RTDs).
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| These deficiencies clearly should have been known by you prior to Novi..-he.- 30, 1985, the deadline for being in compliance with EQ requirements, because ti. m expected that licensees would perform adequate field verification to ensure that equipment was installed in a manner that maintained its qualification, CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 1.A-48
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| Consolidated Edison Company of New York, Inc.
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| and to assure that adequate documentation existed in the files to support qualifications. With respect to the Weidmueller & Westinghouse terminal blocks, IE Circular No. 78-08 (Item 3), IE Information Notice (IN) No. 82-03 and IN No. 84-47, which were sent to you on May 31, 1978, March 4, 1982, June 15, 1984, respectively, documented the need to recognize that terminal blocks should be installed in enclosures, and the substantial reduction of l insulation resistance values between terminal points during a simulated LOCA test. In addition, an issue concerning the qualification of terminal blocks was identified by the NRC at Indian Point 2 in Inspection Report No. 50-247/78-30, which was sent to you in October 1978. These Information Notices clearly should ,
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| have alerted you to the deficiencies which were subsequently identified af ter the 1 deadline.
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| With respect to the ASCO solenoid valves and NAMCO limit switches, which were not properly installed or sealed, the appropriate sealing requirements were provided in the vendor test report, and therefore, these requirements clearly should have been known and folloved. Additional examples of inadequately installed or sealed instruments were subsequently identified in your review of this matter indicating that the deficiencies were not isolated. With respect to the cable splices associated with the electrical penetrations, IE Circular No. 78-08 (item 5),
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| which was sent to you on May 31, 1978, stated that electrical cable splices, associated with electrical penetrations at Monticello were determined to be unqualified. In addition, an issue concerning qualification of cable splices was identified by the NRC in Inspection Report No. 50-247/78-30, which was sent to ycu in October 1978. The inadequate seal lengths would have been evident had you taken reasonable measures to conduct walkdowns of the field installations.
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| With respect to the RTD wires, the potential moisture intrucion problem in electrical connections was identified in IN No. 84-57 which was sent to you on July 27,1984. In this IN licensees were alerted to potential problems in which early designs and installations did not provide an adequate moisture intrusion boundary.
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| The violations described in this Notice demonstrate that Consolidated Edison Company's management did not provide sufficient attention to the EQ program at Indian Point 2 to assure that the program was completely in compliance with NRC requirements as of November 30, 1985. To emphasize the importance of environmental qualification and meeting regulatory deadlines, I have been authorized, af ter consultation with the Deputy Director of Enforcement and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) in the amount of Seventy-Five Thousand Dollars ($75,000) for the violations described in the enclosed Notice. In accordance with the " Modified Enforcement Policy l Relating to 10 CFR 50.49," contained in Generic Letter 08-07 (Enclosure 2), the violations described in the enclosed Notice have been determined to be mode le and to have affected some systems and components, and therefore are cor.sidered to be an EQ Category 8 problem. The base value of a civil penalty for an EQ Category B problem is $150,000.
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| I NUREG-0940 I.A-49
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| Consolidated Eaison Company of New York, Inc.
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| In determining the civil penalty amount, the NRC considered the four factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49" for escalation and mitigation of the base civil penalty amount. These factors '
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| consist of (1) identification and prompt reporting of the EQ deficiencies
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| ( 50%); (2) best efforts to complete EQ within the deadline ( 50%);
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| (3) corrective actions to result in full compliance ( 50%); and (4) duration i of a violation which is significantly below 100 days (-50%). 1 With respect to the first factor, 25% mitigation is warranted since the majority of the items were identified by your staff in their follow up response to NRC Information Notice 86-53. However, full 50% mitigation based on this factor is not warranted since some of the items (I.A and I.BT were identified by the NRC. With respect to the second factor, the efforts made by Consolidated Edison to comply with the EQ rule within the deadline are considered neither exceptional nor poor and therefore, neither mitigation nor escalation of the civil penalty was considered appropriate. With respect to the third factor, 25% mitigation is warranted in light of the fact that once the violat'ons were identified, appropriate corrective actions were taken. In particular, the Weidmuller terminal blocks were promptly replaced once the deficiencies were identified.
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| However, full 50*. mitigation based on this factor is inappropriate since your response to one of the six deficiencies, the Raychem cable splice problem, was slow in that a full scale plant walkdown was not conducted until more than a year after the deficiency was identified. With respect to the fourth factor, mitigation is inappropriate since these EQ violations existed in excess of 100 days. Therefore, in summary, a 50% reduction to the base civil penalty amount is appropriate.
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| I In addition, certain items of unqualified equipment were able to be qualified !
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| during the inspection, or shortly thereafter. These violations are classified at Severity Level IV in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Action, 10 CFR Part 2, Appendix C (Enforcement Policy) (1988) and are set forth in Section II of the enclosed Notice.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| NUREG-0940 I.A-50 l 1
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| Consolidated Edison Company' of New York, Inc.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget, otherwise required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, b
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| Williarc T. Russell Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Imposition of Civil Penalty
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| : 2. Generic Letter 88-07 cc.w/ enc 1:
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| Jude G. Del Percio, Manager, Regulatory Affairs P. Kokolakis, Director, Nuclear Licensing Brent L. Brandenburg, Assistant General Counsel Walter Stein, Secretary - NFSC Department of Public Service, State of New York Public Document Room (POR)
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| Local Public Document Room (LPOR)
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| Nuclear Safety Information Center (NSIC)
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| NRC Resident Inspector ,
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| State of New York l
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| I NUREG-0940 I.A-51
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| NOTICE OF VIOLATION AND !
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| PROPOSED IMPOSITION OF CIVIL PENALTY Consolidated Edison Company Docket No. 50-247 Indian Point 2 License No. OPR-26 EA 88-142 During an NRC inspection conducted on May 12-16, 1986 and December 14-18, 1987 l of the licensee's program for environmental qualification (EQ) of equipment, NRC inspectors identified violations of NRC requirements or reviewed other violations identified by the licensee. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety of Nuclear Power Plants," contained in NRC Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular i violations and associated civil penalty are set forth below:
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| I. VIOLATION ASSFSSED A CIVIL PENALTY 10 CFR 50.49(d), (f), and (j), respectively, require, that (1) a list of electric equipment important to safety be prepared, and information concerning performance specifications, electrical characteristics and postulated environmental conditions for this equipment be maintained in a qualification file; (2) each item of electric equipment important to safety shall De qualified by testing of identical or similar equipment and qualification based on similarity shall include a supporting analysis ,
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| to show that the equipment to be qualified is acceptable; and (3) a record i of the qualification shall be maintained in an auditable form to permit !
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| verification that each item of electrical equipment important to safety is qualified and that the equipment meets the specified performance requirements under postulated environmental conditions.
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| Contrary to the above, prior to November 30, 1985 until the dates specified herein, environmental qualification files for certain electrical equipment did not include the required documentation to demonstrate environmental qualification of the equipment. Examples of this violation include:
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| A. As of December 18, 1987, 8 Weidmuller Terminal Blocks (used in Resistance Temperature Detectors for measuring reactor coolant temperature) were not qualified in that insulation resistance was not measured during a LOCA qualification test to assure that instruments would function properly during postulated LOCA i conditions. i 1
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| B. As of May 15, 1986, three ASCO solenoid valves and two NAMCO limit switches were not qualified in that they were installed in a condition j that was not similar to that in which they were tested. Specifically, one of the solenoid valves was found with a cover plate secured only by one loose screw, two solenoid valves had improperly installed RTV l conduit seals in that there were gaps in the sealant rendering the seal ineffective, and the conduits connected to the two limit switches were loose rendering the conduit seals ineffective. There was no supporting analysis to establish qualification in the installed condition.
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| NUREG-0940 I.A-52 I 4
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| Notice of Violation C. As of the 1987 refueling outage, at least 52 UE&C instrument and control cable splices and other UE&C power cable splices, all located inside the reactor containment, were not qualified in that these splices were installed with less than the vendor specified seal length and were not similar to the tested condition, and no supporting .
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| analysis established qualification as installed, The seal length I problems that existed in instrument and control cable splices were assumed to also exist by the licensee for power ccble splices.
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| D. As of the 1987 refueling outage, Raychem cable splices, used in at least 4 locations inside containment (for the Reactor Head Vent and Residual Heat Removal System) were not qualified in that the splices, installed with less than the vendor specified seal length, were not similar to the tested condition and no supporting analysis established qualification as installed.
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| E. As of June 16, 1986, Westinghouse Model No. 542247 Terminal Blocks used in 7 transmitter loops inside containment, were not qualified in that the subject blocks were not in enclosures, as originally tested, and no supporting analysis established qualification as I installed.
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| F. As of the 1987 refueling outage, the resistance temperature detectors (RTD) used in four reactor coolant hot and cold legs were not qualified in that the RTDs did not have the specified vapor tight connections and were not similar to the tested conditions, and no supporting analysis established qualification as installed.
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| These violations constitute an EQ category B problem.
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| Civil Penalty - $75,000 (These EQ violations existed in excess of 10C days of plant operation).
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| II. VIOLATIONS NOT ASSESSED A CIVIL PENALTY A. 10 CFR 50.49(d), (f), and (j), respectively, require, that (1) a list of electric equipment important to safety be prepared, and information concerning performance specifications, electrical characteristics and postulated environmental conditions for this equipment be maintained in a qualification file; (2) each item of electric equipment important to safety shall be qualified by testing of identical or similar equip-ment and qualification based on similarity shall include a supporting I analysis to show that the equipment to be qualified is acceptable; and i (3) a record of the qualification shall be maintained in an auditable !
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| form to permit verification that each item of electrical equipment l
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| important to safety is qualified and that the equipment meets the j specified performance requirements under postulated environmental '
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| conditions. l l
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| NUREG-0940 I.A-53 ;
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| Notice of Violation Contrary to the above,
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| : 1. at the time of the inspection on May 16, 1986, the qualification of RHR pump motor 21 RHRPM (File #2) was not adequately established for the radiation dose expected in the area in that the Westinghouse letter, upon which the qualification was based, did not reference a particular test report, nor was there any licensee evaluation or audit of the test.
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| : 2. prior to May 1986, qualifications for Anaconda cable (new file
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| #31F), Okonite cable (new file #31G) and Brand Rex cable (new file #31H) were not established in that no EQ file existed for the cables until May 1986. In addition, the cables were not on the EQ master list until May 12, 1986. j
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| : 3. before June 4, 1986, qualification for AIW Amerlink type SIS cable was not established in that no EQ files and qualification data existed for this cable and this cable was not in the EQ master list.
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| : 8. 10 CFR 50.49(d)(1) requires performance specifications to be established for the electrical equipment to be qualified.
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| Contrary to the above, as of May 16, 1986, appropriate fynctional performance requirements (insulation resistance) for the instrumen-tation cables, which require qualification, had not been established.
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| I These are Severity Level IV violations. (Supplement 1) !
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| Pursuant to the provisions of 10 CFR 2.201, Consolidated Edison Company (Licensee) is hereby required to submit a written statement of explanation to the Deputy Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) th? corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance was or will be achieved.
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| If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the licensee may pay the civil penalty by letter to the Deputy Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty 5 proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Deputy Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should NUREG-0940 I.A-54
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| Notice of Violation the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to' protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the mitigation factors in the
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| " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualifi-cation of Electrical Equipment Important to Safety for Nuclear Power Plants,"
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| contained in Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement j or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of I the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section i 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Drauty Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Deputy Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, U. S. Nuclear Regulatory Commission, Region I, 475 Allendale Road, King of Prussia, P.i, 19406 and a copy to the NRC Resident Inspector, Indian Point 2.
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| 1 FOR THE NUCLEAR REGULATORY COMMISSION William T. Russell Regional Administrator King of Prussia, Pennsylvania DatedydayofNovember1988.
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| thisj NUREG-0940 1.A-55
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| pa nso UNITED STATES
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| # $ NUCLEAR REGULATORY COMMISslON S REGION lli 5 f 799 ROOSEVELT ROAD corn ettvu. itunOis soin NOV 231988 I
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| Docket No. 50-255 1 l
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| Licensee No. DPR-20 EA 88-138 Consumers Power Company ATTN: Gordon L. Heins Senior Vice President l Energy Supply 1 212 West Michigan Avenue Jackson, Michigan 49201 Gentlemen: j
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY '
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| (NRC INSPECTION NO. 50-255/86032(DRS))
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| This refers to the inspection conducted on December 8, 1986 through January 13, 1987 to review the program for the environmental qualification (EQ) of equipment at the Palisades Nuclear Plant. The inspection report was sent to you by {{letter dated|date=February 17, 1987|text=letter dated February 17, 1987}}. During the inspection, violations of NRC requirements were identified involving the environmental qualification of certain items of electric equipment. On June 24, 1988, an enforcement conference was conducted with Mr. D. Hoffman and nembers of your staff and Dr. C. J. Paperiello, and members of the NRC staff to dis;uss the violations, their root causes, and your actions to correct the violations and to prevent recurrence.
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| The violation, described in Section I of the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), involves the failure to specify appropriate performance requirements, and to conduct appropriate testing or testing and analysis of certain electric equipment important to safety. This violation involved the failure of 55 Rosemount transmitters, 38 ASCO solenoid valves, and 15 Limitorque actuators to be environmentally qualified because of the failure to specify appropriate performance requirements and conduct appropriate testing or testing and analysis or assure that the equipment was tested in its expected configuration as installed in the plant prior to the EQ deadline of November 30, 1985. The deficiencies identified in the qualification 1 of these components affected a moderate number of plant systems. I Based on NRC review of these findings, it appears that you clearly should have known of these deficiencies. Specifically, with regard to the testing of Rosemount transmitters, you did not specify, and thus satisfy, appropriate ;
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| instrument accuracy criteria based on the maximum error assumed in the plant ;
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| safety analysis. Instrument accuracy is a fundamental qualification requirement. With regard to the lack of adequate sealing of the ASCO solenoid NUREG-0940 1.A-56 l 1
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| Consumers Power Company 2 NOV 231988 valves and their associated conduit / junction box systems, your files contained I vendor data that indicated failures due to moisture intrusion and recommended that the valves have a properly sealed vented conduit / junction box. system; ,
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| however, for certain valves requiring moisture intrusion protection, such protection was not installed. In addition, Franklin Research Center, as an NRC consultant, had identified to you the need for seals at the solenoid enclosure interface in its report in 1982. It appears that the basis upon which the NRC accepted your conclusion that such seals were not required has changed and is no longer valid. It seems that adequate analyses were not performed to assure that these solenoid valves would perform their safety function during and following design basis accidents. Thus, information was available prior to the November 30, 1985 deadline which, if properly evaluated, would have clearly indicated the need to have properly sealed solenoid valve systems. With regard to the SVi4 EP-50 lubricant, your files did not contain an adequate test or analysis that the lubricant in the tested Limitorque actuators was identical or similar to the lubricant used in the actuators installed in the containment. Limitorque maintenance instructions which were available to the licensee before the EQ deadline specify that "for nuclear containment units, Nebula EPO and EP1 are the only approved lubricants for SMB-000 to 5." Furthermore, INP0 Significant Event Report (SER) 7-84, which was available to the licensee, reiterates Limitorque's recommendation that either Exxon Nebula EPO or EP1 be used in motor operators of all model numbers used in nuclear containment service. With regard to the plugged T-drains in the Limitorque actuator motor bousings, information in your files indicated that the actuators were qualified with the T-drains installed and the actuators were supplied with these T-drains. In addition, Information Notice 83-72 described qualification concerns in%1ving drain plugs on Limitorque actuators. You clearly should have known of the need to install and maintain in working order T-drains on these components.
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| The violation described in Section I of the Notice demonstrates that Consumers i Power Company's management did not provide adequate attention to the EQ program at Palisades to ensure that equipment important to safety was environmentally qualified. To emphasize the importance of environmental qualification of electrical equipment important to safety and meeting regulatr y deadlines, I have been authorized, after consultation with the Deputy Executive Director for Regional Operations, and the Director, Office of Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) in the amount of One Hundred Fif ty Thousand Dollars ($150,000) for Violation I described in the enclosed Notice. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49," contained in Generic Letter 88-07 (Enclosure 2),
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| Violation I has been determined to be moderate and to have affected several systems and components. Therefore, this is considered to be an EQ Category B violation. The base value of a civil penalty for an EQ Category B violation is
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| $150,000.
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| NUREG-0940 I.A-57
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| Consumers Power Company 3 NOV 231989 In determining the civil penalty amount, the NRC considered the four factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49," for escalation and mitigation of the base civil penalty amount. These factors consist of (1) identification and prompt reporting of the EQ deficiencies (i 50%); (2) best efforts to complete EQ within the deadline (i 50%);
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| (3) corrective actions to result in full compliance (i 50%); and (4) duration of a violation which is significantly below 100 days (- 50%).
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| With respect to the first factor, neither mitigation nor escalation of the base j civil penalty is appropriate because you identified two examples of Violation I and the NRC identified the other two examples. With respect to the second .
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| factor, neither mitigation nor escalation is appropriate because, while you did 4 shut down on November 30, 1985 to try to achieve compliance with 10 CFR 50.49, this is balanced by the overall limited efforts expended to comply with the November 30, 1985 EQ deadline. With respect to the third factor, escalation by 25 percent is appropriate since the timeliness, degree of initiative, and the comprehensiveness of the corrective actions for one of the four significant deficiencies were only minimal. The replacement of the unqualified Rosemount transmitters, which represented a majority of the significant deficiencies, was not completed until November 4, 1987 and revisions to emergency operating procedures to compensate for the unqualified transmitters were not made until prompted by the NRC. With respect to the fourth factor, 25 percent mitigation is appropriate since the violations existed for 59 days of operation. Based upon all of the above factors, neither mitigation nor escalation of the base civil penalty is considered warranted.
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| The violation described in Section II of the Notice involve the failure to maintain complete files of documentation to demonst ate that certain items i of equipment important to safety were qualified to perform their intended function (s) during the postulated environmental coiditions. The qualification file deficiencies affected many plant systems and components including:
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| General Electric, Rockbestos, and butyl rubber cables; Viking penetrations; and replacement equipment. This violation has been categorized at a Severity Level IV in accordance with the " Modified Enforcement Policy Relating to )
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| 10 CFR 50.49" in that these items were able to be qualified during the i inspection or shortly thereafter.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether fmther NRC enforcement action is i necessary to ensure compliance with NRC reaciatory requirements.
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| NUREG-0940 I.A-58 l
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| Consumers Power Company 4 D 231988 I
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget, as required by the Paperwork Reduction Act of 1980, Pub. L., No. 96-511.
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| Sincerely, Ci
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| $&A---
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| A. Bert Davis Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Imposition of Civil Penalty
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| : 2. Generic Letter 88-07
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| : 3. Inspection Report No. 50-255/86032(DRS) cc w/ enclosures:
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| Mr. Kenneth W. Berry, Director Nuclear Licensing Gerald B. Slade, General Manager DCD/DCB (RIDS)
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| Licensing Fee Management Branch Resident Inspector, RIII Project Manager, NRR Ronald Callen, Michigan Public Service Commission Michigan Department of Public Health NUREG-0940 I.A-59
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| I NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Consumers Power Company Docket No. 50-255 Palisades Plant License No. DPR-20 EA 88-138 During an NRC inspection conducted on December 8, 1986 through January 13, 1987 of the licensee's program for environmental qualification (EQ) of equipment, violations of NRC requirements were identified. In accordance with the " Modified Enforcement'Po11cy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety of Nuclear Power Plants," contained in Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impcse a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205.
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| The particular violation and associated civil penalty are set forth below:
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| l I. Violation Assessed a Civil penalty 10 CFR 50.49(a) and (g) require, in part, that no later than November 30, 1985, each holder of a license to operate a nuclear power plant establish a program for qualifying the electric equipment important to safety and qualify that equipment.
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| 10 CFR 50.49(d)(1) requires that the qualification file include the performance specifications under conditions existing during and .following design basis accidents.
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| 10 CFR 50.49(f) requires each item of electric equipment important to safety be qualified by testing or testing and analysis.
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| Contrary to the above, as of December 8, 1986, Consumers Power Company failed to qualify the following equipment designated important to safety by appropriate testing or testing and analysis, as evidenced by the following examples:
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| : a. Fifty-five Rosemount Model 1153 transmitters, in various safety system control and indication circuits, were not demonstrated to be qualified in that performance requirements were not specified and shown to be satisfied for instrument accuracy under postulated accident conditions.
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| : b. Thirty-eight ASCO solenoid valves, installed in some safety systems, were not qualified in that (1) these valves were insensately sealed to prevent moisture intrusion or (2) the recommended sealed vented conduit / junction box system was not implemented. ASCO test report AQR-67368 indicated test failures and recommended a sealed vented NUREG-0940 I.A-60
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| l Notice of Violation 2 WOV 23 WB3 l conduit / junction box system. Franklin Research Center identified the need for seals at the solenoid enclosure interface. However, neither the recommended systems were installed nor other adequate means to prevent moisture intrusion provided.
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| : c. Eight Limitorque actuators, installed in the High Pressure Safety Injection (HPSI) system inside containment, had SUN EP-50 lubricant in the main gear cases. The licer,ee's EQ files did not contain '
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| appropriate testing or testing and analysis to demonstrate that the lubricant was qualified to permit the Limitorque actuator to meet its specified performance requirements under postulated high temperature and radiation accident conditions.
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| : d. Seven Limitorque actuators in the High Pressure and Low Pressure Safety Injection systems were installed with plugged T-drains in their motor housings. Qualification was based on actuators with T-drains installed. Therefore the EQ files did not demonstrate that the actuators with plugged T-drains were qualified to meet their specified performance requirements under postulated accident conditions.
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| This is an EQ Category B violation.
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| Civil Penalty - $150,000.
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| II. Violation Not Assessed a Civil Penalty 10 CFR 50.49(a) ;nd (g) require, in part, that no later than November 30, 1985, each holder of a license to operate a nuclear power plant establish a program for qualifying the electric equipment important to safety and qualify that equipment.
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| 10 CFR 50.49(d)(1) requires that the qualification file include the performance specifications under conditions existing during and following design basis accidents.
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| 10 CFR 50.49(j) requires a record of the qualification be maintained in an auditable form to permit verification that each item of electrical equipment important to safety is qualified and the equipment meets the specified performance requirements under postulated environtrental conditions.
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| [ Contrary ta the above, as of December 8, I?86, Consumers Power Company I failed to prepare tnd maintain the follovcing qualification files te permit verification that equirr ent important to safety is qualified and meets the specified performance requirements, including insulation I resistance, ender postulated environmental conditions, as evidenced by i
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| the following examples:
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| NUREG-0940 I.A-61 1
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| Notice of Violation 3 NOV 231988
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| : a. The qualification files for General Electric XLPE/PVC cable I
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| and XLPE/ Neoprene cable used for instrument, power, and control circuits did not demonstrate qualification in that performance ,
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| l requirements were not specified and shown to be satisfied for the i l insulation resistance characteristics of these cables.
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| : b. The qualification file for Rockbestos Firewall III XLPE/ Neoprene cable used for instrument, power, and control circuits inside and outside of containment did not demonstrate qualification in that performance requirements were not specified and shown to be satisfied for the insulation resistance characteristics of the cable and did not demonstrate adequate similarity of the tested and installed I cable in that the specific formulation of the cable was not identified.
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| : c. The qualification file for Viking penetrations using Bendix potting compound connectors and sealing washers did not demonstrate qualifi-cation in that performance requirements were not specified and shown to be satisfied for the insulation resistance characteristics of the potted connectors.
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| : d. Qualification files for replacement equipment, including those for Limitorque valve operators, Namco position switches, and Masoneilan electric pneumatic converters, were inadequate in that they inaccurately claimed qualification to DDR Guidelines, when in fact qualification was required to be under 10 CFR 50.49.
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| : e. The qualification files for butyi rubber insulated cables outside containment were inadequate in that performance requirements were i not specified and shown to be satisfied for insulation resistance for the postulated radiation conditions.
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| This is a Severity Level IV violation.
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| Pursuant to the provisions of 10 CFR 2.201, Consumers Power Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation:
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| (1) admission or denial of the alleged violation; (2) the reasons for the violation if admitted; (3) the corrective steps that have been taken and the .
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| results achieved; (4) the corrective steps that will be taken to avoid further !
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| l l
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| NUREG-0940 I.A-62 l
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| | |
| Notice of Violation 4 NOV 231988 violations; and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an Order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Ac~., 42 U.S.C. 2232, this response shall be submitted under oath or affirmatic:s.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, ar order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked an an " Answer to a Notice of Violation" and may: (1) deny the violation listed in this Notice in whole or in part; (2) demonstrate extenuating circumstances; (3) show error in this Notice; or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the mitigation factors in the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney Genert.1, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to l Section 234c of the Act, 42 U.S.C. 2281c.
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| The responses to the Director, Office of Enforcement, ,oted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a l Notice of Violation) should be addressed to: Director, Office of Enforcement, 1
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| l NUREG-0940 I.A-63
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| Notice of Violation 5 NOV 231983 U.S. Nuclear Regulatory Commission, ATTN: Docurrpnt Control Desk, Washington, D.C. 20555, with a copy to the Regione.1 Administrator, Region III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137 and a copy to the NRC Resident Inspector, Palisades.
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| FOR THE NUCLEAR REGULATORY COMMISSION h "
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| A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois This 23rd day of November 1988 NUREG-0940 1.A-64
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| a ase
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| *+
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| ''. UNITED STATES
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| [
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| j NUCLEAR REGULATORY COMMISSION
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| $ f REGION 11
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| : j. 101 MARIETTA ST. N.W.
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| ,,,,, ATLANTA. GEORGIA 30323 00T 2
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| * Docket Nos. 50-413 and 50-414 License Nos. NPF-35 and NPF-52 EA 88-132 Duke Power Company ATTN: Mr. H. B. Tucker, Vice President Nuclear Production Department 422 South Church Street Charlotte, NC 28242 Gentlemen:
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| | |
| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N05. 50-413/88-07 AND 50-414/88-07)
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| This refers to the Nuclear Regulatory Commission (NRC) inspection conducted at both the Catawba Nuclear Station, Units 1 and 2, and the Duke Power CGmpany (DPC) Design Offices in Charlotte, NC, during the period February 1-5, 1986. The inspection included a review of the program for the environ-mental qualification (EQ) of electrical equipment under 10 CFR 50.49.
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| During the inspection, violations of NRC requirements were identified inv71ving the lack of environmental qualification for certain components of electrical equipment in isolated systems in both units. The inspection also t included a review of the circumstances surrounding your identification of I the u, qualified wide range Reactor Coolant System (RCS) hot and cold leg l
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| resistance temperature detectors (RTO), which were unqualified because they were not installed in accordance with the tested configuration. The report documenting this inspection was sent to you by {{letter dated|date=May 4, 1988|text=letter dated May 4,1988}}. As a result _ of this inspection, a significant failure to comply with regulatory requirements was identified, and accordingly, NRC concerns relating to the inspection were discussed in an Enforcement Conference held on July 1, 1988.
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| The letter summarizing this Conference was sent to you on July 25, 1988.
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| The violations described in the enclosed Notice uf Violation and Proposed Imposition of Civil Penalty (Notice) involved the failure to comply with the requirements of 10 CFR 50.49 for both units. Unit 1 is subject to the
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| " Modified Enforcement Policy Relating to 10 CFR 50.49 Environmental Quali-fication of Electrical Equipment Important to Safety for Nuclear Power Plants," contained in NRC Generic Letter 88-07. Unit 2, by virtue of its being licensed after the November 30, 1985, deadline for EQ compliance, is subject to the normal Enforcement Policy of 10 CFR Part 2, Appendix C. The duelity of Enforcement Policy notwithstanding, a single Notice of Violation and Prcposed Imposition of Civil Penalty is appropriate in this case because of the similarity of the violations for both units; equitability in applying the Enforcement Policies in this case is achieved by addressing the overall EQ program at the Catawba Nuclear Station; and, in fairness, it is appro-priate to assess the EQ problem at the facility as a whole.
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| NUREG-0940 I.A-65
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| i Duke Power Company 2 OCT 2 4 G88 l i
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| The violations described in Section I of the enclosed Notice included the failure to properly install the RCS hot and cold leg wide range RTDs in accordance with the tested configuration; failure to adequately evaluate the qualification of non-safety valve operators installed inside Unit 1 contain-ment in the Containment Air Return and Hydrogen Skimmer System (VX); and finally, failure to ensure that valve operators on both units had function-ing T-drains installed similar to the qualified test configuration.
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| The unqualified RTD configuration resulted from a breakdown in your design interface controls to properly translate design specifications for EQ equipment into installation instructions for the craft end your failure to perform adequate walkdowns of EQ equipment. The lack of functioning T-drains on some Limitorque valve operators can also be attributed to your failure to perform adequate walkdowns. The violation involving the instal-lation of non-safety valve operators into the Hydrogen Skimmer System resulted from an inadequate engineering evaluation which failed to consider all the facets of proof necessary to qualify a component to the requirements of the EQ rule.
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| The NRC believes that Duke Power Company clearly should have known about the environmental qualification deficiencies identified above for Unit 1, and clearly would have discovered the problems had an adequate level of atten-tion been applied to the environmental qualification program requirements which included design interface control and field verification inspections.
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| The issue regarding the submerged RTD installations should have been dis-covered in 1984 when questions were raised by NRR concerning the capability of the RTDs to function while submerged. Not only is the need to install functional T-drains on the inside containment actuators required by the test report for the actuators, but it should be a routi e practice to have all actuators fully functional. Moreover, DPC was in.ormed in 1984 that valve operators in the VX system did not meet their specifications and were not qualified for installation inside containment. It is clear that a program for environmental qualification of electrical equipment should include, as a fundamental element, a comprehensive as-built field inspection program to verify that equipment was installed in the configuration in which it was tested for qualification. Such was not the case for the RCS RTDs in Unit I where the RTD wires were not qualified for submergence in the installed ,
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| configuration and the problem was not discovered during your review of the i installation. Finally, Duke Power Company had available information such as IE Circular 79-05, several IE Notices such as 79-03 and 83-72, and NUREG-0588, " Interim Staff Position on Environmental Qualification of Safety-Related Electrical Equipment," which addressed the need to environ-mentally qualify such items as moisture intrusion seals, motor operators, transmitters, and other safety-related electrical equipment for harsh environments.
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| It is evident that Duke Power Company has taken an overall aggressive approach to EQ and that considerable cnrporate-wide effort has been applied NUREG-0940 I.A-66
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| i Duke Power Company 3 OCT 2 41988 to the program; however, there were specific program portions which were deficient as evidenced by these violations. The prompt corrective action which addressed the specific problems was quickly applied to other DPC stations and this is indicative of active management involvement.
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| To emphasize the importance of environmental qualification of electrical equipment at the Catawba Nuclear Station, Units 1 and 2, and that regulatory deadlines are met, I have been authorized, after consultation with the Deputy Executive Director for Regional Operations, and the Director, Office of Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars
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| ($50,000) for the violations described in Section I of the enclosed Notice.
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| In accordance with the " Modified Enforcement Policy Relatin 50.49," contained in NRC Generic Letter 88-07 (Enclosure ,2)g toviolations the 10 CFR described in Section I of the enclosed Notice have been determined to be an isolated problem, having affected a limited number of systems and components, and therefore is considered to be an EQ Category C problem.
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| The base amount of a civil penalty for an EQ category C problem is $75,000.
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| In determining the civil penalty amount, the NRC considered the four factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49," for escalation and mitigation of the base civil penalty amount. These factors consist of (1) identification and prompt reporting of the EQ deficiencies
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| ( 50%); (2) best efforts to complete EQ within the deadline ( 50%);
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| (3) corrective actions to result in full compliance ( 50%); and (4) duration of violation which is significantly below 100 days (-50%).
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| The escalation and mitigation factors were considered as follows: No escalation or mitigation was applied for identification and prompt reporting after considering both the fact that the licensee and the NRC each iden-tified one of the two violations for which proper corrective actions were taken, and the fact that although the licensee identified the third violation, it was not properly corrected. Fifty percent mitigation was applied for best efforts to complete EQ within the deadline. Duke Power Company has been sensitive to EQ requirements and generally maintained a high degree of attention to the E0 program. Twenty-five percent mitigation was applied for corrective actions to result in full compliance. Specifi-cally, Duke Power Company initiated shutdown to undertake immediate correc-tive action on the RCS RTDs. Further, the corrective actions included j extensive training enhancements which were incorporated into the station EQ program which should help to preclude similar problems in the future.
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| However, these efforts were partially offset by the fact that two Limitorque motor operated valves without functioning T-drains were installed in the Unit 1 VX system, after the deadline, to correct Violation I.B. With respect to the fourth factor in the Modified Enforcement Policy, mitigation is inappropriate since these EQ violations, with the exception of Violation I.B. existed in excess of 100 days for Unit 1. The application of the mitigation factors reduced the civil penalty to the minimum $50,000 as provided by Generic Letter 88-07 for significant EQ failures.
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| NUREG-0940 I.A-67
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| Duke Power Company- 4 00T 2 41988 The first violation described in Section II of the enclosed Notice involved hydrogen skimmer fan motors in Unit 2, which were not installed in accord-ance with the tested configuration, in that the breather drains were not-installed. This violation was categorized as a Severity Level IV in accord-ance with 10 CFR Part 2, Appendix C. The second violation involved an 1 inadequate EQ file for the Unit 1 Hydrogen Recombiner tape splices which was categorized as a Severity Level V violation because prior to the end of the inspection the equipment was shown to, in fact, be qualifiable.
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| You are required to respond to this letter and should follow the instruc-
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| 'tions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your )
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| response to 'this Notice, including your proposed corrective a.tions and the - {
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| results of future inspections, the NRC will determine whether further NRC J enforcement action is necessary to ensure compliance with NRC regulatory j requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice." Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.
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| The responses directed by this letter and its enclosures are not subject to the clearance procedures of the Office of Management and Budget as required )
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| by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Should you have any questions concerning this letter, please contact us.
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| Sincerely,
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| - 6 U
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| MalcdTm L. Ernst Acting Rey,onal Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Imposition of Civil Penalty l 2, Generic Letter 88-07 !
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| cc w/encls: )
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| T. S. Owen, Station Manager State of South Carolina t i
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| NUREG-0940 I.A-68
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| i NOTICE OF VIOLATION AND PROPOSED IMPOSITIOT0F CIVIL PENALTY l Duke Power Company Docket Nos. 50-413 and 50-414 '
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| Catawba Nuclear Station License Nos. NPF-35 and NPF-52 Units I and 2 EA 88-132 During the Nuclear Regulatory Commission (NRC) inspection conducted on February 1-5, 1988, violations of NRC requirements were identified. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act),
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| 42 U.S.C. 2282 and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| I. Violations Assessed a Civil Penalty A. 10 CFR 50.49(d), (e), (f), (j), and (k) state in part that (1) the licensee shall have a list of electric equipment important to safety that addresses the environmental conditions, including temperature, pressure, humidity, radiation, chemicals, and sub-mergence; (2) the qualification program must include and be based on submergence if subject to being submerged; (3) each item of electric equipment important to safety shall be qualified by testing of, or exoerience with, identical or similar equipment, and the qualification shall include a supporting analysis to show the equipment to be qualified is acceptable; (4) a record of qualification must be maintained in an auditable form; and (5) electric equipment important to safety which was previously qualified in accordance with NUREG-0588 (for comment version),
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| " Interim Staff Position on Environmental Qualification of Safety-Related Electrical Equipment," need not be requalified to 10 CFR 50.49.
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| NUREG-0588, Section 2.2(5) states that " equipment should be located above flood level or protected against submergence by locating the equipment in qualified watertight enclosures... Where l equipment could be submerged, it should be identified and demon-strated to be qualified by test for the duration required."
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| : 1) Contrary to the above, from the initial operation of Unit I under the full power license issued on January 17, 1985 until January 1988, the Reactor Coolant System (RCS) hot and cold i leg wide range resistance temperature detectors (RTD), Model NUREG-0940 1.A-69
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| Notice of Violation 2 l
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| RdF, were not qualified in that the junction boxes where the RTD pigtail wires were terminated could 'ecome submerged and were not qualified for submergence; the RTD wiro were not-qualified for submergence in the installed configuration, that is, the hydrostatic hose assembly that was to encapsu-late the wires to prevent moisture intrusi.on had been removed during installation; and the qualification file did not address the installed configuration as being different from the tested configuration due to submergence. .
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| 1
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| : 2) Contrary to the above, from the initial operation of Unit 2 under the full power license issued on May 15, 1986, until January 1988, the Reactor Coolant System (RCS) hot and cold" leg wide range resistance temperature detectors (RTD), Model .
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| RdF, were not qualifiec' in that the junction boxes where the l RTD pigtail wires were terminated could become submerged and were not qualified for submergence; the wires were not qualified for submergence in the installed configuration, that is, the hydrostatic hose assembly that was to encapsu-late the wires to prevent moisture intrusion had been removed during installation;'and the qualification file did not address the installed configuration as being different from ;
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| the tested configuration due to submergence.
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| B. 10 CFR 50.49(f), (j), and (k) state in part that (1)'each item of electrical equipment important to safety shall be qualified by testing of, or experience with, identical or similar equipment, and the qualification shall include a supporting analysis to show the equipment to be qualified is acceptable; (2) a record of-qualification must be maintained to verify that each item important to safety is qualified for its application and meets its specified performance requirements; and (3) electric equipment important to safety which was previously qualified in accordance with NUREG-0588 (for comment version), " Interim Staff Position on Environmental Qualification of Safety-Related Electrical Equip-ment," need not be requalified to 10 CFR 50.49. I l
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| Contrary to the above, from November 30, 1985, until the time J of an inspection, which was completed on January 10, 1986, the licensee's environmental qualification (EQ) files did not adequately document qualification for the two Limitorque motor operated valves installed in the Unit 1 Containment Air Return and Hydrogen Skimmer System (valve nos. IVX1A and IVX2B). The installed valves were procured at non-safety without test docu- ;
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| mentation and the licensee's EQ files failed to establish <
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| similarity between the installed valves and a qualified tested !
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| configuration.
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| NUREG-0940 1.A-70
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| Notice of Violation 3 C. 10 CFR 50.49(f), (j), and (k) state in part that (1) each item of electric equipment important to safety shall be qualified by testing of, or experience with, identical or similar equipment, and the qualification shall include a supporting analysis to show the equipment to be qualified is acceptable; (2) a record of qualification must be maintained to verify that each item important to safety is qualified for its application and meets its specified performance requirements; and (3) electric equipment important to safety which was previously qualified in accordance with NUREG 0588 (for comment version), " Interim Staff Position on Environmental Qualification of Safety-Related Electrical Equip-ment," need not be requalified to 10 CFR 50.49.
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| : 1) Contrary to the above, from initial plant operations until the time of the inspection which was completed on February 5, 1988, a total of three inside containment Limitorque motor operated valves in Unit I were not installed in accordance with the qualified tested configuration in that T-drains were painted over, plugged or not installed. Furthermore, the deficiencies were not evaluated in the environmental qualification file. The affected valves are identified as follows: IKC3648, 1KC394A, and INM2008.
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| : 2) Contrary to the above, from initial plant operation of Unit 2 under the full power license issued on May 15, 1986, until the time of the inspection which was completed on February 5, 1988, a total of 17 inside containment Limitorque motcr operated valves were not installed in accordance with a qualified tested configuration in that T-drains were painted over, plugged or not installed. Furthermore, these defi-ciencies were not evaluated in the environmental qualifi-cation (EQ) file. The affected Unit 2 valves were: 2KC345A, 2KC394A, 2KC413B, 2KC429B, 2NC054A, 2NC250A, 2NC2518, 2NC252B, 2NC253A, 2NM187A, 2NM190A, 2NM1978, 2NM2008, 2NM207A, 2NM210A, 2NM025A, and 2WL450A.
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| This is an EQ Category C problem.
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| Civil Penalty - $50,000 II. Violations Not Assessed a Civil Penalty A. 10 CFR 50.49(f) and (k), state in part that (1) each item of electric equipment important to safety shall be cualified by testing of, or experience with, identical or similar equipment, and the qualification shall include a supporting analysis to show l the equipment to be qualified is acceptable; and (2) electric equipment important to safety which was previously qualified in NUREG-0940 1.A-71
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| e t i
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| Notice of Violation 4 accordance with NUREG 0588 (for comment version), " Interim Staff Position on Environmental Qualification of Safety-Related Electrical Equipment," need not be requalified to 10 CFR 50.49.
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| , l i
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| Contrary to the above, at the time of the inspection which was I completed on February 5, 1988, the Hydrogen Skimmer fan motors on 1 Unit 2 were not installed in accordance with the tested configu-ration in that the breather drains were not installed and this deficiency was not addressed in the EQ file.
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| This is a Severity Level IV violation (Supplement I).
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| B. 10 CFR 50.49(f) and (j) state in part that (1) each item of electric equipment important to safety shall be qualified by testing uf, or experience with, identical or similar equipment, and the qualification shall include a supporting analysis to show the equipment to be qualified is acceptable; and (2) a record of qualification must be maintained to verify that each item important to safety is qualified for its application and meets its specified performance requirements.
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| Contrary to the above, at the time of inspection which was completed on February 5, 1988, the file for the Hydrogen Recombiner for Unit I did not contain a similarity analysis as required to show that the installed tape splice was similar to a tested, qualified configuration.
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| This is a Severity Level V violation (Supplement 1).
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| Pursuant to the provisions of 10 CFR 2.201, Duke Power Company (licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of the letter transmitting this Notice. This reply should be clearly arked as a " Reply to a Notice of Violation" and should include for each violation: (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Not.;e, an order may be_ issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to ;
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| extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted i under oath or affirmation.
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| 1 Within the same time as provided for the response required above under 10 CFR 2.201, the licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, NUREG-0940 I.A-72
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| Notice of Violation 5 with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement., U.S. Nuclear Regulatory Commission. Should the licensee fail to cnswer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the factors addressed in the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
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| Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compro-mised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforce-ment, U.S. Nuclear Regulatory Commitsion, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, Region II and a copy to the NRC Resident Inspector, Catawba Nuclear Plant.
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| FOR THE NUCLEAR REGULATORY COMMISSION T.7 .J -
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| b f /r;LS--- u ,/
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| Malcolm L. Ernst Acting Regional Administrator Dated at Atlanta, Georgia, this.) ct) day of October 1988 NUREG-0940 1.A-73
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| | |
| m UNITED sT ATEs
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| [pagg b, NUCLEAR REGULATORY COMMISSION yg '
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| REGloN 11
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| ; o 101 MARIETTA STREET. N.W.
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| *; f ATLANTA. GEORGI A 30323
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| %...../
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| MAR 17 S88 Docket No. 50-302 License No. OPR-72 EA 87-216 Florida Power Corporation Mr. W. S. Wilgus Vice President Nuclear Operations ATTN: Manager, Nuclear Licensing Post Office Box 219 Crystal River, FL 32629 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 50-302/87-35 AND 50-302/88-03)
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| This refers to the Nuclear Regulatory Commission (NRC) inspections conducted by Mr. R. E. Weddington at the Crystal River facility on October 14-16, 1987, and by Mr. F. N. Wright on January 5-7, 1988. The inspection of October 14-16, 1987, included a review of the circumstances surrounding a significant potential for overexposure of personnel in the vicinity of the reactor cavity
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| - access which was identified by a member of your staff and was reported to the NRC on October 9, 1987. The inspection of January 5-7, 1988, included a review of the circumstances surrounding unauthorized entries into a high radiation area without a radiation monitoring device and into a radiographer's controlled area. The reports documenting these inspections were sent to you by letters dated November 19, 1987, and February 8, 1988.
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| As a result of the October and January inspections, significant failures to comply with NRC regulatory requirements were identified. NRC concerns relative to the October inspection findings were discussed in an Enforcement Conference held on December 11, 1987. The letter summarizing this Conference was sent to you on December 18, 1987. NRC concerns relative to the January inspection were discussed at an Enforcement Conference held on March 9, 1988.
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| The violations described in Section I of the enclosed Notico of Violation and
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| * Proposed Isrposition of Civil Penalty (Notice) involved failures to lock, cost, barricade, and issue a Radiation Work Permit to control tecess to a high radiktion area; failure to provide adequate instruction and training to employees working in the restricted area; and failure to establish adequate procedures for radiation protection and refueling operations. The events that resulted in these violations included the removal of several lead bricks from a permanent shielding barrier blocking the reactor cavity access by an unlicensed Auxiliary Nuclear Operator who looked into the area beneath the reactor vessel '
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| to check for water leakage past the seal plate. When the lead bricks were removed from the reactor cavity 1ccess, a high radiation area of 40 Rem / hour at 18 inches from the access (55 Rem / hour at the center of the opening) was created which was uncontrolled with respect to barricading, posting, and access by use of a Radiation Work Permit. This radiation field existed for a period NUREG-0940 I.A-74
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| Florida Power Corporation MAR 1 7 ggg ofapproximatel[30to45minutesuntilitwasdiscoveredandcortrolledbya l health physics technician. During this time two individuals worked in the
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| {
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| vicinity of the opening and at least seven individuals walked through the l 1
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| radiation field.
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| This event resulted in an unplanned exposure that violated plant administrative <
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| limits. It is fortuitous that only the initial Auxiliary Nuclear Operator who )
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| removed the lead bricks received any significant exposure. Although the i calculated conservative estimated exposures to the initial operator were i 1.8 Rem to the whole body and 6.6 Rem to the extremities, which are less than the NRC limits, the NRC is concerned that these viciations, collectively, caused a significant potential for personnel exposures in excess of NRC limits.
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| Unauthorized entries into Pressurized Water Reactor (PWR) cavity areas have been a continuing problem within the industry, which have resulted in exposures in excess of NRC limits and the potential for life threatening exposures as dose rates in these areas may be on the order of several thousand Rem per hour.
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| You were informed of this problem via three NRC Information Notices (IN)
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| (IN 82-51, " Overexposure in PWR Cavities;" IN 84-19, "Two Events Involving Unauthorized Entries Into PWR Reactor Cavities;" and IN 86-107, " Entry into PWR Cavity with Retractable Incore Detector Thimbles Withdrawn") and by INPO Significant Operating Experience Report (50ER) 85-3.
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| There were several root causes that contributed to this event which are similar-to the root causes of unauthorized entries into PWR reactor cavities at other facilities. They include a lack of adequate communication, hecith physics controls, and knowledge of the hazards. Weaknesses in the associated training program and the lack of a good' method for early detection of water leakage past j the reactor cavity seal plate also contributed to this event. In addition, there were no written specifications for replacing the fixed shield wall after an entry made during the previous refueling outage in 1985, and the bricks were not placed back into the wall in as substantial a manner as they had been originally.
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| The violations described in Section II of the enclosed Notice involved failure to provide a radiation monitoring device to an individual inside a posted High Radiation Area as required by your Technical Specification, and failure to follow radiation control procedures. NRC Inspection Report Nos. 50-302/86-06 and 50-302/86-26 sent to you on March 25, 1986, and September 2, 1986, respec-tively, each of vhich was issued with a Notice of Violation for prior instances (on January 28 and February 19, 1986) where individuals entered posted High Radiation Areas without radiation monitoring devices. Because "similar violations,"
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| I as described in the NRC Enforcement Policy, are of significant concern to the l NRC, please give particular attention in your response to the identification of the root cause of this problem and your corrective action to prevent recurrence.
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| The NRC is also concerned that upon discovery of the most recsnt event ycur health physics personnel did not take action to remove the individual from the l
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| High Radiation Area, but let him remain in the area without the necessary l controls for approximately thirty minutes until he had completed his work. This l failure to take prompt corrective action is also of concern to the NRC and your response should describe those actions you have taken or planned to ensure that l immediate action is taken to correct unsafe conditions when they are observed.
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| l l NUREG-0940 I.A-75 l
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| L _ __ _
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| I Florida Power Corporation MAR 17 SE To emphasize thr serious nature of these events and the need for improvements in the administ ation and control of your Radiation Safety Program and your training program to ensure the safe performance of licensed activities and adherence to NRC requirements, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Hundred Thousand Dollars j (5100,000) for the violations described in the enclosed Notice. 1 1
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| l In accordance with the " General Statement of Policy and Procedure for NRC l Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the violations described in the enclosed Notjce have been categorized in the aggregate as a Severity Level III problem. The base value of a civil penalty for a Severity Level III violation or problem is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered, and the base civil penalty amount h4s been increased by 100 percent. In the determination of the civil penalty amount, consideration was given to your identification of the problems, your prompt reporting of the events, and your extensive corrective actions. However,
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| ; because of: (1) your prior notice of similar reactor cavity events as demon-strated by your receipt of NRC ins 82-51, 84-19, and 86-107 and your receipt of INPO SOER 85-3; (2) the fact that a work order to install a strongback on the existing lead brick barricade with an appropriate locking device was generated in 1985, was still outstanding at the time of this event, and if completed )
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| would have prevented the occurrence of the reactor cavity access event; (3) the fact that there were several opportunities to discover the reactor cavity access problem in that several members of your staff, including a foreman, passed through the vicinity, saw the operator removing the lead bricks from the shield wall, but did not recognize or report the problem; and (4) the fact that the violations involving unauthorized entries are similar to violations occurring in 1986; the civil penalty was escalated 100 percent. As indicated in the Notice, $75,000 of the civil penalty is for the reactor cavity event because of its greater significance.
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| You are required to respond to this letter and the enclosed Notice and should l follow the instructions specified therein when preparing your response. In ycur response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actiot, and the results of future inspections, the NRC will determine whether furtier NRC enforcement action is necessary to ensure compliance with NRC reculatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub..L. No. 96-511.
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| NUREG-0940 I.A-76
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| )
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| MAk j Florida Power Corporation 7 1988 Should you havraby questions concerning this letter, please contact us.
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| Sincerely, e
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| J. Nelson Grace Regional Administrator
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| ==Enclosure:==
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| Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl:
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| P. F. McKee, Director, Nuclear Plant Operations E. C. Simpson, Director, Nuclear Site Support I
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| NUREG-0940 I.A-77 I
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| l NOTICE OF VIOLATION l AND l PROPOSED IMPOSITIOT OF CIVIL PENALTY Florida Power Corporation Docket No. 50-302 Crystal River, Unit 3 License No. DPR-72 EA 87-216 During the Nuclear Regulatory Commission (NRC) inspections conducted on October 14-16, 1987, and January 5-7, 1988, violations of HRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| I. Violations Involving the Reactor Cavity Access Event A. Technical Specification 6.12.1 requires that a high radiation area in which the intensity of the radiation is greater than 1,000 millirem per hour be barricaded and conspicuously posted as a high radiation area and entrance thereto controlled by issuance of a Radiation Work Permit. In addition, locked doors are required to be provided to prevent unauthorized entry into such area.
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| Contrary to the above, the licensee failed to adequately control access to high radiation areas in that:
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| : 1. Between 1985 and October 9, 1987, a locked door was not provided to control access to the reactor cavity located on the 95 foot elevation of the Reactor Building.
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| : 2. On October 9, 1987, the licensee failed to barricade, post as a high radiation area, and control by issuance of a Radiation Work Permit access to such a high radiation area on the 95 foot elevation of the Unit 3 Reactor Building in the vicinity of the reactor cavity access. The intensity of radiation in the area was up to 40 Rem / hour at 18 inches from the opening to the reactor cavity.
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| B. 10 CFR 19.12 requires that all individuals working in or frequenting at:y portion of a restricted area shall be instructed in the purpose and functions of protective devices empicyed, shall be instructed of their responsibility to report promptly to the licensee any c.ondition which may lead to or cause a violation of Commission regulations and licenses or unnecessary exposure to radiation or to radioactive ,
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| natorial, and shall be instructed in the appropriate response to :
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| warnings made in the event of any unusual occurrence or malfunction ]
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| I I
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| NUREG-0940 I.A-78 1
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| Notice of Violation ~
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| that esy involve exposure to radiation or. radioactive material. The extent of thes,= instructions shall be commensurate with potential
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| . radiation health protection problems in the restricted area.
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| Contrary to the above, the licensee failed to adequately provide instruction to an Auxiliary Nuclear Operator working in the restricted area of the Reactor Building on October 9,1987, on the limitations and possible failure modes-of a radiation survey instrument that had been provided for his use in controlling his exposure in the restricted area and on the appropriate response to take when the radiation level present exceeded the maximum scale reading on the radiation survey meter.
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| C. Technical Specification 6.11 requires that procedures for personnel I radiation. protection shall be prepared consistent with the requirements of 10 CFR Part 20 and shall be approved, maintained, and adhered to for all operations involving personnel radiation exposure.
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| Technical Specification 6.8.1.b requires that written procedures shall be established, implemented, and maintainet covering refueling operations.
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| Contrary to the above, the licensee's procedures for personnel radia-tion protection and refueling operations were inadequate as evidenced by the October 8, 1987 reactor cavity access shielding removal event in that they did not specify that:
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| : 1. permanent shielding removed during outage activities is to be reinstalled properly;
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| ; 2. health physics 'is to be notified prior to the removal of permanent shielding;
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| : 3. health physics is to be notified when unexpected radiological conditions are encountered or scope of previously authorized work changed;
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| : 4. high radiation areas in the Reactor Building area are to be posted and controlled following a plant shutdown and prior to allowing general access; and I 5. personnel assigned to observe for seal leakage in the Reactor Building while filling the fuel transfer caral are to be instructed in the proceduri for observing leaks and the precautions to be observsd while performing that task, particularly with regarJ to entries into the reactor cavity.
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| II. Violations Involving Unauthorized Entrie_s A. Technical Specification 6.12.1 requires that with respect to a high radiation ares in which the radiation intensity is greater than 100 mrem per hour but less than 1,000 mrem per hour and any individual parmitted to enter such areas shall be provided with a radiation NUREG-0940 I.A-79
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| n 3
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| Notice of Violation . monitoring device which continuously indicates the radiation dose rate in the area.
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| Contrary to the above, on December 23, 1987, a radiation worker entered the "B" D-Ring area of the Reactor Building, a posted high radiation area with dose rates up to 350 mrem per hour, without a radiation. monitoring device which continuously indicated the
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| ' radiation dose rate in the arec.
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| : 8. Technical Specification 6.11 requires that procedures for personnel radiation protection shall be prepared consistent-with the requirements of 10 CFR Part 20 and shall be approved, maintained, and adhered to for all operations involving personnel radiation exposure.
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| Licensee' Procedure MTAPR-7.0, Controlling Access to Radiographic Areas, Revision 5, requires persons entering a radiographer's controlled area to obtain authorization from the radiographer-in-charge of the test.
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| Contrary to the above, on October 24,.1987, a radiation worker entered the "A" D-Ring area of the reactor building, a radiographer's controlled area without approval from the radiographer-in-charge.
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| These violations have been evaluated in the aggregate as a Severity Level III problem (Supplement IV).
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| Cumulative civil penalty - $100,000 ($75,000 for the violations in Section I and $25,000 for the violations in Section II)
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| Pursuant to the provisions of 10 CFR 2.201, Florida Power Corporation is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice.. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for eacn violation: (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved (4) the corrective steps which will be taken to avoid further violations, and (5) the
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| ; date when full compliance will be achieved. If an adequate reply is not received within the time specified-in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action.as may.be proper shoulo not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority
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| , of Section 182 of the Act, 42 U.S C. 2232, this response shall be submitted under oath or affirmation.
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| Within the saus time as provideo for the response required above under 10 CFR 2.201, the licensee mar pay tne civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty prooosed above, or the cumulative amount the civil penalties if .rore than one civil penalty is proposed, or may prctest imposition of the civil penalty in whole or in part by a written answer NUREG-0940 1.A-80 i
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| Notice of Violation )
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| i addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in j whole or in part, such answer should be clearly marked as an " Answer to a l Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed.
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| In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the five facters addressed in :
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| Section V.B of 10 CFR Part 2, Appendix C (1987), should be addressed. Any ,
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| written answer in accordance with 10 CFR 2.205 should be set forth separately I from the statement or explanation in reply pursuant to 10 CFR 2.201 but may '
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| incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
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| Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. ,
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| The responses to the Director, Office of Enforcement, noted above (Reply to a '
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| Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, Region II and a copy to the NRC Resident Inspector, Crystal River.
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| FOR THE NUCLEAR REGULA10RY COMMISSION
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| , d "
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| J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia thisI'lfday of March 1988 i
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| i NUREG-0940 1.A-81 1
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| y"
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| [ g
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| 'g UNITED STATES NUCLEAR REGULATORY COMMISSION
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| $ . WASHINGTON, D. C. 20$55 )
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| % **"* / NOV li' 1988 Docket No. 50-302 License No. DPR-72 EA 87-216 Florida Power Corporation Mr. W. S. Wilgus <
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| Vice President Nuclear Operations ATTN: Manager, Nuclear Licensing Post Office Box 219 Crystal River, Florida 32629 Gentlemen:
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| ==SUBJECT:==
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| ORDER IMPOSING A CIVIL MONETARY PENALTY This refers to your response of May 16, 1988, to our Notice of Violation and Proposed Imposition of Civil Penalty issued on March 17, 1988, concerning activities conducted at your Crystal River facility. A civil penalty in the amount of $100,000 was proposed to emphasize the serious nature of the radio-logical events and the need for improvements in your radiation safety program.
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| In your response, you admitted violation I.A. I.C.3, I.C.5, II.A and II.B. and ,
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| denied violations I.B and I.C.1, 2 and 4. After careful consideration of the )
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| bases for your denial of Violations I.B and I.C.1, 2 and 4, we have concluded, for the reasons presented in the Appendix to the enclosed Order, that the violations occurred as stated in the Notice of Violation except for Violation i.C.4 Violation I.C.4 is being withdrawn. Your corrective actions for all viciations stated in your response are acceptable and no additicnal response is required. We will examine the implementation of your corrective actions during future inspections.
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| We also have evaluated your request for mitigation of the civil penalty. l Based on the information provided, we have determined that mitigation of this civil penalty amount by 50 percent is warranted for the reasons stated in the Appendix to the enclosed Order. Accordingly, we hereby serve the enclosed Order imposing a civil monetary penalty in the amount of $50,000.
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| In accordance with Section E.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its crclosure will be placed in the NRC Public Document Room.
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| Sincerely, 7
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| $ ~
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| , Deputy Executive Director
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| . ) raes M. Tay)l Operations for Regiona
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| {f
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| ==Enclosure:==
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| See Not Page NUREG-0940 I.A-82
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| UNITED STATES NUCLEAR RECULATORY COMMISSION In the Matter of ) Docket No. 50-302 Crystal River Unit 3 ) License No. DPR-72 i Crystal River, Florida ) EA 87-216 ORDER IMPOSING CIVIL MONETARY PENALTY I
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| Florida Power Corporation, Crystal River, Florida (licensee) is the holder of Operating License No. DPR-72(license) issued by the Nuclear Regulatory Commis-sion (Comission or NRC) on January 28, 1977. The license authorizes the licensee to operate the Crystal River facility in accordance with the condi-tions specified therein.
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| II NRC inspections of the licensee's activities under the license were conducted on October 14-16, 1987 and January 5-7, 1988. The results of these inspections indicated that the licensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition i
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| of Civil Per.alty (NOV) wcs served upon the licensee by {{letter dated|date=March 17, 1988|text=letter dated March 17, 1988}}. The.NOV stated the nature of the violations, the provisions of the NRC's requirements that the license had violated, and the amount of the civil penalty proposed for the violations. The licensee responded to the NOV by {{letter dated|date=May 16, 1988|text=letter dated May 16, 1988}}. In its response, the licensee admitted certain violations, denied other violations, and stated that the Enforcement Policy had been inappropriately l applied in this case and that the facts of the matter support full remission of j the civil penalty.
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| l NUREG-0940 1.A-83 1
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| 1
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| III After consideration of the licensee's response and the statements of fact, ;
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| explanations, and argument for mitigation contained therein, the Deputy Execu- !
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| tive Director for Regional Operations has determined, as set forth in the Appendix to this Order, that the violations, except for Violation I.C.4, occurred as stated and, for reasons set forth in the attached Appendix, the penalty proposed for the violations described in the Notice of Violation and Proposed Imposition of Civil Penalty should be mitigated by 50 percent and imposed.
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| l IV i
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| In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act 1
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| of 1954 as amended (42 U.S.C. 2282, PL 96-295 and 10 CFR 2.205, IT IS HEREBY l ORDERE THAT:
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| The licensee pay a civil penalty in the amount of Fifty Thousand Dollars ($50,000) within 30 days of the date of this Order, by check, draf t, or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, U.S. J Nuclear Regulatory Cominission, ATTN; Document Control Desk, Washing-ton, D.C. 20555.
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| i NUREG-0940 I.A-84
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| I I
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| )
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| 4 V
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| The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing shall be clearly marked as a " Request for an Enforcement Hearing" and shall be addressed to the Director, Office of Enforcement, U.S.
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| fluclear Regulatory Commission, ATTil: Document Control Desk, Washington, D.C.
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| 20555, with a copy to the Regional Administrator, Region II, 101 Marietta St.eet, N.W., Atlanta, Georgia 30323.
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| If.a hearing is requested, the Commission will issue an Order designating the time and place of th'e hearing. If the licensee fails to request a hearing within 30 days of the date of this Order, the provisions to this Order shall be.
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| effective without further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection.
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| In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be whether the licensee committed the violations that are denied and whether the pre: sed civil penalty mitigated by 50 percent should be imposed.
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| FOR THE NUCLEAR REGULATORY COMMISSI0tl A
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| f[sM.Tay W.?
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| , Deputy Executive Director for Operations l
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| Dated at Rockville, fiaryland ,
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| this j'Ttiay of November 1988 NUREG-0340 I.A-85
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| l APPENDIX l
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| EVALUATION AND CONCLUSION l INTRODUCTION l
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| On October 14-16, 1987 and January 5-7, 1988, inspections were conducted at the Crystal River facility. Violations identified during these inspections led to the issuance of a Notice of Violation and Proposed Imposition of Civil Penalty on March 17, 1988. Florida Power Corporation, in their response, admitted violations 1.A.1 and 2, I.C.3 and 5, II.A and B; denied violations I.B I.C.1,2 and 4 and requested mitigation of the civil penalty. Provided belcw are: (1) a restatement of each violation denied, (2) a summary of the licensee's response regarding each denied violation, (3) NRC's evaluation of the licensee's response, (4) the licensee's request in support of withdrawal of the proposed civil penalty, and (5) NRC's conclusions regarding the violations and the proposed civil penalty.
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| I. VIOLATION I.B Restatement of Violation 10 CFR 19.12 requires that all individuals working in or frequenting any portion of a restricted area shall be instructed in the purpose and functions of protective devices employed, shall be instructed of their responsibility to report promptly to the licensee any conditinn which may lead to or cause a violation of Commission regulations and licenses or unnecessary exposure to radiation or to radioactive material, and shall be instructed in the appropriate response to warnirgs made in the event of any unusual occurrence or malfunction that may involve exposure to radiation or radioactive material. The extent of these instructions shall be commensurate with uotential radiation health protection problems in the restricted area.
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| Contrary to the above, the licensee failed to adequately provide instruc-tion to an Auxiliary Nuclear Operator working in the restricted area of the Reactor Building on October 9, 1987, on the limitations and possible failure modes of a radiation survey instrument that had been provided for his use in controlling his exposur e in the restricted area and on the appropriate response to take wher, .ne radiation level present exceeded the maximum scale reading on the radiation survey meter.
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| Sumary of Licensee's Response Florida Power Corporation deniet the violation and believes it should be withdrawn. The ANO receised training on radiation detection instements during the Rediation Protection itsson provided in the Ast % tant huclear Auxiliary Operator course and the Auxiliary Tuclear Opera ,o courses for I nch-licensed operators. This traiaing included information on radiatien detection principles, ionization chambers, properticnal counters, and Gefger-Mueller (GM) tubes. The radiation detecticn instrument utilized by the ANO did not respond incorrectly er fail, it indicated en off-scale reading in response to the high radiation field tc which it was exposed.
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| Based on the individual's training and extensive nrk experience history i inclucing ruelear navy expericrce, non-licensad operator training, Gereral i NUREG-0940 1.A-86
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| Appendix -? -
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| Employee Training, and his Crystal River Unit 3 (CR-3) work experience, it is reasonable to assume he knew the correct response to an off-scale radiation detection instrument. It is also clear from the AN0's actions (i.e., pattern of brick removal, dosimetry positioning, warning of others, etc.) that additional training was unnecessary. The ANO failed to take the proper actions not out of lack of training but due to his decision to perform work that exceeded the authorized scope of approved activities.
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| Florida Power Corporation subsequently provided specific supplemental (
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| retraining to the ANO on the use and limitations of survey instruments.
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| Radiation Safety Procedures have also been enhanced with respect to response to off-scale readings, and General Employee Training has been enhanced to include failure modes of survey instruments. These actions by Florida Power Corporation represent positive actions to improve the training and instruction already provided to radiation workers. The NOV could be read to assume that adoption of these additional measures is an indication that previous practices were insufficient to meet regulatory requirements. Such a view is contrary to the Enforcement Policy in that it could discourage improvements out of fear that the NRC will construe such improvements as an admission of past violations.
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| HRC Evaluation The inspection revealed that the ANO was trained in certain subjects related to survey instruments but, was not trained on the limitations and possible failure modes of radiation survey instruments and the correct response to take to off-scale readings. The inspector reviewed the lesson plans with licensee representatives and verified that these subjects were not addressed. The licensees subsequent staterrent that these topics were added to the training program also indicates they were not there when reviewed by the inspector. TFe staff cannot agree with the licensee's statement that it is reasonable to assume the individual knew the correct response to an off-scale instrument since the individual was confronted with that very situation and did not respond appropriately. Supporting this position is the fact that the second ANO also failed to respond to an off-scale survey instrument, indicting there most likely was a deficiency in their training in this area. The AN0s stated in interviews with the inspector that they had not received training on the correct response to take when off-scale instrument readings are observed. The NRC decision to cite this violation was based on a review of the facts and was not, as claimed by the licensee, based on construing their corrective actions as an admission of a violation. This violation was first presented in the October 16, 1987 exit interview as docurrented in the inspection report which occurred prior to the corrective actions described by the licensee.
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| The licensee's corrective actions appear 6ppropriate and in no way were used as a basis for identifying this circumstance as a violation, pPCConclusion for the above reason, the NRC staff concludes that the violation occurred as stated.
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| NUREG-0940 1.A-87
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| i l
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| i Appendix 1 II. VIOLATION _I.C.
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| Restatement of Violation Technical Specification 6.11 requires that procedures for personnel radiation protection shall be prepared consistent with the requirements of 10 CFR Part 20 and shall be approved, maintained, and adhered to for all operations involving personnel radiation exposure.
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| Technical Specification 6.8.1.b requires that written procedures shall be I r.stablished, implemented, and maintained covering refueling opeations.
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| Contrary to the above, the licensee's procedures for personnel radiation protection and refueling operations were inadequate as evidenced by the October 8,1987 reactor cavity access shielding removal event in that they did not specify that:
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| : 1. permanent shielding removed during outage activities is to be rein-stalled properly.
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| : 2. health physics is to be notified prior to the removal of permanent shielding;
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| : 3. health physics is to be notified when unexpected radiological conditions are encountered or scope of previously authorized work changed;
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| : 4. high radiation areas in the Reactor Building area are to be posted and controlled following a plant shutdown and prior to allowing general access; and
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| : 5. personnel assigned to observe for seal leakage in the Reactor Build-ing while filling the fuel transfer canal are to be instructed in the procedure for observing leaks and the precautions to be observed while performing that task, particularly with regard to entries into the reactor cavity.
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| Sumary of Licensee's Response Florida Power Corporation admits the violation based on examples 3 and 5 l but denies the violation with respect to exemples 1, 2, and 4 A. Licensee's Comment On Vio!ation I.C.1 j The original function of the lead bricks placed at the reactor cavity )
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| access was two fold. First to function as shielding and second as a ;
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| barrier to pret/ept inadvertent access to the cavity area. Since fEC i admits Violation I, A.1 which states the t,arrier was inadequate to i meet the locked gate criteria, the shielaing cualities of the barrier i is the issue here. FPC contends that v:ork instructions are adequate i to ccritrol the removal and reinstallation of shielding.
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| NUREG-0940 I.A-88 l
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| Appendix The lead bricks were installed prorarly at the end of CR-3's 1985 refueling outage as can be shown by the reduction of radiation levels on radiation surveys taken in the reactor cavity area fol!owing the installation of the lead bricks. Shielding installation instructions are routinely included on Radiation Work Permits in the " Remarks and Special Instructions" section. A review of RWP's 85-550 and 85-551 which covered installation and removal of shielding for the 1985 refuel outage provided the following instructions:
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| (a) HP to direct placement of shielding.
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| (b) HP to be present at the start of each job.
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| These RWPs show that it is standard practice at CR-3 for Health Physics to oversee evolutions involving shielding.
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| FPC concludes that the lead bricks at the reactor cavity access were installed properly after the 1985 refuel outage inasmuch as they provided adequate shielding prior to'their unauthorized removal.
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| Therefore, adequate guidance was provided for the control of shield-ing.
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| NPC Evaluation At the time the shield wall was replaced in 1985, the licensee intended the shield wall to function as the physical barrier to access the cavity area. The wall also served a radiation shielding function. The craft group reinstalled the shield wall without any written specifications and the adequacy of their work, either as a barrier or as shielding, was not formally reviewed upon completion.
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| The instru:tions provided on RWP's 85-550 and 85-551 were also inadequate in that they failed to provide specifications for rein-stallatior, of this shielding (e.g., shims were to be added such that the bricks could not be easily removed) and they did not call for HP to be present at the completion of the shielding installation to ensure thi.t the shield had been properly installed. Thus, the licensee did not have adequate procedures ir place to ensure that the shielding was properly reinstalled.
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| B. Licensee's Comment On Violation I.C.2 A?1 radiation workers at CR-3 are require 1 to comply with Radiation SFaty Procedures (RSPs). General Employee Training also specifies to .'ever remove temporary shielding without Health Physics approval.
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| The precedure RSP-101, " Basic Radiological Safety Information and Instructions for Radiation Workers," revision 8, was in effect at the '
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| time of the incident and states in Section 3.1.3, " Rules within the RCA,." step 3.1.3.7, " notify Health Physics personnel and obtain appropriate approvals prior to breeching any container, containment, system and/or component integrity." Section 2.3.5 defines contain-ment (s)/ container (s) as "any device (e.g., bag, box, drum, tent, NUREG-0940 I.A-89
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| (
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| Appendix glove box, etc.) used to control the release of radioactive material or radiation." The lead bricks served as a containment device and a radiological control device in regard to the high radiation area that existed in the cavity area. The ANO proceeded to remove the shield-ing contrary to radiation protection program instructions and procedural requirements in an effort to discover leakage from the seal plate. If the AN0 had followed RSP-101, he would have contacted Health Physics prior to removing the shielding as required.
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| NEC Evaluation The inspector determined that the licensee's procedures did contain guidance on notifying health physics before removing temporary shielding but did not address comparable controls for permanent i shielaing. The licensees position that shielding is considered a
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| " containment device" and is therefore covered by their procedure goes beyond what one would reasonably expect a radiation worker to consider a containment. It should be noted that at the time of the inspection the licensee did not offer the explanation that they considered their shielding as containment. Assuming procedure RSP-101 was intended to address shielding, its guidance was inadequate to convey its intent.
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| C. Licensee's Comment On Violation I.C.4 In order for the Reactor Building to be accessed, RWPs must be issued. For an RWP to be issued, surveys must be performed in the designated work areas. When high radiation areas are identified during these surveys, they must be posted cod controlled. Therefore, following a plant shutdown, surveys must be performed and high radiation areas posted and controlled prior to allowing general access to the Reactor Building. These actions are covered in HPP-106, ,
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| " Radiation Work Permit Procedure," and HPP-202, " Scheduled Radio-logical Surveys and Controls." Therefore procedures are adequate to {
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| assure the Reactor Building is posted and controlled following a plant shutdown and prior to allowing general access.
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| NRC Evaluation This violation is withdrawn.
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| III. LICENSEE'S REQUEST FOR WITHDRAWAL OF THE CIVIL PENALTY Summary of Licensee's Position I
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| Florida Power Corporation believes that the violations were the result of actions by individuals beyond the authorized scope and are not indicative of programmatic weaknesses in the radiation protectico program. The h0V and the associated civil penalty could be read to imply that the adoption of introvements in response to the events in question is an indication of deficiencies in the program. Such a view is fur.damentally unfair and is contrary to the Enforcement Policy in that it mey tend to discourage soluntary improvements by licensees. The licensee urges caution is using NUREG-0940 I.A-90 l
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| Appendix the term " reactor cavity access" since this event differed significantly from this class of events in the industry's experience since access, per se, was never attempted.
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| The licensee reviewed the applicability of the mitigation factors in the NRC Enforcement Policy. The licensee promptly identified the problem and voluntarily reported the event to the NRC telephonically and with an LER.
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| Immediate and followup corrective actions were extensive.
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| The licensee discussed the factors for escalation of the civil penalty stated in the March 17, 1988 letter transmitting the NOV. The licensee acknowledges that there had been an outstanding work order since 1985 to provide a lockable barrier for the cavity access, but priority on complet-ing it was based on the presumed edequacy of the lead bricks as a barrier.
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| Personnel who observed the ANO had reason to believe that he was authorized to remove the lead bricks, there was no reason for them to report any apparent improper radiological activities and none of the personnel had authority to stop the work.
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| In regard to the events described in the second violation, they were committed by the same individual, who was eventually terminated. The fact that the individual was allowed to remain in the high radiation area was reasonable considering the dose rates in the area.
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| In regard to the four prior notifications of similar events, the licensee stated that workers tere made aware of the hazard and the shield wall barrier was evaluated for adequacy. No action taken by management can prevent individual actions which are cutside the bounds of preestablished programs.
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| NRC Evaluation The NRC Enforcement Policy states that licensee's are generally held responsible for the acts of their employees. The staff believes that the root cause of this problem was a lack of management controls in this area as evidenced by inadeouate training and supervision as detailed in the NOV and not merely employee misconduct. The NRC's characterization of violations and severity levels was based on a review of the facts as determined by the onsite inspections and the licensee's presentation at the Enforcement Conferences. The NRC did not view the corrective actions as admissions of any problem not otherwise fully supported and indicated by the facts at hand. The NRC Enforcement Policy recognizes the importance of licensee initiative in identifying.and correcting problems. The staff does not agree that this event was significantly different from other industry events of this type. A common element of each uncontrolled access to the cavity area involved potential or actual entry by personnel while searching for leaks. The ANO did not actually enter the cavity in this case, but could have had he removed additional shielding bricks. It is fundamental that individuals be knowledgeable of the potential hazards in the reactor cavitv. The admission of Violr* >n I.C.5 is in itself of significance.
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| NUREG-0940 I.A-91
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| l Appendix l Based upon the licensee's response regarding mitigation and escalation of the civil penalty, the NRC has reconsidered the amount of the civil penalty.
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| The NRC recognizes that the licensee reported these events, even though they were not required to be reported, and has taken extensive corrective action. However, the NRC maintains that the licensee's Radiation Safety Program was deficient regarding the events because of: (1) the prior notice of similar reactor cavity events; (2) the fact that a work order to install a strongback on the existing lead brick barricade with an appropriate locking device was outstanding since 1985, and if completed would have prevented the occurrence of the reactor cavity access event; (3) the fact that there were several opportunities to discover the reactor cavity access problem in that several members of the licensee's staff passed through the vicinity but did not recognize or report the problem; i and (4) the fact that the violations involving unauthorized entries are similar to violations occurring in 1986. The NRC has also reevaluated this case with other similar cases including the two cases the licensee noted in its response (EA 84-13 involving Carolina Power and Light Company and EA 86-38 involving Florida Power and Light Company). These cases are not controlling since different circumstances were involved in each case. Even if similar circumstances were involved, it is not clear that the results in the two cases noted by the licensee are justified under the present Enforcement Policy in view of the significance of the violations. However, after reconsidering your reporting of these events and your extensive corrective actions against your past performance and prior notice of similar events, the NRC is mitigating the civil penalty to $50,000.
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| IV. NRC Conclusion The NRC has reviewed Florida Power Corporation's response to the proposed imposition of civil penalty and arguments for withdrawal of the civil penalty.
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| The NRC concludes that the violations, except for Violation I.C.4, occurred 4 as stated in the proposed imposition of civil penalty and that an adequate ]
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| basis for mitigation of the civil penalty has been provided by the licensee.
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| Consequently, a proposed civil penalty in the amount of $50,000 should be imposed.
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| l NUREG-0940 I.A-92
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| UNITED STATES Z'
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| [a m MCo NUCLEAR REGULATORY COMMISSION REGION st j ' 101 M ARIETT A STREET. N.W.
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| j g ATLANT A, GEORGI A 30323
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| % .;f.. / uAy o41988 Docket No. 50-302 License No. DPR-72 EA 88-34 Florida Power Corporation Mr. W. S. Wilgus Vice President Nuclear Operations ATTN: Manager, Nuclear Licensing Post Office Box 219 Crystal River, Florida 32629 entlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-302/87-41)
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| This refers to the Nuciear Regulatory Commission (NRC) inspection conducted at the Crystal River Nuclear Plant on November 30 - December 4,1987. The ,
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| inspection included a review of the circumstances surrounding diesel generator overload due to failure to take appropriate corrective actions to resolve a design error. The report documenting this inspection was sent to you with a {{letter dated|date=January 12, 1988|text=letter dated January 12, 1988}}. As a result of this inspection, a significant failure to comply with NRC regulatory requirements was identified, and accordingly, NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on February 22, 1988.
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| The violation described in the enclosed Notice of Violation and Proposed imposition of Civil Penalty (Notice) involved a failure to take appropriate corrective action to resolve a deficiency regarding the electrical loads placed on one of two plant emergency diesel generators (EDGs), namely, EDG/A. It appears that this failure was caused by errors made in the interpretation of the EDG vendor's load ratings and in the assessment of equipment electrical loads in incorporating a design change in May 1980, which connected the emergency feedwater pump as an automatic load to EDG/A. This failure resulted in the lack of assurances that the onsite emergency power system would perform its intended safety function for certain worst case accident scenarios for which the system was initially designed. This potential EDG overload condition was identified by Florida Power Corporation (FPC) during an NRC Operational Safety Team Inspection (OSTI) in August 1987. A reevaluation performed by FPC determined that the EDG vendor's ratings had been improperly interpreted and that an incorrect and non-conservative power factor (0.8 vice 0.9) was applied to determine the total loads that were to be carried by the EDGs. At that time the design electrical load was calculated to be as high as 3545 KW under worst case accident scenarios. This calculated load exceeded the EDG vendor's rated performance capability of 2750 KW (continuous operation), 3000 KW (for 2000 hours cumulative operation), and 3300 KW for 30 minutes of cumulative operation).
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| NUREG-0940 I.A-93
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| Florida Power Corporation MAY 0 41988 The possibility of a deficiency regarding the overloading of EDG/A was originally identified by FPC in May 1980, even using the incorrect power factor of 0.8.
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| To resolve this matter, tests were conducted which incorrectly concluded that I the EDGs were not overloaded; however the tests were in error since they did !
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| not represent flow conditions which would be encountered under the worst case i accident conditions. Therefore, from May 1980 until October 1987, the plant I operated at times with a potentially overloaded EDG< In addition, the OSTI found during its special inspection that surveillance test requirements in the plant Technical Specifications permitted operation of the EDGs in excess of the electrical load rating provided by the EDG vendor. In this regard, correspondence received from the EDG vendor in September 1987, confirmed that the maximum load ratings for EDG/A had been exceeded in the performance of the Technical Specification-required 18-month surveillance tests. This oversight is attributed to FPCs incorrect application of the EDG vendor's ratings.
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| We recognize that this problem was identified as a result of programmatic review processes initiated as a result of the FPCs Configuration Management Program (CMP). In this particular case, on or about September 14, 1987, FPC received correspondence from the EDG manufacturer which led to the realization that the EDG 30-minute rating had been exceeded during the performance of the EDG 18-month surveillance test. FPC subsequently initiated a reevaluation of the EDG loading which revealed the power factor error. A review of the .
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| chronology associated with this problem, particularly the period from June 1987 when a problem related to under-v'oltage conditions when some loads were transferred to the EDGs and from August 19,87 when the first indication of a potential problem was discovered during performance testing to October 1987 when the Technical Specification / Design Basis conflict was reported, suggests a less than ,
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| aggressive corrective action strategy for resolving a potentially serious problem. I To emphasize the importance of the identification and correction of problems in the area of design and incorporation of design changes into Technical Specifications l and procedures, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987)
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| (Enforcement Policy), the violation described in the enclosed Notice has been categorized as a Severity Level III violation. The escalation and mitigation factors in the Enforcement Policy were considered. While we recognize that you identified the EDG problem, you had prior opportunity to identify the problem in June 1987. While you have committed to enhance the CMP, this effort was started at the urgings of. the NRC to correct weaknesses in your past performance in design control. For these reasons, no adjustment of the base civil penalty amount has been deemed appropriate.
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| The CMP represents a positive management commitment to programmatic configuration enhancement; however, weaknesses still exist in your design control process as is evidenced by the EDG issue, which need to be remedied in your planned efforts to improve the effectiveness of the CMP for prompt corrective action in the resolution of design problems. Your intention (discussed at the Enforcement Confer.ence) to keep the NRC briefed on CMP status, to keep the Senior Resident NUREG-0940 I.A-94
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| Florida Power Corporation MAY 0 41989 Inspector briefed on significant CMP findings, to discuss CMP issues at quarterly management meetings with NRC., and to provide periodic written reports to the NRC staff regarding the CMP strongly supports your corrmitment.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Hotice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. In addition, you should describe what action has been taken, or that you plan to take to determine whether there may be other systems affected by design evaluation errors in need of prompt corrective action. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of tt- C's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, e copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Should you have any questions concerning this letter, please contact us.
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| Sincerely,
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| - J. Nelson Grace Regional Administrator
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| ==Enclosure:==
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| Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl:
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| P. F. McKee, Director, Nuclear Plant Operations E. C. Simpson, Director, Nuclear Site Support NUREG-0940 I.A-95
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| 1 NOTICE OF VIOLATION AND PROPOSED IMPOSITIDT0F CIVIL PENALTY t
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| Florida Power Corporation Docket No. 50-302 l Crystal River 3 License No. DPR-72 1 EA 88-34 During the Nuclear Regulatory Comission (NRC) inspection conducted on November 30 - December 4, 1987, a violation of NRC requirements was identified.
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| In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the NRC proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (ACT), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:
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| 10 CFR Part 50, Appendix B, Criterion XVI, requires measures be established to assure that conditions adverse to quality, such as failures, malfunctions,
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| ' deficiencies, deviations, defective materials and equipment, and non-conformances are promptly identified and corrected.
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| Contrary.to the above, from May 1980 until October 1987, the licensee failed to assure that a condition adverse to quality, namely, a potentially overloaded emergency diesel generator (EDG), was promptlynidentified and -
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| corrected. Specifically: (a-) the load on EDG/A, for certain design basis events, would have been approximately 3545 kw which is ebove the manufacturer's published 30-minute rating of 3300 kw; (b) on everal occasions, the licensee performed the 18-month surveillance testing of both A and B diesel generators _with loads above the 3000 kw rating, and the licensee failed to identify and perform, after each such run, the manufacturer's recommended inspection of certain critical components; and (c) the licensee had not identified that surveillance testing was performed at a maximum of 3100 kw even though the worst case design basis accident load given in the Final Safety Analysis Report is 3180 kw.
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| This is a Severity Level III violation (Supplement 1)
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| Civil Penalty - $50,000.
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| Pursuant to the provisions of 10 CFR 2.201, Florida Power Corporation is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include: (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may j be, proper should not be taken. Consideration may be given to extending the '
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| response time for good cause shown. Under the authority of Section 182 of the Act 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| NUREG-0940 I.A-96 i
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| Notice of Violation MAY 0 41988 Within the s?.me time as provided for the response required above under 10 CFR 2.201, the licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory l Commission. Should the licensee fail to answer within the time specified, an l order imposing the civil penalty will be issued. Should the licensee elect to I file an answer in accordance' with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Vialation" and may: (1.) deny the violation listed in this Notice in whole or in port, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed.
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| In addition to protesting the civil penalty,,such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1987), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2. 201 but may incorporate parts of th.e 10 C,FR 2,201 reply by specific reference (e.g., citing page and, paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
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| Upon failure to pay the penalty doe, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282.
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| The responses to the Director Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a i Notice of Violation) should be addressed to: Directv, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, Region II and a copy to the-NRC Resident Inspector, Crystal River.
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| FOR THE NUCLEAR REGULATORY COMMISSION J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia this(gjdayofMay1988 NUREG-0940 I.A-97
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| UNITED STATES
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| /s')'''" *;, NUCLEAR REGULATORY COMMISSION j i W@WOTON, D. C. 20555
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| . a N ,((,, / ZT3: i980 1
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| Docket No. 50-302 License No. DPR-72 t;A cd-J4 Florida Power Corporation l Mr. W. S. Wilgus Vice President Nuclear Operations ATTN: Manager, Nuclear Licensing Post Office Box 219 .
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| Crystal River, Florida 32629 l Gentlemen:
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| ==SUBJECT:==
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| ORDER IMPOSING A CIVIL HONETARY PENALTY This refers to your {{letter dated|date=June 2, 1988|text=letter dated June 2,1988}}, in response to the Notice of Violation'and Proposed Imposition cf Civil Penalty (Notice) sent to you by our {{letter dated|date=May 4, 1988|text=letter dated May 4, 1988}}, and in response to NRC Inspect wn Report No. 50-302/87-al sent to you by our {{letter dated|date=January 12, 1988|text=letter dated January 12, 1988}}. Our letter and Notice of Violation described a Severity Level III problem regarding an
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| , emergency diesel generator's inability to perform its design basis function l because for certain design basis events it would have been loaded in excess of its maxirnum short-term rated load. Your June 2 letter admits that this is a Severity Level III prcblem as defined in 10 CFR Part 2, Appendix C. However, j you requested mitigation of the civil penalty on the basis that the mitigation factors in 10 CFR Part 2. Appendix C, Section V.B. were not appropriately applied in this particuler case. You also believe the NRC may have misunder-stcod the sequence of events involved in the violation, which may have created the impression that your actions were not tirely or sufficiently aggressive.
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| After careful consideration of your answer to the Notice, the NRC staff has concluded, for the reasons set forth in the Appendix to the enclosed Order, that the original civil penalty be mitigated by 50%. Accordingly, the NRC Staff hereby serves the enclosed Order on Florida Power Corporation imposing a civil renetary penalty in the amount of Twenty-Five Thousard Collars ($25,000).
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| Attachment Il to your June 2 letter was submitted pursuant to 10 CFR 2.201. ;
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| The NRC concurs that the actions you have taken to correct those problems '
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| addressed in the Notice have been adequate. Full compliance was achieved at the completion of 'efuel VI for the corrective actions relative to the EDG special inspection and the Technical Specification amendment an' bases revising the EDG surveillance requirement were issued on February 19, 388.
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| Attachment !! also requested NRC concurrence with regard to FPC's proposal to modify its normal renconformance controls systems to provide a systematic approach for resolution of potential discrepancies identified by the FPC Configuration Marecer.:ent Program. We encourage your efforts to review the design documentation to identify and resolve design problems. While your CERTIFIED MAIL F,ETURN RECliPT REQUESTED NUREG-0940 I.A-98
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| l 1
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| Florida Power Corporation proposed systematic approach for potential discrepancies is currently ur. der review by the Region II staf f, you should be aware that the Commission has recently approved the enclosed modification to the enforcement policy which will give more credit to licensee's self-identific6 tion of prcblems as part of comprehensive corrective action programs.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice, "Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its er. closure will be placed in the NRC's Pcblic Document Room.
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| Sincerely,
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| , ,/'
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| \
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| J . s M. Taylo
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| [ /M Deputy Executive Director for Regional Operations
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| ==Enclosures:==
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| : 1. Order Imposing Civil Monetary Peralty w/ Appendix
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| : 2. Enforcement Policy NUREG-0940 1.A-99
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| UNITED STATES NUCLEAR REGULATORY COMMISSION >
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| In the Matter of ) Docket No. 50-302 Crystal River Unit 3 ) License No. DPR-72 Crystal River, Florida ) EA 88-34 ORDER IMPOSING CIVIL MONETARY PENALTY l
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| I Florida Power Corporation, Crystal River, Florida (licensee) is the holder of Operating License flo. DPR-72 (license) issued by the Nuclear Regulatory Commis-sion (Commission or NRC) on January 28, 1977. The license authorizes the licensee to operate the Crystal River facility in accordance with the condi-tions specified therein.
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| II An NRC inspection of the licensee's activities under the license was conducted on November 30 - December 4, 1987. The results of r.nis inspection indicated that the licensee had not conducted itr. activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalty (Nutice) was served upon the licensee t'y {{letter dated|date=May 4, 1988|text=letter dated May 4,1988}}. The Notice stated the nature of the violation, the provision of the NRC's require- i ments that the licensee had violated, and the amount of the civil penalty proposed for the violation. The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalty by {{letter dated|date=June 2, 1988|text=letter dated June 2,1988}}. 'n its response, the licensee admits the violation and does rot take issue with the Severity Level, but requests mitigation of the civil penalty on the basis that the mitigation factors in 10 CFR Part 2, Appendix C, Section V.B. were not appropriately applied in assessing the penalty.
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| NUREG-0940 I.A-100
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| j III i After consideration of the licensee's response and the statements of fact, explanations, and argument for mitigation contained therein, the Deputy Execu-tive Director for Regional Operations has determined, as set forth in the Appendix to this Order, that the original penalty praposed for the violation designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be mitigated by 50"..
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| IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2282, FL 96-295) and 10 CFR 2.205, IT IS HEREBY ORDERED THAT:
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| The licensee pay a civil penalty in the amount of Twenty-Five Thousand Dollars ($25,000) within 30 days of the date of this Order, by check, craft, or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, U.S. Nuclear l
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| Regulatory Commission, ATTN: Document Control Desk, Washington, D.C.
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| l 20555.
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| 1 V
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| The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing shall be clearly marked as a "Pequest for an Enforcement NUREG-0940 I.A-101
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| }
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| Hearing" and shall be addressed to the Director, Office of Enforcement, U.S.
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| Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C.
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| 20555, with a copy to the Assistant General Counsel for Enforcement, the Regional Administrator, Region II, and to the NRC Resident Inspector, Crystal River, Unit 3.
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| If a. hearing is requested, the Comission will issue an Order designating the time and place of the hearing. If the licer.see fails to request a hearing within 30 days of the date of this Order, the provisions to this Order shall be effective without further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection. l In the event the licensee requests a hearing as provided above, the issue to be considered at such hearing shall be:
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| whether on tne basis of the violations set forth in the Notice of Violation and Proposed Imposition of Civil Penalty referenced in Section II above, which the licensee has admitted, this Order should be sustained.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| __, _ /
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| Wr da es M. Tay , Deputy Executive Director for Operations Dated at Rockville, Maryland thisjl4dayofOctober1988 NUREG-0940 I.A-102
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| APPENDIX EVALUATION AND CONCLUSION On Ma; 4, 1988 a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for violations identified during an NRC inspection. Florida Power Corporation responried to the Notice on June 2,1988. The licensee admits the violation, but requests mitigation of the civil penalty.
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| Restatement of Violation 10 CFR Part 50, Appendix B Criterion XVI, requires measures be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective materials and equipment, and non-conformances are promptly idcntified and corrected.
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| Contrary to the above, from May 1980 until October 1987, the licensee failed to assure that a condition adverse to quality, namely, a potentially overloaded emergency diesel generator (EDG), was promptly identified and corrected.
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| Specifically: (a) the load on EDG/A, for certain design basis events, would have been approximately 3545 kw which is above the manufacturer's published 30-minute rating of 3300 kw; (b) on several occasions, the licensee performed the 18-month surveillance testing of both A and B diesel generators with loads above the 3000 kw rating, and the licensee failed to identify and perform, af ter each such run, the manufacturer's recommended inspection of certain critical components; and (c) the licensee had not identified that surveillance testing was performed'at a maximum of 3100 kw even though the worst case design basis accident load given in the Final Safety Analysis Report is 3180 kw.
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| Sun: mary of Licensee's Response Florida Power Corporation (FPC) admits that the violation occurred and does not take issue with its Severity Level. However, FPC requests mitigation of the civil penalty on the basis that the mitigation factors in 10 CFR Part 2, Appendix C, Section V.B., were not appropriately applied in assessing the penalty. Its arguments in support of mitigation are that its corrective actions were timely and aggressive, that it identified the violation, and that proper credit was not given for its Configuration Management Program.
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| t,RC Evaluation Under the NRC's Enforcement Policy, in effect at the time of the violation was identified, reductions of up to 50% of the base civil penalty may be given I
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| when a licensee identifies the violation and promptly reports it to the NRC.
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| l In weighing this factor, consideration will be given to, among other things, the length of time the viola' tion existed prior to, discovery, the opportunity available to discover the violation, the ease of discovery and the promptness and completeness of any required report. In addition, the staff gives credit for effective comprehensive licensee programs for detection of prcblems that may constitute, or lead to violation of regulatory requirements.
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| With respect to the prcblem as described in the NOV, the staff credits the licensee with identifying the problem. The staff recognizes that the problem existed for approximately seven years as a result of a fundamental error that was incorporated at the time of a design modification (January 1980), but notes that there wds not a reasonable opportunity to discover the problem prior to NUREG-0940 I.A-103
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| | |
| Appendix .
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| the time when the licensee began a detailed review of the EDG loading in June 1987. The staff has reconsidered the complexity of the problem as it l related to the length of time that it took the licensee to fully realize and understand the extent of the problem, and the promptness and completeness with which the licensee submitted the required reports. While the licensee argues that mitigation for identification is appropriate based on their comprehensive '
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| Configuration Management Program (CMP), the FF.C notes that in the case of this violatten, the problem was not discovered from the CMP, but rather while determining the setting for an emergency diesel generator directional power relay which was being added to correct problems disclosed during an event l described in LER 84-003-00. Nevertheless, the staff has concluded to mitigate the original civil penalty by 50% for this factor.
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| Nitigation of 50% may also be given for corrective actions which are unusually prompt and extensive. On the other hand, the civil penalty may be increased by as much as 50% if initiation of corrective action is not prompt or if the corrective action is only minimally acceptable. In weighing this factor, i
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| consideration will be given to, among other things, the timeliness of the corrective action, degree of licensee initiative, and the comprehensiveness l
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| of the corrective action--such as whether the action is focused narrowly to the specific violation or broadly to the general area of concern.
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| Although the special testing which was conducted to empirically confirm the loading calculations was an important part of the licensee's corrective action, the performance of these tests was only done at the insistence of the NRC to support the licensee's request for an exemption from the requirements of GDC-17.
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| Furthermore, while the licensee is complying with the terms of the exemption, the licensee has not yet implemented the long-term solution to bring the facility into compliance with GDC-17. As noted in the staff's NOV, the CMP represents a positive commitment to programmatic ccr. figuration enhancement; l however, weaknesses still exist and need to be remedied in your planned efforts to improve the effectiveness of the CMP for prompt corrective action in the resolution of design problems. Therefore, tased on a review of the above considerations for the factor of corrective actions, the base amount was not mitigated or escalated, i NRC Conclusion For reasons set forth herein, the NRC Staff has concluded that the licensee has provided an adequate basis for mitigation of the civil peralty by 50%.
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| Consequently, the civil penalty in the amount of $25,000 shculd be imposed.
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| I NUREG-0940 I.A-104 1
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| l o UNITED STATES 3%
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| 3 ,1 )ZL ; NUCLEAR REGULATORY COMMISSION WASmNGTON, D. C. 20555 gll[f['l y;
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| +
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| idAN 2 C 1983 Decket No. 50-160' License No. R-97 EA 88-32 Georgia Institute of Technology 900 Atlantic Drive, N.W.
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| Atlanta, Georgia 30332 Gentlemen:
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| ==Subject:==
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| ORDER MODIFYING LICENSE, EFFFECTIVE IMMEDIATELY Enclosed herewith is an Order modifying your license (effective immediately).
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| The. Order requires you to immediately suspend certain activities under the subject NRC license until the requirements of the Order are satisfied.
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| You are required to respond to the enclosed Order, and in preparing your response, you should follow the instructions specified in the Order.
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| In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enclosed Order will be placed in the NRC's Public Document Room.
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| A response to this letter or the accompanying Order is not subject to the clearance procedures of the Office of Management and Budget, as required by the Paperwork Reduction Act of 1980, PL 96-511.
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| Sincerely,
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| /
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| Y a s M. Tay1 , Deputy Executive trector for Regional Operations
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| ==Enclosure:==
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| Order Modifying License (Effective Immediately) cc: Dr. T. E. Stelson, Vice President Research I NUREG-0940 I.A-105
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| UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION In the Matter of ) l I )
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| l GEORGIA INSTITUTE OF TECHNOLOGY )' -Docket No. 50-160 900 Atlantic Drive, N.W. ) License No. R-97 Atlanta, GA 30332 ) EA 88-32 ORDER MODIFYING LICENSE, EFFECTIVE IMMEDIATELY l
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| l l I 1
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| The Georgia Irstitute of Technology (Georgia Tech) is the holder of Operating License No. R-97 issued by the Nuclear Regulatory Commission (NRC or Commission) on December 29, 1964, and subsequently amended. The license, as amended, authorizes Georgia Tech to operate its modified research reactor located on its campus in Atlanta, Georgia, at power le.vels up to 5 megawatts (thermal) for research and development activities in accordance with the conditions specified therein.
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| II ;
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| l The Georgia Tech Research Reactor (GTRP) is utilized to ccr. duct irradiation experiments including the irradiation of topaz and other gem-quality n.inerals.
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| During the week of August 17, 1987, the improper opening of an irradiated topaz container resulted in contamination of the reactor building. An inspection of the licensee's operational and health physics activities, including actions pertaining to this contamination event, was conducted on December 16, 1987, and January 4-5, 1988 during which it was learned of the August contamination event.
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| The inspection revealed that the experiment conditions and manipulation of the NUREG-0940 I.A-106
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| l experiment materials resulted in unexpected elevated radiation levels from the experiment container and also the unmonitored release of Cadmium-115 (Cd-115) r in the reactor building. The exposure dose rate at one foot from the experiment material was approximately 3 rem per hour (R/hr) on August 18, 1987 and qualitative measurements of radioactive contamination indicated levels on masolin wipes of approximately 20 mR/hr on August 19, 1987. The NRC staff also determined during the inspection that the IJcensee had not provided adequate exposure assessments for personnel involved in the August 1987 incident, nor had the licensee conducted adequate verification surveys to demonstrate that the contamination had not been spread by personnel to areas outside of the 1
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| reactor building. Inspection findings indicated that the licensee had not conducted its activities in full ccmpliance with NRC requirements. A written Notice of Violation has not been issued at this time; additional inspection activities are being conducted. Nonetheless, the following safety concerns, which could result in unnecessary personnel radiatien exposures and the potential spread of contamination away from the reactor building as a result of experiment manipulations, have already been identified:
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| A. On May 4, 1987, an enforcement conference was held with the licensee in which the licensee outlined steps to be implemented to improve the management controls over operations and health physics at the GTRR to assure safe operation. These actions included steps to assure appropriate interaction between health physics and cperations components of the organization. A recent inspection has shown these actions have not been fully successful and indicate that management control problems continue.
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| NUREG-0940 1.A-107
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| B. The licensee's health physics and operating procedures were inadequate i'n that they failed to address the precautions and equipment to )
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| I prevent unnecessary exposure and contamination during handling ard l manipulation of materials irradiated during experiments at the GTRR. l C. The licensee failed to follow operating procedures as required by Technical Specifications as follows:
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| : 1. The August 1987 experiment involved irradiation of topaz gemstones for a total of 41.8 megawatt hours compared to 30 megawatt-hours authorized on the Request for Minor Experiment Approval regarding tnpaz irradiations dated April 3, 1987.
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| : 2. Procedure 3102, Quality Assurance for Experiments, October 28, 1982, requires.that the approval form for Category 4
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| {
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| l experiments, such as the topaz irradiation, address quantitative controls of reactivity, activation, shielding, cooling and materials. Request for Minor Experiment Approval, dated i April 3, 1987, regarding the topaz irradiation lists the estimated isotopic activities to be " nil." However, following l
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| an initial irradiation in April 1987, activation of the i
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| experiment materials, including the container, resulted in radiation levels of approximately 3 R/hr at a distance of one foot from the container. These elevated exposure levels were not evaluated or included in experiment plans for the August 1987 topaz irradiation.
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| NUREG-0940 1.A-108 L_______________
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| D. Assessments of internal and external personnel exposures for personnel involved in the August 1987 incident and decontamination event were not adequate in that they did not determine and document intakes of radioactive material, extremity dose or skin dose.
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| E. Surveys conducted were inadequate as follows:
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| : 1. Continuous air samples collected from within the reactor building during the August 1987 incident were not adequate to determine intakes in that they were not representative of concentrations.
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| of radioactive material in the work area.
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| : 2. Subsequent to the August 1987 incident, surveys were inadequate to define the extent and amount of radioactive contamination in the reactor building, en personnel', and in personal property offsite which could have been potentially contaminated.
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| l 1
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| i F. At the time of the inspection the licensee had failed to complete a thorough review of the August 1987 contamination event regarding its cause or causes, nor had sny corrective measures been implemented as of January 5, 1988 to prevent recurrence during future experiments.
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| G. Licensee management has indicated that there are other events similar to the August 1987 event that also have not yet been fully evaluated by the licensee. These safety concerns were the subject of discussions NUREG-0940 I.A-109
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| between Region II and the licensee on January 7, 1988. Upon the conclusion of these discussions, Region II verbally requested, and the licensee agreed that irradiation experiments would be suspended until further notice.
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| III After consideration of the apparent violations and safety hazards posed by the licensee's conduct of experiment activities, as exhibited during the August 1987 event, and the subsequent lack of aggressive review and corrective actions by the licensee, I have determined that certain actions by the licensee are requjred, and an Order modifying the Georgia Institute of Technology license is necessary, to protect the health and safety of the public and licensee's employees.
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| i Therefore, pursuant to 10 CFR 2.204, I find that the public health, safety, and interest require that that this Order be effective immediately.
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| IV Accordingly, pursuant to Sections 104, 161b, 161c, 1611, 161o, 182 and 186 of the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2011 et seq., and 10 CFR 2.204, IT IS HEREBY ORDERED, EFFEC 11VE IMMEDIATELY, THAT:
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| A. The licensee shall cease utilization of the reactor facility for irradiation experiments until the following conditions are met and the NRC approves, in writing, the resumption of irradiation experiments.
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| I NUREG-0940 1.A-110
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| : 1. Pianagement controls over facility operation, including irradiation experiments, are assessed to identify weaknesses.
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| : 2. A formal review is conducted, including record reviews and in-depth personnel interviews, to determine (a) if other occurrences similar to the August 1987 incident have occurred, and (b) the principal root causes of the August 1987 incident and any other similar incidents.
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| : 3. An assessment of internal exposure, external whole body, extremity, and skin doses to personnel involved in the August 1987 incident (any cther identified incidents) and/or decontamination activities is conducted.
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| : 4. The GTRR health physics and operatirig procedures are reviewed to identify inadequacies which contributed to the August 1987 contamination event (and any other identified events).
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| : 5. Corrective actions are identified and a schedule established for implementing the corrective actions, including necessary changes in management controls, operations, and procedures.
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| : 6. A training program addressing all changes to management controit, operations, and procedures is developed and implemented.
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| NUREG-0940 1.A-111
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| i 4
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| : 7. The licensee's reviews and assessments of the above matters are documented and a summary of these reviews and assessments,
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| -including corrective actions and appropriate schedules, are submitted in writing to the NRC for review and approval.
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| Results of the licensee's survey of the house of the individual
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| ~
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| C.
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| involved in the August 1987 contamination event shall be provided in writing to the NRC within 10 days of the issuance of this order.
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| The Regional Administrator, Region II, may in writing relax or rescind any of the above conditions upon written request and demonstration of good cause by the licensee. l V
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| The licensee or any person other than the licensee adversely affected by this Order may request a hearing on this Order within twenty days of its issuance.
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| Any recuest for hearing shall be sent to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555. Copies shall also be sent to the Assistant General Counsel for Enforcement at the same address and the Regional Administrator, NRC Region II, 101 Marietta St., NW, Suite 2900, Atlanta, GA 30323. If a person other than the licensee requests a hearing, that person shall set forth with particularity the manner in which the petitioner's interest is adversely affected by this Order and shall address the criteria set forth in 10 CFR 2.714(d). A REQUEST FOR HEARING SHALL NOT STAY l THE IMMEDIATE EFFECTIVENESS OF THIS ORDER.
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| NUREG-0940 I.A-112
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| If a hearing is requested by the licensee or any person who has an interest adversely affected by the Order, the Comission will issue an Order designating the time and p' lace of any such hearing. If the Licensee fails to request a hearing within 20 days of the date of this Order, the provisions of this Order shall be final without further proceedings. If a hearing is held, the issue to be considered at such hearing shall be whether this Order should be sustained.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| /
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| \ g J s M. Tay1 , Deputy Executive Director for Regional Operations Dated at Bethesda, Maryland thisjodayofJanuary1988 l
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| NUREG-0940 1.A-113
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| [o now*o, UNITED STATES
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| ! 7.
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| NUCLEAR REGULATORY COMMISSION
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| [ ,I WASHINGTON, D. C. 20666
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| */
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| m n me Docket No. 50-160 License No. R-97 EA 88-32 l
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| Dr. J. P. Crecine, President !
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| The Georgia Institute of Technology 900 Atlantic Drive, N.W.
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| Atlanta, Georgia 30332 Gentlemen:
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| 1
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| ==SUBJECT:==
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| CONFIRMATORY ORDER MODIFYING LICENSE, EFFECTIVE IMMEDIATELY Enclosed herewith is an Order modifying your license, effective immediately, that confirms the commitment made verbally during an Enforcement Conference on February 23, 1988. 1 The Order confirms your commitment to continue the s spension of all reactor operations at the Neely Nuclear Research Center until you have resolved all ,
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| safety questions to your satisfaction and the NRC has approved, in writing, the l resumption of operations. The conditions of the January 20, 1988 Order remain '
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| in effect and are not modified by this Confirmatory Order.
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| In accordance with 10 CFR 2.790 of the NRC's " Rule of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enclosed Order will be placed in the NRC's Public Document Room.
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| Responses to this letter or the accompanying Order are not subject to the clearance procedures of the Office of Management and Budget, as required by the Paperwork Reduction Act of 1980, PL 96-511.
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| l Sincerely, l
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| i \
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| fJa'sM.Tay . Deputy Executive Director or Regional Operations
| |
| | |
| ==Enclosure:==
| |
| | |
| Confirmatory Order Modifying License.
| |
| Effective Inunediately cc: Dr. T. E. Stelson, Vice President for Research CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 1.A-114 t
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| UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION In the Matter of )
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| ) Docket No. 50-160 GEORGIA INSTITUTE OF TECHNOLOGY ) License No. R-97 Atlanta, Georgia ) EA 88-32 CONFIRMATORY ORDER MODIFYING LICENSE, EFFECTIVE IMMEDIATELY I
| |
| The Georgia Institute of Technology (Georgia Tech) is the holder of Operating License No. R-97 issued by the Nuclear Regulatory Commission (NRC or Commission) on December 29, 1964, and subsequently amended. The licen:;e, as amended, authorizes Georgia Tech to operate its modified research reactor located on its campus in Atlanta, Georgia, at power levels up to 5 megawatts (thermal) for research and development activities in accordance with the conditions specified therein.
| |
| II As a result of safety concerns identified during NRC inspections conducted on December 16, 1987, and January 4-5, 1988, and raised as a result of an August 1987 contamination event, an ORDER MODIFYING LICENSE. EFFECTIVE IMMEDIATELY was ist,ued to Georgia Tech by the NRC on January 20, 1988. That ORDER required that (a) the licensee cease utilization of the reactor facility for irradiation experiments until certain listed conditions were met and the NRC approves, in writing, the resumption of irradiation experiments, and (b) the results of the licensee's survey of the house of the individual involved in the August 1987 contamination event be provided in writing to the NRC within 10 days of the Order.
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| Subsequent to issuing the Order of January 20, 1988, the NRC initiated an investigation of alleged improper safety-related activities associated with NUREG-0940 I.A-115
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| l l
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| 2-the operation of the Georgia Tech Research Reactor (GTRR). That investigation is contint.ing.
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| On February 15, 1988, the President of the Georgia Institute of Technology directed the imediate suspension of all reactor operations at the Neely Nuclear Research Center which includes operation of the GTRR. He also announced that an independent evaluation of Georgia Tech's program and procedures would be performed by an outside expert.
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| l During an Enforcement Conference on February 23, 1988, the NRC discussed a number of preliminary safety concerns that have come out of its investigation te dete. These concern:i, togethsr with pnvlously H'. awn events over the past year, give the NRC substantial concerns about the operation of the reactor.
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| The President stated that, as evidenced by his suspension of all reactor operations, he was also concerned. He then stated that Georgia Tech would not resume any reactor operations until the independent evaluation was completed, appropriate actions wet-e taken on recommendations from that evaluation and from an internal investigation which he had initiated, the President was assured that all safety questions were adequately resolved, and the NRC concurred in the resumption of operations.
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| III Due to NRC's concerns regarding the adequacy of management of the operation of the GTRR and the ongoing investigation of safety-related matters, I have determined that these consnitments are required in the interest of the public health and safety an6, therefore, should be confirmed by an imediately effective order.
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| NUREG-0940 I.A-116
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| IV Accordingly, pursuant to Sections 104, 161c, 1611, 161o, 182, and 186 of the l
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| Atomic Energy Act of 1954, as amended, and the Comission regulations in 10 CFR 2.204 and 10 CFR Part 50, IT IS HEREBY ORDERED, EFFECTIVELY IMMEDIATELY, THAT:
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| l License No. R-97 is modified to prohibit resumption of operation of the GTRR until:
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| l A. The licensee has identified, based on its reviews as well as the-review of its independent evaluator, the root causes of the problems that may impact on the safe operations of the reactor and provided a listing of these issues to the Regional Administrator, Region II;
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| : 8. The President of the licensee has provided in writing to the Regional Administrator, Region II, a description of the actions taken to resolve the issues that may impact on the safe operation of the reactor and the reasons why he has determined that the suspension of reactor operations should be lifted; and C. The Regional Administrator, Region II, has approved in writing the resumption of reactor operations.
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| The Regional Administrator, Region II, may in writing relax or rescind any of the above conditions upon written request and demonstration cf good cause by the 11censee.
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| 1 NUREG-0940 1.A-117
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| V The licensee or any other person adversely affected by this Order may request a hearing or,this Order within twenty days of its issuance. Any rec,uest for hearing shall be sent to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, Washington, D.C. 20555. Copies shall also be sent to 1 the Assistant General Counsel for Enforcement at the same address and to the Regional Administrator, NRC Region II, 101 Marietta St., NW, Suite 2900, Atlanta, GA 30323. If a person other than the licensee requests a hearing, that person shall set forth with particularity the manner in which the peti-tiener's interest is adversely affected by tiils Order and shall address the criteria set forth in 10 CFR 2.714(d). A REQUEST FOR HEARING SHALL NOT STAY THE IMMEDIATE EFFECTIVENESS OF THIS ORDER.
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| If a hearing is requested by the licensee or any person who has an interest adversely affected by the Order, the Commission will issue an Order designating the time and place of any such hearing. If the Licensee fails to request a hearing within 20 days of the date of this Order, the provisions of this Order shall be final without further proceedings. If a hearing is held, the issue to be considered at such hearing shall be whether this Order should be sustained.
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| FOR THE NUCLEAR REGULATORY COMMISSION ;
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| Ja s M. Taylor, puty Executive Director j (or Regional Operations Dated at Bethesda, Maryland this 17th day of March 1988 NUREG-0940 I.A-118 j i
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| ..a *e aw f t UNITED STATES i
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| 3
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| .< j e
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| NUCLEAR REGULATORY COMMISSION REGION 11 3 8 101 AdARIETTA ST.. N W.
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| 'o *# ATLANTA, GEORGIA 30323 NOV 151988 Docket No. 50-160 License No. R-97 EA 88-32 Georgia Institute of Technology ATTN: Dr. J. P. Crecine, President 225 North Avenue Atlanta, Georgia 30332 Gentlemen:
| |
| SU8 JECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N0. 50-160/87-08 AND NRC 01 INVESTIGATION REPORT NO. 2-88-003)
| |
| This refers to the Nuclear Regulatory Commission (NRC) inspection conducted at the Georgia Institute of Technology (Georgia Tech), Neely Nuclear Research Center (NNRC) on December 16, 1987, January 4-5, 1988, and January 14-22, 1988 and an investigation conducted by the NRC Office of Investigations. The inspection included a review of NNRC procedures and management controls associated with control of irradiation experinients. The report documenting the inspection was sent to you by {{letter dated|date=February 10, 1988|text=letter dated February 10, 1988}}. As a result of this inspection, significant deficiencies in management control of operations at your facility were identified, including inadequate evaluation of experiments before they were authorized and inadequate controls over post irradiation activities. Consequently, tne NRC issued an Order on January 20, 1988, suspending authorization to conduct irradiation experiments with the reactor and requiring certain program upgrades.
| |
| As a result of our identification of significant management control problems during the inspection and failure to comply with regulatory requirements, NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on February 23, 1988. The letter surinarizing this Conference was sent to you on March 14, 1988. On February 15, 1988 you directed the immediate suspension of all reactor operations to assure that all safety questions were resolved. An Order, confirming your commitment not to restart the reactor with-out NRC approval, was issued on March 17, 1988.
| |
| On September 1, 1988, we provided you a copy of the synopsis of the NRC Office of Investigations (01) report concerning alleged discrimination by Georgia Tech management against employees for engaging in protected activities. An enforce-ment conference on this issue was held on September 19, 1988. The letter summarizing this conference was sent to you on October 11, 1988. Your letter of September 19, 1988 requested a copy of the Investigation Report. This request is being reviewed tiy the NRC staff.
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| The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involve (1) failure to follow approved I procedures and failure to have adequate procedures for conduct and control of experiments and for radiological safety activities and (2) failure to conduct NUREG-0940 I.A-119
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| Georgia Institute of Technology 2 NOV 151988 f adequate surveys to evaluate the extent of radiological hazards which may have been present. These violations resulted from failure to implement adequate management controls and programs necessary to assure licensed activitiee are conducted in a safe manner in accordance with NRC and facility requirements.
| |
| The OI report concluded that a severe state of disharmony and conflict er,isted between the operations and health physics staffs and this condition appeared to have escalated and intensified since July 1,1987 when all staff personnel were placed under the same management structure. Poor management at all levels substantially contributed to this atmosphere. It was the failure of management evident during the January 1988 inspection that caused the NRC to issue an Order on January 20, 1988 and the Confirmatory Order of March 14, 1988.
| |
| The NRC OI investigation identified numerous examples of perceived harassment by management as well as staff factions. The involuntary dismissal of two health physics employees in February 1988 was viewed by the health physics staff as retaliation for discussing safety concerns with the NRC. While there are some indications to support this perception, such that adverse actions may have been taken because the employees were engaged in protected activities, there is, in our view, insufficient evidence to conclude that a violation of 10 CFR 50.7 occurred. Although you are not being cited, we believe the environ-ment was conducive to such potential violations and had the potential to affect adversely the safety of reactor operations. This is clearly a significant regulatory concern. We recognize that you have made substantial changes to the organization and management to remedy this matter. Nonetheless, you should continue to assure and reinforce to all your managers and supervisors involved with NRC-licensed activities the clear understanding of the right of employees to raise safety concerns with Georgia Tech management or the NRC without fear of reprisals, and the necessity for maintaining a work environment conducive to safe operations. Your actions in this area will be reviewed by NRC in future inspections.
| |
| Your attention is also directed to our concerns with activities at the Neely Nuclear Research Center that led to the May 20, 1988 Enforcement Conference with a Senior Reactor Operator. As you know, we determined that specific enforcement action against that individual was not warranted. In fact, we concluded that the principal cause of his marginal performance was attributable to ineffective management, including a lack of adequate procedures, standards and expectations.
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| Georgia Teh has a particular responsibility in that you develop scientists and engineers who will have important roles in the nuclear industry of the future.
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| As we discussed during the September 19, 1988 Enforcement Conference, you share cur belief that these students' attitude toward safety must be influenced by example as well as by education.
| |
| In February, March, May, and September 1988, you and members of your staff met with the NRC staff to discuss these management issues and your own assessment of the problems at NNRC. In addition, you have provided responses to the NRC Orders detailing your actions to correct the problems identified by the NRC and yourself.
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| He note that you have instituted extensive personnel, procedural, training, and organizational changes and have also increased the direct management attention to the NNRC program. We cor. ducted inspections in August and November 1988 to NUREG-0940 1.4-120
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| i l
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| Georg6 Institute of Technology NOV 151988 l
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| assess the eff ectiveness of your corrective actions and believe your actions address our concerns. Nonetheless, to emphasize the importance to your managers of the necessity of assuring lasting and effective compliance with NRC require-ments, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to ;
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| l issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Five Thousand Dollars ($5,000) for the violations described in the enclosed Notice. h accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988)
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| (Enforcement Policy), the violations described in the enclosed Notice have been categorized as a Severity Level III problem because they are representative of failures in management that are of significant regulatory concern and could have resulted in very serious safety consequences. The base value of a civil penalty for a Severity Level III violation or problem is $2,500. The escalation and mitigation factors in the Enforcement Policy were considered, and the base civil penalty was escalated 100 percent because of your prior poor performance in adherence to procedures and radiological controls, and because of your failure to take prompt corrective action to deal with management control problems. Similar concer'ns regarding your management controls and involvement in implementation of your programs for radiation protection, reactor operations and control of experiments were previously identified in two Notices of Violations issued April 14, 1987 and May 26, 1987. In addition, an enforcement conference was held on May 4,1987 to discuss the need for increased management control of the health physics and reactor operations activities. In this meeting the NRC stressed the importance of compliance with Technical Specifications and internal procedures and an effective corrective actions program.
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| We note that the issues associated with these violations have been the subject of meetings, inspections, and correspondence. Thus, a significant amount of information has been provided to the NRC concerning corrective steps which have been taken. Therefore, if you do not plan to protest the violations, a I response to the violations is rat necessary. However, should you desire to respond to the violations you may refer to these meetings, inspection reports, and correspondence and should follow the instructions specified in the enclosed Notice when preparing your response. Please refer to the instructions in the enclosed Notice regarding payment or protest of the civil penalty. Based on the significance of the management control problem and the amount of attention this matter has received from NRC and Georgia Tech managers, including meetings, l enforcement conferences, and Orders, we expect that the corrective actions taken f and planned will be effective in assuring that the NNRC is operated in a safe manner in accordance with NRC and facility requirements. The NRC will monitor the effectiveness of the corrective actions during future inspections and, should our expectations not be met, will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| NUREG-0940 1.A-121
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| Georgia Institute of Technology NOV 151988 !
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| l The responses to this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely,
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| / -
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| Malcolm L. Ernst Acting Regional Administrator
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| ==Enclosure:==
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| Notice of Violation and Proposed i Imposition of Civil Penalty.
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| cc w/ enc 1:
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| l Dr. A. P. Sheppard, Acting Vice President for Research Dr. R. A. Karam, Director Neely Nuclear Research Dr. J. S. Tulenko, University of Florida Dr. T. S. E11eman, North l Carolina State University Dr. R. U. Mulder, University of Virginia State of Georgia NUREG-0940 I.A-122
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| l NOTICE OF VIOLATION l AND j PROPOSED IMPOSITIDT0F CIVIL PENALTY 1 Georgia Institute of Technology Docket No. 50-160 Research Reactor License No. R 97 EA 88-32 During the Nuclear Regulatory Commission (NRC) inspection conducted on December 16, 1987, January 4-5, and January 14-22, 1988, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (ACT),
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| 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| A. Technical Specifications 6.4.b(2) and 6.4.b(6) require written procedures to be provided and utilized for installation and removal of experiments .
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| and experimental facilities; and radiation and radioactive contamination control.
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| Technical Specification 6.3.e requires a Quality Assurance Program covering the design, fabrication, and testing of experiments, including pro d ures for verification of kinds and amounts of their material contents to assure compliance with Technical Specification in Section 3.4.
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| Technical Specification 3.4.f requires materials of construction and fabrication and assembly techniques in experiments be specified.
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| Licensee Procedure, Request for Minor Experiment Approval, Reference No. R7420, dated April 4, 1987, limits topaz irradiation times to 30 megawatt hours (MW-hrs) and lists expected radiation levels from cadmium and aluminum material used in the experiment to be " nil."
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| Licensee Procedure, 3102, Quality Assurance for Experiments, dated October 28, 1982, specifies that for the Experimenters Checklist and Schedule Form, quantitative controls of the experiment, that is reactivity, radiation, temperature, and material constraints, are addressed and reviewed by licensee management prior to conducting experiments.
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| Contrary to the above, for a topaz irradiation experiment which resulted in a subsequent contamination event during the week of August 17, 1987, the licensee failed to follow approved procedures and i failed to have adequate procedure 3 in that:
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| l 1. Licensee Procedure 3102 was inadequate in that it specified i only a review by management prior to conducting experiments and failed to specify a post-experiment review to determine if radiation levels and other experiment parameters are consistent with expected values.
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| NUREG-0940 I.A-123
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| 1 1
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| Notice of Violation 2. The irradiation time for the topaz experiment exceeded the 30 MW-hrs limit allowed by the Request for Minor Experiment Approval Form. The total irradiation time was 41.8 MW-hrs.
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| : 3. Licensee operation and health physics procedures to control and/or prevent the spread of radioactive contamination and to control personnel exposure while handling and manipulating irradiated experiment material were inadequate in that measures, such as fume hoods or containment structures, were not specified 1 and surveys were not required at exit points to all contaminated or contamination cont,'ol areas.
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| : 4. Licensee procedures were inadequate in that the materials and methods for construction and fabrication of the cadmium layer used in the topaz irradiation experiment were not specified.
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| : 5. Licensee procedures for analyzing for airborne radioactive con-taminants were inadequate in that samples in which gross analysis .
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| concentrations exceeded 10 CFR Part 20, Appendix B, limits were not I required to be maintained a sufficient time to allow for decay of l natural radon daughter products and then be recounted to evaluate the actual radiation hazards present as a result of reactor l operations.
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| : 6. Licensee procedures for urine bioassay analyses and internal exposure evaluation were inadequate in that standard methodology to quantify results of radionuclides analyses in urine was specified only for tritium and appropriate biological retention models to relate calculated bcdy burdens to a person's estimated intake of airborne radioactive contaminants were not specified.
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| : 7. The licensee did not have procedures detailing the calibration and operation of the sodium iodide (Nal) detection system used to conduct quantitative "in vivo" chest surveys for radionuclides potentially deposited within the body.
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| B. 10 CFR 20.201(b) requires the licensee to make or cause to be made such surveys as (1) may be necessary for the licensee to comply with regulations in Part 20, and (2) are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present.
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| 10 CFR 20.201(a) defines " survey" to mean an evaluation of the radiation hazards incident to the production, use, release, disposal, or presence of radioactive materials or other sources of radiation under a specific set of conditions.
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| Contrary to the above, for a contamination event ghich occurred during the week of August 17, 1987, the licensee failed tu conduct surveys or conducted inadequate surveys to evaluate the extent of radiation hazards which may have been present in that:
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| i NUREG-0940 I.A-124
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| Notice of Violation 3
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| : 1. The expected activation of the irradiated material and subsequent dose rates were not adequately evaluated on the Request for Minor Experiment Approval Form, dated April 4,1987, in that " nil" was stated when dose rates of approximately 3 rem per hour (R/hr) were observed.
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| : 2. Radiation contamination surveys of all surfaces potentially exposed to airborne contamination (for example, walls and other vertical surfaces) in the reactor building were not conducted.
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| : 3. Surveys verifying the absence of radioactive contamination at the residence of the operator involved in the August 1987 event and who may have transferred contamination from the reactor building on his personal clothing were not conducted in a timely manner.
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| A contamination survey was conducted and results reviewed on January 11, 1988.
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| C. 10 CFR 20.103(a) requires that no licensee shall possess, use, or .
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| transfer licensed material in such a manner as to permit any individual in a restricted area to inhale a quantity of radioactive material in eny period of one calendar quarter greater than the quantity which would result from inhalation for 40 hours per week for.13 weeks at uniform concentrations of radioactive material in air specified in Appendix B, Table 1, Column 1.
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| 10 CFR 20.103(a)(3) requires that for purposes of determining compliance with the requirements of this sectior., the licensee shall use suitable measurements of concentrations of radioactive materials in air for detecting and evaluating airborne radioactivity in restricted areas and in addition, as appropriate, shall use measurements of radioactivity in the body, measurements of radioactivity excreted from the body, or any combination of such measurements as may be necessary for timely detec-tion and assessment of individual intakes of radioactivity by exposed individuals.
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| Contrary to the above, for a contamination event which occurred during the week of August 17, 1987, the licensee failed to conduct suitable measurements of concentrations of radioactive materials in air or measurements of radioactivity in or excreted from the body in that:
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| 1
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| : 1. Air samples collected and analyzed for radioactive concentrations in air were not representative of concentrations of radioactive material to which personnel were exposed.
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| : 2. The urine bioassay analysis conducted to evaluate the operator's exposure to airborne radioactive contamination during the August 1987 event was inadequate in that the quantitative analysis was not performed for the major radionuclides contaminant, cadmium-115, originally identifled by the licensee.
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| : 3. The "in-vivo" chest survey analysis conducted to evaluate the operator's exposure to airborne radioactive contamination during the August 1987 event was inadequate in that background count levels and and the minimum limits of detection for the analysis necessary to quantify the results obtained were not determined.
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| NUREG-0940 I.A-125
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| i l
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| I Notice of Violation 4_ {
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| (
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| D, 10 CFR 20.401(b) requires each licensee to maintain records in the same units used in this part, showing the results of surveys required by 20.201(b).
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| 10 CFR 20.401(c) requires that records of results of surveys and monitoring maintained pursuant to Paragraph (b) of this section shall be preserved for tro years after completion of the survey.
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| Contrary to the above, for a contamination event which occurred during the week of August 17, 1987, the licensee failed to maintain records for facility and personnel survey records in that:
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| : 1. Records of all radiation contamination surveys conducted for the facility to <ialjneate the extent and levels of contamination throughout the containment building prior to and during decontamination activities on August 19-20, 1987, were not maintained.
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| : 2. Records of "in vivo" chest surveys conducted during August 20-21, 1987, for the operator contaminated with radioactive material were not maintained. !
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| l Collectively, these violations have been evaluated as a Severity Level III problem (Supplements I and IV).
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| 1 Civil Penalty - $5,000 (assessed equally among the violations). j 4
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| While a response to the Notice of Violation is not required unless you plan to protest the violations, puesuant to the provisions of 10 CFR 2.201, Georgia Institute of Technology (~ icensee) may submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. If a reply is submitted, it should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved.
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| Under the authority of Section 182 of the Act, 42 U.S.C. 2232, any such response shall be submitted under oath or affirmation.
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| Within 30 days of date of this Notice, the licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission.
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| Should the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this NUREG-0940 I.A-126
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| Notice of Violation Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, thebe
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| , should five h rs addressed addressed. Any in written answer in accordance with 10 CFR 2.205 should be set forth separately l from the statement or explanation in reply pursuant to 10 CFR 2.201 but may l incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing l page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
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| Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a
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| *:otice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory i Commission, Region II.
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| I FCR THE NUCLEAR REGULATORY COMMISSION i
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| 7] g
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| //
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| Malc61m L. Ernst Nx g_ _
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| Acting Regional Administrator Dated at Atlanta, Georgia this/5 @ day of November 1988 NUREG-0940 I.A-127
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| see, UNtTED STATES ,
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| /
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| g NUCLEAR REGULATORY COMMtSSION REGION lil
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| [ g-tsenoostvgLTnoao
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| * -E
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| * OLEN ELLYN, ILLlNOtt 60137 o,
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| I
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| %,,,,../ JUN t 1988 Docket No. 50-461 License No. NPF-62 EA 88-90 Illinois Power Company ATTN: Mr. W. C. Gerstner Executive Vice President 500 South 27th Street Decatur, IL 62525 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS NO. 50-461/87026(DRS) AND NO. 50-461/88010(DRS))
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| This refers to the special safety inspections conducted during the periods of August'17 through October 13, 1987 and February 25 through harch 31, 1988, of activities at the Clinton Nuclear Station authorized by NRC License No NPF-62.
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| These inspections reviewed implementation of the requirements for assuring.
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| environmental qualification (EQ) of electrical equipment. As a result of these inspections, certain of your activities appear to be in violation of NRC requirements. Two of these examples were identified as Potentially Enforceable / Unresolved Items in NRC Inspection Report No. 50-461/87026(DRS) sent to you by {{letter dated|date=November 6, 1987|text=letter dated November 6, 1987}}. A third example was licensee identified and discussed in NRC Inspection Report No. 50-461/88010(DRS) sent to you by {{letter dated|date=April 20, 1988|text=letter dated April 20, 1988}}. An enforcement conference was held in the Region III office on March 31, 1988 between you and other members of your j staff, and Dr. C. J. Paperiello and other members of the NRC staff during which j the violations, their root causes and your corrective actions were discussed. f The violation described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) concerns the failure on the part of the engineering staff to appropriately translate the design specifications for electrical equipment important to safety into installation directions and to ensure that the installed configuration was the same as the tested configuration.
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| These failures caused equipment to be installed which differed from the tested (qualified) configuration. The unqualified junction boxes, AMP KYNAR butt splices and Thomas and Betts nylon wire caps had been installed since the beginning of plant operations and represented significant equipment problems l which could have led to equipment failures during postulated accident conditions in numerous systems important to safety.
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| Your nonconformance report (issued September 16, 1986) and NRC violation 50-461/
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| 87026-036(DRS) (issued November 6, 1987) relating to corrosion due to the absence of drainage openings in one electrical equipment junction box should have alerted l you for a potential generic problem. Your failure to take prompt and effective corrective actions is of rep @ atory concern. We request that your response describe your actions to preclude similar corrective action failures.
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| CERTIFIED MAIL RETURN RECEIPT RE0 VESTED NUREG-0940 1.A-128 1
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| Illinois Power Company 2 JUN 1 1988 During the enforcement conference, you stated that your methodology for testing butt splices and wire caps was consistent with industry practice.
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| IE Information Notice No. 85-39, "Auditability of Electrical Equipment Qualification Records at Licensee's Facilities," states, in part, that an EQ test report, in and of itself, does not completely support a determination that equipment is qualified and that similarity of the tested configuration to that installed configuration in the plant must be established. Additional information such as an evaluation of the adequacy of the test conditions may be needed. For example,10 CFR 50.49(k) endorses NUREG-0588, which requires meeting IEEE Standard 323-1974, "IEEE Standard for Qualifying Class IE Equipment for Nuclear Power Generating Stations," that provides that equipment speci'ications and test plans should include, as applicable, the mounting and connection method and configuration. As such, equipment should be mounted, positioned, and connected in a manner that simulates its expected installation unless an analysis can be performed and justified to show the equipment's performance would not be altered by other means of mounting and connection. Ana'lytical data should contain the specific features, postulated failure modes or the failure effects to be analyzed.
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| Standard 323-1974 supports our position that the equipment should be tested under the most adverse conditions it would experience throughout its expected life. The installed configuration for the wire caps and butt splices did not prevent them fr'om being in contact with each other or surrounding grounded metal. Therefore, these devices should have been tested in contact with ground since that is a possible configuration and failure mode.
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| To emphasize the importance of adequate engineering control of installation instructions to ensure qualification of electricL1 equipment important to safety, I have been authorized, af ter consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Seventy-Five Thousand Dollars ($75,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR, Part 2, Appendix C (1988) (Enforcement Policy), the violation described in the enclosed Notice has been categorized at a Severity Level III. The escalation and mitigation factors in the Enforcement Policy were considered and the base civil penalty amount has been increased by 50%. Your prompt and extensive corrective action once the problem was identified to you is offset by the prior notices you have had concerning the junction boxes in the form of IE Information i Notice 84-57, a previous NRC violation (50-461/87026-03(b)) and your own Nonconforming Material Report written on September 16, 1936 and the multiple examples found for each violation involving numerous safety-related systems.
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| The enforcement action being taken in this case is based on the normal enforcement policy of 10 CFR Part 2, Appendix C (1988). Because Clinton Nuclear Station was granted an operating license after the November 30, 1985 EQ deadline, the enforcement policy for EQ violations for operating reactors, provided in Generic Letter 88-07, was not considered applicable.
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| l NUREG-0940 I.A-129
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| WN I
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| Illinois Power Company 3 1 1988 You are required te respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should dacument the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, W
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| I A. Bert Davis Regional Administrator
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| | |
| ==Enclosures:==
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| {
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| : 1. Notice of Violation {
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| and Proposed Imposition of Civil Penalty
| |
| : 2. Inspection Reports No. 50-461/87026(DRS);
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| No. 50-461/88010(DRS) cc w/ enclosures:
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| Licensing Fee Management Branch Resident Inspector, RIII Roy Wight, Manager Nuclear Facility Safety Mark Jason, Assistant l Attorney General, '
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| Environmental Control Division Richard Hubbard J. W. McCaffrey, Chief, Public Utilities Division H. S. Taylor, Quality Assurance Division NUREG-0940 I.A-130
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| i l
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Illinois Power Company Docket No. 50-461 Clinton Nuclear Station License No. NPF-62 EA 88-90 During an NRC inspection conducted on February 25 through March 31. 1988, a violation of NRC requirements was identified. In accordance with the
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| " General Statement of Policy and Procedure fcr NRC Enforcement Actions,"
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| 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:
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| 10 CFR 50.49(f) requires, in part, that each item of electric equipment important to safety be qualified by testing and/or analysis under postulated environmental conditions.
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| Contrary to the above, as of August 19, 1987, the following equipment important to safety was not qualified by appropriate testing and/or analysis which reflected the installed configuration:
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| A. One hundred and ninety-six AMP KYNAR electrical butt splices installed in valve actuators, solenoid valves and electrical junction boxes affecting multiple safety systems, B. One hundred and fif ty-six junction boxes without drainage openings (weep holes) affecting multiple safety systems, and C. Two hundred and seventy Thomas and Betts nylon wire caps installed in ninety dual voltage Limitorque actuators affecting multiple pieces of equipment important to safety.
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| This is a Severity Level III violation (Supplement I).
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| Civil Penalty - $75,000.
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| Pursuant to the provisions of 10 CFR 2.201, Illinois Power Company (Licensee) is hereby required to submit a written statement or explanation to the Director, l Office of Enforcement, U.S. Nuclear Regulatory Commission within 30 days of the I date of this Notice. This reply should be clearly marked as a " Reply to a Notice l
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| of Violation" and should include for each alleged violation: (1) admission or NUREG-0940 I.A-131
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| l Notice of Violation 2 JUN 1 1988 l
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| denial of the alleged violation; (2) the reasons for the violation if admitted; (3) the. corrective steps that have been taken and the results achieved; (4) the corrective steps that will be taken to avoid further violations; and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other actions as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part; (2) demonstrate extenuating circumstances; (3) show error in this Notice; or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, in whole or in part, such answer may request remission or mitigation of the penalty.
| |
| In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g.,
| |
| citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
| |
| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a l
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| l NUREG-0940 1.A-132
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| l JUN Notice of Violation 3 1 1988 Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington D. C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, IL 60137 and a copy to the NRC Resident Inspector, Clinton.
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| FOR THE NUCLEAR REGULATORY COMMISSION d*
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| A. Bert Davis Regional Administrator Dated at, Glen Ellyn, Illinois this l' day of June 1988 l
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| l NUREG-0940 I.A-133
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| i l
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| pwag 4
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| 8 8., UNITED STATES
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| [,_ '
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| c g NUCLEAR REGULATORY COMMISSION y, . E WASHINGTON, D. C. 205$5
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| ( . . . . * */ OCT 2 01988 Illinois Power Company j ATTN: Mr. W. C. Gerstner -
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| Executive Vice President 500 South 27th Street Decatur, Illinois 62525 Gentlemen:
| |
| | |
| ==SUBJECT:==
| |
| ORDER IltPOSING CIVIL MONETARY PENALTY This refers to your {{letter dated|date=June 29, 1988|text=letter dated June 29, 1988}}, in response to the Notice of Violation and Proposed Imposition of. Civil Penalty sent to you by our {{letter dated|date=June 1, 1988|text=letter dated June 1, 1988}}. Our letter and Notice describe three violations identified by the NRC.
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| To emphasize the importance of adequate engineering control of installation instructions to ensure qualification of electriril equipment important to safety, a civil penalty of Seventy-Five Thousand Dollars ($75,000) was proposed.
| |
| In your response, you admitted Violation B occurred as stated in the' Notice of Violation, but denied Violations A and C. In addition, you requested remission of the proposed civil penalty.
| |
| After consideration of your response, we have concluded, for the reasons given in the Appendix attached to the enclosed Order Imposing Civil Ponetary Penalty, that you did not provide sufficient basis for withdrawal of Violation A or for remission of the proposed ci"il penalty. However, the NRC staff reconsidered its position on Violation C. Alchough you did not conform with the EQ reaufrements, the NRC staff has determitied that Violation C is most appropriately classified at Severity Level IV. Further, because there has been extensive disc.cssion on l this violation and corrected actions have been taken for it, a revis Notice i will not be issued. Accordingly, we hereby serve the enclosed Orde on Illinois i Power Company imposing a civil penalty in the amount of Seventy-Five Thousand Dollars ($75,000). We will review the effectiveness of your corrective acticns during a subsequent inspection.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 J
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| Title 10, Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room.
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| Sincerely,
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| /
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| ar .s MV
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| .Tayh,DeputyExecutiveDirector I for Regional Operations
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| ==Enclosure:==
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| Order Imposing Civil Monetary Penalty with Appendix cc w/ enclosure: See Next Page CERTIFIED MAIL 1 xtiuxn xtttivi REQUESTED NUREG-0940 I.A-134 l
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| l l UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of' ) Docket No. 50-461 l- Illinois Power Company ) License No. NPF-6?
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| (ClintonNuclearStation) ) EA 88-90 ORDER IMPOSING CIVIL MONETARY PENALTY I
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| Illinois Power Company (licensee) is the holder of Operating License No. NPF-62 issued by the Nuclear' Regulatory Commission (NRC or Commission) on, April 17, 1987.
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| The license authorizes the licensee to operate the Clinton Nuclear Station in accordance with the conditions specified therein.
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| II
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| ! Special safety inspections of the licensee's activities were conducted during the periods April 17 through October 13, 1987 ar.. February 25 through March 31, 1988. (NRC Inspection Reports No. 50-461/87026(DRS) and No. 50-461/88010(DRS)).
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| The results of the inspections indicated that the licensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was served upon the licensee by {{letter dated|date=June 1, 1988|text=letter dated June 1, 1988}}. The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalty proposed for the violations.
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| The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalty by {{letter dated|date=June 29, 1988|text=letter dated June 29, 1988}}. In its response, the licensee denied Violations A and C and admitted Violation B. In addition, the licensee requested remission of the civil penalty.
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| NUREG-0940 I.A-135
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| l 1
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| 1 III After consideration of the licensee's response and the statements of fact, explanation, and argument for mitigation contained therein, the Deputy Executive Director for Regional Operations has determined, as set forth in the Appendix to this Order, that Violation A occurred as stated and that the penalty proposed for the violation designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be imposed. With respect to Violation C it was determined that although the licensee failed to meet the EQ requirements of 10 CFR 50.49 the violation is most appropriately classified at Severity Level IV and should be removed as a violation supporting the proposed civil penalty.
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| IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT:
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| The licensee pay a civil monetary penalty in the amount of Seventy-Five Thousand Dollars ($75,000) within 30 days of the date of this Order, by check, draft, or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTH: Document Control Desk, Washington, D.C. 20555.
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| The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing should be clearly marked as a " Request for an Enforcement Hearing" and should be addressed to the Director, Office of Enforcement, U.S.
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| NUREG-0940 1.A-136
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| 20555, with a copy to the Regional Administrator, Regicn III, 799 Roosevelt Road, Glen Ellyn, Illinois, 60137, and a copy to the NRC Resident Inspector, Clinton Nuclear Station.
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| If 6 hearing is requested, the Commission will issue an Order designating the time and place of the hearing. If the licensee fails to request a hearing within 30 days of the date of this Order, the provisions of this 0,rder shall be effective without further proceedings. If payment has not been made at that time, the matter may be referred to the Attorney General for collection.
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| In the event the licensee requests a hearing as provided above, the issue to be considered at such hearing shall be:
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| (a) whether the licensee.was in violation of NRC requirements as /_scrit'ed in Violation A set forth in the Notice of Violation and Proposed Imposition of Civil Penalty referenced in Section II above, and (b) whether, on the basis of that violation and Violation B set forth in the Notice and admitted by the licensee, this Order should be sustained.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| /
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| VM m M. Taylor Deputy Executive Director r Regional perations Dated at Rockville, Maryland this ;)oWday of October 1988.
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| NUREG-0940 I.A-137
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| APPENDIX EVALUATION AND CONCLUSION On June 1, 1988,'a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for violations identified during an NRC inspection.
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| Illinois Power Company responded to the Notice on June 29, 1988. In its response, the licensee admitted that Violation B occurred, but denied that Violations A and C occurred as stated in the Notice. The licensee argues that the NRC's actions in proposing a civil penalty for Violations A and C is not consistent with sound regulatory practices and that remission of the penalty is warranted. The contested violations are restated below, followed by a summary of the licensee's response, the NRC evaluation, and the NRC conclusion.
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| I. Restatement of Violation A 10 CFR 50.49(f) requires, in part, that each item of electric equipment important to safety be qualified by testing and/or analysis under postulated environmental conditions.
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| Contrary to the above, as of August 19, 1987, the following equipment important to safety was not qualified by appropriate testing and/or analysis which reflected the installed configuration:
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| One hundred and ninety-six AMP KYNAR electrical butt splices installed in valve actuators, solenoid valves and electrical junction boxes affecting multiple safety systems.
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| Summary of Licensee's Response The licensee denies that Violation A occurred as stated, in that it had a qualification test report for the most severe environmental condition anticipated in a design basis accident (DBA). The licensee stated that the samples were tested in a configuration similar to their installation in the plant. The licensee noted that in the cover letter accompanying the Notice of Violation, the NRC stated that the butt splices and the wire nuts should have been tested in contact with a ground "since that is a possible configuration and failure mode." When a walkdown of butt splices was performed, none were found in contact with a metal ground. The licensee believes that the NRC's view of the environmental qualification testing required for these items is a result of a new interpretation by the NRC of the applicable regulations and of industry standards.
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| NRC Evaluation of Licensee's Response Although the licensee had a qualification test report on AMP KYNAR butt splices for severe environmental parameters anticipated during a DBA at Clinton, the tested configuration of the AMP KYNAR butt splices did not simulate an installation in which the splices were touching each other er the metal enclosures. Since Clinton installation and maintenance procedures provide no restrictions for ensuring that splices do not touch each other or the metal housing, severe failures in these configurations were postulated by the NRC during the inspection and were confirmed during testing of the splices.
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| l NUREG-0940 1.A-138
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| Appendix The licensee in its response stated that during a walkdown subsequent to l the NRC finding, none of the splices were found to be in contact with a metal ground. However, it _is not clear to the NRC how the licensee could assume that several splices installed in a congested metal junction box or equipment housing would not touch the metal enclosure and thereby have the potential of being grounded. In addition, prior to the NRC finding, the licensee had no evidence to support a conclusion that the splices were not touching the enclosure since such a configuration was allowed by installation design or could result due to maintenance activities. In short, a butt splice in contact with ground is an expected configuration.
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| It was also noted that the licensee's response did not address postulated failures due to splices touching each other and there was no record in the licensee's EQ documentation to show that any evaluations or tests of such a configuration had been performed.
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| The NRC's view of this violation does not reflect a new interpretation of the EQ regulations and standards. 10 CFR 50.49(k) establishes NUREG-0588, I
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| Category I, requirements as being acceptable for qualification of- original equipment. NUREG-0588, Category I, Section 2.2(3) refers to IEEE 323-1974, Section 6.3.1.2 which states, in part, that equipment during a type test shall be maintained in a manner and a position that simulates its expected installation when in actual use. The NRC has proposed a number of other environmental qualification enforcement actions for cases in which installed equipment was not maintaired in the condition or position of the tested equipment. The NRC recognizes that there is no specific requirement to consider splice-to-splice and splice-to-metal housing configurations.
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| However, given the rather unique application of the AMP KYNAR butt splices, inside containment at Clinton, the NRC concludes that considering such configurations is necessary and not unreasonable. Based on the above considerations, the licensee had not conducted a test to demonstrate qualification of the butt splices in the expected mounting configuration in wh ch splices touch each other or the metal enclosure nor was it demonstrated that such configuration should not be considered.
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| Restatement of Violation C 10 CFR 50.49(f) requires, in part, that each item of electric equipment important to safety be qualified by testing and/or analysis under postulated environmental conditions.
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| Contrary to the above, as of August 19, 1987, the following equipment important to safety was not qualified by appropriate testing and/or analysis which reflected the installed configuration:
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| Two hundred and seventy Thomas and Betts nylon wire caps installed in ninety dual voltage Limitorque actuators affecting multiple pieces of equipment important to safety.
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| Summary of Licensee's Response The licensee denies that Violation C occurred as stated, in that these caps were tested by Limitorque for anticipated environmental conditions during a DBA at the Clinton Station. The licensee states that the caps NUREG-0940 I.A-139
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| Appendix were tested in the configuration installed in the plant. The licensee believes that the NRC's view that environmental qualification testing of these items was not adequate is the result of a new interpretation by the NRC of industry standards. )
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| NRC Evaluation of Licensee's Response The licensee's EQ documentation did not address the testing of any kind of nylon wire caps. Subsequent to the finding, the licensee contended that a letter from the vendor (Limitorque) confirmed that Thomas and Betts wire cups were used; however, a letter from a vendor, in lieu of test data, is not considered an adequate basis for the environmental qualification of the component. Since there was no evidence in the EQ files that the wire caps had been tested, the NRC was unable to determine if the installed configuration was adequate.
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| NRC's view of this violation does not represent a new interpretation of the EQ regulations and standards. NUREG 0588, Category I, Section 5(2) states that a certificate of conformance by itself is not acceptable l unless it is accompanied by test data and information on the qualification program. Examining the applicable industry standard, it is fou6d that IEEE 323-1974, Section 6.2(5), states that qualification of Class 1E equipment shall include identification of the design life of any components which may have a life shorter than that of the complete equipment. Since the test report does not state that Thomas and Betts wire caps were used in the tested actuators, the vendor correspondence does not state that the wire caps were used in the tested actuators (and were unprotected), and since no data was provided which supports the vendor's asser+io..s, insuf-ficient evidence exists to support qualification. Furthermore, cecause the suspect caps were mada of nylon, a material susceptible to radiation and thermal aging, the licensee should have addressed the mounting confi-guration and th^ condition of the caps during and after LOCA testing.
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| In conclusion, the NRC staff maintains that Violation C represents a violation of EQ requirements. However, after reconsidering the signifi-cance of the violation the NRC staff recommends that it be classified at Severity Level IV. Further, because this violation has been the subject of extensive discussion and corrective actions have been taken, it is recommended that a revised Notice not be issued.
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| II. Summary of Licensee's Request for Remission The licensee believes that Violatior.s A and C as stated in the Notice of Violation and Proposed Imposition of Civil Penalty did not occur and that other extenuating circumstances exist which make escalation of the civil penalty unwarranted and render remission of the penalty appropriate.
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| Past Performance The licensee states that Illiriois Power Company's performance in the area of environmental qualification of equipment at Clinton Pcwer Station has been generally good. Similarly, during August through October of 1987, the NRC conducted an in-depth evaluation of the EQ program and found that it complies with NRC EQ requirements and, with limited specific exceptions, was properly implemented.
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| NUREG-0940 1.A-140
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| Appendix Prompt and Effective Corrective Action For two of the examples cited in the alleged violation (AMP KYNAR butt splices and the nylon wire caps), corrective action was prompt and effective, resulting in completion of corrective action with no impact on plant operation. The NRC recognized in the cover letter accompanying the Notice of Violation that the corrective action in response to this item was " prompt and effective."
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| Other Extenuating Circumstances The licensee states that the Notice of Violation that was issued by NRC Region III has concluded that the tests reviewed and accepted by Illinois Power Company were not adequate because the butt splices and wire caps were not tested while restrained to a grounced metal surface. Furthermore, when testing the nylon wire caps in the fashion required by the NRC, the only way that the wire caps coulc be held in contact with metal was to physically restrain them to the actuator casing; otherwise contact could not be maintained. Thus, contact of these items with metal is only a speculative possibility that is unsupported by the design requirements or by the installations actually observed in the plant.
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| NRC Evaluation of Licensee's Request for Mitigation or Remission The NRC staff has concluded that the removal of Violation C does not affect the civil penalty proposed. Violation A and B alone are sufficient for a Severity Level III violation and therefore the civil peralty is proposed based only on those two violations.
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| NRC reviews each proposed civil per.alty on its own merits and adjusts the base civil penalty values upward or downward appropriately. The criteria for these adjustments ara set forth in 10 CFR Part 2, Appendix C.V.B.
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| Adjustments to the base civil penalty may be made for the factors described below:
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| : 1. Promat Identification and Reporting - Reduction of up to 50% of the base civil penalty may be given when a licensee identifies the violation and promptly reports the violation to the -NRC. In this case, the violations were identified by the NRC. Therefore, no reduction was made.
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| : 2. Corrective Action to Prevent Recurrence - Unusually prompt and extensive corrective action may result in reducing the proposed civil penalty as much as 50% of the base value. On the other hand, the civil penalty may be increased as much as 50% of the base value if initiation of corrective action is not prompt or is only minimally acceptable. The licensee took prompt actions to develop Justifications for Continued Operation and to test the AMP KYNAR butt splices, however, the actions taken by the licensee were inadequate following the dis-covery by the NRC in August 1987 that a junction box did not have a weep hole (Violation B which was admitted by the licensee). The licensee considered it an isolated case, but later found 155 others. Although prompt and extensive corrective actions were not taken for all of the identified violations, the licensee did so for 1 of the 2 problems and therefore 25% mitigation is appropriate.
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| NUREG-0940 I.A-141
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| Appendix 3. Past Performance - Reduction by as much as 100% of the base civil penalty may be given for good prior performance in the general area of concern. On the other hand, the base civil penalty may be increased by as much as 100% for prior poor performance in the general area of concern. In this case, neither escalation or mitigation was deemed appropriate since the NRC has not conducted prior broad inspections in this area and therefore has an inadequate basis for judging past performance.
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| : 4. Prior Notice - The base civil penalty may be increased by as much as 50% for cases where the licensee had prior knowledge of a problem as a result of a licensee audit, or specific NRC or industry notification. In this case, the licensee has prior notice about the junction box problem in the form of IE Information Notice 84-57, a previous NRC violation (50-461/87026-03(b)), and a lic,ensee i Nonconforming Material Report dated September 16, 1986. Therefore, because the licensee had prior notice on one of the violations 25%
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| escalation is appropriate.
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| : 5. Multiple Occurrences - The base civil penalty may be increased as much as 50% where multiple examples of a particular violation were identified during the inspection period. Based on numerous examples (196 AMP KYNAR butt splices and 156 junction boxes) and the numerous systems involved, the base civil penalty was increased by 50 percent.
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| In its presentation of "Other Extenuating Circumstances," the licensee maintains that splice-to-splice contact is not a realistic possibility.
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| Despite the licensee's assertion, the NRC staff concludes that the existence of a splice-to-splice contact is a realistic possibility where a mass of wires and splices are confined to the volume of an actuator casing. There-l fore, thesc devices should have bera tested in the splice-to-splice con-figuration, since this represents possible failure mode. This matter was addressed previously in the Ap,;endix as was the NRC staff's revised positiun relative to Violation C.
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| As a result of the above considerations, the NRC has determined that a civil j penalty increased 50% above in the base civil penalty is appropriate.
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| l III. NRC Conclusions The NRC staff has concluded that Violation A did occur as stated in the Notice of Violation and no basis has been provided for remission or mitigation of the civil penalty. Accordingly, the proposed civil penalty in the amount of $75,000 should be imposed.
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| NURF1-0940 I.A-142
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| UNITED STATES
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| [pa nic k NUCLEAR REGULATORY COMMISSION g ) g nEcios m t, 5 y m aoostvcu noao cu~ cuvu. u ~ois sein OCT 21 1989 i
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| Docket No. 50-331 l License No. DPR-49 1 EA 87-83 Iowa Electric Light and Power Company ATTN: Mr. Lee Liu President and Chief Executive Officer IE Towers P. O. Box 351 Cedar Rapids, IA 52406 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-331/87009(DRS))
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| This refers to the NRC special inspection conducted on April 13-29, 1987, at Duane Arnold Energy Center, of activities authorized by NRC License No. DPR-49. The inspection was conducted by a special environmental qualification (EQ) inspection team to assess the adequacy of the program implemented at Duane Arnold Energy Center in meeting the EQ requirements of 10 CFR 50.49. This inspection included an examination of EQ records to verify that they contained appropriate analysis and documentation to support the environmental qualification of electrical equipment. A copy of the inspection report was sent to you by {{letter dated|date=May 18, 1987|text=letter dated May 18, 1987}}. The results of the inspection were discussed on June 29 and July 24, 1987, during enforcement conferences with your staff in the Region III office. An apparent violation of EQ requirements was identified.
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| Example a. of the violation in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involved the installation of AMP nylon-insulated butt splices in the drywell, steam tunnel, and other High Energy Line Break areas. Th2se splices were installed in systems and components that were important to safety without documentation of adequate testing and/or analysis, as required by 10 CFR 50.49, to support the environmental qualification of these splices.
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| Environmental qualification of equipment important to safety was required by November 30, 1985. You should have clearly known by this date that these components were not environmentally qualified. The DDR Guidelines, Appendix C.
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| (as endorsed by 10 CFR 50.49(k)) identify nylon as susceptible to significant degradation from thermal and radiation aging and Section 5.2.3 provides guidance for testing such materials. The test report that you relied on to NUREG-0940 I.A-143
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| Iowa Electric Light 2 OCT 21 1988 and Power Company show qualification for these splices did not include irradiation and thermal aging of the splices. Further, the generic testing relied on by y w to support qualification for radiation was clearly inadequate because separate effects analysis did not simulate the combined degrading effects of radiation and steam that would be encountered during accident conditions. Finally, the test report referred only to " insulated splices" with no manufacturer or formulation specified and you clearly should have recognized such information as inadequate because similarity of the tested splices to the nylon splices installed could not be established.
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| I Example b. of the violation in the enclosed Notice invoked the installation of l AMP KYNAR butt splices in some 10 CFR 50.49 designated systems and components that were important to safety. The violation resulted when these splices were installed without ensuring that the expected and installed configuration had been qualified by an appropriate test. In your July 22, 1987 letter, you stated that AMP Qualification Test Report No. 110-11004 was relied upon to establish qualification of these AMP KYNAR splices. In the above test, however, you did not test the splices in their anticipated installed plant j configuration in which the splices would be in contact with each other or their surrounding grounded metal housing. Therefore, you clearly should have known that these butt splices were unqualified because the tested configuration did i not match the installed configuration.
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| To emphasize the importance of environmental qualification and meeting regulatory deadlines, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) in the amount of Fifty Thousand Dollars
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| ($50,000) for the violation described in the enclosed Notice. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49," (Modified Policy), attached to Generic Letter 88-07 (Enclosure 2), the violation described in the enclosed Notice involving several hundred unqualified splices in various applications, has been determined to be moderate, to have affected some systems, and therefore is considered to be an EQ Category B violation.
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| The base civil penalty for an EQ Category B violation is $150,000.
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| In determining the civil penalty emount, the NRC considered the four factors set forth in the Modified Policy for escalation and mitigation of the base civil penalty amount. These factors consist of: (1) identification and prompt reporting of the EQ deficiencies (150%); (2) overall best efforts to complete EQ within the deadline (150%); (3) corrective actions to result in full compliance (150%), and (4) duration of a violation which is significantly below 100 days (-50%).
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| NUREG-0940 I.A-144
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| i l
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| Iowa Electric L' 4t 3 OCT 21 1989
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| *nd Power Compa y With respect to the first factor, mitigation of the base civil penalty by (
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| 50 percent is appropriate because both violations were identified by the licensee. With respect to the second factor, mitigation of the base civil penalty by 50 percent is appropriate because of the licensee's best efforts l in EQ. With the exception of the two violations set forth in the Notice of Violation and Proposed Imposition of Civil Penalty and the two Severity Level IV violations issued with NRC Inspection Report 50-331/87009, the NRC has concluded that the licensee exerted best efforts to complete EQ within the deadline. The EQ files were found to be easily auditable and, except for the cited deficiencies, complete. The overall quality of the EQ program demonstrated that it had been monitored extensively both through audits and surveillance, With respect to the third factor, 50% mitigation was applied for prompt and extensive corrective actions. The licensee did shut down on December 9, 1986 immediately after it became aware of failures of AMP nylon-insulated butt splices that had been tested at Wyle Labs on December 4-5, 1986.
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| Thesc splices were then replaced and/or taped. In addition, all AMP KYNAR butt splices were promptly replaced and/or taped after the deficiencies were identified. With respect to the fourth factor, mitigation is inapp;opriate because the ioentified EQ violations existed in excess of 100 days.
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| After evaluating these *netors, a total mitigation of 150 percent of the '
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| $150,000 base civil pe;.aity is appropriate. However, the Modified Policy, provides that civil penalties for Category A and B violations should not be less than 550,000 to emphasize that significant environmental qualification failures are unacceptable. Accordingly, we have determined that, in this instance, a $50,000 civil penalty is appropriate. While the Modified Policy provides that under certain circumstances full mitigation is appropriate, such cases are limited to Category C violations.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether or not further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this lettre and its enclosures will be placed in the NRC Public Document Roc-NUREG-0940 I.A-145
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| Iowa Electric Light 4 OCT 21 1988 -
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| and Power Company ;
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| )
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| The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
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| Sincerely O
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| d' &h dl M A. Bert Davis i Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Imposition of Civil Penalty
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| : 2. Generic Letter 88-07
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| : 3. Inspection Report No. 50-331/87009(DRS) cc w/ enclosures: I R. Hannen, Plant l Superintendent - Nuclear I R. Salmon, Technical Services Superintendent John A. Eure, Iowa Department of Public Health NUREG-0940 1.A-146
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Iowa Electric Light and Power Docket No. 50-331 Company License No. DPR-49 Duane Arnold Energy Center EA 87-83 j During an NRC inspection conducted on April 13-29, 1987, a violation of NRC requirements was identified. In accordance with the Modified Enforcement Policy Relating to 10 CFR 50.49, " Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants," attached to Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:
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| 10 CFR 50.49(f) re, quires each item of electrical equipment important to safety to be environmentally qualified by testing and/or analysis.
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| 10 CFR 50.49(k) specifies that requalification of electric equipment important to safety is not required if the Commission has previously required qualification in accordance with " Guidelines for Evaluating Environmental Qualification of Class IE Electrical Equipment in Operating Reactors," November 1979 (DDR Guidelines).
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| DDR Guidelines, Section 5.2.2, states that type tests should only be considered valid for equipment identical in design and material construction to the test specimen and any deviations should be evaluated as part of the qualification documentation.
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| Contrary to the above, from November 30, 1985 to December 9, 1986, the licensee operated the plant with unqualified electrical equipment important to safety as evidenced by the following examples:
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| : a. AMP nylon-insulated butt splices, used in some items of electrical equipment important to safety, were not environmentally qualified by adequate type testing. While a type test was done, the tested splices were not demonstrated to be identical to the installed AMP splices in that the manufacturer and the formulation of the tested splices were not specified. Further, the testing relied on by the licensee did not simulate the combined degrading effects of radiation and steam that would be encountered by the installed splices during accident conditions.
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| NUREG-0940 I.A-147
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| Notice of Violation 2 OCT 2 i iges
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| : b. AMP KYNAR butt splices, used in numerous items of electrical equipment important to safety, were not environmentally qualified by appropriate testing and/or analysis in that the tested configuration did not simulate the configuration of the splices installed in the plant. Specifically, the tested splices were not tested in contact with each other or their surrounding grounded metal housing.
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| This is an EQ Category B violation.
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| Cumulative civil penalty - 550,000 (assessed equally between the examples).
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| Pursuant to the provisions of 10 CFR 2.201, Iowa Electric Light and Power Company (the licensee) is hertby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation; (2) the reasons for the violation if admitted; (3) the corrective steps that !
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| have been taken and the results achieved; (4) the corrective steps that will be taken to avoid further violations; and (5) the date when full compliance ,
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| will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draf t, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should l the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part; (2) demonstrate extenuating circumstances; (3) show error in this Notice; or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| NUREG-0940 1.A-148
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| Notice of Violation 3 OCT 2 i 1988 i
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| In requesting mitigation of the proposed penalty, the four factors addressed in Modified Enforcement Policy Relating to 10 CFR 50.49, " Environmental Qualification of Electric Equipment Important to Safety for Nuclear Power Plants," attached to Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administr; tor, Region III U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137, and a copy to the NRC Resident Inspector at the Duane Arnold Energy Center.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| >L hm A. Bert Davis Regional Administrator Dated a This &j Glen day of Ellyn, OctoberIllinois 1988.
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| NUREG-0940 I.A-149
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| r,#" "'% UNITED STATES y '', NUCLEAR REGULATORY COMMISSION
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| $ U REGION IV 811 RYAN PLAZA DRIVE. SUfTE 1000 ARUNGTON, TEXAS 70011 EF 251988 Docket No. 50-298 '
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| EA 88-159 Nebraska Public Power District (NPPD) L ATTN: George A. Trevors '
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| Division Manager - Nuclear Support Post Office Box 499 Columbus, Nebraska 68601 6sntlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-298/86-28)
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| This refers to the NRC inspection conducted November 3-7, 1986, at the Ceoper Nuclear Station (CNS) of activities authorized by NRC License No. OPR-46. The inspection was conducted by a special environmental qualification (EQ) inspection team to assess the program implemented at CNS to ensure that electrical equipent important to safety is qualified according to the requirements of 10 CFR 50.49.
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| This inspection included examination, of NPPD EQ records to verify that they contained appropriate analyses and documentation to support the EQ of electrical equipment installed in the plant. A copy of the inspection report was sent to you by {{letter dated|date=April 1, 1987|text=letter dated April 1, 1987}}. The results of the inspection were discussed on June 20, 1988, during an enforcement conference held in the NRC Region IV office in Arlington, Texas. Because the inspection report issued in this case is not as detailed as those the NRC normally supplies to its licensees, a detailed review of the pertinent issues is included as an enclosure to this letter.
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| The violations in Part I of the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involved the failure to ensure, either by adc
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| * ste testing or analysis, that the following equipment was qualified:
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| l (1)KeriteHTK/FR600voltcable;(2) Thomas &BettsSta-koncableconnectors (splices) to Fenwal/Patel temperature switches; and (3) Scotch 130/70/17 tape CERTIFIED MAIL RETURN RtTETFT REQUESTED NUREG-0940 I.A-150
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| Nebraska Public Power District cable splices to Limitorque motor operators. The NRC analysis of these issues demonstrates that NPPD clearly should have known, prior to the November 30, 1985 deadline for cor+1eting your environmental qualifications program that the requirements of 10 CFR 50.49 were not met.
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| With regard to the Kerite 600V cable, the reports (December 9,1982 SER and the November 24, 1982 Franklin Research Center TER) available on this matter as well as the March 24, 1984 meeting between NPPD and the NRC provided clear notice that qualification of this type of cable had not been established.
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| Further, NPPD clearly would have known that qualification had not been demonstrated if an adequate review of the Franklin Research Center test anomalies, regarding degradation of this type of cable during and after LOCA testing, had been performed. In the case of the Thomas and Betts Sta-kon cable connectors NPPD clearly should have known that qualification had not been demonstrated because testing had only established qualification in a steam environment rather than the full accident environment to which the connectors would have been subjected. Finally, in the case of the Scotch 130/70/17 tape cable splices NPPD clearly should have recognized that qualification had not been demonstrated because the installed splices were over cable with a braided fiberglass jacket which was not representative of the tested configuration in which the splices were installed over unjacketed insulated cable.
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| These violations are an indication to NRC of a need to place greater attention on ensuring that equipment important to safety will perform its intended function in harsh environments and that regulatory deadlines are met. Also of concern to the NRC is the fact that, at the time af the inspection, you were unable to verify whether Kerite HTK/FR 600-volt cable, an item on your list.of electrical equipment important to safety about which the NRC had questions, was installed in the plant. You later determined that this cable was installed in the plant. Accordingly, I have been authorized, after consultation with the Director, Office of Enforcement and the Deputy Executive Director for Regional Operations, to issue the Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) in the amount of One Hundred Fifty Thousand Dollars
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| ($150,000) for the violations described in the enclosed Notice. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49," contained in Generic Letter 88-07 (Enclosure 3), the violations described in Part I of the enclosed Notice have been determined to affect a. limited number of systems _and components, and therefore are considered to be an EQ Category C problem. The base value of a civil penalty for an EQ Category C problem is $75,000 In determining the civil penalty amount, the NRC considered the four factors ;
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| set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49," for escalation and mitigation of the base civil penalty amount. These factors consist of: (1) identification and prompt reporting of the EQ deficiencies by the licensee (2 50%); (2) best efforts to complete EQ within the deadline (2 50%); (3) corrective actions to result in full compliance ( 50%); and (4) duration of a violation which is significantly below 100 days (- 50%).
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| With respect to the first factor, all three items were identified by the NRC and, at the time of the inspection, you did not know whether Kerite cable was used in the plant. Thus, a 50-percent increase in the base penalty is NUREG-0940 1.A-151
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| l Nebraska Public Power District !
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| i warranted. With respect to the second factor, no adjustment appears warranted.
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| We recognize that your program to perform additional testing, replace and upgrade components, and perform additional analyses on other items was complete prior to November 30, 1985. However, your best efforts were not applied with regard to the required analyses to support the qualification of some equipment :
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| and to verify that equipment on your EQ list was or was not used in the plant.
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| With respect to the third factor, a 50-percent increase is warranted in that, as of the date of the Enforcement Conference, your corrective actions for one of these three items had not resulted in full compliance, although the NRC believes no operability issues now exist with the hardware in your plant. With respect to the fourth factor, mitigation is inappropriate since these violations existed in excess of 100 days. In total, a 100 percent increase in the base civil penalty amount is appropriate.
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| The violations in Part II of the Notice of Violation (Enclosure 1) are violations that were not assessed a civil penalty. Violations A and B are classified at Severity Level IV because during the inspection or shortly thereafter the licensee was able to demonstrate that the equipment was qualifiable. With respect to Part II, Item C, of the Notice, NPPD has taken sufficient corrective action to demonstrate that full compliance has been achieved. Therefore, no response to Part II, Item C, of the Notice is required pursuant to the provisions of Section 2.201 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional l actions you plan to prevent recurrence. After reviewing your response to this '
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| Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by +.his letter and the enclosed Notice are not subject to the clearance procedure of the Office of Management and Budget as required by the Paperwork Reduction Action of 1980, PL 96-511.
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| Sincerely, l <
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| b Robert D. Martin Regional Administrator
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| ==Enclosures:==
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| See attached NUREG-0940 I.A-152
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| Nebraska Public Power District ;
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| l
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| ==Enclosures:==
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| 1
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| : 1. Notice of Violation and Proposed Imposition of Civil Pei;alty
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| : 2. Addendum to NRC Inspection Report 50-298/86-28
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| : 3. Generic Letter 88-07 cc w/ enclosure:
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| -Cooper Nuclear Station ATTN: Guy Horn, Division Manager
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| -of Nuclear Operations P.O. Box 98 Brownville,-Nebraska 68321 Kansas Radiation Control Program Director Nebraska Radiation Control Program Dire' ir NUREG-0940 1.A-153
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| OCT 251988 i
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NebraskaPublicPowerDistrict(NPPD) Docket: 50-298 Cooper Nuclear Station (CNS) Operating License: DPR-46 EA 88-159 During an NRC inspection of the environmental qualification (EQ) of equipment conducted on November 3-7, 1986, violations of NRC requirements were identified.
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| In accordance with the " Modified Enforcement Policy Relatita to 10 CFR 50.a9, Environmental Qualification of Electrical Equipment Important ;.: Safety for i Nuclear Power Plants" contained in Generic Letter 88-07, the Nucle c P.sgulatory '
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| enalty pursuant to Section 234 of the Commission proposes Atomic Energy Act of 1954,to asimpose amended a civil p(Act), 42 U.S.C. 2282, and 10 CFR 2.205 for the violations in Part l'of this Notice. The violations in Part II of this notice have not been assessed a civil penalty. The particular violations and associated civil penalty are set forth below:
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| .I. Violations Assessed a Civil Penalty A. 10 CFR 50.49(f) requires that electric equipment important to safety be qualified by certain specified methods of testing identical or similar equipment under identical or similar postulated accident conditions with analysis appropriate to M that the equipment to be qualified is acceptable, j 10 CFR 50.49(k) provides that licensees are not required to requalify electric equipment important to safety in accordance with 10 CFR 50.49(f) if the Consnission has previously required qualification of that equipment in accordance with " Guidelines for Evaluating Environmental Qualification of Class IE Electrical Equipment in Operating Reactors," November 1979 (DOR Guidelines). Such qualification was previously required by Comission Memorandum and Order CLI-80-21 on May 23.,1980.
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| Paragraph 5.2.5 of the DOR Guidelines states that operational modes tested should be representative of the actual application requirements I (e.g., components which operate normally energized in the plant should be normally energized during the tests, and motor and electrical cable loading during the test should be representative of actual .
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| operating conditions) and that if a component fails at any time i during the test, even in a so called " fail safe" mode, the test '
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| should be considered inconclusive with regard to demonstrating the ability of the component to function for the entire period prior to the failure. !
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| Contrary to the above, as of November 7,1986, Kerite 600 volt cable, type HTK/FR ;
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| in that: ($)wasnotqualifiedbyinaccordancewiththeDORGuidelines numerous failures occurred during the post design basis 1 event (DBE) high potential cable testing, therefore making the test NUREG-0940 1.A-154
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| Notice of Violation inconclusive and failing to demonstrate the ability of the cable to function for the entire postulated accident and postaccident period; and (2) the documented test results did not meet acceptable insulation resistance (IR) measurement levels during DBE testing to demonstrate that the cable's operability would not be compromised.
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| B. 10 CFR 50.49(f) requires that electric equipment important to safety be qualified by certain specified methods of testing identical or similar equipment under identical or similar postulated accident conditions with analysis appropriate to show that the equipment to be qualified is acceptable.
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| 10 CFR 50.49(k) provides that licensees are not required to requalify electric equipment important to safety in accordance with 10 CFR 50.49(f) if the Commission has previously required qualification of that equipment in accordance with " Guidelines for Evaluating Environmental Qualification of Class IE Electrical Equipment in Operating Reactors," November 1979 (DOR Guidelines). Such qualification was previously required by Comission Memorandum and Order CLI-80-21 on May 23, 1980 Paragraph 5.1 of the DOR Guidelines states that the qualification method employed for a particular application of equipment is largely a matter of technical judgement based on (1) severity of service conditions (i.e., accident and service life); (2) structural and material complexity of equipment; and (3) the degree of certainty as related to the safety importance of the equipment function. Also as a minimum, the qualification for severe temperature, pressure, and steam service conditions to mitigate the consequences of DBEs should be based on type testing. Qualification for other service conditions may be accomplished by analysis supported by test data.
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| Contrary to the above, as of November 7,1986, Fenwal/Patel Model 17023 temperature switches were not qualified in accordance with the DOR Guidelines in that the qualification of the interfacing cable connector splices (Thomas & Betts Model RA 18 and 18 RA, Sta-kon with PVC insulation) was not based on full accident conditions, including radiation and temperature aging effects for full service life. [The Thomas & Betts Sta-kon connector splice qualification was based on accident steam testing only.]
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| C. 10 CFR 50.49(f) requires that electric equipment important to safety be qualified by certain specified methods of testing identical or similar equipment under identical or similar postulated accicant conditions with analysis appropriate to show that the equipment to )
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| be qualified is acceptabic.
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| 10 CFR 50.49(k) provides that licensees are not required to requalify electric equipment important to safety in accordance with 10 CFR 50.49(f) if the Comission has previously required qualification NUREG-0940 I.A-155 i
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| i Notice of Violation of that equipment in accordance with " Guidelines for Evaluating Environmental Qualification of Class 1E Electrical Equipment in Operating Reactors," November 1979 (00R Guidelines). Such ,
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| qualification was previously required by Commission Memorandum and l Order CLI-80-21 on May 23, 1980.
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| Paragraph 5.2.6 of the D0R Guidelines states that equipment interfaces should be representative of the actual installation in order for the test to be considered conclusive, and, an as-built inspection in the j field to vcrify that the equipment was installed as tested should be i performed.
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| Paragraph 5.2.2 of the D0R Guidelines states that the type test should only be considered valid for equipment identical in design and material construction to the test specimen. Any deviations should be evaluated as part of the qualification documentation.
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| Contrary to the above, as of November 7, 1986, Scotch 130/70/17 tape cable splices to Series SMB Limitorque motor operators, were not qualified in accordance with the D0R Guidelines in that similarity between the splice type tested and those installed in motor operators was not established. There was no documentation in the file to demonstrate qualification of Scotch 130/70/17 tape splice installations in use in applications involving motor leads with fiberglass braided ,
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| jackets. (
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| i In the aggregate, the above violations constitute an EQ Category C problem. I Civil Penalty - $150,000 (This problem existed in excess of 100 days of plant operation.)
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| 1
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| !!. Violations Not Assessed a Civil Penalty A. 10 CFR 50.49(f) requires that electric equipment important to safety ,
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| be qualified by certain specified methods of testing and/or analysis to show that the equipment to be qualified is acceptable.
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| 10 CFR 50.49(k) provides that licensees are not required to requalify electric equipment important to safety in accordance with 10 CFR 50.49 if the Comission has previously required qualification of that equipment in accordance with " Guidelines for Evaluating Environmental Qualification of Class 1E Electrical Equipment in Operating Reactors,"
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| November 1979 (DOR Guidelines). Such qualification was previously required by Comission Memorandum and Order CLI-80-21 on May 23, 1980.
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| Paragraph 5.2.5 of the 00R Guidelines states that: (1) operational modes tested should be representative of the actual application requirements (e.g., cable loading during the type test should be representative of actual plant oprating conditions); and (2) failure criteria should include instrument accuracy requirements based on the maximum error assumed in the plant safety analysis.
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| NUREG-0940 I.A-156
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| Notice of Violation l Contrary to the above, as of November 7,1986, Boston Insulated Wire (BIW) cable, type Bostrad 7E, was not qualified in accordance with i the D0R Guidelines in that documentation did not adequately demonstrate qualification because of failure to show that the equipment's specified performance requirements were satisfied. Although this cable was qualified by a test report, the analysis in the files was inadequate in that it used a 20 and 50 foot length of cable for the supporting type test, rather than the fully installed cable lengths.
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| No consideration was given for splices and penetrations installed as a part of the CNS plant configuration, to meet specified plant performance requirements, such as instrument accuracy.
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| This is a Severity Level IV violation. (SupplemeritI)
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| B. Paragraph (j) of 10 CFR 50.49 requires that a record of qualification must be maintained in an auditable form for the entire period during which the covered item is installed or is stored for future use to permit verification that each item of electric equipment important to safety covered by 550.49 is qualified for its application and meets the specified performance requirements when subjected to the conditions predicted to be present when it must perform its safety function up to the end of its qualified life.
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| Paragraph (k) of 10 CFR 50.49 permits equipment to be qualified according to the D0R Guidelines.
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| Paragraph 5.2.5 of the 00R Guidelines requires complete and auditable records for the type testing qualification to be considered valid.
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| Section 5(1) of NUREG-0588 (Category I) requires qualification documentation to verify that each type of electrical equipment is qualified for its application. The basis for qualification shall include an explanation that shows the relationship between all facets of proof needed to support the adequacy of the complete equipment.
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| Contrary to the above. as of November 7,1986, information in the files for instruments qualified to NUREG-0588,- Revision 1 and D0R Guidelines, (various pressure / level switches and transmitters l contained in EQDP Nos. 12, 13, 36, 37, 49, 76, 81, 217, 222, and 1 228), did not adequately establish qualification because the equipment documentation failed to address mounting, orientation, and interface requirements.
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| This is a Severity Level IV violation. (Supplements) l C. 10 CFR Part 50 Appendix B. "!!!. Design Control," in part, requires
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| 'at measures be established for the selection and review for
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| , witability of appilcation of materials, parts, equipment, and processes that are essential to the safety-related functions of the structures, systems and components.
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| NUREG-0940 I.A-157
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| i Notice of Violation ,
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| i Contrary to the above, as of November 7,1986 the licensee's measures to ensure the suitability of application of materials, parts, equipment', and processes was inadequate. Specifically, Raychem coaxial cable, type Rayolin F was approved for use in environmental qualification applications even though the available documentation did not adequately demonstrate material similarity of the tested cable and the Rayolin F cable, as required by 10 CFR 50.49.
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| This is a Severity Level IV violation. (Supplements)
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| Pursuant to the provisions of 10 CFR 2.201, Nebraska Public Power District (Licensee) is hereby required to submit a written statement or explanation (with the exception of Part II, Item C) to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a copy to this office, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each albged violation:
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| (1) admission.or denial of the alleged violation, (2) the reasons for the violation if admitted (3) the corrective steps that have been taken and the results achieved, (4),the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. .If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violation (s) listed in this Notice in whole or in part; (2) demonstrate extenuating circumstances; (3) show error in this Notice; or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, mitigation factors in the
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| " Modified Enforcement Policy Relating to 10 CFR 50.49 Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, should be addressed. Any written answer in tecordance with 10 CFR 2.205 should be set forth separately from the NUREG-0940 1.A-158
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| Notice of Violation statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, 611 Ryan Plaza Drive, Suite 1000, Arlington, Texas 76011, and a copy to the NRC Resident Inspector, Cooper Nuclear Station.
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| FOR THE NUCLEAR REGULATORY COMMISSION At //
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| ''XfAJ fg4f Robert D. Martin'
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| ~
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| Regional Administrator Dated at Arlington, Texas, this 25th day of October 1988.
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| NUREG-0940 I.A-159
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| Enclosure 2 Addendum to NRC Inspection Report 50-298/86-28 Violation I.A - Kerite 600 Volt Cable, Type HTK/FR, EQ Oata Package (EQDP) No. 5 The Kerite 600 volt cable is used inside and outside the primary containment (drywell) at Cooper Nuclear Station (CNS). While EQ applications for use of this cable, as contained in the EQ files (EQF), are for outside as well as inside the drywell, the primar Franklin Research Center (FRC)y testdocument used to establish report F-C4020-2. Although the qualification FRC was
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| , temperat A / pressure accident test profile represented inside drywell 4 l conditions and enveloped the postulated CNS recirculation line break loss of j cooling accident (LOCA), the FRC test report demonstrated numerous failures '
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| during high potential cable testing and unacceptable insulation resistance (IR) measurements. As a result of a review of the FRC test results, the NRC inspection team concluded that Kerite 600 volt HTK/FR cable was not qualified for inside drywell use. Although this cable appears to have been purchased for power and control applications, the EQDP No. 5 did not restrict the use of this cable for only these applications and, consequently, there was no prohibition against using this cable for instrumentation circuits inside the drywell. Also because NPPD had no analysis in the EQF to address the FRC type testing anomalies for outside drywell applications, the NRC also concluded that Kerite 600 volt HTK/FR power, control, and instrument cable was not qualified for outside drywell applications.
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| The FRC test report demonstrated that the majority of cables tested failed to maintain the high voltage potential required in the FRC test program. The NRC position with regard to cable used in power (480VAC) and control (125VAC and 125VDC) applications requires the cable to be loaded with appropriate current and voltage during the design basis event (DBE) testing, and satisfactorily pass a post DBE dielectric high potential withstand test without failure (i.e.,
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| breakdown and shorting). The dielectric high potential withstand test is in ;
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| accordance with the industry standard, IEEE Std 383-1974, for type testing of Class 1E electric cables. The FRC test report in the licensee's EQF demonstrated that the Kerite 600 volt power and control cable was not qualified for the accident profile conditions within the drywell.
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| The FRC test report also demonstrated very low IR measurements during and after the FRC DBE testing. The NRC position with regard to instrument cable applications is to require that test data taken during the DBE testing demonstrate that leakage current will not affect or compromise the operability of the instrumentation. For instrument cable application an analysis of the effects of degraded IR's on circuit accuracies must be considered. Since the licensee did not consider the effects of degraded IR's on instrument accuracy, the Kerite 600 volt cable, if used in instrument applications would not be qualified for the accident profile conditions within the drywell.
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| In addition, although the FRC test report documented extreme type testing for inside drywell use, no other type test or analysis for Kerite 600 volt cable was available to the NRC at the time of the inspection which would demonstrate qualification of this cable for outside drywell applications.
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| NUREG-0940 1.A-160
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| l
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| -2 During the time of the NRC inspection, the licensee indicated that no Kerite 600 volt type HTK/FR cable was used in EQ applications either inside or outside the drywell even though Kerite 600 volt cable was listed on the 10 CFR 50.49 master equipment list (MEL). NPPD had four cable manufacturers, identified by component identification code (CIC), listed on the MEL. However, in the EQF, 11 EQDP's listed five cable manufacturers including Kerite. Based upon the fact that Kerite 600 volt cable was included in the MEL and the EQDP's, the NRC believed that the Kerite 600 volt cable was used in EQ applications throughout the plant and noted that the EQDP for Kerite 600 volt cable did not adequately support qualification. Because NPPD did not believe that Kerite cable was used in EQ applications, their response indicated that the apparent lack of qualification was not an immediate EQ concern. During the inspection, it was determined that when NPPD was given a cable tag number connected to an EQ equipment item, that the plant had no way of identifying the cable type or cable manufacturer. Cable pull cards and termination cards have not been retained since station construction. As the result of the NRC's findings, NPPD committed to perform a cable review to verify that Kerite 600 volt cable was not used. This review was to be completed by June 1988.
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| Subsequent to the NRC inspection, by {{letter dated|date=June 17, 1987|text=letter dated June 17, 1987}}, NPPD indicated to the NRC that the cable qualification information supplied by Kerite was not properly analyzed by NPPD and that the actual use of the Kerite 600 volt cable at CNS was unknown.
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| During the spring 1988 refueling outage NPPD identified Kerite 600 volt cable in use within the drywell in EQ applications as a result of a plant walkdown.
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| The cable,for actuators which the residual involved heat motor lead app removal (lications RHR) to six motor and reactor operated recirculation valve (RR) systems, was immediately replaced.
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| In additiun, NPPD also determined that Kerite 600 volt cable was currently being used in applications outside the drywell, NPPD confirmed that these applications involved power and control circuits. As the result of this finding, NPPD decided to have additional accident type testing of Kerite 600 volt cable performed. This testing us conducted in May 1988 at the Corporate Consulting and Development Company, Ltd. (CCL) and sponsored by Patel Engineers, a consultant to NPPD. The test procedure and results were submitted to the NRC for review in June 1988. The testing used naturally aged Kerite 600 volt cable taken from the drywell at CNS. The Kerite 600 volt cable survived this type test with acceptable results. Based upon these results, in a response {{letter dated|date=July 13, 1988|text=letter dated July 13, 1988}}, NPPD added an analysis to the EQF to demonstrate that Kerite cable installed outside of the drywell is qualified.
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| While NPPD replaced this cable within the drywell and conducted a successful test, CNS had been operating since the November 30, 1985 deadline until June 1988 using the FRC test report as the basis for qualification without sufficiently analyzing the test anomalies and failures, thereby operating with unqualified (undocumented) cable both inside and outside of the drywell.
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| NUREG-0940 1.A-161
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| l l
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| Violation I.B - Thomas & Betts (T&B) Sta-kon Cable Connectors to Fenwal/Patel Temperature Switches EQ Data Packages (EQDP) No. 220, 220A, and 235 The T&B Sta-kon cable connectors, Model RA 18 (female) and 18 RA (male), used to splice Class IE field wiring to Fenwal/Patel, Model 17023, temperature switches are installed near each main steam line (MSL). These temperature switches affect the main steam, high pressure coolant injection, reactor core isolation cooling, residual heat removal, and reactor water cleanup systems.
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| At the time of the NRC inspection EQDP No. 220A for the temperature switches in the EQF did not contain analyses, data, or documentation to establish qualification of the T&B connectors for the full accident environment, nor did it establish the qualified service life for radiation and temperature aging effects. In their response letter of June 16, 1987, NPPD indicated that EQDP No. 220 contained the source documents for qualification of the Fenwal/Patel temperature switches. This letter also indicated that this qualification was inadequate in that the qualification was based only on accident steam testing which only enveloped the required pressure, temperature, and relative humidity for the accident operability time. The qualification did not include the required accident and service life radiation, temperature, and aging effects.
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| To resolve this deficiency, NPPD prepared EQDP No. 235 (in place on April 16, 1987) which enhanced all qualification documentation for the T&B Sta-kon connectors including two additional steam accident type test reports of October 21 and December 16, 1986. NPPD indicated however, during the enforcement conference on June 20, 1988 at the Region IV office, that the '
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| additional subsequent testing was not essential to establish the qualification ;
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| of the T&B Sta-kon connectors.
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| With regard to NPPD's subsequent testing, the first type test at severe temperature, pressure, and steam service conditions of October 21, 1986, resulted in an anomaly with regard to improper IR measurements. The test was repeated and successfully passed on December 16, 1986. The NRC understands that both tests were run on two configurations of T&B Sta-kon connector pairs inside a NEMA-4 enclosure in which (1) the s (naturally aged and supplied by NPPD); and (plice
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| : 2) the was insulated splices used Patel with PVC Engineers tubing Conformal Ce nir,g (PECC) applied between the splice and outer PVC tubing. Both !
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| tests for NPPD were sponsored by Patel Engineers at CCL. The test report was i submitted to the NRC Region IV office in a separate cover response letter on June 29, 1987 '
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| CNS had been operating since the November 30, 1985 deadline until April 16, 1987, during which EQDP No. 235 did not exist and only the original type test for steam conditions was in the qualification file (EQDP 220), and qualification documentation to establish qualification for accident and service life radiation, temperature, and aging effects were not in the file. These qualifications are required by'the 00R Guidelines.
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| I NUREG-0940 1.A-162 l
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| Violation I.C - Scotch Over 130/70/17 Tape Cable Splices to Limitorque Motor Operators, EQ Data Package (EQDP) Nos. 31A, and 40.
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| The Scotch 130 (inner insulation)/70 (outer insulation)/17 (jacket) tape splices, were used to splice motor lead power connections from Limitorque Model SMB-000, SMB-3, and SMB-4 motor operators to Class IE field cables with fiberglass braided jackets outside of the drywell. The systems affected are (1) primary containment; (2) high pressure coolant injection; (3) reactor equipmentcooling;and(4)mainsteam. The three motor type / insulations contained in EQDP No. 31A were (1) Reliance /AC and DC Class B insulation; (2) Porter Peerless /AC Class B insulation; and (3) Electric Apparatus /AC Class B insulation, all qualified using the Limitorque B0003 test documentation in which type testing was performed at FRC. A review of EQDP 31A and the associated package, EQDP 40, by the NRC indicated that there was no evidence that could demonstrate qualification of Scotch 130/70/17 tape splices for installation on cables with fiberglass braided jackets.
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| In a response {{letter dated|date=June 17, 1987|text=letter dated June 17, 1987}}, NPPD indicated that the Scotch 130/70/17 tape splices had been removed and replaced with Okonite tape splices. The Scotch splices were replaced due to the licensee's inability to qualify the splices and their possible effect upon plant operation that was determined during a Limitorque walkdown and equipment operational analysis.
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| During the enforcement conference held at the Region IV office on June 20, 1988, NPPD indicated that 30 out of a total of 88 EQ motor operators had originally been using Scotch splices during the period of October 1984 to October 1986. The replacement of the Scotch splices with the Okonite splices was accomplished using maintenance work requests. NPPD further indicated that all necessary replacements have been accomplished and that EQDP No. 40 for Scotch tape splices has been removed from the EQF and archived. CNS, however, had been operating since the November 30, 1985 deadline until as late as November 1986 with Scotch 130/70/17 tape splices. These splices were not considered to be qualified in that documentation for establishing qualifications was unavailable.
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| Violation II.A. Boston Insulated Wire (BlW), Bostrad 7E, EQDP No.6 The analysis contained in EQDP 6 did not clearly address the results of the BIW testing as it applies to the Bostrad 7E cable installed at CNS. The analysis was inadequate in that insulation resistance (IR) values (Leakage current) for 20 and 50 foot cables, measured during the type test, were used in the calculations for determining whether the installed cable met the specified functional performance requirements of the plant safety analysis. The IR values in the calculations were not converted to a per foot basis such that the acceptable leakage currents could be determined considering the overall plant circuit runs, such as length of cable, splices, penetrations, and any other probable leak paths applicable to the CNS plant. NPPD used the IR values NUREG-0940 I.A-163
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| 1 directly from the Franklin test report in determining acceptability. The failure to use actual circuit run IR values prevented NPPD from making an adequate analysis of the circuit run effects on instrument or component accuracy.
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| The NPPD response letter to NRC, June 17, 1987, stated that the analysis in EQDP No. 6 was not clear, required further clarification, and further analyses would address the necessary functional accuracy aspects related to the CNS instruments / components.
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| During the enforcement conference between NPPD and NRC Region IV on June 20, 1988, NPPD indicated that all BIW Bostrad 7E cables were installed at CNS prior f to the November 30, 1985, deadline and that IR measurements during type testing are now getting the proper attention in accordance with the latest regulatory guidance available. NPPD was in the process of preparing the additional analysis to address the specified functional performance requirement.
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| In a {{letter dated|date=July 13, 1988|text=letter dated July 13, 1988}}, NPPD provided an updated status of the June 17, 1987 analycis with respect to EQDP No. 6. This letter, which also addressed the additional analysis discussed during the enforcement conference, stated that the functional analysis of the BIW Bostrad 7E cable, to demonstrate that the IR values are acceptable for EQ applications, was completed by June 1988. This analysis will be incorporated into EQDP No. 6.
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| Violation II.B. Mounting Orientation and Interfaces of Various Pressure / Level Switches and Transmitters, EQDP No's 9, 12, 13, 33, 33A, 36, 37, 49, 76, 81, 217, 222, and 228 At the time of the NRC inspection, the above EQDP's for pressure and level transmitters, switches, and conduit seals did not address mounting orientation and interfaces of the equipment requiring environmental qualification. It could not be verified from the EQF that this equipment at CNS was installed in the same configuration that it was type tested in. NPPD concurred with the inspection findings that this was a weakness in the EQF and committed tn correct it. Since NPPD showed evidence that mounting, orientation. and interfaces were contained in the installation instructions for EQ equipment in other files, these generic omissions in the EQF were only considered to be file deficiencies.
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| Failure to address mounting, orientation, and intcrface requirements in the EQF for instruments, components, and e Guidelines and NUREG-0588 (Category I)quipment
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| . This fai'ure is is contrary to the considered a generic DOR concern. CNS had been operating since the November 30, 1985 deadline without this qualification documentation in the EQF.
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| The NPPD response letter to NRC dated June 17, 1987, indicated a lack of a proper evaluation by NPPD. The preparation and review of these qualifications ,
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| in the EQF were considered to be an oversight. NPPD comitted to revise the l EQDP's to incorporate the necessary mounting, orientation, and interface l requirements not currently addressed. '
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| NUREG-0940 1.A-164 l
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| During the enforcement conference between NPPD and NRC Region IV held on June 20, 1988, NPPD indicated that references to documents, which give description of component and equipment mounting, orientation, and interface requirements, would be included in the EQF.
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| Violation II.C. Raychem Coaxial Cable, Rayolin R and F, EQ Data Package (EQDP) No. 4 During the NRC inspection, EQDP No. 4 contained documentation for five types of Raychem coaxial cable (M1 through M5) as installed throughout the plant including containment. Types M1 through M3 were listed as containing Rayolin F insulation and M4 and M5 were listed as containing Rayolin R. It could not be determined whether the Rayolin F and Rayolin R insulation materials that were type tested were the same as those installed. The Nebraska Public Power District (NPPD) response letter to NRC dated June 17, 1987, verified that Rayolin R material is a regular cross-linked polyolefin insulation used in cable types M4 and M5 which is suitable for class 1E harsh environment applications. Rayolin F material, however, is a foam cross-linked polyolefin insulation used in cable types M1, M2, and M3 for standard service cable applications and generally not suitable for class 1E harsh environment applications. M1, M2, and M3 cable type documents have since been removed from the EQDP No. 4 file. During the enforcement conference held on June 20, 1988, HPPD indicated that the cable review task had completed their walkdown in June 1988 and neither Rayolin F (M1, M2, and M3) nor Rayolin R (M4 and M5) are used in EQ applications at Cooper Nuclear Station (CNS). NPPD indicated that EQDP No. 4 has been removed from the equipment qualification file (EQF), and placed in the archives.
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| NPPD had been operating since the November 30, 1985, deadline until June 1988 without having sufficiently analyzed and having knowledge as to whether the unqualified standard service cables (Rayolin F) were being used in EQ applications at CNS. NPPD had no basis for the qualification of Raychem coaxial cable, Rayolin F, in that it did not adequately demonstrate similarity between the tested and the susceptive installed cables at CNS.
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| 1 NUREG-0940 I.A-165
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| l i
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| # "'8%, UNITED STATES fi '
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| ; NUCLEAR REGULATORY COMMISSION
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| !'f3 ts i#
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| REoioN ev 811 RYAN PLAZA DRIVE. SUITE 1000
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| '% ,[,~} , / ARUNGTON, TEXAS 79011 j
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| j OCT I 219P9 Docket No. 50-285 License No. DPR-40 '
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| EA 88-145 I Omaha Public Power District ATTN: R L. Andrews, Division Manager-Nuclear Production 1623 Harney Street Omaha, Nebraska 68102 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL' PENALTY (NRC INSPECTION REPORT 50-285/88-15)
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| This refers to the inspection conducted during the period April 6 through May 13, 1988 at the Fort Calboun Station by personnel of the NRC Region IV office. As a result of this inspection, two violations of NRC requirements were and reported identified to the involving NRC: p(roblems
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| : 1) the potential that had forbeen discovered a coninon mode by the licensee failure of the Safety injection and Refueling Water Tank (SIRWT) level controllers resulting in a possible loss of safety in Loss of Coolant Accident (LOCA)jection ; and (2)and a loss containment spray flow of containment during a integrity because of a failure to reinstall a test cap on a pressure sensing line after completion o'f a leak rate test. The details of these violations were described l
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| in an NRC inspection report sent to you on June 1,1988. An enforcement !
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| conference was held in the Region IV office on June 8, 1988,.to discuss these I violations. '
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| i Violation A in the enclosed Notice of Violation and Proposed Imposition of '
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| Civil Penalty (Notice) involves the potential for a common mode failure of the air-operated SIRWT low level switches and is considered by the NRC staff to be a significant violation of NRC requirements. Because of le3kage past the accumulator check valves, which separate the non-safety-related and the safety-related air supply to the SIRWT low level switches, a problem identified during testing in April 1988, a loss of the normal air supply to these level controllers
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| -coincident with a LOCA could have resulted in the premature actuation of the CERTIFIED Mall RETURN RECEIPT REQUESTED NUREG-0940 I.A-166
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| nry I? e Omaha Public Power District recirculation actuation signal, which, if the containment sump were dry, could have resulted in the failure of the high head safety injection and containment spray pumps. Although this problem was identified in April 1988, it could have been identified earlier had you responded more aggressively to the results of an NRC inspection in late 1985, in which a failure to test instrument air accumulator check valves was identified. The NRC staff considers the original iristallation of check valves designed for steam and water in the instrument air system at the Fort Calhoun Station and the failure of your programs to identify the SIRWT instrument air accumulator check valves as safety-related and to conduct appropriate tests to assure the performance of their safety function as major contributors to this violation.
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| Violation B in the enclosed Notice involves a loss of containment integrity because of the failure to reinstall a test cap on a containment instrument pressure sensing line (3/8-inch) after completion of a local leak rate test.
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| The cap was discovered missing during an audit that was in response to a previous violation issued in May 1987. Apparently, it had been missing for over a year. The NRC staff considers this violation significant because the missing cap could have resulted in a significant increase in radiation exposure to the public and plant personnel in the event of a design basis accident.
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| Technical Specification limits for leakage (local type B and C) were exceeded by a factor of almost seven. In addition, the missing cap was not brought to the attention of the proper level of management which caused the Engineered Safety Features instrumentation, which was affected, not to be placed in a tripped or bypassed condition. Further, it was not until the next day that the cap was replaced.
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| Violations A and B are similar in that an extended period of time elapsed before these potential safety significant problems were identified and corrected although NRC inspections had indicated deficiencies in these areas.
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| For each case, a more aggressive response to correcting the previous deficiencies may have led to an earlier discovery of these problems and would have minimized the duration of the degraded plant conditions. To emphasize the importance of promptly correcting deficiencies that have been brought to your attention, I have been authorized, after consultation with the Director, Office of Enforcement, and Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Polic Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988)y and i (Enforcement Policy), Violations A and B described in the enclosed Notice have been categorized as a Severity Level Ill probicm. The basc value of a civil penalty for a Severity Level III problem or violation is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered.
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| The NRC recognizes that: you identified these violations; once the violations were identified, the corrective actions taken were broad and considered the implications of the violations; and your past performance in the area of maintenance and surveillance has been good. The NRC views the implementation of the Design Bases Reconstitution Program as a very positive action and NUREG-0940 I.A-167
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| OCT l 2 !900, Omaha Public Power District encourages your efforts in this program to continue. The NRC also notes that: q these violations should have been discovered earlier had more aggressive action been taken; immediate corrective actions to replace the missing test cap were not taken; and there was an extended duration for which the violations existed.
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| Therefore, on balance, neither mitigation nor escalation of the base civil penalty was considered appropriate.
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| The NRC staff also identified, as a result of this inspection, a concern with regard to the the SIRWT outlet Valves LCV-383-1 and LCV-383-2, which provide parallel suction to the safety injection and containment spray pumps and isolate the SIRWT in the recirculation mode, and which are supplied by a single air accumulator assembly. While the single air accumulator was a part of the original licensing basis, the NRC staff understands that you plan to add an i additional accumulator in the near future. This matter is presently under review by the Office of Nuclear Reactor Regulation.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. in your i
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| response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act '
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| of 1980, PL 96-511.
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| Sincerel ,
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| b ' /t' Robert D. Martin Regional Administrator
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| ==Enclosure:==
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| Notice of Violation and Proposed i Imposition of Civil Penalty cc: I See attached J
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| NUREG-0940 1.A-168
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| Or.T I 2 m NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Omaha Public Power District Docket No. 50-285 ft. Calhoun Station License No. DPR-40 EA 88-145 During an NRC inspection conducted during the period April 6 through May 13, 1988, violations of NRC requirements were identified, in accordance with the
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| " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| A. Safety Injection and Refueling Water Tank Level Switches 10 CFR Part 50, Appendix B, Criterion XI, Test Control, and the Fort Calhoun Station, Unit 1, Updated Final Safety Analysis Report,' Appendix A, Approved Quality Assurance Program, require a test program be established to assure that all testing required to demonstrate that structures, systems, and components will perform satisfactorily in service is identified and performed. Also, the test program shall include, as appropriate, preoperational and operational tests during plant operation.
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| Contrary to the above, as of April 1988, the licensee had not established an adequate program to assure that certain check valves were tested to demonstrate these valves would perform satisfactorily in service. Specifi-cally, check valves associated with the air-operated Safety Injection and Refueling Water (SIRW) tank low level switches (A/, B/, C/, and D/FIC-383) were not tested during operation to assure that they would perform their intended safety function under certain accident conditions. When tested in April 1988, these check valves were found to leak excessively.
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| B. Loss of Containment Integrity
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| : 1. Technical Specification 2.8, " Limiting Conditions for Operation-Refueling Operations," requires certain conditions be satisfied during any refueling operations, including the requirement that all automatic containment isolation valves shall be operable or at least one valve in each line penetrating containment shall be closed.
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| Contrary to the above, refueling operations occurred during the period April 8-13, 1987, with a 3/8-inch containment pressure sensing instrument line left open to the outside atmosphere. This line had been open since March 27, 1987, when a maintenance technician l performing Surveillance Test ST-CONT-3 removed and did not replace a l
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| l l
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| NUREG-0940 1.A-169
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| OCT I? y Notice of Violation test cap on this line. There is neither an automatic containment isolation valve for this instrument line nor was manual Isolation Valve A/HCV-742 closed such'that no valve in the instrument line could be automatically closed or.was maintained closed to prevent an open path from the containment.
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| : 2. Technical Specification 2.6(1).a, " Limiting Condition for Operations-Containment Systems," requires that containment integrity not be violated unless the reactor is in cold shutdown condition.
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| Technical Specification, Definitions-Containment Integrity, defines i containment integrity, in part, by requiring that "(5) The uncontrolled I containment leakage satisfies Specification 3.5."
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| TechnicalSpecification3.5(4).c,"SurveillanceRequirement-Containment Tests," requires, in part, that "The combined leakage rate of all penetrations and valves subject to Type B and Type C tests shall be less than or equal to 0.6 La."
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| Contrary to the above, during the period May 28, 1987 to April 19, 1988, while the reactor was not in a cold shutdown condition, the leakage rate (as calculated by the licensee) through the uncapped containment pressure sensing instrument line connected to Penetra-tion M-38, subject to Type C testing, during a design basis accident would have exceeded 0.6 La by a factor of approximately seven (418,000 vs. 62,451 standard cubic centimeters per minute based on 0.6 La). I
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| : 3. Technical Specification 2.15 and associated Table 2-3, Footnote f,
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| " Limiting Condition for Operations - Instrument Operating Requirements for Engineered Safety Features" require, with regard to the contain-ment high pressure channels, that if one channel becomes inoperable, that channel must be placed in the tripped or bypassed condition ;
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| within eight hours from the time of discovery of loss of operability. !
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| Contrary to the above, when the test cap for the containment pressure instrument sensing line connected to Penetration M-38 was discovered ,
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| missing on April 18, 1988, at approximately 3:15 p.m. by licensee j personnel, the engineered safety features channel associated with l redundant Instruments A/PC-742-1 and A/PC-742-2 were placed in a i tripped or bypassed condition. The missing test cap was not replaced until approximately 9:45 a.m. on April 19, 1988. ;
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| Violations A and B have been categorized in the aggregate as a Severity Level III problem (Supplement 1). ;
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| Civil Penalty - $50,000 (assessed equally between the violations).
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| NUREG-0940 I.A-170
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| OCT : ? ~
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| Notice of Violation Pursuant to the provisions of 10 CFR 2.201, Omaha Public Power District (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a
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| " Reply to a Notice of Violation" and should include for each alleged violation:
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| (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penaltics if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalties will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty ,
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| in whole or jn part, such answer should be clearly marked as an " Answer to a i Notice of Violation" and may: (1) deny the violations listed in this Notice in wholeorinpart[4)showotherreasonswhythepenaltyshouldnotbeimposed.(2) this Notice, or dem In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR, Part 2, Appendix C (1988) should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph nunbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| l Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, ma.y be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| NUREG-0940 I.A-171 i
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| Notice of Violation The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region IV, and a copy to the NRC Resident Inspector at the Fort Calhoun Station.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| ~
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| h \ /
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| f(g El --
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| P,0bert D. Martin Regional Administrator Dated at Arlington, Texas this 12th day of October 1988 l
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| i l
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| NUREG-0940 1.A-172
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| y
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| [ $.
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| UNITED STATES NUCLEAR REGULATORY COMMISSION g f, j REGION I w e 475 ALLENDALE ROAD K8NG OF PRUCSI A, PENNSYLVANIA 19408 September 19, 1988 Docket Nos. 50-387 and 50-388 License Nos. NPF-14 and NPF-22 EA 88-143 Pennsylvania Power & Light Company ATTN: Mr. Harold W. Keiser Senior Vice President - Nuclear 2 North Ninth Street Allentown, Pennsylvania 18101 Gentlemen:
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| ==Subject:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Combined Inspection Reports Nos. 50-387/86-21; 50-388/86-22 and 50-387/86-25; 50-388/86-28)
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| This refers to the NRC inspections conducted on September 15-19, 1986 and November 17-21, 1986 to review the program for the environmental qualification (EQ) of equipment at Susquehanna, Units 1 and 2. The inspection reports were sent to you on October 31, 1986 and February 10, 1987, respectively. During the inspections, violations of NRC requirements which were identified by you, involving the lack of environmental qualificati n of certain items of electric equipment used in both units, were also reviewed. On June 30, 1988, an enfor e-ment conference was conducted with you and members of your staff to discuss the significance and extent of the violations, causes of the violations, and the corrective actions taken or planned.
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| One of the violations, which is described in Section I of the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), included the failure to maintain, for certain items of electric equipment, sufficient records to demonstrate that the items were qualified to perform their intended function (s) during the postulated environmental conditions. These items, which were identified by your staff, included Marathon terminal blocks in three motor operated valves at each unit, and Raychem heat shrink tubing splices in four Main Steam Isolation Valves at each unit. These terminal blocks and splices were used in areas to ensure certain containment functions would operate as intended durIng postulated accident environmental conditions.
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| These deficiencies clearly should have been known to you prior to November 30, 1935, which was the deadline for being in compliance with the EQ requirements.
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| With respect to the Marathon terminal blocks, you clearly should have known of the deficiencies because prior to November 30, 1985, the NRC issued Information Notices (IN) such as IN No. 83-73 which identified potential problems with the use of underrated terminal blocks in Limitorque operators. Further, a reasonable engineering review clearly would have also identified that the Marathon terminal blocks were not qualified for their required service because the accident profile was not bounded by the tested temperature profile.
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| NUREG-0940 I.A-173
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| Pennsylvania Power & Light Company With respect tc, the Raychem splices, you clearly should have known of the deficiencies because you had information from the vendor. Specifically, you had instructions from Raychem that specified the qualified use range for the heat shrink diameter that was employed and you clearly should have reviewed the design and installation of the splices which would have identified that the heat shrink diameter exceeded the qualified use range.
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| The violations described in this Notice demonstrate that sufficient attention was not provided to the EQ program at Susquehanna, as evidenced by inadequate engineering review, inadequate consideration of vendor installation informa-tion, and inadequate Quality Control of these activities. Further, af ter you identified the deficiencies in the Marathon terminal blocks, Models 300 and 6000 in June, 1986, adequate corrective actions were not then taken in that this series of the terminal blocks was replaced with the Series 1600 Marathon terminal blocks which were also unqualified. These terminal blocks were subsequently replaced on September 30, 1986 and October 15, 1986 for Units 1 and 2, respectively.
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| Accordingly, I have been authorized, after consultation with the Director of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) in the amount of Fif ty Thousand Dollars ($50,000) for the violation described in the enclosed Notice. In accordance with the
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| " Modified Enforcement Policy Relating to 10 CFR 50.49," contained in Generic j Letter 88-07 (Enclosure 2), the violation described in the enclosed Notice j has been determined to have affected a few systems and components, and therefore is considered to be an EQ Category C violation. The base value of a civil penalty for an EQ Category C violation is $75,000. I In determining the civil penalty amount, the NRC considered the four factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49", for escalation and mitigation of the base civil penalty amount. These factors consist of (1) identification and prompt reporting of the EQ deficiencies (150%); (2) best efforts to complete EQ within the deadline ( 50%); (3) cor-rective actions to result in full compliance ( 50%); and (4) duration of a violation which is significantly below 100 days (-50%).
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| With respect to the first factor, 50% mitigation is appropriate because both issues were identified by your staff and properly evaluated against applicable reporting requirements. With respect to the second factor, 25% mitigation is l appropriate because your efforts to enlist the support of several different external groups with equipment qualification expertise (to assist in setting up your equipment qualification program, and to audit and upgrade your program in a timely manner), reflect best efforts to complete the equipment qualification program within the deadline. However, during the NRC inspections it was apparent that a substantial amount of the work to upgrade the plant EQ files had been performed after the November 30, 1985 deadline and therefore full mitigation for this factor is not appropriate. With respect to the third factor, 25% escalation is appropriate because adequate corrective actions were not taken for the terminal block deficiency when it was initially identified in June 1986. As described above, when you discovered the unqualified terminal blocks you replaced them with other terminal blocks that were later also determinea to be unqualified.
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| NUREG-0940 I.A-174
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| l Pennsylvania Power & Light Company With respect to the fourth factor, mitigation is inappropriate since these EQ violations existed in excess of 100 days. Therefore, on balance, 50% reduction to the base civil penalty amount is appropriate. However, in accordance with Section IV.B of the enclosure to Generic Letter 88-07, the minimum 550,000 civil
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| )
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| penalty is being assessed. Although the policy permits full mitigation under certain conditions, full mitigation is inappropriate in this case again because your corrective actions for the initial deficiency with the Marathon terminal blocks was inadequate.
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| You are required to respond to this letter and sh'ould follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NP.C will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget, otherwise required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, O ' A-Re 1 d ator
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Imposition of Civil Penalty
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| : 2. Generic Letter 88-07 ce w/encis:
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| A. R. Sabol, Manager, Nuclear Quality Assurance E. A. Heckman, Licensing Group Supervisor R. G. Bryam, Superintendent of Plant-SSES H. W. Hirst, Manager, Joint Generation Projects Department R. J. Benich, Services Project Manager, General Electric Company B. A. Snapp, Esquire, Assistant Corporate Counsel H. D. Woodeshick, Special Office of the President J. C. Tilton, III, Allegheny Electric Cooperative, Inc.
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| Public Document Room (PDR)
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| Local Public Document Room (LPDR)
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| Nuclear Safety Information Center (NSIC)
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| NRC Resident Inspector Commonwealth of Pennsylvania NUREG-0940 I.A-175
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| l NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Pennsylvania Power and Light Company Docket Nos. 50-387 and 50-388 Susquehanna Units 1 and 2 License Nos. NPF-14 and NPF-22 EA 88-143 During NRC inspections conducted on September 15-19, 1986 and November 17-21, 1986, of the licensee's program for environmental qualification (EQ) of equip-ment, violations of NRC requirements were identified. In accordance with the
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| " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualifi-cation of Electrical Equipment Important to Safety of Nuclear Power Plants,"
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| contained in Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| I. VIOLATION ASSESSED A CIVIL PENALTY 10 CFR 50.49 (f), and (j), respectively, r equire that, in part, (1) each item of electric equipment important to safety shall be qualified by testing of identical or similar equipment with supporting analysis where appropriate to show that the equipment to be qualified is acceptable; and (2) a record of the qualification shall be maintained in an auditable form to permit verification that each item of electrical equipment important to safety is qualified and that the equipment meets the specified performance requirements under postulated environmental conditions.
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| i Contrary to the above, prior to November 30, 1985, the following items I were not demonstrated to be environmentally qualified:
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| : 1. The qualification of the three Marathon 300 and 6000 series terminal blocks in limitorque valve operators at each of the two units was not established under certain environmental conditions in that the accident temperature profile was not bounded by the tested temperature profile, nor did analysis of the test data show that these terminal blocks were acceptable. This condition was identified on June 17, 1986.
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| : 2. The qualification of four Raychem splices in each unit, used in Main Steam Isolation Valve solenoid pigtail leads, had not been established under certain environmental conditions in that no qualification data existed to support qualification of the small heat shrink sleeving as used in the bolted splices. This condition was identified in August 1986.
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| This violation constitutes an EQ category C violation.
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| Civil Penalty - 550,000 (This EQ violation existed in excess of 100 days of plant operation).
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| NUREG-0940 I.A-176
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| l l
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| Notice of Violation II. VIOLATIONS NOT ASSESSED A CIVIL PENALTY A. 10 CFR 50.49(f) requires that qualification of each item of electrical equipment important to safety shall be qualified by testing of identical or similar equipment with supporting analysis where appropriate to show that the equipment to be qualified is acceptable.
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| Contrary to the above, prior to an NRC inspection on November 17, 1986,
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| : 1. the qualification of Valcor high temperature wires was not established. The qualification was based on questionable test' data (unrealistically high insulation resistance measurements during simulated LOCA test). Subsequently, interim qualification of these wires was established before the end of the inspection i using additional data.
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| : 2. the qualification of Target Rock Solenoid valves was not established in that a difference existed between the valves tested and the valves installed, and there was no supporting similarity analysis in the qualification file provided. An adequate similarity analysis was provided before completion of the inspection.
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| Because qualification was established before the end of the inspection for both examples above, this is a Severity Level IV violation.
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| (Supplement I)
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| : 8. 10 CFR 50, Appendix B, Criterion V states, in part, that activities affecting quality shall be accomplished in accordance with instruc-tions and procedures.
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| Procedure DC 151.0 and Memorandum SS-2129k, dated March 20, 1986, specify instructions for accomplishing activities affecting quality and require that Replacement Item Equivalency Evaluations (RIEE) be incorporated into applicable EQ binders via a Binder Change Notice (BCN)
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| Contrary to the above, as of November 17, 1986 the completed RIEE had not been incorporated into the applicable EQ binders, via BCN, to reflect that the installed Rosemount model 1153 transmitters were equivalent to the specified Rosemount 1151 transmitters.
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| This is a Severity Level V violation (Supplement I).
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| Pursuant to the provisions of 10 CFR 2.201, Pennsylvania Power and Light Company (Licensee) is hereby required to submit a written statement of explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for NUREG-0940 I.A-177
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| i l
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| Notice of Violation each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance was or will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CF-2.201, the licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the mitigation factors in the
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| " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualifi- !
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| cation of Electrical Equipment Important to Safety for Nuclear Power Plants," I contained in Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, a copy to the Regional Administrator, U. S. Nuclear Regulatory NUREG-0940 I.A-178
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| Notice of Violation Commission, 475 Allendale Road, King of Prussia, PA, 19406 and a copy to the NRC Resident Inspector, Susquehanra 1 and 2.
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| FOR THE NUCLEAR REGULATORY COMMISSION W, h liam T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania thisj9dayofSeptember1988 NUREG-0940 1.A-179
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| y'
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| [T
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| * o UNITED STATES NUCLEAR REGULATORY COMMISSION !
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| y y REGION I l
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| *
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| * 475 ALLENoALE ROAD j KINO oF PRUSSI A, PENNSYLVANIA 194o6
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| ....+
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| November 15, 1988 Docket Nos. 50-277; 50-278 License Nos. DPR-44; DPR-56 i
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| EA 88-237 Philadelphia Electric Company ATTN: Mr. C. A. McNeill Executive Vice President-Nuclear 2301 Market Street Philadelphia, Pennsylvania 19101 Gentlemen:
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| ==Subject:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC Combined Inspection Nos. 50-277/88-26; 50-278/88-26 and 50-277/88-31; 50-278/88-31)
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| This refers to the two NRC physical security inspections conducted on July 25-29, 1988 and August 27-29, 1988 at the Peach Bottom Atomic Power Station, Delta, Pennsylvania. The reports of these inspections were sent to you on September 12, 1988. During ea-h inspection, NRC inspectors reviewed the circumstances associated with violations identified by your staff and reported to the NRC. Further, another violation of physical security requirements was identified by the inspectors. On September 22, 1988, an Enforcement Conference was conducted with you and members of your staff to discuss the violations, their causes, and your corrective actions.
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| The violations, which are described in the enclosed Notice of Violation and Propcsed Imposition of Civil Penalties, included (1) numerous examples of failure to take appropriate compensatory measures for degraded vital area barriers in that a guard or watchman was not posted as required to control access to the opening, or the. posted individual was found in a position where he could not physically control access or was found to be sleeping (the majority of these examples occurred in July and August 1988); (2) issuance of a vital area key to an unauthorized individual, as well as the failure to detect the missing key during subsequent key inventories and the failure by the security personnel to promptly take appropriate compensatory measures when your staff eventually detected that the key was missing; and (3) a failure to provide and/or maintain adequate assessment of portions of two protected area barriers and associated isolation zones.
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| With respect to the first violation, the NRC is concerned that either adequate communication did not exist between maintenance personnel and the security department to ensure appropriate measures were taken, or security personnel did not properly implement those compensatory measures. The NRC recognizes that all but one of the failures were identified by your staff, and appropriate CERTIFIED HAIL RETURN RECEIPT REQUESTED NUREG-0940 1.A-180
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| Philadelphia Electric Company disciplinary actions were taken. Further, the significance of any of the individual failures is low in that either the vital areas were located within other vital areas or the degradation could not easily have been exploited. Nevertheless, the examples in Violation I.A of the sleeping guards (Item I.A.4) are particularly significant in view of the attention given to assure that your employees are attentive to their duties as a result of the shutdown order. Further, the numerous occurrences of this violation demonstrate that appropriate action was not taken by management to preclude recurrence of these failures.
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| With respect to the second violation, involving, in part, issuance of a vital area key to an unauthorized individual, the NRC is concerned that numerous opportunities existed to recognize this error and take appropriate corrective measures, but these opportunities were missed by security personnel. For example, although two key inventories were performed by the security force, it was not recognized that the key was missing. Furthermore, when the error was eventually detected, corrective measures, as described in security procedures, were not promptly initiated, and these measures, when initiated, were not properly implemented. This is even more significant because the unauthorized individual to whom the key was assigned, after entering the vital area, left the door unlocked and it remained unlocked and without compensatory measures until discovered by a PECo Shift Security Assistant.
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| The NRC is concerned that the majority of the examples of the first violation, as well as all of the examples of the second violation, occurred in July and August 1988, notwithstanding the fact that three management meetings were conducted with PECo regarding peach Bottom since February to discuss serious weaknesses in the program, and these weaknesses had been raised with your staff during an inspection in June 1987. The NRC recognizes that a self-assessment of the security program was performed subsequent to the February 1988 meeting, that security program upgrades are being made at Peach Bottom, and a change in the security contractor has occurred. Nonetheless, the improvements made to date were not effective in precluding the occurrence of the violations.
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| The recent violations further demonstrate the importance of strong utility oversight and appropriate management attention to the program, as well as thorough analysis of root causes whenever deficiencies in the program are identified, so that effective corrective actions are taken to prevent recurrence.
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| Therefore, to emphasize these concerns, I have been authorized, after con-sultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penaities in the amount of Fifty Thousand Dollars ($50,000) for the two violations described in Section I of the enclosed Notice. The violations in Section I are each classified at Severity Level III in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy). The base civil penalty amount for a Severity Level III violation or problem is $50,000.
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| NUREG-0940 I.A-181
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| l Philadelphia Electric Company -Ee i l
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| W!th respect to Violation I.A., the penalty has been mitigated by 50% because of your identification and reporting of the incidents. With respect to Violation I.B. the penalty has been mitigated by 50% since the corrective actions by management, once the problem was identified by them, were considered unusually prompt and extensive.
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| You are required to respond to this letter and should follow the instructions f specified in the enclosed Notice when preparing your response. In your '
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| response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. ,
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| 1 Portions of the enclosed Notice contain details of your security program that have been determined to be exempt from public disclosure in accordance with 10 CFR 73.21 (Safeguards Information). Therefore, those portions will not be placed in the NRC Public Document Room and will receive limited distribution.
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| Further, in your response to this letter and Notice, you should place all l Safeguards Information in enclosures, so as to allow your letter (without enclosures) to be placed in the Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, P. L. No. 96-511.
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| Sincerely, Orizt-1 C* r;d By
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| .. . _ _ _ . . T . .. z _1L William T. Russell Regional Administrator
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| | |
| ==Enclosure:==
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| Notice of Violation and Proposed Imposition of Civil Penalty (Contains Safeguards Information (SGI))
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| NUREG-0940 I.A-182 i i
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| 1
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| % UNITED STATES
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| ((
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| NUCLEAR REGULATORY COMMISSION REGION I 5 t 475 ALLENDALE ROAD KING OP PRuttlA, PENNSYLVANIA 19406 l September 21, 1988 i Docket No. 50-286 l License No. DPR-64 EA 88-145 Power Authority of the State of New York Indian Point 3 Nuclear Power Plaat ATTN: Mr. John C. Brons Senior Vice President Nuclear Generation 123 Main Street White Plains, New York 10601 Gentlemen:
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| ==Subject:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS NOS. 50-286/86-10; 50-286/86-24; 50-286/87-20; and 50-286/87-22)
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| This refers to several NRC inspections conducted between August 16, 1986 and September 25, 1987 to review the program for the environmental qualification (EQ) of equipment at Indian Point 3. The inspection reports were sent to you on May 30, 1986, February 10, 1987, September 22, 1987 and January 7, 1988.
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| During the inspections, violations of NRC requirements were identified involving the lack of qualification of certain items of electric equipment used at the facility. Furthermore, the inspectors also reviewed other EQ violations identified by your staff. On July 19, 1988, an enforcement conference was conducted with you and members of your staff to (1) discuss the extent and significance of the violations, causes of the violation, and the corrective actions taken or planned, and (2) discuss several other factors in light of the Modified Enforcement Policy for EQ requirements which is described in the enclosure to NRC Generic letter 88-07.
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| The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), included the failure to maintain, for certain items of electric equipment, sufficient records to demonstrate that the items were qualified to perform their intended function (s) during the postulated environmental conditions, and/or the failure to ensure that the equipment was installed in a qualified configuration. These items, the majority of which were identified by your staff, included a cable connector assembly for High Range Radiation Monitors, Marathon Terminal Blocks, 480 volt motor lead splices, and Lewis Thermocouple cable.
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| These deficiencies clearly should have been known by you prior to November 30, 1985, the deadline for being in compliance with EQ requirements, because it was reasonable to assume that (1) licensees would perform adequate field verifica-tion to ensure that qualified equipment was used at the facility and was CERTIFIED MAIL
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| ((TURNRECEIPTREQUESTED NUREG-0940 I.A-183
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| Power Authority of the State 2 of New York inst,alled in a manner that maintained its qualification, and (2) adequate documentation existed in the qualification files to support the qualifications.
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| In the case of the High Range Radiation Monitor cable connector assembly, which was installed in an unqualified configuration, you clearly should have known of this condition because your equipment qualification documentation recognized the need for heat shrink tubing at the coaxial cable connection to the radiation monitor. With respect to the Marathon Terminal Blocks, which were not qualifiable for inside containment use, you clearly should have known of the deficiency because the installation instructions specifically identified the type of terminal block that was to be installed. You clearly should have known of the deficiency with the 480 volt motor lead splices because the need to perform an evaluation to establish differences between installed and tested configurations and to perform an analysis of the effect on qualification for these differences is a basic requirement of any environmental qualification program. Finally, with respect to the Lewis Thermocouple cable, you clearly should have known that the similarity analysis betwean the tested and the installed cable was inadequate because the differences in the cable materials was great and the extrapolation of test data too large to reasonably justify qualification by similarity analysis.
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| The violations described in this Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) demonstrate that Power Authority of the State of New York's management did not provide suf ficient attention to the EQ program at Indian Point 3 to assure that the program was completely in compliance with NRC requirements as of November 30, 1985. Accordingly, I hcve been authorized, after consultation with the Director of Enforcement and the D e uty Executive Director for Regional Operations, to issue a civil penalty in the amount of Seventy Five Thousand Dollars (575,000) for Violation I described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49,"
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| contained in Generic Letter 8B-07 (Enclosure 2), the extent of the problem described in Violation I of the enclosed Notice has been determined to be moderate and to have affected some systems and components, and therefore is considered to be an EQ Category B violation. The base value of a civil penalty for an EQ Category B violation is $150,000.
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| In determining the civil penalty amount, the NRC considered the four factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49",
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| for escalation and mitigation of the base civil penalty amount. These factors consist of (1) identification and prompt reporting of the EQ defi-ciencies ( 50?;); (2) best efforts to complete EQ within the deadline ( 50*;);
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| (3) corrective actions to result in full compliance ( 50?;); and (4) duration of a violation which is significantly below 100 days (-50?;).
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| Vith respect to the first f actor, 25?; mitigation is warranted since a majority of tLa items in the Notice were identified by your staff. However, full 50?;
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| mitigation based on this factor is not warranted since some of the items (the 480V mo*.or splices and the Lewis Thermocouple cabk ) were identified by the NRC.
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| With respect to the second factor, although the NRC recognizes efforts were made by the Power Authority of the State of New York to comply with the EQ NUREG-0940 I.A-184 l
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| Power Authority of the State 3 of New York rule within the deadline a number of EQ files were found to be incomplete with missing documentation needed to establish qualification; difficulty was encountered by the NRC in auditing the EQ files and there was indication at the time of the inspection of last minute reviews and approval signatures for E0 files; therefore, these efforts form no basis for escalation or mitigation of the civil penalty. With respect to the third factor, 25% mitigation is warranted for your corrective actions because you quickly corrected the quali-fication deficiencies associated with the HRRM cable connector assembly and the Marathon Terminal Blocks. However, full 50% mitigation based on this factor is inappropriate since at the time the 480 volt motor lead splice deficiencies were identified by the NRC, aggressive resolution of this issue by your staff was not initiated. In addition, numerous deficiencies identified by your EQ audits in January 1985 and August 1987 took an excessive time to be resolved.
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| With respect to the fourth factor, mitigatica is inappropriate since these EQ violations existed in excess of 100 days. Therefore, on balance a 50% reduction to the base civil penalty amount is appropriate.
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| Certain items of unqualified equipment were able to be qualified during the inspection, or shortly thereafter and these items constitute a separate violation which is classified at Severity Level IV in accordance with the " General State-ment of Policy and Procedure for NRC Enforcement Action, 10 CFR 2 Appendix C (Enforcement Policy) (1988) and is set forth in Section II of the enclosed Notice.
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| Though not the subject of a Notice, as mentioned above, the NRC staff is concerned that at the time of the inspections, numerous EQ files were incomplete and file auditability was poor even though the files had been significantly improved in the weeks immediately preceding the inspection.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget, otherwise required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, William T. Russell Regional Administrator NUREG-0940 I.A-185
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Power Authority of the State of New York Docket No. 50-286 Indian Point 3 License No. DPR-64 EA 88-148 During several NRC inspections conducted between April 16, 1986 and September 25, 1987 of the licensee's program for environmental qualification (EQ) of equipment, NRC inspectors identified violations of NRC requirements and reviewed other violations identified by the licensee. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety of Nuclear Power Plants," contained in NRC Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:
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| : 1. VIOLATION ASSESSED A CIVIL PENALTY 10 CFR 50.49(d), (f), and (j), respectively, require, in part, that (1) a list of electric equipment important to safety be prepared, and information concerning performance specifications, electrical characteristics and postulated environmental conditions for this equipment be maintained in a qualification file; (2) each item of electric equipment important to safety shall be qualified by testing and/or analysis of identical or similar equipment, and the qualification based on similarity shall include a supporting analysis to show that the equipment to be quali-fied is acceptable; and (3) a record of the qualification shall be maintained in an auditable form to permit verification that each item of electrical equipment important to safety is qualified and that the equipment meets the specified performance requirements under postul?ted environmental conditions.
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| Contrary to the above, from November 30, 1985 until certain dates specified herein, the following items were not demonstrated to be environmentally qualified,
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| : a. As of September 2, 1986, qualification of the containment High Range l Radiation Monitors (Nos. R-25 cnd R-26) cable connector assembly was !
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| deficient in that the cable / connector assembly was installed in a configuration different than tested in that the installed assembly was missing the environmental Raychem heat shrink tubing.
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| : b. As of September 2, 1986, qualification of six series 200-300 Marathon Terminal Blocks inside containment (used in safety related circuits ;
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| for containment sump level indication, recirculation sump level indicator, and containment water level indication) was deficient.
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| Specifically, these terminal blocks are not qualifiable for the NUREG-0940 I.A-186
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| I I
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| 1 I
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| Notice of Violation 2 particular inside containment application because of the potential for electrical shorting due to moisture buildup.
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| : c. As of August 21, 1987, the qualification of 480 volt motor lead splices, used as power leads for twenty-nine motors in Engineered Safeguards, Auxiliary Feedwater and Auxiliary Coolant Systems, was deficient in that an evaluation had not been performed of differences between installed and tested configuration.
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| : d. As of September 25, 1987, the qualification of Lewis Thermocouple cable used in Hydrogen Recombiners (for monitoring the temperature of the recombiner elements for control of the recombiner), was deficient. Specifically, the similarity analysis was inadequate in that it failed to adequately justify the acceptability of differences, such as insulation formulation, between the cable tested and installed cable.
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| l These violations constitute an EQ category B violation.
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| Civil Penalty - 575,000 (These EQ violations existed in excess of 100 days of plant operation).
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| II. VIOLATION NOT ASSESSE0 A CIVIL PENALTY 10 CFR 50.49(d), (f), and (j), respectively, require, that (1) a list of electric equipment important to safety be prepared, and information concerning performance specifications, electrical characteristics and postulated environmental conditions for this equipment be maintained in a qualification file; (2) each item of electric equipment important to safety shall be qualified by testing and/or analysis of identical or similar equipment, and the qualification based on similarity shall include a supporting analysis to show that the equipment to be qualified is acceptable; and (3) a record of the qualification shall be maintained in an auditable form to permit verification that each item of electrical equipment important to safety is qui.lified and that the equipment meets the specified performance requirements under postulated environmental conditions.
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| Contrary to the above, examples of the violation include:
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| : a. From November 30, 1985 until September 25, 1987, thirteen items of electrical equipment important to safety were not included on the EQ master list of electric equipment important to safety. The specific items not properly incorporated onto the EQ Master List are those 13 items specifically not required by Regulatory Guide 1.97 which are listed in licensee memorandum No. EQ-IP-87-301, dated September 8, 1987.
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| NUREG-0940 I.A-187
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| Notice of Violation 3
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| : b. From November 30, 1985 until September 25, 1987, qualification for Silicon Rubber Insulated Cable was not established in that the cable had not been tested for submerged applications. A similarity analysis was performed based on test data for a cable with different insulating materials, but the effects of different chemical composition and the variation of the manufacturing process were not fully evaluated.
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| However, the cable was considered qualifiable considering the large margin to failure.
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| : c. From November 30, 1985 until August 24, 1987, the qualification for 14 AWG single conductor Amerlink cables was not established in that the qualification documer 's supporting cable qualification were not i complete. Specifically, the qualification test results, although available, had not been incorporated in the qualification file.
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| This is a Severity Level IV violation. (Supplement I)
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| Pursuant to the provisions of 10 CFR 2.201, Power Authority of the State of New York (Licensee) is hereby required to submit a written statement of explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance was or will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required abos- under 10 CFR 2.201, the licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty., in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, l (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| NUREG-0940 I.A-188
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| Notice of Violation 4 1
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| In requesting mitigation of the proposed penalty, the mitigation factors in the
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| " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualifi-cation of Electrical Equipment Important to Safety for Nuclear Power Plants,"
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| contained in Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g. , citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, j remitted, or mitigated, may be collected by civil action pursuant to Section i 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, nottd above (Reply to a l Notice of Violation, letter with payment of civil penalty, and answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, U. S. Nuclear Regulatory Commission, 475 Allendale Road, King of Prussia, PA, 19406 and a copy to the NRC Resident Inspector, Indian Point 3.
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| FOR THE NUCLEAR REGULATORY COMMISSION William T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania thisq/ day M of September 1988.
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| NUREG-0940 I.A-189
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| [ 4, UNITED STATES y
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| %.. j NUCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20555
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| ( I N **"" /
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| NOV 21 1988 Docket No. 50-346 License No. NPF-3 EA 88-234 Toledo Edison Company ATTN: Mr. Murray R. Edelman President Edison Plaza 300 Madison Avenue Toledo, Ohio 43652 .
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| Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY AND ORDER MODIFYING LICENSE (NRC INSPECTION REPORTS NO. 50-346/88012(DRP)
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| AND N0. 50-346/88027(DRP))
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| This refers to the inspections conducted on May 4 through September 2, 1988,- ,
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| of your quality control (QC) and quality assurance (QA) activities at the j Davis-Besse Nuclear Power Station (Davis-Besse), Oak Harbor, Ohio. These ;
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| inspections concerned an allegation regarding the discriminatory layoff by '
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| your former QC Supervisor, Mr. Louis R. Wade, of a contract QC Inspector who i had raised safety concerns to your senior management. l These inspections also concerned other allegations of activities cc.iducted .
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| hy or under the direction of Mr. Wade which violated NRC requirements. The i resui'5 of these inspections were described in the subject inspection reports sent to you on September 12 and 22, 1988. On September 26, 1988, we held an enforcement conference batween Mr. D. C. Shelton and others of your staff and Mr. A. B. Davis and others of the NRC staff during which the violation, its root causes and your corrective actions were discussed. The report describing the results of that enforcement conference and a followup meeting on September 28, 1988 was forwarded to you on September 30, 1988.
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| In July of 1986, a QC Inspector identified deficiencies in the installation of an electrical wire splice and subsequently initiated a Potential Condition Adverse to Quality Report (PCAQR). Mr. Wade was instrumental in having the report improperly invalidated instead of processing it in accordance with station procedures. Despite the invalidation of the PCAQR, the QC Inspector was still concerned about the issue and refused to dismiss it. In an attempt to resolve this issue, Mr. Wade requested that the QC Inspector formally document and clarify his concern. The QC Inspector did so in a memorandum dated October 10, 1986, and provided copies to Mr. Wade's direct supervisor, Lorren 0. Ramsett, and the Senior Vice-President, Nuclear, Joe Williams. As a result of this memorandum, Mr. Ramsett investigated the matter and subsequently, after several disc.ussions with the QC Inspector and Mr. Wade, issued a tremorandum dated October 29, 1986, to Mr. Wade reprimanding him for his improper handling of the QC Inspector's safety concern.
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| NUREG-0940 I.A-190
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| Toledo Edison Company In the meantime, during the period between late September and early October 1986, as a result of an upcoming reduction in force, Mr. Wade requested that the lead QC inspectors provide him with a list indicating the layoff sequence for contract QC inspectors. The QC Inspector who had raised the previous safety concern, had been listed on the applicable layoff priority list as an individual who should be retained, if possible, due to his good work history and diverse capabilities. Despite this recommendation, Mr. Wade directed the layoff of the QC Inspector. As a result, on October 31, 1986, that QC Inspector was laid off. The QC Inspector was one of the first contract QC inspectors to be laid off and he was the first QC inspector to be laid off from his particular QC section. Moreover, within 15 days, the vacancy in that section created by his employment termination was filled by another contract QC inspector. The NRC has concluded that the termination of that QC Inspector was a discriminatory act in violation of 10 CFR 50.7 as described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty.
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| The actions of Mr. Wade could have a significant effect on the willingness of individuals to raise safety concerns. An essential element of quality programs is an aggressive, proactive approach to the identification and resolution of safety concerns at an incipient stage to preclude later problems.
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| To emphasize the need for you: (1) to ensure that your supervisors and managers do not take discriminatory actions against employees for bringing forward safety concerns, and (2) to ensure that your employees feel free to bring safety concerns to managements attention, I have decided to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Eighty Thousand Dollars ($80,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988)
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| (Enforcement Policy), the violation described in the enclosed Notice has beer categorized at a Severity Level II based on Supplement VII of the Enforcement Policy because the action taken by Mr. Wade was considered deliberate and his position was considered above first-line supervision.
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| The base value of a civil penalty for a Severity Level II violation is $80,000.
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| The escalation and mitigation factors in the Enforcement Policy were evaluated as follows. Because the NRC identified the violation during the review of an allegation, mitigation of the civil penalty was not considered warranted.
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| Consideration was given to mitigation of the base civil penalty due to your extensive corrective actions including the employment termination of Mr. Wade and the notification of your staff and management of the seriousness of this na tter. However, after considering the earlier notification of this problem provided to Mr. Ramsett and Corporate Counsel during the NRC inspection and investigation in July and August 1988 and your lack of initiative to implement corrective actions until late September, mitigation of the base civil penalty is inappropriate. Because your performance in this area has been good, as evidenced by the absence of citations made by the NRC and adverse findings made by the Department of Labor, mitigation is warranted for past good performance.
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| With regard to prior notice of similar events, there has not been prior notice which should have caused you to prevent this violation justifying escalation.
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| Because there was only one occurrence of this violation during the inspection period, the civil penalty was not escalated on the basis of multiple NUREG-0940 I.A-191
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| l Toledo Edison Company occurrences. The duration of the violation was also considered. Specifically, l
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| a civil penalty may be increased to reflect the added significance resulting from the duration of the effects of tne violation. In this case, the violation occurred in October 1986 and was not rectified until September 1988. During that extended period, there was a significant potential of a " chilling effect" on employees' willingness to bring forward safety concerns. The impact of this violation could have been reduced if your management had questioned the circum-stances surrounding the QC Inspector's layoff. Specifically, Mr. Ramsett met with the QC Inspector on his last day at the site and gave him a copy of the memorandum that criticized Mr. Wade's improper handling of the QC Inspector's valid safety concern. If Mr. Ramsett had questioned why the same QC Inspector involved in this issue was being laid off, the violation could have been identi-fied sooner, thereby reducing the potential " chilling effect". Escalating the penalty for duration is warranted. Based on balancing the above considerations, no adjustment to the base civil penalty is warranted.
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| In addition to the inspection finding regarding the discriminatory action taken by Mr. Wade, our inspections also disclosed concerns regarding his performance. These concerns were addressed in the inspection report and Notice of Violation transmitted to you by {{letter dated|date=September 22, 1988|text=letter dated September 22, 1988}}.
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| Because of these findings, we no longer have confidence that activities performed by Mr. Wade or under his direction will be conducted in accordance with NRC requirements. We understand from our enforcem2nt conference with you that you removed Mr. Wade from his supervisory position in August 1988, that you removed his access to your facility in September 1988, and that you have terminated his employment effective November 1988. Because of our concern regarding this individual, we are issuing the enclosed Order Modifying License.
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| The Order directs that Toledo Edison Company provide the NRC with notice shc11d Mr. Wade be reinvolved in safety-related activities authorized under the Davis-Besse Operating License.
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| You are required to respond to this letter and should follow the instructions '
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| specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence of the violation described in the enclosed Notice. You should also respond to the enclosed Order indicating action taken to comply with its provisions. In your responses, you should describe what involvement Mr. Ramsett had in these matters, why your QA program did not disclose these problems earlier, and what actions you are taking or have planned regarding the failure to identify and resolve these problems. In addition, you should describe what actions ycu are taking to determine if any safety concerns have been identified, but have not been properly handled as a result of the potential " chilling effect" the discrimination violation may have j caused. After reviewing your response to this hotice, including your proposed l corrective actions and the results of future NRC inspections, the NRC will i determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. l In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.
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| NUREG-0940 1.A-192
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| l l
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| I Toledo Edison Company .4- )
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| The responses directed by this letter and the enclosed Notice are not subject J to the clearance procedures of the Office of Manageme.it and Budget, as required l by the Paperwork Reduction Act of 1980, Pub. L., No. 96-511.
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| Sincerely, x
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| Ja es M. Taylor eputy Executive Director for Regional Operations
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| ==Enclosures:==
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| 1.- Notice of Violation and Proposed Imposition of Civil Penalty
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| : 2. Order Modifying License
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| : 3. Inspection Report No. 50-346/88012(DRP)
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| : 4. Inspection Report No. 50-346/88027(DRP) cc w/ enclosures:
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| L. Wade D. Shelton, Vice President-Nuclear L. Storz, Plant Manager DCD/DCB(RIDS)
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| Licensing Fee Management Branch Resident Inspector, RIII Harold W. Kohn, Ohio EPA James W. Harris, State of Ohio Robert M. Quillin, Ohio Department of Health State of Ohio, Public Utilities Commission NUREG-0940 I.A-193
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Toledo Edison Company Docket No. 50-346 Davis-Besse Nuclear Power Station License No. NPF-3 EA 88-234 During NRC inspections conducted on May 4 through September 2, 1988, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act),
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| 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:
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| 10 CFR 50.7, " Employee Protection," prohibits discrimination by a Commission licensee against an employee for engaging in certain protected activities.
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| Discrimination includes discharge and other actions related to compensation terms, conditions, and privileges of employment. Protected activities include identifying and ensuring the correction of safety violations.
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| Contrary to the above, on October 31, 1986, a Quality Control Inspector was discharged from work at the Davis-Besse Nuclear Power Station by the Quality Centrol Supervisor for identifying and pursuing resolution of the failure of the Quality Control Supervisor to follow a quality related procedure.
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| This is a Severity Level II violation (Supplement VII).
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| Civil Penalty - $80,000.
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| Pursuant to the provisions of 10 CFR 2.201, Toledo Edison Company is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Conunission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply)to a Notice of Violation" and should include for each alleged violation: (1 admission or denial of the alleged violation; (2) the reasons for the violation if adnitted; (3) the corrective actions that have been taken and the results achieved; (4) the corrective actions that will be taken to avoid further violations; and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an Order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other actions as may be proper should not be taken. Consideration may be given to extending the respunse time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2282, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required under 10 CFR 2.201, ,
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| the Licensee may pay the civil penalty by letter to the Director, Office I of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition cf the civil penalty in whole or in part by a written answer addressed to the Director, NUREG-0940 I.A-194
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| )
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| i Notice of Violation Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an Order imposing the civil penalty will te issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violation listed in this Notice in whole or in part; (2) demonstrate extenuating circumstances; (3) show error in this Notice; or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, in whole or in part, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, the be
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| , should factors addressed addressed. Any in written answer in accordance with 10 CFR 2.205 should be set forth separately frcm the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provision of 10 CFR 2.105, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTH: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region III, U,S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137 and a copy to the NRC Inspector at the Davis-Besse Nuclear Power Station.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| /
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| J[ M. Taylor, u y Executive Director or Regional Operations Dated at Rockville, Maryland this # day of November 1988 NUREG-0940 I.A-195
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| UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of )
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| Toledo Edison Company ) Docket No. 50-346 Davis-Besse Nuclear Power Station ) License No. NPF-3
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| ) EA 88-234 ORDER MODIFYING LICENSE I
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| The Toledo Edison Company (Licensee) is the holder of Operating License No. NPF-3 issued by the Nuclear Regulatory Commission (NRC/ Commission) on April 22, 1977.
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| The license authorizes the Licensee to operate the Davis-Besse Nuclear Power Station (Davis-Besse) in accordance with the conditions specified therein.
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| II A special NRC safety inspection (Inspection Report No. 50-346/88027(DRP)) I conducted during the period from May 4 through September 2, 1988, and an NRC investigation (Investigation No. 3-88-008) confirmed an allegction regarding the discriminatory layoff by the former Quality Control (QC) Manager at Davis-Besse, Louis R. Lade, of a contract QC Inspector who had raised safety concerns to licensee senior management. Specifically, the NRC concluded that the termination of the QC Inspector was a discriminatory act in violation of 10 CFR 50.7 and is described in a Notice of Violation and Proposed Imposition of Civil Penalty being issued this date. The details of the 10 CFR 50.7 violation are as follows.
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| On July 10, 1986, a Potential Condition Adverse to Quality Report (PCAQR) was written by a QC Inspector concerning deficiencies in the installation of an l electrical wire splice. Mr. Wade (who at the time was a QA engineer) was instrumental in having the PCAQR ir. properly invalidated instead of processino NUREG-0940 1.A-196
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| l it in accordance with station procedures which require that PCAQRs be processed through the Shift Supervisor, the Plant Technical Support Department and the PCAQR Review Board. (Mr. Wade was promoted shortly thereafter to QC Supervisor and then'to QC Manager in 1987.) Because the QC Inspector was still concerned about the issue and refused to dismiss it, Mr. Wade requested that he formally document and clarify his concerns. The QC Inspector reiterated his safety concerns and the improper way his concerns were handled in a memorandum dated October 10, 1986, and provided copies to the Quality Assurance (QA) Director l
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| l and the Senior Vice-President, Nuclear. As a result of the QC Inspector's memorandum, the QA Director (Mr. Wade's supervisor) investigated the matter and subsequently after several discussions with Mr. Wade, issued a memorandum:
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| dated October 29, 1986, to Mr. Wade reprimanding him for his improper handling of the QC Inspector's safety concerns.
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| During the period between late September and early October 1986, in preparation for an upcoming reduction in contact QC inspector workforce due to the end-of-outage reduction in workload, Mr. Wade requested that the lead QC inspectors provide him with a list indicating the layoff sequence for contract QC inspectors.
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| This QC Inspector's lead considered the QC Inspector to be one of approximately four or five inspectors who were good performers with iruitidisciplinary inspection skills who should not be laid off if possible. There is no question that the QC organization thought highly of the QC Inspector who was considered a competent and respected inspector. Despite the recommendation to retain the QC Inspector if possible, Mr. Wade directed that the QC Inspector be laid off.
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| Therefore, en October 31, 1986, the QC Inspector was laid cff. In addition, the QC Irispector was cne of the first contract QC inspectors to be laid off and he was the first GC inspector to be laid off from his particular QC section.
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| NUREG-0940 I.A-197 )
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| Moreover, within 15 days, the vacancy in that section created by his employment termination was filled by another contract QC inspector.
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| At the enforcement conference on September 26, 1988, the licensee informed the staff that it had removed Mr. Wade's site access on September 23, 1988, and that it had terminated Mr. Wade's employment effective November 1988.
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| III In addition to the discrimination issue addressed in Section II above, additional concerns have been identified relative to the performance of Mr. Wade. A sec6nd special NRC safety inspection (Inspection Report No. 50-346/88012 (DRP)) confirmed other allegations of activities conducted by or under the direction of Mr. Wade.
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| A Notice of Violation concerning several violations identified during this inspection was issued cn September 22, 1988.
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| IV i
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| Based on the results of the NRC inspection and investigation, the staff has concluded that Mr. Wade intentionally removed the QC Inspector from the Davis-Besse facility for raising a safety issue. For alnost two years, until disclosure by the NRC, the effect of this act had the potential to " chill" the proper actions of others. The conduct of Mr. Wade removing the QC Inspector who was properly raising safety issues cannot be tolerated. The public beelth and safety requires an effective quality assurance program in order to provide NUREG-0940 1.A-198
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| assurance that licensed activities are properly conducted. Moreover, a basic tenet of the Comission's quality assurance requirements, is that quality control workers must be free to be able to raise safety concerns without fear of retaliation.
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| The actions of Mr. Wade as described in Section II and III above, demonstrate that he cannot be relied upon to assure that quality assurance programs are properly conducted and that quality control workers will be permitted and encouraged to raise safety issues. Therefore, I have determined that I no longer have reasonable assurance that licensed activities conducted by or under the supervision of Mr. Wade will be conducted in accordance with NRC requirements. Accordingly, I have concluded that it is necessary for the NRC to be informed if Mr. Wade is rehired to permit the NRL to determine, at that time, whether further regulatory action is required.
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| V Accordingly, pursuant to Sections 103, 161 b, i, and o, 182, and 186 of the Atomic Energy Act of 1954, as amended, and the Commission's regulations in 10 CFR 2.204 and 10 CFR Part 50, IT IS HEREBY ORDERED THAT:
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| License No. NPF-3 is amended adding the following condition:
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| The Licensee shall provide the NRC Regional Administrator, RIII, written notice within one week of Mr. Louis R. Wade's re.nvolvement in safety-related activities authorized under License No. APF-3. The notice shall include a statement from the Licensee as to its basis for concluding that, in light of Mr. Wade's conduct which resulted in his removal, he will properly carry out licensed activities.
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| NUREG-0940 1.A-199
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| 1.
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| 1 The Regional Administrator, Region III, may relax or terminate this condition for good cause shown.
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| VI The Licensee, Mr. Wade, or any other person adversely affected by this Order may request a hearing within 30 days after issuance of this Order. Any answer to this Order or any request for hearing shall be submitted to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555. Copies shall also be sent to the Assistant General Counsel for I
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| Enforcement at the same address and to the Regional Administrator, U.S. Nuclear Regulatory Commission, Regien III, 799 Roosevelt Road, Glen Ellyn, Illinois 60137. If a person other than the Licensee requests a hearing, that person shall set forth with particularity the manner in which the petitioner's interest is adversely affected by the Order and should address the criteria set forth in 10 CFR 2.714(d). Upon the failure of the Licensee, Mr. Wade, or any other person adversely affected by this Order to request a hearing within i the specified time, this Order shall be final without further proceedings.
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| If a hearing is requested, the Commission will issue an order designating the time and place of any hearing. If a hearing is held, the issue to be considered at such hearing shall be whether this Order should be sustained, r0R THE NUCLEAR REGULATORY COMMISSION
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| \ 1(
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| d s M. Tayle , Deputy Executive Director
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| / or Regiona'1 Operatior.s Rockville, Maryland Dateda(dayofNovember1988.
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| this y NUREG-0940 1.A 200
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| l l
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| A )
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| f / % UNITED STATES
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| . p9 3, 'gg NUCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20555 g
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| %'***** /
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| , JUL 0 81988 Docket Nos. 50-072 and 50-107 License Nos. R-25 and P-126 EA 88-64 Dr. James J. Brophy Vice President of Research University of Utah Salt Lake City, Utah 84112
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| | |
| ==SUBJECT:==
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| ORDEFi MODIFYING LICENSES AND NOTICES OF VIOLATIOM AND DEVIATION (NRC INSPECTION REPORT 50-407/88-01; 50-072/88-01)
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| Gentlemen:
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| This refers to the special inspection conducted during February 16-19, 1988, at the University of Utah, Salt Lake City, Utah, by H. Chaney, R. Evans, and D. Powers of this office. During this inspection, NRC personnel identified several violations that were discussed with you and your staff at an enforcement conference on March 28, 1988, at the NRC Region IV office in Arlington, Texas.
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| The violations identified during the inspection included the failure to perform Technical Specification (TS) surveillance, failure to establish procedures for alterations of core components, failure to perform adequate radiological surveys (two examples), failure to provide required airborne monitoring equipment, failure to follow physical security procedures, failure to secure fuel handling equipment, and failure to properly submit changes to the Physical Security. Plan. Even though earlier corrective actions improved the oversight of the Reactor Safety Committee, we are concerned that your program for problem identification and correction has been ineffective. In this particular case, the root cause appears to be a lack of management support in providing the necessary resources to ensure that identified problems are effectively corrected in a timely manner.
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| Collectively, the violations identified during this inspection demonstrate that a better understanding of the regulatory requirements and facility procedures is needed and that greater attention to detail in performing day-to-day duties is necessary. Management must ensure that the facility audit and review program is thoroughly and aggressively implemented.
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| In order to address the need for aggressive management oversight of facility activities I have determined that tue Order, enclosed as Appendix A, be issued confinning the commitment you made to the NRC in a {{letter dated|date=June 14, 1988|text=letter dated June 14, 1988}} to retain an individual to serve as reactor supervisor. Though not discussed in your letter, the NRC staff understands that the professor that has been acting as the reactor supervisor will continue to devote approximately one quarter of his time toward reactor a:tivities.
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| Additionally, in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Action," 10 CFR Part 2, Appendix C (1988), the violations NUREG-0940 I.A-201
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| University of Utah described in the enclosed Notice, in Appendix B, have been classified at a Severity -
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| Level IV.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice and Order when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After' reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure i compliance with NRC regulatory requirements. l The inspection findings additionally found that your activities deviated from commitments made to the NRC. This deviation is discussed in Appendix C to this letter. You are requested to respond to this deviation in writing. Your response should be based on the specifics contained in the Notice of Deviation enclosed with this letter.
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| The inspection findings ab.o included several significant program weaknesses, which were documented 'n NRC Inspection Peport 50-072/88-01; 50-407/88-01 as open items. We recognize that an explicit regulatory requirement pertaining to each open item identified in the inspection report does not currently exist.
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| Mowc & you are requested to submit a written statement within 30 days of your receipt of this letter describing your action for each open item identified in the inspection report including: (1) steps which have been taken, (2) steps which will be taken, and (3) a schedule for completion of actions.
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| In accordance with 10 CFR 2.790(d), the documentation enclosed concerning your physical security plan (Attachment to the Notice) is exempt from disclosure.
| |
| Therefore, that attachment will not be placed in the Dublic Document Room.
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| The responses directed by this letter and the enclosed Notices are not suoject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL No. 96-511.
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| Sincerely,
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| /
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| O ybm J esM.Taylgt,DeputyExecutiveDirector for Regional Operations
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| /
| |
| | |
| ==Enclosures:==
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| : 1. Appendix A - Confirmatory Order
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| : 2. Appendix B - Notice of Violation (w/ Attachment containing Proprietary Information)
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| : 3. Appendix C - Notice of Deviation See next page for cc's.
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| NUREG-0940 1.A-202
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| | |
| r i
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| j Appendix A 4 UNITED STATES OF AMERICA
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| $ NUCLEAR REGULATORY COMMISSION 1
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| b In the matter of Docket Nos. 50-072 and 50-407
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| % University of Utah License Nos. R-25 and R-126 EA 88-64 ORDER MODIFYING LICENSES I
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| The University of Utah (the Licensee), located in Salt Lake City, Utah, is'the holder of Licenses R-25 and R-126 issued by the Nuclear Regulatory Commission (NRC/Comission). License No. R-25 authorizes the Licensee to operate an AGN-201 research reactor (5 watt thermal power maximum) on its campus for the conduct of educational activities in accordance with the conditions specified therein. Amendment No. 10 (renewal of ifcense) to the license was issued May 2, 1979. The license expires on Septemoer 12, 1997. License R-126 authorizes the Licensee to operate a TRIGA research reactor (100 kilowatt thermal power) on its campus for the conduct of educational activities in accordance with the conditions specified therein. Amendment No. 5 (renewal of license) w&s issued April 17, 1985. The Itcense expires April 17, 2005.
| |
| II The University of Utah reactors are located on campus in the Merrill Engineering Building, Nuclear Engineering Laboratory (NEL) and are utilized to conduct irradiations in support of academic studies. The NEL staff is comprised of a Reactor Administrator (tenured professor), reactor supervisor (tenured professor) and two graduate students who are licensed senior reactor operators. The Reactor Administrator only presides over the Reactor Safety Comittee and is not experienced in research reactor operations, while the Reactor Supervisor spends approximately 20 percent of his time involved in reactor activities.
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| NUREG-D940 I.A-203
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| The two graduate students are pursuing advanced degrees and are considered part time employees.
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| III
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| \
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| A special team inspection was conducted during February 16-19, 1988, to assess the licensee's conduct of operations. The inspection was prompted by observa-tions from NRC inspectors and consultants that roodifications to the facility and reactors had been made without NRC approval. During this inspection, seven violations, a deviation, and several programmatic concerns (open items) involving reactor operations, radiation protection, and physical security were identified. NRC Inspection Report 50-072 and 50-407/88-01 discusse's these inspection findings. Although no unauthorized modifications to either reactor were found to have been made, a lack of management support for the reactor probrams, a lack of full time technical support of day-to-day reactor activities, i
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| and failure to thoroughly review and apply adequate corrective action to audit findings in a timely manner were determined to be the root causes of the !
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| ' l licensee's problems. 1 As the result of a previous inspection in 1986 (50-407/86-01; E0-072/86-01),
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| 4 the Licensee was issued a Civil Penalty ($3,500) due to radiation protection program breakdowns. Corrective actions taken in response to those radiation i
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| protection problems somewhat improved the licensee's audit program and did ;
| |
| correct specific violations and concerns. However, those corrective actions 1
| |
| appar(ntly did not bring about broad enough changes to prevent occurrence of '
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| problems in other areas as evidenced by the findings of the most recent NRC inspection. l NUREG-0940 1.A-204
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| . _ - - - . . - -- - a
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| | |
| i l
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| On March 28, 1988, an enforcement conference was held with the Licensee in which each item of concern, identified in the February 1988 inspection, was reviewed. Because the Licensee failed to demonstrate that positive corrective actions had been taken to improve technical support for the NEL and provide the reactor supervisor relief from some of his other duties and academic responsibilities, a Confirmatory Action Letter (CAL 88-06) was issued on March 30, 1988, confirming that the NEL reactors would remain shut down until the Region IV office had reviewed the Licensee's response to the violations discussed at the enforcement conference and has authorized the Licensee, in writing, te operate the reactors. As of the date of this Order NRC Region IV has not autcorized the Licensee to restart either reactor.
| |
| Based on the enforcement conference discussions and further review the licensee decided that increasing the staffing level at the NEL was necessary. In a {{letter dated|date=June 14, 1988|text=letter dated June 14, 1988}} the licensee comitted to retaining a qualified individual to serve as reactor supervisor and whose job description requires the individual spend three quarters of his time carrying out the duties and responsibilities of that position. I have determir:ed tilat, given the significance of the licensee's comitments in assuring the safe operation of the reactors, the comitments should be incorporated as conditions to the facility's licenses.
| |
| IV In tiew of the foregoing and pursuant to Section 104, 161b, 1611, and 182 of the Atomic Energy Act of 1954, as amended, and the Comission's regulations in 10 CFR 2.204 and 10 CFR Part 50, IT IS HEREBY ORDERED THAT LICENS M Nos. R-25 AND R-126 ARE N0')IFIED AS FOLLOWS:
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| NUREG-0940 I.A-205 l\ -
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| | |
| A. The Licensee shall retain a full time professor who has at least one year of research reactor experience to act as the reactor supervisor.
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| B. The professor retained as reactor supervisor shall devote at least 75 percent of his employed time to carrying out the duties and responsibilities of the reactor supervisor as defined in facility procedures and technical specifications.
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| The Regional Administrator, Region IV may relax or terminate any of the above conditions for good cause shown.
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| V The Licensee or any other person adversely affected by this Order may, within 30 days of the date of this Order, request a hearing. A request for a hearing should be clearly marked as a " Request for Hearing" and shall be addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN:
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| Document Control Desk, Washington, D.C. 20555. A copy of the hearing request shall also be sent to the Assistant General Counsel for Enforcement, Office of the General Counsel, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, and to the Regional Administrator, Region IV, 611 Ryan Plaza Drive, Suite 1000, Arlington, Texas 76011. If a person other than the Licensee requests a hearing, that person shall set forth with particularity the manner in which the petitioner's interest is adversely affected by this Order and should address the criteria set forth in 10 CFR 2.714(d).
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| NUREG-0940 I.A-206
| |
| | |
| i i
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| If a hearing is requested, the Commission will issue an Order designating the time and place of the hearing. If a hearing is held, the issue to be considered at such hearing shall be whether this Order should be sustained. Upon failure of the licensee and any other person adversely affected by this Order to answer or request a hearing within the specified time, this Order shall be final without further proceedings.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| /
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| es M. Taylo Deputy Executive Director for Regional Operations Dated at Rockville, Maryland, this 8thday of July 1988.
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| NUREG-0940 I.A-207
| |
| | |
| Appendix B NOTICE OF VIOLATION University of Utah Docket Nos. 50-072 and 50-407 Salt Lake City, Utah License Nos. R-25 and R-126 EA 88-64 During an NRC inspection of the Nuclear Engineering Laboratory (NEL) conducted on February 16-19, 1988, violations of NPC requirements were identified. In accordance with the " General Statement of Policy and Procedures for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violations are listed below:
| |
| : 1. Failure to Perform Technical Specification (TS) Surveillance TRIGA TS 4.2(3) requires a channel check of the fuel element temperature '
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| measuring channel be made each time the reactor is operated. This surveillance is performed by comparing the indicated instrumented fuel element temperature with previous values for the current core configuration and power level.
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| Contrary to the above, the NRC inspectors determined on February 19, 1988, that the licensee had not fully implemented the requirements of TS 4.2(3) in that evaluations of fuel temperature versus core configuration and reactor power level were not being conducted. This violation was also identified in a June 6, 1987, Reactor Safety Committee (RSC) audit.
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| However, no action was taken to resolve the self-identified violation.
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| Severity Level IV violation (Supplement I).
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| : 2. Failure to Develop Written Operating Procedures for Core Alterations TRIGA TS 6.8 requires that written operating procedures shall be adequate to ensure the safety of operation of the reactor, and that procedures shall be developed as a minimum for core changes and performing preventative maintenance on the reactor and associated equipment.
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| Contrary to the above, the NRC inspectors determined on February 18, 1988, that during December 1987 the licensee had shuffled fuel and performed maintenance on the core's trapezoidal heavy water (D2 0) tank without adequate written procedures. During reactor startup operations following the December 1987 maintenance on January 4, 1988, an unexpected criticality was experienced due to the reactor operator's lack of knowledge in recent core changes involving fuel movements and installation of the improperly reassembled 2D 0 tank into the core.
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| Severity Level IV violation (Supplement I).
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| : 3. Failure to Perform Adequate Radiological Surveys l
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| 10 CFR Part 20.201(a) states, in part, that "As used in the regulations . . . ' Survey' means an evaluation of the radiation hazards incident to the . . . use, release, disposal, or presence of radioactive !
| |
| materials or other sources of radiation under a specific set of conditions. When appropriate, such evaluations include a physical survey of the locations of materials . . . and measurements of levels of radiation . . . present." Part 20.201(b) requires, in part, that "Each NUREG-0940 1.A-208
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| | |
| I Notice'of Violation licensee shall make or cause to be made such surveys as (1) may be necessary for the licensee to comply with regulations . . . (2) are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present."
| |
| : a. Contrary to the above, the NRC inspectors determined by independent surveys on February 17, 1988, that a part of the TRIGA reactor pneumatic sample transfer system had gamma radiation levels at contact, near 'one end of the apparatus, of approximately 120 millirem per hour (mr/hr). Licensee documentation showed that the rabbit terminus was removed from the reactor core and surveyed on February 1, 1988. The licensee's results indicated that the rabbit terminus had gamma radiation levels of only 18 mr/hr on contact.
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| : b. Contrary to the above, the NRC inspectors determined on February 17, 1988, during independent contamination surveys that the NEL exhaust ventilation system was contaminated internally to a level of approximately 3,000 disintegrations per minute per 100 cm2 The
| |
| -licensee's routine surface contamination serveys had not identified this contamination.
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| Severity Level IV violation (Supplerent IV).
| |
| /
| |
| : 4. Failure to Install a Continuous Airborne Radioactivity Monitor TRIGA TS 5.0, " Design Features," and TS 5.4, " Radiation Monitoring System," state, in part, that "This specification describes the functions and essential components of the . . . system for continuously monitoring airborne radioactivity . . . (2) Function of Continuous Air Radiation Monitor (beta-gamma sensitive detector with particulate collection capability): Monitor concentration of radioactive particulate activity in the pool room, alarm and readout at control console."
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| Contrary to the above, the NRC inspectors determined on February 18, 1988,.
| |
| that a continuous particulate air monitor had not been installed. This item was also addressed in a June 6, 1987, RCS audit.
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| Severity Level IV violation (Supplement IV).
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| : 5. See Attachment Pursuant to the provisions of 10 CFR 2.201, University of Utah is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, Region IV, within 30 days of the date of the letter transmitting this Notice. This reply, should be clearly marked as a " Reply to a Notice of Viclation" and should include for each violation (including Violation 5 provided in the attachment): (1) the reason for the violation if admitted, (2) the corrective steps that have been taken and the results achieved, (3) the corrective steps that will be taken to avoid further violations, and (4) the date when full compliance will be achieved.
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| If an adequate reply is not received within the time specified in this Notice, NUREG-0940 I.A-209
| |
| | |
| Notice of Violation an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Where good cause is shown, consideration will be given to. extending the response time.
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| FOR THE NUCLEAR REGULATORY COMMISSION
| |
| -, s/'
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| / es for M.Regional , Deputy Executive Dire.ctor Tay1 Operations 1
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| Dated at Rockville, Maryland this 8th day of July 1988.
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| Attachment (Proprietary Information)
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| NUREG-0940 I.A-210
| |
| | |
| Appendix C NOTICE OF DEVIATION University of Utah Docket: 50-407 Nuclear Engineering Laboratory License: R-126 Based on the results of an NRC inspection conducted February 16-19, 1988, a deviation from the licensee's commitment to the NRC was identified. The deviation involved the maintaining of alarm setpoints or the facilities area radiation monitors as committed to in the licensee's application and supporting documentation for renewal of the TRIGA reactor operating license. In accordance Enforcementwith the " General Actioris," Statement 10 CFR Part of Policy 2, Appendix (and Procedure C 1988), the deviationforisNRC listed below:
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| Failure to Maintain Alarm Setpoints on Area Radiation Monitors The licensee committed in response to NRC's question 46 (1983-84 license renewal) that the low and high alarm setpoints for the three TRIGA facility area radiation monitors (TS 5.4 required) were 0.1 and 1 millirem perhour(mr/hr),respectively.
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| Contrary to the abcVe, in deviation from that written commitment, the NRC inspectors determi.ied on February 19, 1988, the licensee had been maintaining (for an indeterminate period of time) the area rad 4 tior monittrs' low and high alarm setpoints at 1 and 10 mr/hr, respectively.
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| (407/8801-08)
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| Please provide to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region IV, in writing within 30 days of the date of this Notice, the reason for the deviation, the corrective steps which will be taken to avoid further deviations, and the date when your corrective action will be completed. Where good cause is s.hown, consideration will be given to extending the response time.
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| Dated at Rockville, Maryland 4 this 8th day of July 1988.
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| NUREG-0940 I.A-211 l
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| | |
| . p* ncy
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| *Y k UNITED STATES
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| ; # 3 NUCLEAR REGULATORY COMMISSION i REGION ll
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| ?,
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| *[ 101 MARIETTA ST.. N W.
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| ATLANTA, GEORGIA 30323 NOV 101983 Docket Nos. 50-280, 50-281 License Nos. DPR-32, DPR-37 EA 88-215 Virginia Electric and Power Company ATTN: Mr. W. R. Cartwright, Vice President ]
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| Nuclear Operations ;
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| Post Office Box 26666 .
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| Richmond, Virginia 23261 4 Gentleman:
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| | |
| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 50-280/88-26, 50-281/88-26, 50-280/88-28, i AND 50-281/88-28) )
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| i This refers to the Nuclear Regulatory Conunission (NRC) inspections conducted by )
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| W. E. Holland and L. E. Nicholson at Surry Power Station on June 5 through !
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| July 30, 1988. These inspections included a review of the cleanliness / foreign material exclusion controls in place for safety-related systems at the Surry Power Station from November 1986 through July 1988. Also, the inspections focused on the licensee reported foreign material which was identified in June ,
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| 1988 in both the Unit 1 and Unit 2 containment sumps. The reports documenting these inspections were sent to you by letters dated August 12 and August 30, 1988, respectively. As a result of those inspections, significant failures to comply with NRC regulatory requirements were identified, and accordingly, NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on September 16, 1988. The letter sunnarizing this conference was sent to you on October 12, 1988.
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| The violation described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involved failure to ensure that cleanli-ness and foreign material exclusion conditions were maintained during mainte-l nance and modification activities, which resulted in degraded safety-related systems. Testing of one of the Unit 1 Recirculation Spray Pumps in June 1988, resulted in your discovery of foreign material in the pump suction flow paths of both the Recirculation Spray and Safety Injection Systems. This condition existed for an extended period of time and, as you noted during the Enforcement Conference, was probably construction debris from early plant modifications in the 1970s. Further, we note that you recently discovered considerable damage to both Inside Recirculation Spray Pumps or. Unit 2. Although the damaae was partially attributed to the method of surveillance testing, there is a strong potential that this debris contributed to the damage and brought into question the operability of the pumps. Other more recent examples of inadequate clean-liness controls associated with work on safety-related systems were also noted.
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| l These concerns were identified by both your Quality Assurance organization and independently by the NRC inspectors before and during the inspection period.
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| We are especially concerned about the apparent lack of implementation of your cleanliness controls program as described in your Topical Report (VEP 1-5A),
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| and the potential impact on operability of safety-related systems.
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| NUREG-0940 I.A-212
| |
| | |
| Virginia Electric and Power Company NOV 0 E8 Although the specific cause of this violation was a lack of adequate clean-liness controls when working on safety-related systems, a broader issue is the lack of management action in the cleanliness program area that permitted cleanliness and foreign material exclusion problems to go undetected for an extended period of time. Your recognition of the problem in the containment sumps after identification of the condition during testing, and corrective action in this specific area, was appropriate. However, potential degradation of multiple safety systems due to a lack of knowledge of the condition of the containment sumps is indicative of an inadequate foreign material exclusion and inspection program over the years.
| |
| To emphasize our concerns with regard to your inadequate implementation of a program which could affect operability of safety-related systems and the period of time in which adequate controls were not in place, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violation described in the enclosed Notice.
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| In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy),
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| the violation in the enclosed Notice has been categorized at a Severity Level III. The base civil penalty amount for a Severity Level III violation is
| |
| $50,000. The escalation and mitigation factors in the Enforcement Policy were considered. No mitigation was deemed appropriate for your identification and reporting because the problem in this case was self-disclosing. Although your corrective actions after identification of the problem in the sump area were extensive, any mitigation of the civil penalty for corrective actions was offset by prior notice in that there have been a number of past problems with cleanliness control at the plant that should have caused you to implement broad programmatic changes to prevent the recurrence of such problem.;. Specifically, the presence of foreign materials resulting from inadequate cleanliness control has been a problem both in the reactor coolant system, where fretting of fuel rods was observed, as well as in the main feedwater system.
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| You are required to respond to this letter and the enclosed Notice and should follow the instructions specified therein when preparing your response. In your response, you should document the specific actions taken and any addi-tional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
| |
| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| NUREG-0940 I.A-213
| |
| | |
| Virginia Electric and Power Station NOV 101988
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| ~
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| Should'you have any questions concerning this letter, please contact us.
| |
| Sincerely, Ico m L. EpNt Acting RegioMal Administrator
| |
| | |
| ==Enclosure:==
| |
| | |
| Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enc 1:
| |
| D. L. Benson, Station Manager N. E. Hardwick, Manager - Nuclear Programs and Licensing Commonwealth of Virginia l
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| i 1
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| i l
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| NUREG-0940 I.A-214 1
| |
| | |
| 1 NOTICE OF VIOLATION AND PROPOSED IMPOSITIDTOF CIVIL PENALTY Virginia Electric and Power Company Docket No. 50-280, 50-281 Surry Units 1 and 2 License No. DPR-32, DPR-37 EA 88-215 During the Nuclear Regulatory Commission (NRC) inspection conducted between the period of June 5 to July 30, 1988, a violation of NRC requirements was identified.
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| In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:
| |
| 10 CFR 50, Appendix B, Criterion V, as implemented by the licensee's Topical Report, VEP 1-5A, requires that activities affecting quality shall be prescribed by documented procedures of a type appropriate to the circumstances and shall be accomplished in accordance with these pro-cedures. The procedures shall include appropriate quantitative or qualita-tive acceptance criteria for determining that important activities have '
| |
| been satisfactorily accomplished.
| |
| Contrary to the above, maintenance and modification activities affecting ;
| |
| quality were either accomplished without adequate procedures or acceptance criteria to assure adequate cleanliness and foreign material exclusion control or such procedures and acceptance criteria were not properly implemented. Specific examples include:
| |
| (1) In June 1988, the licensee found foreign material in the Unit-1 inside recirculation spray pump IA test strainer, both Unit 2 inside recirculation spray pump containers, and both Unit 2 low head safety ;
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| injection pump suction lines. The foreign material which resulted from various inadequate maintenance and modification activities included screws, nuts, pieces of metal, wire, various non-metallics, one angle grinder head, and one ten inch wrench.
| |
| (2) During the April - June 1988 Unit I refueling outage, the following modifications were accomplished on safety-related systems without specification or assurance of cleanliness or foreign material exclusion prior to system closure:
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| (a) Design Change (DC) 88-01-1, "Inside Recirculation Spray Pump Full Flow Test Line";
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| (b) Design Change (DC) 87-22-1, " Replacement of Containment Recircula-tion Spray Coolers";
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| (c) Design Change (DC) 86-13-1, "R.G. 1.97 - Containment Spray Flow and Pressurizer Heater Status."
| |
| (3) In April 1988, the following work orders were accomplished in the Unit I containment sump on a safety-related system without procedures,
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| .NUREG-0940 I.A-215
| |
| | |
| Notice of Violation controls, or specification of cleanliness or foreign material exclusion requirements:
| |
| (a) Work Order Job Number 3800062569, " Remove RS Sump Grating,"
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| 4/18/88; (b) Work Order Job Number 3800062573, " Inst RS Sump Blnk (Sump)
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| PT-16.4," 4/18/88.
| |
| (4) On July 5,1988, using Special Test Procedure 1-ST-214. " Operability of IRS Pumps," system and test spoolpieces were removed and installed on the Unit 1 inside recirculation pump. The procedure did not specify verification that cleanliness or foreign material exclusion was maintained during the reassembly of the system, nor were the flange ends of the system spoolpiece on the discharge side blanked as required by the procedure.
| |
| (5) During the fall, 1986, Unit 2 refueling outage, the following safety-related work orders were accomplished without procedures and controls to assure cleanliness or material accountability control in the containment sump:
| |
| (a) Work Order Job Number (WOJN) 3800040809, " Rem./ Inst. RS Sump Grating," dated 10/10/86.
| |
| (b) WOJN 3800040816, " Inst /Remy 12" Suct Fng Pen 68," dated 10/10/86.
| |
| (c) WOJN 3800040817, " Inst /Remy Suct Fng Pen 69," dated 10/10/86.
| |
| (d) WPJN 3800046068, " Inst. RS Sump Grating," dated 11/24/86.
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| This is a Severity Level III violation (Supplement I).
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| Civil penalty - $50,000.
| |
| Pursuant to the provisions of 10 CFR 2.201, Virginia Electric and Power Company (licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a
| |
| " Reply to a Notice of Violation" and should include for each violation:
| |
| (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violati ms, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
| |
| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the NUREG-0940 I.A-216
| |
| | |
| Notice of Violation Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
| |
| In requesting mitigation of the proposed penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, the be
| |
| , should fiveaddressed.
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| factors addressed Any in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
| |
| Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 3.S.C. 2282.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear R3gulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323.
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| FOR THE NUCLEAR REGULATORY COMMISSION M colm L Ernst c ing Re ional Administrator Dated at Atlanta, Georgia this /o % day of November 1988 NUREG-0940 1.A-217
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| i l
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| I I
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| I I
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| I.B. REACTOR LICENSEES, SEVERITY LEVEL III "!OLATION, NO CIVIL PENALTY NUREG-0940
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| 1 pn nacq UNITED STATES g o g NUCLEAR REGULATORY COMMisslON f '> ,( [ 7, REGION lli E* # '
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| , E 799 nOOSEVELT RO AD CLEN ELLYN, ILLINot5 60137 D f.
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| ocr , e m5 Docket No. 50-295 License No. DPR-39 EA'88-199 Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, IL 60690 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION This refers to Licensee Event Report No. 86-040-00 and Supplemental Licensee Event Report No. 86-040-01 that Commonwealth Edison Company (CECO) submitted to NRC by letters dated November 25, 1986 and May 1, 1987, respectively.
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| These letters reported that, while inspecting environmentally qualified (EQ) splices in Zion Unit 1, your staff identified three transmitters that had improperly terminated leads. This matter, which constituted a violation of NRC regulatory requirements, was discussed on August 17, 1988 during an enforcement conference in the NRC Region III offices between Mr. T. J. Maiman and others of your staff and Mr. A. B. Davis and others of the NRC staff.
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| The violation described in the enclosed Notice of Violation involved the installation of two Rosemount transmitters and one Barton transmitter with leads landed on unqualified terminal blocks rather than spliced utilizing environmentally qualified splices, as required. CECO clearly should have known that the terminal blocks were not qualified because its EQ files did not contain any information to show that the terminal blocks had been !
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| qualified by test and/or analysis for use in this EQ application. Also, Ceco l itself recognized that terminal blocks could not be used for instrumentation inside containment such as the pressure transmitter at issue. In addition, a modification package involved in this violation (22-1-81-49) specified splices in the installation of the transmitters. However, specific installation instructions were issued without clear direction to splice the.
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| leads and this resulted in two transmitters (1LT-503/1LT-504) being improperly installed with terminal blocks while two transmitters (1LT-501/1LT-502) were installed with the required splices.
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| In accordance with the Modified Enforcement Policy Relating to 10 CFR 50.49, contained in Generic Letter 88-07 (Enclosure 2), the violation described in the enclosed Notice has been determined to be an isolated problem, having ]
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| affected a limited number of systems or components, and has been classified j as an EQ Category C violation. Normally, a civil penalty would be proposed; j however, after consultation with the Director, Office of Enforcement, and the 1 l
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| NUREG-0940 I.B-1 l
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| a
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| Commonwealth Edison Company 2 0CT 191989 Deputy Executive Director for Regional Operations, I have decided that a civil penalty will not be proposed in this case because CECO has satisfied the five criteria of the Modified Enforcement Policy Relating to 10 CFR 50.49 contained in Generic Letter 88-07, which provide a basis for full mitigation. These criteria are: (1) the violation was isolated and affected a limited number of systems (Category C violation); (2) CECO identified the violation; (3) the violation was promptly reported to the NRC; (4) the violation was corrected and full compliance was achieved within a reasonable time; and (5) CECO demonstrated best efforts to complete EQ within the deadline.
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| The NRC has reviewed your LER 86-040-00 and supplementary LER 86-040-01 transmitted by letters dated November 25, 1986 and May 1, 1987, respectively.
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| These LERs provided a description, a cause, and an analysis of the event, as well as your corrective actions. These corrective actions have been reviewed and the NRC has no further questions regarding this matter at this time.
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| Consequently, a, reply to the Notice is not required.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure-will be placed in the NRC Public Document Room.
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| Sincerely, 4 4 4
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| A. Bert Dav j
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| Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation
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| : 2. Generic Letter 88-07 cc w/ enclosures:
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| Cordell Reed, Senior Vice President T. J. Maiman, Vice President, PWR Operations H. Bliss, Nuclear Licensing Manager G. J. Plim1, Station Manager Jan Norris, Project Manager, Licensing Fee Management Branch Resident Inspector, RIII J. W. Mc Caffrey, Chief, Public Utilities Division Mayor,' City of Zion DCD/DCB (RIDS)
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| See Attached Distribution NUREG-0940 I.B-2
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| NOTICE OF VIOLATION Commonwealth Edison Company Docket No. 50-295 Zion, Unit 1 License No. DPR-39 EA 88-199 As a result of Licensee Event Report No. 86-040-00 dated November 25, 1986 and Supplemental Licensee Event Report No. 86-040-01 dated May 1, 1987, and in accordance with the Modified Enforcement Policy Relating to 10 CFR 50.49,
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| " Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, the following violation was identified:
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| 10 CFR 50.49(f) and (g) require that, prior to November 30, 1985, each item of electric equipment important to safety be environmentally qualified by test and/or analysis.
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| Contrary to the above, from November 30, 1985 until January 1987 terminal blocks were installed in the circuitry for Barton Pressure Transmitter IPT-403 and Rosemount Level Transmitters ILT-503 and ILT-504, electrical equipment important to safety, which were not demonstrated to be environmentally qualified in that the licensee's EQ files did not contain any record of testing or analysis to environmentally qualify the terminal blocks for use in these applications.
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| This is an EQ Category C violation.
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| The licensee provided information which showed that action had been taken to correct the identified violation. Consequently, no reply to this Notice is required and the NRC has no further questions regarding this matter.
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| FOR THE NUCLEAR REGULATORY COMMISSION A
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| A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois this /44 day of October 1988 NUREG-0940 I.B-3 !
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| l po ngo . UNITED STATES h, NUCLEAR REGULATORY COMMISslON 4 3 1. g REGloN Ilt s y no noostvcot nono occu ettv~. iw~ois oin i
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| ....* OCT 2 i 1989 l
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| l Docket No. 50-265 I
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| License No. DPR-30 EA 88-217 i
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| i Commonwealth Edison Company ATTN: Mr. Cordell Reed I Senior Vice President l Post Office Box 767 i Chicago, Illinois 60690 Geritlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION (NRC INSPECTION REPORTS NO. 50-254/88015[DRP]
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| AND NO. 50-265/88015[DRP])
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| This refers to the inspection conducted during the period June 5 through August 6, 1988, at the Quad Cities Nuclear Power Station, Units 1 and 2, Cordova, Illinois. The inspection included a review of a licensee identified event where the automatic transfer function of a Motor Control Center (MCC) failed during modification testing. An enforcement conference was held in the Region III Office on August 26, 1988 to discuss the event, its causes, and corrective actions.
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| On June 22, 1988, during a modification test Quad Cities personnel discovered that MCC 28/29-5 would not automatically transfer from the Bus 29 feed to the Bus 28 feed. Licensee investigation of the event showed that a wire was not landed according to the approved electrical drawing. It appears that the wiring problem has existed since initial installation prior to 1971. Although testing of the automatic transfer circuit has been routinely conducted, these tests were inadequate and did not completely test the automatic transfer circuit.
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| The NRC considers the event significant; the automatic transfer function of MCC 28/29-5 is needed in the event of a large break Loss of Coeling Accident (LOCA) concurrent with a Loss of Offsite Power (LOOP) and a failure of the Unit 2 Diesel Generator. Had the above situation occurred, MCC 28/29-5 would not have been available to supply power to the RHR injection valves. This is in contrast to the Quad Cities Final Safety Analyr,is Report Section 8.2.3.1.
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| CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.B-4
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| i Commonwealth Edison Company 2 OCT 21 1988 that states that the breakers feeding 480 volt motor control center 28/29-5 from 480 volt Bus 29 will open automatically and the breaker feeding 480 volt motor control center 28/29-5 from 480 volt Bus 28 will close automatically to supply motor control center 28/29-5 from DG 1/2 should DG 2 fail during a loss of offsite power. Therefore, based on these considerations, the staff has determined that this is a violation of the requirements in Technical Specification (TS) 3.5.A.3 - that the LPCI mode of the RHR system be operable -
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| in that the LPCI injection valves for both recirculation loops would not have opened, preventing LPCI from injecting, and the recirculation pump suction and discharge valves in both recirculation loops would have been prevented from shutting. In addition, the only available low pressure core cooling supply would have been a single core spray pump. The staff recognizes that this equipment failure would have been evident in the control room and operator actions from the control room could have corrected the problem.
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| In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Act' ions," 10 CFR Part 2, Appendix C (1988), the violation described in the enclosed Notice has been classified at a Severity Level III.
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| A civil penalty is considered for a Severity Level III violation. However, after consultation with the Director, Office of Enforcement and the Deputy Executive Director for Regional Operations, I have decided that a civil penalty will not be imposed in this case because you identified the problem >
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| and promptly reported it to the NRC and because your extensive corrective actions to prevent recurrence, and good prior performance in the area of concern offset the added significance of this violation due to the duration.
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| NRC acknowledges that your new modification program which requires comprehensive testing of components was the primary factor in identifying this event. It is the policy of the NRC to encourage this type of comprehensive corrective action in identifying and responding to events of this type.
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| 'You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice" Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| NUREG-0940 1.B-5 l l
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| Commonwealth Edison Company 3 OCT 21 1988 The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
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| Sincerely, O ._-
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| $D0 W w A. Bert Davis Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation
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| : 2. Inspection Reports No. 50-254/88015[DRP];
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| No. 50-26$/88015[DRP]
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| cc w/ enclosures:
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| H. Bliss, Nuclear Licensing Manager R. L. Bax, Plant Manager DCD/DCB (RIDS)
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| Licensing Fee Management Branch Resident Inspector, RIII Richard Hubbard J. W. McCaffrey, Chief, Public Utilities Division l
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| l l
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| NUREG-0940 I.B-6
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| 4 4
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| I NOTICE OF VIOLATION Commonwealth Edison Company Docket No. 50-265 Quad Cities Nuclear Power Station License No. OPR-30 Unit 2 EA 88-217 During an NRC inspection conducted on June 5 through August 6, 1988, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy end Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violation is listed below:
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| Technical Specification (TS) 3.5.A.3 requires that the LPCI mode of the RHR system be operable whenever irradiated fuel is in the reactor vessel and prior to reactor startup from a cold shutdown condition. From and after the date the LPCI mode of the RHR system is made or found to be inoperable for any reason, TS 3.5. A.5 permits continued reactor operation only during the succeeding seven days (pro,vided other related equipment designated in TS 3.5. A.5 is operable). If the requirements of TS 3.5.A.5 cannot be met, TS 3.5.A.6 requires an orderly shutdown to be initiated and the reactor to be in the cold shutdown condition within 24 hours.
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| Contrary to the above, as a result of a motor control center's (MCC 28/29-5) inability to provide automatic transfer for certain situations (large break LOCA concurrent with LOOP and failure of the Unit 2 Diesel Generator), the LPCI mode of the RHR system was inoperable from October 1971 (the time when irradiated fuel was in the Unit I reactor) to June 22, 1988 (the time when the MCC's wiring problem was discovered). During this period the reactor was operating without complying with the ACTION requirements as described in TS 3.5.A.5 and TS 3.5.A.6.
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| This is a Severity Level III violation (Supplement I).
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| Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company is hereby required to submit a written statement or explanation to the U.S.
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| Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington D.C.
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| 20555, with a copy to the Regional Administrator, Region III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137, and a copy to the NRC Resident Inspector of the date of the letter transmitting this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted; (2) the corrective actions that have been taken and the results achieved; (3) the corrective actions that will be taken to avoid further violations; and (4) the date when full compliance will be achieved.
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| NUREG-0940 I.B-7
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| l Notice of Violation 2 OCT 21 1988 1
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| Where good cause is shown, consideration will be given to extending the response time. If an adequate reply is not received within the time specified in this Notice, an Order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| ' cO A~o A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois This ?.l sTday of October 1988 l
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| )
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| NUREG-0940 1.B-8
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| e*# *8%, UNITED STATES l ps. .
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| f' , NUCLEAR REGULATORY COMMISSION l
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| k "f8 REGION IV 611 RYAN PLAZA DRIVE, SUITE 1000 o,, ,
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| AnLINGTON, TEXAS 79011 ICV I51988 Docket No. 50-458
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| . License No. NPF-47 EA 88-249 1
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| Gulf States Utilities ATTN: Mr. James C. Deddens Senior Vice President (RBNG),
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| Nuclear Licensing Post Office. Box 220 St. Francisville, Louisiana 70775 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION (NRC INSPECTION REPORT N0. 50-45P. 3-22)
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| This refers to the inspection conducted between August 29 and September 15, 1988, by .NRC's Resident Inspectors at the River Bend Station. This inspection focused on the circumstances surrounding Gulf States Utilities' discovery on August 29 that heaters in both divisions of the River Bend fuel building ventilation charcoal filtration system had been deenergized at a time when the plant's technical specifications required them to be available. The results of this inspection were provided to you in an inspection report dated September 29, 1988, and were discussed with you during an enforcement conference conducted by telephone on October 6.
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| l This inspection disclosed that the heaters, which are required in an emergency I situation to maintain the efficiency of the charcoal filters in removing j radioactive iodines from fuel building effluents, would not have been available if needed because the control switches were in the "stop" position. This condition had existed from August 27 until discovered by plant operators on the evening of August 29. The inspection also disclosed that plant operators missed several opportunities to discover this situation between August 27 and ;
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| August 29, and that GSU personnel had recognized in 1986 the possibility that !
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| these heater circuits could be deenergized without any visible or audible indications to alert operators. Although aware of this potential safety problem, GSU had not implemented corrective actions. These findings are discussed in more detail in the referenced inspection report.
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| Both the fact that these heaters were deenergized when plant conditions required them to be operable and the fact that GSU had not implemented corrective action for a problem identified in 1986 are violations of NRC requirements and are included in the enclosed Notice of Violation (NOV).
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| The root causes of these violations appear to include: a deficiency, at least i in this instance, in your system for ensuring that corrective actions that are !
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| initiated to resolve known problems are fully implemented in a timely manner; a deficiency in your shift turnover procedures in that you had modified your NUREG-0940 I.B-9
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| I WV I 51988 Gulf States Utilities procedures in April 1987 and inadvertently deleted a checklist that had included checking the status of the fuel building ventilation system; and a deficiency in the control board checks conducted between August 27 and August 29, 1988, in that operators did not detect the mispositioned heater switches. j i
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| In determining the overall safety significance of these violations, NRC considered GSU's analysis of the safety significance of the heaters being inoperable and agrees that the unavailability of the heaters may not substantially affect the efficiency of the charcoal filtration units in many accident scenarios (e.g., when the relative humidity of the air passing through the ventilation system is less than 70 percent). However, the importance NRC places on ensuring that plants are operated in compliance with requirements incorporated in technical specifications is not diminished even in situations when the immediate safety significance may not be great. It is significant that your operations staff had identified a problem in verifying the operability of these heaters, yet your internal engineering priority reviews did not consider the proposed resolution of this problem necessary, even though the operability of these heaters is required by the River Bend Station Technical Specifications. Thus, in this instance, a breakdown in your corrective action program resulted in the unavailability of the heaters when i required. In the view of the NRC, any problem identified by your plant operations staff that involves equipment operability considerations should be given the highest priority for resolution to ensure Technical Specification i requirements are satisfied.
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| In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violations described in the enclosed Notice have been classified collectively as a Severity Level III problem. A civil penalty is considered for a Severity Level III violation. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, I have decided that a civil penalty will not be proposed in this case based on our evaluation of the civil penalty adjustment factors in Section V.B. of the Enforcement Policy. Although both your failure to implement corrective actions for a previously identified problem and your failure to discover this condition for at least two days despite several opportunities to do so are cause for increasing the base civil penalty assigned to Severity Level III violations, those factors are offset by the fact that you initiated extensive short and long-term corrective actions once the problem was identified, and by the fact that your past regulatory performance in identifying and correcting deficiencies has been good.
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| You are required to respond to this letter and should follow the instructions l specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC wili determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| NUREG-0940 I.B-10
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| NOV I 51988 1 i
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| Gulf States Utilities The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, 3
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| Robert D. Martirl ( /
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| Regional Administrattfr
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| ==Enclosure:==
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| Notice of Violation cc: Louisiana Radiation Control Program Director NUREG-0940 I.B-11
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| NOV l 51988 i
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| NOTICE OF VIOLATION !
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| Gulf States Utilities Docket No. 50-458 River Bend Station License No. NPF-47 St. Francisville, Louisiana EA 88-249 During an NRC inspection condur.ted on August 29 through September 15, 1988, two violations of NRC requirements were identified. In accordance with the 1
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| " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violations are listed below: (
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| l A. River Bend Station Technir.al Specification (TS) Limiting Condition for Operation (LCO) 3.6.5.6 requires that two independent fuel building i ventilation charcoal filtration subsystems be operable in Operational j Sonditions 1, 2 and 3. ;
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| Contrary to the above, River Bend Station was operated in Operational I Conditions 1, 2 and 3 from August 27, 1988 to 7:50 p.m. (CDT) on August 29, 1988, with both divisions of the fuel building ventilation charcoal filtration subsystems inoperable as a result of their associated heater breakers having been deenergized.
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| B. 10 CFR 50, Appendix B, " Quality Assurance Criteria for Nuclear Power Plants and Fuel Reprocessing Plants," states in Criterion XVI, " Corrective Action," that " Measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective riaterials and equipment, and nonconformances are promptly identified and corrected."
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| GSU Quality Assurance Directive, QAD-16, " Corrective Action," which describes the measures and delineates the requirements for identifying, documenting, reporting and correcting conditions adverse to quality (Nuclear safety), states, in part, that " Procedures shall require that corrective action be promptly initiated and adequately documented by the responsible department to correct the condition and to determine if action is necessary to preclude its recurrence."
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| Contrary to the above, River Ber "tation Condition Report 86-0875, l written on July 1, 1986, identi: a deficiency in the design of the I fuel building ventilation charr.oal iiltration system in that the system )
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| did not provide operators ad%uate indication of situations in which the system heaters may be deene led ard unavailable if needed, a deficiency for which corrective action was not taken as of August 29, 1988, when the licensee discovered the heaters had been deenergized for a two day period.
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| Although Modificatbn Request (MR) 86-1214, written in September 1986, would have resulted in alarms being added to the system to alert operators to situations when the heaters may be deenergized, MR 86-1214 was cancelled on April 23, 1988, and no other suitable corrective actions were taken.
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| l Collectively, these violations have been classified as a Severity l Level 111 pcoblem (Supplement 1). j NUREG-0940 1.B-12 l
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| NOV l 51988 Notice of Violation Pursuant to the provisions of :.0 CFR 2.201, Gulf States Utilities is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, Region IV, and a copy to the NRC Resident Inspector and the Director, Office of Enforcement, within 30 days of the date of the letter transmitting this Notice. This reply, should be clearly marked as a " Reply to a Notice of Violation" and should include for each viola-tion: (1) the reason for the violation if admitted, (2) the corrective steps that have been taken and the results achieved, (3) the corrective steps that will be taken to avoid further violations, and (4) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be _ modified, suspended, or revoked or why such other actlon as may be proper should not be taken. Where good cause is shown, consideration will be given to extending the response time.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| ~ -
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| . dobert D. PfirU T Regional Admin stra Dated a Arlington, Texas, this/ day of November 1988.
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| NUREG-0940 I.B-13
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| l
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| #% UNITED STATES a k NUCLEAR REGULATORY COMMISSION
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| [
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| 5 j
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| a REGION 1 475 ALLENDALE ROAD 0,, KINO oF PRUSSIA, PENNSYLVANIA 19406 October 17, 1988 Docket No. 50-309 License No. OPR-36 EA 88-206 Maine Yankee Atomic Power Company ATTN: Mr. J. B. Randazza 83 Edison Drive Augusta, Maine 04336 Gentlemen:
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| ==Subject:==
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| NOTICE OF VIOLATION (NRC Inspection Report No. 50-309/87-16)
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| This refers to the NRC inspec ion conducted on July 20-24, 1987, to review the program for the environmental qualification (EQ) of equipment at Maine Yankee.
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| The inspection report was sent to you on November 19, 1987. During the inspec-tion, the NRC reviewed violations of NRC requirements identified by your staff involving the lack of qualification of certain items of electric equipment.
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| On August 22, 1988, an enforcement conference was conducted with members of your staff to discuss the significance and extent of the violations, causes of the violations, and the corrective actions taken or planned. Further, application of the enforcement policy set forth ir, Generic Letter 88-07 was also considered.
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| One of the violations, which is described in Section I of the enclosed Notice of Violation, involved the use of certain items of electrical equipn.snt at the facility which were not included on the list of electrical equipment important to safety, and for which qualification files did not exist to verify that these items would perform their intended functions during the postulated environmental conditions that would exist during an accident. The specific items consisted of: (1) Continental Cable used in four of the Reactor Coolant System hot and cold leg Resistance Temperature Detectors (RTD); and (2) a States Terminal Block used in one of the four affected RTDs. The RTOs are used to monitor long term Reactor Coolant System temperature as a part of the Post Accident Sampling System and they also pruvide temperature inputs to the Reactor Regulating System and the Appendix R Alternate Safe Shutdown System. The violation occurred because the initial plant walkdowns were not controlled by adequate procedures.
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| The NRC recognizes that these deficiencies were (1) identified by your staff during an upgrade of qualified splices in response to an internal audit conducted at your facility, and (2) promptly corrected by replacement of the cable with qualified cable, and elimination of the need for the terminal block.
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| Further, the NRC also recognizes that documentation of equipment qualification at Maine Yankee has in general been good, and that the qualification files were readily auditable at the time of the inspection. Nonetheless, these deficien-cies clearly should have been known to you prior to November 30, 1985, which was the deadline for being in compliance with the EQ requirements, because NRC CERTIFIED MAIL RETURN RECEITT REQUESTED NUREG-0940 1.B-14
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| Maine Yankee Atomic Power Co. 2 D0R Guidelines, Section 3.0, specifically identified electrical cable to be one of the components to be included in the qualification list and because IE Circular 78-08 (Item 3), Information Notice 82-03 and Information Notice 84-47 were sent to all licensees on May 31, 1978, March 4, 1982 and June 15, 1984, respectively, to alert licensees of the need to qualify terminal blocks.
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| However, the Continental cable and the States Terminal Block were not identified during the initial plant walkdowns and the NRC maintains that a reasonable walkdown clearly should have identified deficiencies such as lack of qualifi-cation for such fundamental components as cable and terminal blocks.
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| In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49,"
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| contained in Generic Letter 88-07 (Enclosure 2), the violation described in Section I of the enclosed Notice has been determined to be isolated and to have affected a few systems and components, and therefore, is considered to be an EQ Category C problem. The base value of a civil penalty for an EQ Category C problem is $75,000. However, after consultation with the Diretor, Office of Enforcement and the Deputy Executive Director for Regional Operations, I have decided that the civil penalty in this case should be mitigated in its entirety for reasons set forth herein. Although Section IV.B of the Enclosure to the Generic Letter 88-07, states that a minimum $50,000 should normally be issued, full mitigation of the civil penalty is appropriate, in accordance with the specific guidance described therein, because (1) the violations were isolated and affected only a few systems; (2) the violations were identified by your staff and promptly reported to the NRC; (3) the violations were corrected within a reasonable amount of time; and (4) Maine Yankee made best ef' orts using external groups to support, audit, and upgrade the plant EQ program to complete EQ within the November 30, 1988 deadline.
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| Certain items of unqualified equipment, subsequently replaced, were determined to be qualifiable within a reasonable period. These iten.. constitute a separate violation which is classified at Severity Level IV in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Action,"
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| 10 CFR 2, Appendix C (Enforcement Policy) (1988). This violation is set forth in Section II of the enclosed Notice.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.
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| Because the violations set forth in the enclosed Notice were identified, corrected, as well as reported, as required, by the Maine Yankee Atomic Power Company, no response to the Notice is required.
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| Sincerely, William T. Russell Regional Administrator NUREG-0940 I.B-15
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| NOTICE OF VIOLATION Maine Yankee Atomic Power Company Docket No. 50-309 Maine Yankee License No. DPR-36 EA 88-206 During an NRC inspection conducted on July 20-24, 1987, of the licensee's program for environmental qualification (EQ) of equipment, violations of NRC requirements identified by the licensee were evaluated. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety of Nuclear Power Plants," contained in Generic Letter 88-07, as well as the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the particular violations are set forth below:
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| : 1. VIOLATION CLASSIFIED IN ACCORDANCE WITH GENERIC LETTER 83-07 10 CFR 50.49(d), (f), and (j), respectively, require, that (1) a list of electric equipment important to safety be prepared, and information concerning performance specifications, electrical characteristics and postulated environmental conditions for this equipment be maintained in a qualification file; (2) each item of electric equipment important to safety shall be qualified by testing of identical or similar equipment under identical or similar postulated conditions, and qualification based on similarity shall include a supporting analysis to show that the equip-ment to be qualified is acceptable; and (3) a record of the qualification shall be maintained in an auditable form to permit verification that each item of electrical equipment important to safety is qualified and that the equipment meets the specified performance requirements under postulated environmental conditions.
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| Contrary to the above, from November 30, 1985 until May 26, 1987, Continental Cable used in four of the Reactor Coolant System hot and cold leg Resistance Temperature Detectors (RTD), and a States terminal block, used in the Reactor Coolant System cold leg RTD loop circuit, were not included on the list of equipment important to safety and were not demonstrated to be qualified in that documentation did not exist in a qualification file to verify that this cable and terminal block, which are items important to safety, would perform their intended safety function under accident conditions.
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| This violation constitutes an EQ category C problem.
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| II. VIOLATION CLASSIFIED IN ACCORDANCE WITH 10 CFR PART 2, APPENDIX C 10 CFR 50.49(f) requires that qualification of each item of electrical equipment important to safety be qualified based on testing of, or experience with, identical equipment or similar equipment with supporting analysis to show that the equipment is acceptable.
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| NUREG-0940 I.B-16
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| 2 Contrary to the above,
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| : a. from November 30, 1985 until May 26, 1987, documentation did not exist in a qualification file to establish qualification of two Weidmuller terminal blocks (associated with the containment sump level instrument) to verify that the blocks would function properly in a post accident condition.
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| : b. from November 30, 1985 until June 22, 1988, documentation did not exist in a qualification file to establish the qualification of four solenoid operated valves (used to isolate the HPSI charging pump suction from the Primary Vent and Drain System) to verify that the valves would function properly in a postulated high radiation condition.
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| This is a Severity Level IV violation (Supplement I).
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| Because both the violations set forth above were identified, corrected, as well as reported, as required, by the Maine Yankee Atomic Power Company and the NRC has no outstanding concerns relative to them, no response to this Notice is required.
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| FOR THE NUCLEAR REGULATORY COMMISSION William T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania this -l day of October 1988.
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| i l
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| NUREG-0940 1.B-17
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| p t**"''*< UNITED STATES
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| : e. r ; NUCLEAR ROULATORY COMMISSION REGION IV
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| -k .
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| sti RYAN PLAZA DRIVE, SUITE 1001
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| "% , , } , , # ARuNGTON, TEXAS 78011 OCT l 21994
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| )
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| i Docket No. 50-285 '
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| License No. DRP 40 i EA 88-201 Omaha Public Power District ATTN: K. J. Morris, Division Manager Nuclear Operations 1623 Harney Street Omaha, Nebraska 68102 I
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| l Gentlemen: '
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| | |
| ==SUBJECT:==
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| NOTICE OF VIOLATION (NRC INSPECTION REPORT N0. 50-285/88-22)
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| This refers to the inspection conducted June 29 through July 18, 1988, at the Fort Calhoun Station, Fort Calhoun, Nebraska, and to the violations of NRC requirements discussed with you and other OPPD personnel at an August 11 enforcement conference in NRC Region IV's offices in Arlington, Texas. The l results of the inspection were provided to you in a report dated July 29, 1988.
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| The violations in the enclosed Notice of Violation (Notice) are both related to OPPD's discovery on June 28 that an error had been made in calculating the setpoint for'the Thermal Margin / Low Pressure reactor trip function of the Reactor Protection System. According to your initial calculations, this error resulted in a trip setpoint approximately 79 pounds per square inch atmospheric l (psia) lower than it should have been during Fort Calhoun Cycle 11 operations which began June 7, 1987 Violation A in the Notice involves your failure to implement design control measures adequate to prevent this potentially significant error from being made. Violation B involves one example of your having provided NRC inaccurate information in a July 1,1988, letter in which you described your actions in response to the discovery of this calculational error.
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| Although four channels of the Reactor Protection System's Thermal Margin / Low Pressure (TM/LP) trip function were rendered inoperable, the actual safety significance is kw in that the error was not large and that ample safety margins were present in the other factors included in the calculation to more than compensate for any reduction in safety margins caused by the error. We CERTIFIED Mall RETURN RECEIPT REQUESTED NUREG-0940 1.B-18
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| l OCT l 2 !g9 Omaha Public Power District commend you for both your immediate actions to address the potential safety problem and for the corrective actions you described at the enforcement conference, which involved improving training in the computerized calculational methods and ensuring that the individuals performing the calculations are experienced.
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| Nonetheless, NRC is concerned about the breakdown in your design control process that led to this error. In particular, we are concerned about OPPD having used an inexperienced individual without adequate training to perform a safety-related activity as important as the calculation of the TM/LP reactor trip setpoint, which is designed to prevent reactor operation when the Departure from Nucleate Boiling Ratio (DNBR) is less than 1.18. Moreover, the person performing the oversight review was equally inexperienced. We would have expected that OPPD would have taken the necessary steps to ensure proper application of the newly acquired computer program such as using the vendor to provide an oversight review function for the computer program's first application.
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| OPPD should ensure that its long-term corrective actions are effective in addressing the root causes of this violation, which NRC views as an indication of a significant weakness in your management control process.
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| In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10'CFR Part 2, Appendix C (1988), Violation A described in the enclosed Notice has been classified at a Severity Level III. Normally, a civil penalty is proposed for a Severity Level III violation. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, I have decided that a civil penalty will not be proposed in this case because OPPD identified this problem and reported it promptly to NRC, took immediate action to address the safety implications'and developed long-term actions to minimize the possibility of such a calculational error being made in the future. Violation B in the Notice has been classified at a Severity Level IV. As discussed at the enforcement conference, NRC places a great deal of importance on the accuracy of information provided by licensees.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actiuns you plan to prevent recurrence. Af ter reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| NUREG-0940 I.B-19
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| nr,T 1 2 - -
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| Omaha Public Power District The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. l l
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| Sincere , l b' b Robert D.tMartin (cf -
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| Regional Administrator
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| ==Enclosure:==
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| Notice of Violation cc:
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| Nebraska Radiation Control Program Director I
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| L NUREG-0940 I.B-20
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| l NOTICE OF VIOLATION Oraha Public Power District Docket No. 50-285 Fort Calhoun Station License No. DPR-40 EA 88-201 l
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| During an NRC inspection conducted during the period June 29 through July 18, 1988, violations of NRC requirements were identified. In accordance with the
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| " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violations are listed below:
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| A. 10 CFR Part 50, Appendix B, Criterion 111 states, in part, that measures shall be established to assure that applicable regulatory requirements and the design basis, as defined in Section 50.2, for those structures, systems and components to which Appendix B applies are correctly translated into specifications, drawings, procedures and instructions and that the design control measures shall provide for verifying or checking the adequacy of design.
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| The approved " Quality Assurance Program," Section A.4, " Design Control,"
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| of Appendix A to the updated Safety Analysis Report for the Fort Calhoun Station states, in part, that the verification of engineering and design adequacy of the contractors' design documents is performed in accordance with an OPPD approved quality program and procedures.
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| Paragraph 4.3.5 of Section 5.1 of the licensee's Quality Assurance Manual,
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| " Control of Plant Design and Modifications," states, in part, that design analyses such as physics, stress, thermal, hydraulic, and accident analyses, shall be performed in a planned, controlled, and correct manner.
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| Contrary to the above, OPPD failed to verify the adequacy of design and failed to perform design analyses in a correct manner in that OPPD utilized a computer program supplied by a contractor to perform setpoint analyses for Cycle 11 reactor operations without verifying the adequacy and correct use of the computer code. The licensee failed to determine all factors required to be used in computer-derived calculations of the setpoints for the thermal margin / low pressure reactor trip function of the Reactor Protection System, resulting in setpoints that reduced the margin of safety. This condition existed from June 7,1987, when Cycle 11 operations began, until June 29, 1988, when this condition was corrected.
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| This is a Severity Level III violation (Supplement I) (285/8822-01).
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| B. Section 50.9 of 10 CFR Part 50 states, in part, that information provided to the Comission k a licensee shall be complete and accurate in all material respectf.
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| Contrary to the above, the licensee submitted a letter, dated July 1, 1988, that stated the shift supervisor had placed instructions in his log to reduce reactor power to 80 percent if the excore detectors were used to NUREG-0940 1.B-21
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| Notice of Violation measure linear heat rate. The NRC inspector noted following NRC's receipt of the July 1 letter that the shift supervisor's log did not contain instructions to reduce reactor power to 80 percent.
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| This is a Severity Level IV violation. (Supplement 1) (285/8822-02)
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| Pursuant to the provisions of 10 CFR 2.201, Omaha Public Power District is hereby required to submit a written statement re explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, Region IV, and a copy to the NRC Resident inspector at Fort Calhoun Station within 30 days of the date of the letter transmitting this Notice. The reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation:
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| (1) the reason for the violation if admitted, (2) the corrective steps that have takenbeen taken to avoid and the further results and violations, achieved,)(3) the (4 the date when corrective steps thatwill full compliance will be be achieved. Where good cause is shown, consideration will be given to extending the response time.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| $ hd'g Robert D. Martin Regional Administrator Dated at Arlington, Texas, this 12th day of October 1988.
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| NUREG-0940 1.B-22
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| UNITED STATES km afog'o NUCLEAR GEGULATORY COMMISSION y* , REGION 11 g j 101 MARIETTA STREET N.W.
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| * ATLANTA, GEORGI A 30323
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| \...../ 0EC 101988 Docket No. 50-416 License No. NPF-29 EA 88-286 System Energy Resources, Inc. l ATTN: Mr. W. T. Cottle, Vice President Nuclear Operations Post Office Box 23054
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| -Jackson, Mississippi 39205 Gentlemen:
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| | |
| ==SUBJECT:==
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| NOTICE OF VIOLATION I (NRC INSPECTION REPORT NO. 50-416/88-24)
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| This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by W. W. Stansberry on October 19-20, 1988 at the Grand Gulf Nuclear Station. The i.nspection included a review of the circumstances surrounding the failure of site security force personnel to conduct an adequate search which resulted in contraband being introduced into the site Protected Area on October 10, 1988.
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| The report documenting this inspection was sent to you by {{letter dated|date=November 16, 1988|text=letter dated November 16, 1988}}. As a result of this inspection, a significant failure to comply with NRC regulatory requirements was identified, and accordingly, MC concerns relative to the inspection findings were discussed in an Enforcement Conference held on December 7, 1988. The letter summarizing this Conference .
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| was sent to you on December 16, 1988.
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| The violation described in the enclosed Notice of Violation (Notice) involved a failure by your site security staff to conduct an adequate search of packages received at the site warehouse on October 10, 1988. As a result of that inadequate search, two handguns were subsequently introduced into the site Protected Area where they remained until the next day, October 11, 1988, when a member of your site security staff discovered that the weapons were inside the site Protected Area. Your staff promptly reported the event to the NRC and initiated an investigation to determine the facts anc circumstances of how the >
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| event occurred. This event was caused by security personnel and warehouse storekeepers opening packages simultaneously which resulted in the mixing of screened and unscreened packages. As a result of this confusion, the package containing the weapons was not screened by security personnel and it was sub-sequently taken Anto the Protected Area.
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| As you noted during the Enforcement Conference, this event clearly demon!,trates the importance of following established procedural requirements, attention to detail, and the necessity for the security staff to maintain the highest level of security awareness at all times.
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| NUREG-0940 I.B-23
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| r System Energy Resources, Inc. 2 DEC 161988 for NRC In acccordance Enforcement with the " General Actions," Statement 10 CFR Part 2, Appendix of Policy C (and Procedure 1988), the violation described in the enclosed Notice has been classified as a Severity Level III
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| ~
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| violat.;n.
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| Normally, a civil penalty is considered for a Severity level III violation. I However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, I have decided that a civil penalty will not be proposed in this case because this event was identified and imediately reported by your staff, prompt and extensive corrective action was initiated, and because of the good record of performance which Grand Gulf Nuclear Station has established.
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| You are required to respond to this letter and the enclosed Notice and should follow the instructions specified therein when preparing your response. In your response, you should document. the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requi rements .
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| Should you have any questions concerning this letter, please contact us.
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| Sincerely, 6e Malcolm L. Ernst ActingRegionalAdm[inistrator
| |
| | |
| ==Enclosure:==
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| Notice of Violation cc w/ enc 1:
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| T. H. C"oninger, Vice President, Nuclear Engineering and Support C. R. Hutchinson, GGNS General Manager J. G. Cesare, Director, Nuclear Licensing I cc w/o enc 1:
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| R. T. Lally, Manager of Quality Assurance Middle South Services, Inc.
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| R. B. McGehee, Esquire Wise, Carter, Child, Steen and Caraway N. S. Reynolds, Esquire Bishop, Cook, Purcell & Reynolds '
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| R. W. Jackson, Project Engineer State of Mississippi NUREG-0940 I.B-24 l l
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| l l
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| i NOTICE OF VIOLATION System Energy Resources, Inc. Docket No. 50-416 Grand Gulf Nuclear Station License No. NPF-29 Unit 1 EA 88-286 During the Nuclear Regulatory Commission (NRC) inspection conducted on October 19-20, 1988, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforce-
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| . ment Actions," 10 CFR Part 2, Appendix C (1988), the violation is set forth below:
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| Paragraph 2.E of Grand Gulf Nuclear Station Facility Operating License No. NPF-29 requires the licensee to maintain and implement the approved Physical Security Plan. Paragraph 6.8.1.2 of the Physical Security Plan, paragraph 6.8.5 of Security Procedure 11-S-52-3, and Security Post Orders No. 9 and No. 43 require material being delivered to tne Systems Energy Resources, Inc. warehouse to be searched by security personnel prior to being moved into the Protected Area of the warehouse.
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| Contrary to the above, on October 10, 1988, security personnel failed to properly search delivered packages prior to those packages being moved into the Protected Area of the warehouse, resulting in two handguns reaching the Protected Area of the warehouse.
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| This is a Severity Level III violation (Supplement III).
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| Pursuant to the provisions of 10 CFR 2.201, System Energy Resources, Inc. is hereby required to submit a written statement or explanation to the Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with one copy each to the Director, Office of Enforcement, Regional Administrator, Region II, and the NRC Resident Inspector, Grand Gulf, within 30 days of the date of the letter transmitting this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1)the reason for the violation if admitted, (2)the corrective steps which have been taken and the results achieved, (3) the corrective steps which will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time. If an adequate NUREG-0940 1.B-25
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| l l
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| Notice of Violation 2 reply is not received within the time specified in this Notice, an order may be <
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| issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken.
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| FOR THE NUCLEAR REGULATORY COMMISSION 6x. Malcolm L. Ernst Acting Regional inistrator Dated at Atlanta, Georgia this /dday of December 1988 l
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| i i
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| NUREG-0940 I B-26 l
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| _ _ _ _____ _ _ _ _ ___ _ j
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| II.A. MATERIALS LICENSEES, CIVIL PENALTIES AND ORDERS NUREG-0940
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| l
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| .l p'* **%
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| = 81 UNITED STATES IY" E NUCLEAR REGULATORY COMMISSION )
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| ~(
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| ? #
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| [ REGION 11
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| '01 M ARIETTA ST,, N.W.
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| s
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| ')
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| * ATLANTA, GEORGIA 30323 NOV 181988 Docket No. 70-27 License No. SNM-42 EA 88-225 Babcock and Wilcox Company ATTN: Mr. R. E. Tetrault, Vice President Naval Nuclear Fuel Division Post Office Box 785 Lynchburg, Virginia 24505-0785 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 70-27/88-18 AND 70-27/88-26)
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| This refers to the Nuclear Regulatory Commission (NRC) inspections conducted at the Naval Nuclear Fuel Division facility on June 6-10, July 5-8, July 18-22, August 1-5, August 10-12, and September 6-9, 1988. The inspections included a review of your nuclear criticality safety program. The reports documenting these inspections were sent tn you by letters dated August 17 and September 30, 1988. As a result of these inspections, significant failures to comply with NRC regulatory requirements were identified, and accordingly, NRC concerns relative to the inspection findings were discussed in a management meeting on August 8, 1988 and in an Enforcement Conference held on August 24, 1988.
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| Letters summarizing the management meeting and Conference were sent to you on August 19, 1988 and August 30, 1988, respectively. A Confirmation of Action Letter was also sent to you on July 29, 1988, which confirmed that B&W would not resume processing or movement of special nuclear material in the Compact Reactor fuel and Scrap Recovery areas until after B&W and NRC had met to discuss the results of your corrective actions and NRC had authorized the resumption of processing. Authorizations to resume operations of the Compact Reactor Fuel area and Scrap Recovery area were granted by the NRC on September 2 and October 18, 1988, respectively.
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| The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) include instances of failure to: (1) follow the nuclear criticality safety double-contingency policy, (2) carefully control moderating materials, (3) post certain areas with nuclear criticality safety limits, (4) conduct activities in accordance with operating procedures and posted nuclear criticality safety limits (5) obtain required reviews and approvals by the Nuclear Licensing Board, (6) perform interpretations of nuclear safety limits and controls in accordance with license requirements, and (7) conduct activities in accordance with approved procedures. These conditions, which created a reduced safety margin in some areas of the facility, were indicative of inadequate management attention to the nuclear criticality safety program. In particular, the B&W program lacked a system to assure that adequate nuclear criticality safety limits and controls were established and that ef fective audits were conducted to assure compliance with those established limits and controls. In sum, these violatier.. represent a significant reguincry concern.
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| NUREG-0940 II.A-1
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| Babcock and Wilcox Company NOV 181988 At the Enforcement Conference, B&W presented a position on double contingency which was not acceptable to the NRC. Contrary to the B&W position, procedures and postings do not constitute a double contingency but identify the process controls or conditions which must be maintained to assure that a criticality accident is not possible. B&W's letter of September 2,1988, which is acceptable to the NRC, indicates that B&W has modified its position concerning double
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| ! contingency.
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| During Nuclear Regulatory Commission inspections conducted on August 1-5, August 10-12 and September 6-9, 1988, additional examples of the failure to carefully control moderating materials were identified. The details of this inspection are documented in Inspection Report No. 70-27/88-26. The additional examples are discussed in the enclosed Notice as part of Violation B.
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| To emphasize the need for improvement in your nuclear criticality safety program, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Six Thousand Two Hundred and Fifty Dollars ($6,250) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1988) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem.
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| The base value of a civil penalty for a Severity Level III violation or problem is $12,500. The NRC Enforcement Policy allows for reduction of a civil penalty under certain circumstances. In this case, the base civil penalty amount is reduced by 50 percent because of your unusually prompt and extensive corrective actions which included shutting down two process areas, performing multi-disci-pline internal audits, arranging for external audits, revising operating proce-dures, reevaluating nuclear criticality safety limits and centrols, and developing a nuclear criticality safety performance improvement program.
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| Besides the concerns noted above, we are also concerned about issues brought up in the Enforcement Conference which indic~ated that activities were being conducted that were not authorized by approved written procedures. It is imperative that activities involving special nuclear material be conducted in strict compliance with approved written procedures and that procedures be adequate from a safety standpoint. j In addition to the areas addressed as specific violations in the enclosed Notice, other weaknesses were identified in your nuclear criticality safety program which were documented in the inspection report which do not constitute violations cf NRC requirements. Therefore, your response to this letter should also describe those particular actions taken or planned to strengthen your program in those areas identified as Inspector Followup Items in paragraph 4 of Inspection Report No. 70-27/88-18.
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| You are required to respond to this letter and the enclosed Notice and should follow the instructions specified therein when preparing your response. In >
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| your response, you should document the specific actions taken and any NUREG-0940 II.A-2
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| _ _ _ _ _ .___ _ ______________.____________ - ___ A
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| | |
| Babcock and Wilcox Company NOV 181988 additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is aecessary to ensure compliance with NRC regulatory requirements.
| |
| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
| |
| The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
| |
| Should you have any questions concerning this letter, please contact us.
| |
| Sincerely, J 3^L .-W>)
| |
| 'Malclolm L. Ernst w[
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| Acting Regional Administrator
| |
| | |
| ==Enclosure:==
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| | |
| Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl:
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| C. C. Boyd, Jr.
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| Licensing and Compliance Officer Commonwealth of Virginia NUREG-0940 II.A-3
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITIUK~0F CIVIL PENALTY Babcock and Wilcox Company Docket No. 70-27 Naval Nuclear Fuel Division License No. SNM-42 EA 88-225 During the Nuclear Regulatory Commission (NRC) inspections conducted on June 6-10, July 5-8, July 18-22, August 1-5, August 10-12, and September 6-9, 1988, violations of NRC requirements were identified. In acccrdance with the
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| " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| License Condition 9 of Special Nuclear Material t.icense No. SNM-42 requires the licensee to use special nuclear material in accordance with the statements, representations, and conditions in Sections I through IV and IX of the license application dated February 22, 1982, and supplements thereto.
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| A. Section III, Chapter 1, Paragraph 1.1 of the license application requires the licensee to follow the nuclear criticality double-contingency policy which is incorporated as follows: " Process design should, in general, incorporate sufficient factors of safety to require at least two unlikely, independent, and concurrent changes in process conditions before a criticality accident is possible."
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| Contrary to the above, the licensee did not follow the double contingency policy since, as of July 22, 1988, the design of the following processes, to which the policy does apply, did not incorporate sufficient factors of safety to require at least two unlikely, independent, and concurrent changes in process conditions to make a criticality accident possible in that:
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| : 1. Only one control over process conditions was included in the procedure for transferring solution containing high enriched Uranium-235 (U-235) in the Compact Reactor Fuel (CRF) facility from favorable geometry,11-liter bottles to unfavorable geometry 55-gallon drums. Procedure E61-546: " Waste Handling and Disposal,"
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| Revision 3, April, 1988, allowed the 11-liter bottles to contain quantities of U-235 which could cause a criticality accident if transferred to 55-gallon drums. The procedure also established safe limits on the quantities of U-235 which could actually be transferred.
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| Quantitative measurements of the bottle contents for comparison to these limits were made by a single analysis of a single sample.
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| Since no other controls over process conditions were included in the design, a single, inadvertent departure from the procedure would have made a criticality accident possible.
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| : 2. Only one control over process conditions was included in the procedure used in the Research and Test Reactor Fuel Element (RTRFE) facility for transferring floor cleaning solution from poisoned, unfavorable geometry containers to unpoisoned, unfavorable geometry NUREG-0940 II.A-4
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| Notice of Violation 55-gallon drums. The solution was collected in poisoned containers because of the possibility of accumulating concentrations of U-235 which would cause a criticality accident in unfavorable geometry conditions. The procedure, which was a nuclear criticality safety (NCS) area posting, allowed the transfer of solution having less than a specified concentration. Concentration measurements for comparison to the concentration limit were made by a single analysis of a single sample. Since no other controls over process conditions were included in the design, a single, inadvertent departure from the procedure would have made a criticality accident possible.
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| : 3. No controls were present to prevent the movement of unpoisoned, unfavorable geometry 55-gallon drums from the " general purpose" area, where they were allowed, into the adjacent Uranium Recovery facility where they were prohibited because of the possibility of usage for accumulating concentrated solutions of U-235. Some solutions processed in the recovery facility were sufficiently concentrated to cause a criticality accident if transferred to unpoisoned, unfavorable geometry containers. Since the movement and usage of these drums would make a criticality accident possible, at least two controls were required but were not provided.
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| B. Section !!I, Chapter 2, Paragraph 2.5 of the license application requires that in moderation controlled areas, moderating materials be eliminated or carefully controlled.
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| Contrary to the above, moderating materials in moderation controlled areas were not carefuily controlled in that:
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| : 1. As of July 22, 1988, moderating mater'als in the " general purpose" hood in the uranium recovery facility could inadvertently be introduced in unregulated quantities into the moderation controlled side of the hood from the uncontrolled side of the hood, since only a partial barrier separated the two areas.
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| l 2. As of August 11, 1988, no records of the amount of moderating materials l present at moderation controlled work stations in the RTRFE facility were required by procedure or reliably maintained.
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| : 3. As of September 9, 1988, records of the amount of moderating materials present at moderation controlled work stations in the RTRFE and CRF facilities were inaccureM because of the practice of including weights of absorbed non-moderati g materials in the weights of absorbent moderating materials removed from the work stations.
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| 1 C. Section III, Chapter 1, Paragraph 1.2 of the license application requires that nuclear criticality safety limits be posted in each area where special nuclear material is handled. Two types of signs are required:
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| area signs to specify limits for a particular area or operation and individual signs for worktables, transport carts, and storage racks. The signs are required to provide the following information: type and form of material permitted, allowable quantity, moderator restrictions (if required), and spacing of units (if required).
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| NUREG-0940 II.A-5
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| I Notice of Violation l Contrary to the above, as of July 22, 1988, areas where special nuclear material (SNM) was handled were not posted as required in that:
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| : 1. Numerous gloveboxes (ventilated worktables) in the CRF and RTRFE facilities were not posted individually. Instead, the gloveboxes were listed on area signs.
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| : 2. Area postings in the CRF facility stated that 2.5-liter containers were allowed to be used but did not specify the spacing required for these containers.
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| ]
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| : 3. Area postings in the uranium recovery facility stated that 4.8-liter containers were allowed to be used but did not specify the spacing required for these containers. l
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| : 0. Section II, Chapter 6.0 of the license application requires that all activities involving licensed materials be conducted in accordance with approved operating procedures supplemented with nuclear criticality safety (NCS) postings. j i
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| Contrary to the above, as of July 22, 1988, activities involving licensed material were not conducted in accordance with operating procedures and nuclear criticality. safety postings in that:
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| : 1. Two-quart bottles were being used in process enclosures in the CRF facility for the collection and temporary storage of waste materials (e.g., gloves, paper, wipes, etc.) contaminated with U-235. Neither the work station postings nor any operating procedure allowed such usage.
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| : 2. A two-quart bottle of scrap material containing 380 grams of U-235 was found by an NRC inspector on July 7, 1988 in a process enclosure ;
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| in the CRF facility. Neither the NCS posting for the enclosure nor i any operating procedure permitted the storage of scrap materials in the enclosure.
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| : 3. There were no NCS postings supplementing the procedures for the use of wire mesh containers of approximately 25-gallon capacity in the CRF and uranium recovery facilities for collection and temporary storage of waste materials contaminated with U-235. r
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| : 4. Sample bottles of solution containing U-235 were stored in one-gallon cans in a rack in the uranium recovery facility. The NCS posting for the rack specified a maximum of 3.6 kilograms of U-235 with a specific hydrogen-to-uranium ratio limit, but the limit being used ,
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| for the solution sample storage was 350 grams of U-235 without limiting the hydrogen-to-uranium ratio.
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| : 5. Operation of a vacuum annealing furnace in RTRFE facility required moving uranium within an area where SNM was prohibited by an NCS posting.
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| NUREG-0940 II.A-6
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| Notice of Violation 6. Fifty-five gallon drums were being used throughout the RTRFE facility for the collection and temporary storage of waste materials contaminated with U-235. Neither the NCS postings nor any operating $
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| procedure authorized such usage or storage. l E. Section III, Chapter 2, Paragraph 2.0 of the license application requires ,
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| the licensee's Nuclear Licensing Board (NLB) to review and approve new or '
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| proposed changes in which there is a nuclear safety element not previously reviewed for the specified operation.
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| Section II, Chapter 3.0, Paragraph 3.1 of the license application requires the NLB to review the effect on nuclear criticality safety of new and revised facilities, equipment, and processes involving special nuclear material and to ensure appropriate safety controls are considered.
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| Changes to plant equipment and facilities are required to be submitted to the NLB as License Evaluation Request (LER) reports. Paragraph 3.1.1 specifically requires NLB approval for new storage areas. Paragraph 3.1.2 requires that nuclear criticality safety (NCS) evaluations be performed, as necessary, during the review and approval process.
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| Contrary to the above, as of July 22, 1988, required reviews and approvals by the Nuclear Licensing Board were not performed or were incomplete in that:
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| : 1. Verbal approval had been given for the use of two-quart bottles for collecting waste in the process enclosures in the CRF facility, for the use of 25-gallon wire mesh containers for collecting waste in the CRF and uranium recovery facilities, and for the use of 55-gallon drums for collecting of waste in the RTRFE facility. Although these activities involved nuclear safety elements not previously reviewed and creater' new storage areas, they were not reviewed and approved by the NLB, LERs were not submitteo, and NCS evaluations were not performed.
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| : 2. An interpretation of an existing NCS evaluation was made to allow storage of high-efficiency particulate , air (HEPA) filters containing uranium in the vault shipping and receiving area. This activity involved a nuclear safety element not previously reviewed and created new storage areas, but it was not reviewed and approved by the NLB, and no LER was submitted.
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| : 3. NLB did not review and approve new NCS limits and controls prepared from NCS evaluations and implemented by NCS postings.
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| F. Section II, Chapter 1, Paragraph 1.4 of the license application authorizes !
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| the Nuclear Safety Officer to perform interpretations of existing NCS limits and controls. j Section II, Chapter 2, Paragraph 2.4 of the license application requires that, for performing interpretations of existing limits and controls, the Nuclear Safety Officer must have at least one year of experience performing this type of evaluation under review by someone who has had this type of experience.
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| NUREG-0940 II.A-7
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| l l
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| ' Notice of Violation Contrary to the above, as of July'22, 1988:
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| 1
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| : 1. The Nuclear Safety Officer was performing interpretations not only of j existing limits and controls, but also of proposed NCS limits and controls in that the NCS postings which he prepared from new NCS evaluations required interpretations of the new limits and controls contained in the evaluations.
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| : 2. The Nuclear Safety Officer was performing interpretations of existing NCS limits and controls without having acquired the prerequisite experience in that he had.less than one year of experience performing such interpretations under review by a person who had the requisite experience.
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| G. Section II, Chapter 6.0 of the license application requires that activities of the Regulatory Relations Department be conducted in '
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| accordance with approved procedures.
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| Contrary to the above, activities of the Regulatory Relations Department were not being conducted in accordance with approved procedures in that there were no approved procedures for performing nuclear criticality safety evaluations and interpretations, an activity of the Regulatory Relations Department. I These violations have been evaluated in the aggregate as a Severity Level III problem (Supplement VI).
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| Cumulative civil penalty - $6,250 (assessed equally among the violations). j Pursuant to the provisions of 10 CFR 2.201, Babcock and Wilcox Company (Licensee) is hereby required to submit a written statement or explanation ;
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| to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, l within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each l violation: (1) admission or denial of the violation, (2) the reasons for .
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| the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be
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| . proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or af fi rma tion .
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amoun; of the civil penalties if more than one civil penalty is proposed, or may protest NUREG-0940 II.A-8
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| | |
| l Notice of Violation imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed.
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| In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, , should the five factorsAny be addressed. addressed in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
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| Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II and a copy to the NRC Resident Inspector, Naval Nuclear Fuel Division.
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| Security or safeguards information or other material which may be exempt from disclosure pursuant to 10 CFR 2.790 should be submitted as an enclosure to facilitate withholding it from public disclosure as required by 10 CFR 2.790(d) or 10 CFR 73.21.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| '~
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| 7q/' P <(
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| Malcolm L. Ernst
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| }- '
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| Acting Regional Administrator Dated at Atlanta, Georgia thisle@dayofNovember1988 NUREG-0940 II.A-9
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| p"
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| / t NUCLEAR REGULATORY COMMISSION UNITED STATES g y REGION I
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| * 2 475 ALLENDALE ROAD
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| 'g KING OF PRUSSIA, PENNSYLVANIA 19406 October 7, 1988 Docket No. 70-1100 License No. SNM-1067 EA 88-193 Combustion Engineering, Inc.
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| ATTN: Shelby Brewer Executive Vice President, Nuclear Power Systems Division Post Office Box 500 Windsor, Connecticut 06095 Gentlemen:
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| | |
| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 70-1100/88-05 AND 70-1100/88-06)
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| This refers to NRC inspections conducted on May 25-27, and June 14-17, 1988 at your facility in Windsor, Connecticut, and also the site visit to your facility on August 15, 1988 by Mr. Stewart D. Ebneter, Director of the Region I Division of Radiation Safety and Safeguards. NRC Commissioner Carr accompanied the inspector during one of the inspections, the reports of which were forwarded to you on July 12, 1988. During the inspections, nine violations of NRC requirements were identified. On August 3, 1988, an enforcement conference was conducted with members of your staff to discuss the violations, their causes, and your corrective actions.
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| The violations, which are described in the enclosed Notice, include, but are not limited to: (1) the failure to perform adequate surveys at your facility; (2) the failure by certain individuals to wear gloves while handling certain contaminated equipment, and the failure to supply certain visitors with badges containing criticality monitoring devices, as required; (3) shipment of radioactive waste to a burial ground without meeting all of the shipping requirements, without the waste shipping papers containing the appropriate information, and without proper labeling of the materials; and (4) failure to properly measure the uranium-235 content of certain waste materials.
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| These violations, when considered collectively, are indicative of a lack of management and supervisory oversight of the health physics program. The NRC is particularly concerned because these violations represent another example of what has recently constituted a poor enforcement history at the Windsor facility.
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| For example, on January 25, 1988, a $12,500 civil penalty was issued to you for several violations of radiation protection requirements identified by the NRC in late 1987 and discussed with members of your staff during an enforcement conference on December 1,1987. Furthermore, in March 1988, several violations of criticality requirements were identified, and although the violations were individually classified at Severity Level IV and a civil penalty was not CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-10
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| | |
| i Combustion Engineering, Inc. 2 s
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| assessed, an enforcement conference was conducted with your senior management on May 10, 1988 to discuss these violations and continuing NRC concerns regarding operation of the Windsor facility.
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| The NRC acknowledges that significant improvements have been made since that time to upgrade and more effectively manage the Windsor facility. In particular, organizational changes have been made, development of additional procedures has been initiated, and process equipment has been repaired and upgraded. Furthermore, a Confirmatory Action Letter was issued to you on September 9, 1988 which, in part, confirmed your commitment to have an assessment performed of the fuel manufacturing operations. Notwithstanding the issuance of the Confirmatory Action Letter, and the improvements that have been made to date, these actions on your improvement program do not excuse your failures to meet basic requirements as set forth in the Notice.
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| Therefore, the identification of the violations in the Notice demonstrates the need for acceleration of the pace at which improvements are being made.
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| To emphasize this need, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Twelve Thousand Five Hundred Dollars ($12,500) for the violations described in the enclosed Notice. In accordance with the
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| " General Statement of Policy and Proccdure for NRC Enforcement Actions,"
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| 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violations have been categorized in the aggregate as a Severity Level III problem. The base civil penalty for a Severity Level III violation or problem is $12,500. The NRC considered escalating the amount of the civil penalty based on your recent prior enforcement history and the multiple violations. However, since these factors were used to classify these violations in the first instance as an aggregate Severity Level III problem, the NRC has decided not to utilize these same factors as a basis for escalation of the amount of the civil penalty.
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| You are required to respond to this letter and the enclosed Notice and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement actions are necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclost.e will be placed in the NRC Public Document Room.
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| NUREG-0940 II.A-11
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| | |
| Combustion Engineering, Inc. 3 i
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| l Tne responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, 4)% T. .
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| William T. Russell Regional Administrator
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| | |
| ==Enclosure:==
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| Notice of Violation and Proposed Imposi;1on of Civil Penalty cc w/ encl:
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| Public Document Room (POR) local Public Document Room (LPDR)
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| Nuclear Safety Information Center (NSIC)
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| State of Connecticut I
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| l l
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| l l
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| NUREG-0940 II.A-12
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| | |
| NOTICE OF VIOLATION AND
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| : j. PROPOSED IMPOSITION OF CIVIL PENALTY Combustion Engineering, Inc. Docket No. 70-1100 C-E Power Systems Nuclear Fuel Manufacturing License No. SNM-1067 EA 88-193 During NRC inspections conducted May 25-27, and June 14-17, 1988, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act),
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| 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| A. 10 CFR 20.201(b) requires that each licensee make such surveys as may be l necessary to comply with the regulations in Part 20, and are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present. As defined in 10 CFR 20.201(a), " survey" means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presences of radioactive materials or other sources c* radiation under a specific set of conditions.
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| Contrary to the above, on June 14, 1988, a survey was not made, as necessary, to a n ure compliance with 10 CFR 20.103(a)(3), which requires the licensee to use suitable measurements of concentrations of radioactive materials in air for detecting and evaluating airborne radioactivity in restricted areas. Specifically, on that date, a radiation worker was us ng a Chicago Trash Packer Corporation Model 4500 compactor to compact material contaminated with uranium powder, and no radiological surveys were performed to determine the extent of radioactive contamination on the material being compacted, and appropriate air sampling was not performed in the immediate work area to ensure compliance with the requirements set forth in 10 CFR 20.103.
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| B. Amendment No. 09 to License No. SNM-1067, dated April 8,1987, incor-porates uto the facility license Sectior 3.2.6, " External exposure (Dosimetry Requirements)," of the NRL g proved license application (Part I - Criteria), dated October 22, 1986, which states that all visitors be supplied with indium foil badges.
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| Contrary to the above, from June 14- 17, 1988, certain visitors and contractor personnel were permitted access to the Pellet Shop without being supplied with indium foil badges.
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| NUREG-0940 II.A-13
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| 1 Notice of Violation ?
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| l 1
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| C. Amendment No. 09 to License No. SNM-1067 dated April 8, 1987 incorporates into the facility license Section 3.1.1 " Radiation Work Permit Proce-dures," of the NRC-approved license application (Part 1 - Criteria),
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| dated October 22, 1986 which states, in part, that the Radiation Work Permit will include all safety requirements, protective clothirl and equipment, and health physics monitoring requirements necessary to assure that the proposed operation is conducted in a safe manner. A Radiation i Work Peimit, issued on May 1, 1988, authorized work to_be done on the-Pellet Press No. 4 ventilation system, and required the use of protective clothing, including rubber gloves.
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| Contrary to the above, on May 27, 1988, two workers handled radioactive contaminated parts removed from the Pellet Press No. 4 ventilation system, and these individuals were not wearing gloves as required, D. 10 CFR 19.11 (a) requires that each licensee post current copies of (1) the regulations in this part and in Part 20 of this chapter; (2) the license, license conditions, or documents incorporated into a license by reft rence, and amendments thereto; (3) the operating procedures applicable to licensed activities; and (4) any notice of violation involving radiological working conditions, proposed imposition of civil penalty, or order issued pursuant to Subpart B of Part 2 of this chapter, and any response from the licensee.
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| 10 CFR 19.11(b) states that if posting of a document specified in paragraph I (a)(1), (2) or (3) of this section is not practicable, the licensee may post a notice which describes the document and states where it may be examined. 1 10 CFR 19.11 (d) states that the documents, notices, or forms posted )
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| pursuant to this section shall appear in a sufficient number of places to '
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| permit individuals engaged in licensed activities to observe them on the way to or from any particular activity location to which the document applies, shall be conspicuous, and shall be replaced if defaced or 4 altered.
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| Contrary to the above, between May 25 and May 27, 1988, the licensee did not post the documents specified in 10 CFR 19.11 (a)(1), (2) or (3), or the notice specified in 10 CFR 19.11(b), in a sufficient number of places in Building 5 to permit individuals engaged in licensed activities to observe them on the way to or from any particular licensed activity location. For example, these documents were not posted at the south, southwest or northwest entrances to Building 5. In addition, neither the documents specified in 10 CFR 19.11 (a)(4), nor a notice specified in 10 CFR 19.11(b) were posted at any location in Building 5.
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| E. 10 CFR 20.311(b) states, in part, that each shipment of radioactive waste to a licensed land disposal facility must be accompanied by a shipment manifest that may be shipping papers used to meet Department of Transpor-tation or Environmental Protection Agency regulations or requirements of the receiver, provided that all the information required by 10 CFR 20.311(b) is included.
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| NUREG-0940 II.A-14
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| | |
| Notice of Violation 3 Contrary to the above, the manifests for waste shipments sent to the Barnwell, South Carolina burial site (a licensed land disposal facility) on June 4 and November 2, 1987, did not contain the information required by 10 CFR 20.311(b) in that the proper shipping name and hazard class for several B-25 boxes (Nos. 1103, 1107, 1109 and 1110) were indicated as Radioactive Materials, LSA, n.o.s. UN2912, instead of Radioactive Materials, fissile, n.o.s. UN2918, as required.
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| F. 10 CFR 71.3 states, in part, that a licensee subject to the regulations in this part may not deliver any licensed material to a carrier for transport except as authorized in a general license or a specific license issued by the Commission, or as exempted in this part.
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| 10 CFR 71.1(b)(1) states that a licensee is exempt f rom all requ-irements of 10 CFR Part 71 other than 10 CFR 71.5 and 10 CFR 71.88 with respect to shipment or carriage of a package containing more than a type A quantity of radioactive material if the package contains no fissile material or if the fissile material exemption standard of 71.53 are satisfied.
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| Contrcry to the above, the licensee delivered to a carrier on June 4 and November 2,1987 for transport fissile material (B-25 boxes Nos.1103, 1107, 1109, and 1110) in amounts that did not meet the exemption standards set forth in 10 CFR 71.53, and the licensee did not meet the criteria for-a general license, nor did they possess a specific license issued by the Commission.
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| G. 49 CFR 172.403(a) requires, in part, that unless excepted from labeling by 49 CFR 173.421 through 173.425, each package of radioactive material to be offered for transportation must be labeled with a Radioactive White-I, a Radioactive Yellow-II, or a Radioactive Yellow-III.
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| Contrary to the above, B-25 boxes (Nos. 1103, 1107, 1109 and 1110) containing radioactive material were shipped to the Barnwell, South Carolina burial site on June 4 and November 2, 1987; were not labeled as required in accordance with 49 CFR 172.403(a); and were not excepted from labeling by 10 CFR 173.421 through 173.425. Specifically, the boxes were labeled Low Specific Activity (LSA), and not with the Radioactive White 1, Radioactive Yellow 11, or Radioactive Yellow 111 labels as j required.
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| H. 10 CFR 74.3(a) requires each licensee who is authorized to possess and use more than one effective kilogram of special nuclear material of low I strategic significance to implement and maintain a Commission-approved material control and accounting system.
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| Section 4.2.1 of the NRC-approved Combustion Engineering, Inc., Fundamental Nuclear Material Control Plan (FNMCP) states, in part, that (1) a measure- [
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| ment system has been established and will be maintained for all SNM receipts, removals and inventory items, and all quantities of SNM in the material accounting records will be based on measured values, including low level waste which the FNMCP defines in Table 1.4.1 as shop trash and i
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| NUREG-0940 II.A-15
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| | |
| Notice of Violation 4 filters; (2) a system of measurement has been established for use in the control of and accounting for SNM, including measurements of U and U-235 at appropriate points on proper categories of all nuciaar material receipts, shipments, waste discards and material inventories; and (3) all external transfers of SNM shall be based on measurements. Shop trash is defined by licensee personnel as compactable trash, which does not include non-compactable materials such as springs, tubing, bricks, ventilation system ductwork, etc.
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| Contrary to the above, several Radioactive Waste Drum Release Data Sheets dated between August 3, 1987, and January 18, 1988 (containing entries for waste discards, including shop trash, wood, gloves, plastic pipe, cardboard, brick, tile, rubber hose, ventilation tubing, wire, plastic, chairs, sheetmetal, zirconium tubing, stainless steel springs, and graphite crucibles), indicated that there was no detectable amount (NOA) of the grams uranium, pounds uranium, grams U-235 and millicuries radioactive. However, the U-235 content of those materials, with the exception of shop trash, was not based on any measurement.
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| I. 10 CFR 74.3(a) requires each licensee who is authorized to possess and use more than one effective kilogram of special nuclear material of low strategic significance to implement and maintain a Commission-approved material control and accounting system. Table 1.4.1 of the NRC-approved Combustion Engineering, Inc., Fundamental Nuclear Material Control Plan !
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| (FNMCP) which in part describes this system, indicates that the standards l used for the calibration of the Nondestructive Assay devised for the determination of the U-235 content in absolute filters shall contain 0 and 90 grams of U-235. Section 4.2.3 of the NRC approved Combustion Engineering, FNMCP Annex states that should measurement results indicate that process material are outside the calibrated range, the results will not be used.
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| Contrary to the above, although deta on several of the Radioactive Waste Drum Release Data Sheets indicated that the U-235 content of several filters was outside the range of 0 to 90 grams (101.6 grams, B-25 box No. 1107, dated August 3, 1987; 115.5 grams, B-25 box No. 1110, dated August 26, 1987; and 130.5 grams, B-25 box No. 1109 dated August 21,1987),
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| the results of these measurements were nonetheless used and recorded for shipment to the Chem-Nuclear Systems, Inc., Barnwell Waste Management Facility located in Barnwell, South Carolina, a burial site, on November 2, 1987.
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| Collectively, the above violations have been categorized in the aggregate as a Severity Level III problem (Supplements IV and VI).
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| Collective Civil Penalty - $12,500 (assessed equally among the violations).
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| Pursuant to the provisions of 10 CFR 2.201, Combustion Engineering, Inc.
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| (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a NUREG-0940 II.A-16
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| Notice of Violation 5
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| " Reply to a Notice of Violation" and should include for each alleged violation:
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| (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full cor.nliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violation (s) listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately i from the statement or explanation in reply pursuant to 10 CFR 2.201, but may l incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure l for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| NUREG-0940 II.A-17
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| l Notice of Violation 6 The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406, U.S. Nuclear Regulatory Commission.
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| FOR THE NUCLEAR REGULATORY COMMISSION M T-William T. Russell Regional Administrator Dated 4t, King of Prussia, Pennsylvania this7Mday of October 1988 NUREG-0940 II.A-18
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| I gem aroug UNITED STATES y- g NUCLEAR REGULATORY COMMISSION ;
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| {* r REGION IV f 811 RYAN PLAZA DRIVE, SUITE 1000
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| %, , ,/ ARLINoTON, TEXAS 78011 AUS 251988 Docket No. 30-17765 License No. 35-19455-01 EA 88-169 Computalog, Inc.
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| ATTN: Mr. Jerry DeLong Post Office Box 591 Drumright, Oklahoma 74030 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 30-17765/88-01)
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| This refers to the inspection conducted on May 26-27, 1988, at your facility in Drumright, Oklahoma. During this inspection, the NRC inspectors identified 14 apparent violations of NRC requirements. The results of the inspection were sent to you in a {{letter dated|date=June 22, 1988|text=letter dated June 22, 1988}}. These findings were subsequently discussed with you at an enforcement conference on June 30, 1988, in the Region IV office.
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| The violations, which are described in the enclosed Notice of Violation (Notice), include: (a) failure to have a radiation survey instrument that had been calibrated within the last 6 months, (b) failure to submit personnel basis, (c) failure to perform monitoring physical inventories devicesonfor processingbasis, a semiannual on a timely (d) failure to perform radiation surveys on vehicles transporting radioactive material, (e) failure to perform radiation survey ofsurveys the storage at temporary) job sites, area, (g failure to leak (f) failure to maintain test sealed sources a record at the of proper intervals, (h) failure to maintain a utilization record for radioactive material, (i) failure to store sources of radioactive material according to procedures submitted with the license application, (j) failure to provide shipping papers when transporting radioactive materials, (k) lack of proper
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| } marking on transportation containers, (1) lack of proper labels on transpor-tation containers, (m) failure to maintain on file Department of Transportation Specification 7A, Type A package certification, and (n) failure to maintain on file the special form material performance test results. These violations are of concern to the NRC because collectively, they demonstrate a breakdown in management oversight and control over licensed activities and reveal that your licensed program is in need of significant improvement.
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| As emphasized to you during the enforcement conference, each of these requirements is important to achieving an adequate radiation safety program.
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| It is essential that you assume personal responsibility and devote the CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-19
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| Computalog, Inc. necessary attention to ensuring that NRC regulations and license conditions are being followed. I urge you to fully implement and continue to implement the corrective actions that you described for us during the enforcement conference.
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| To emphasize the need to improve management controls over licensed activities, I have been authorized, after consultation with the Dire tor, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Thousand Dollars ($1,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Polic Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988)y and (Enforcement Policy), the viola':ons described in the enclosed Notice have been categorized in the aggregau at a Severity Level III. The base value of a civil penalty for a Severity Level III problem or violation is $500.
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| The escalation and mitigation factors in the Enforcement Policy were considered. The base civil penalty amount has been '7 creased by 100 percent because of poor past performance in the general area of concern and because some of these types of violations had been identified in a 1985 inspection and you had not taken effective corrective action.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response, in your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, L$ d Robert D. Martin Regional Administrator
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| ==Enclosure:==
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| Notice of Violation and !
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| Proposed Imposition i of Civil Penalty Cc: '
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| Oklahoma Radiation Control Program Director NUREG-0940 II.A-20 l l
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY l
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| Computalog, Inc. Docket No. 30-17765 Drumright, Oklaiama License No. 35-19455-01 EA 88-169 During an NRC inspection conducted on May 26-27, 1988, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act),
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| 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| A. 10 CFR 39.33(a) requires that the licensee keep a calibrated and operable radiation survey instrument capable of detecting beta and gamma radiation at each field station and temporary job site to make radiation surveys as required. 10 CFR 39.33(c) requires that the licensee have each radiation survey instrument calibrated at intervals not to exceed 6 months.
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| Contrary to the above, on the date of the inspection, survey meter, Serial No. 2820, was last calibrated on February 15, 1985, and a second survey meter, Serial No. 2439, was last calibrated May 21, 1985. These were the only two meters possessed by the licensee. Although survey records were not available, customer invoices reviewed by the inspector verified that well logging operations involving licensed materials had been performed after the calibrations had expired.
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| B. 10 CFR 39.65 requires individuals involved in well logging operations to wear personnel monitoring devices at all times during the handling of licensed radioactive materials. If film badges are used, they must be replaced at least monthly. After replacement, each film badge must be processed promptly.
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| Contrary to the above, on the date of the inspection, personnel monitoring badges for the months of January through April 1988 were in the licensee's office at the time of inspection and had not been sent to the film badge I processor for processing. Moreover, some personnel monitoring reports l available showed notations stating that film badges had been sent to the l film badge processor too late to permit proper processing. Examples of this failure included the April and July 1987 badges for one individual and the badges for all of the licensee's personnel during the period February to March 24, 1986.
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| C. 10 CFR 39.37 requires that each licensee conduct a semiannual physical inventory to account for all licensed material received and possessed under the license. The licensee shall retain records of the inventory for 3 years from the date of the inventory for inspection by the Commission.
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| l NUREv 0940 II.A-21
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| i i
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| Notice of Violation Contrary to the above, during the period January 25, 1985 through May 27, 1988, only one undated record of the inventory of sources was available to show the results of inventories. The licensee stated that some inventories had been performed but acknowledged they had not been done at-6-month intervals.
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| I This is a repeat violation. j D. 10 CFR 20.105(b) requires that radiation levels in unrestricted areas be limited so that an individual who was continuously present in the areas one hoir or could not receive in anya 7dose in excess of 2 millirems in any(b) requires that 100 millirems consecutive days. 10 CFR 20.201 each licensee make or cause to be made such surveys as may be necessary to comply with the regulations of Part 20. As defined in 10 CFR 20.201(a),
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| " survey" means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presence of radioactive materials or other sources of radiation under a specific set of conditions. Except for certain records which must be retained until the Commission authorizes their disposition, 10 CFR 20.401(b) and (c)(2) require that each licensee maintain for 2 years after completion of each survey records showing the results of the respective surveys required by 10 CFR 20.201(b).
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| Contrary to the above, on the date of the inspection, no records were available to show the results of radiation surveys performed in the unrestricted areas adjacent to the storage area of radioactive materials.
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| The licensee's representative indicated that a surveys of these areas had been performed.
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| E. 10 CFR 39.35(c) requires that each licensee who uses sealed sources test i each such source for leakage at intervals not to exceed 6 months.
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| Contrary to the above, according to leak test records reviewed on the date of the inspection:
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| : 1. the 5-curie americium-beryllium source, Serial No. T566, was not leak tested between January 25, 1986, and March 30, 1987, and between March 30, 1987, and January 12, 1988;
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| : 2. the 2-curie cesium sources, Serial Nos. CSV-788 and CSV-C22, were not i leak tested between January 25, 1986, and January 12, 1988; and
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| : 3. the 200 millicurie americium calibration sourr.e, Serial 6 . C=170, had not been leak tested since January 25, 1986.
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| The licensee acknowledged that these sources had been in use during the '
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| indicated periods of time.
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| F. 10 CFR 39.39 requires that each licensee maintain records of use of licensed material showing the make, model number, and serial number or a '
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| description of each sealed source used; the identity of the logging l
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| NUREG-0940 II.A-22 l
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| Notice of Violation supervisor who is responsible for the licensed' material; the identity of.
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| logging assistants present; and the location and date of use of the licensed material. The licensee shall retain the records for 3 years from the date of the recorded event.
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| - Contrary to the above, on the date of the inspection, no such records-were available, although customer invoices disclosed that licensed material was used on November 11, 1986; September 29, 1987; October 4, 15, 17, and 19, 1987; November 9,1987; and January 11,14, and 15,1988.
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| G. License Condition 16 requires that the licensee conduct its program in accordance with the statements, representations, and procedures contained in the licensee's application dated June 6, 1980, and the _ letters dated July 14, 1980, and January 31, 1984
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| : 1. Item 5.d of the operating procedures submitted with the application requires a radiation survey program. Item 5.d(2) requires that surveys be taken of each vehicle used to transport radioactive material.
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| Contrary to the above, during the period January 25, 1985 through May 27, 1988, no records were available to verify that surveys had been performed. Because the survey meters had not been calibrated since May 21, 1985, the licensee could not have performed adequate surveys during the period November 21, 1985, to the date of the inspection (a period during which licensed material was transported).
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| : 2. Item 5.d(3) of the operating procedures submitted with the application requires a survey at each temporary job site where source material is used.
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| Contrary to the above, during the period January 25, 1985 through May 27, 1988, no records were available to verify that surveys had t,een performed. Because the survey meters had not been calibrated since May 21, 1985, the licensee could not have performed adequate surveys during the period November 21, 1985, to the date of the inspection (a period in which work involving licensed material had been performed).
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| : 3. The licensee's {{letter dated|date=January 31, 1984|text=letter dated January 31, 1984}}, requires that sources that are not in use be kept in the permanent storage facility.
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| ' Contrary to the above, on the date of the inspection, a 5-curie americium-beryllium srurce, Serial No. T566, and a 2-curie cesium-137 source, Serial No. CSV-788 had been stored on a truck for approximately 4 to 6 weeks.
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| H. 10 CFR 71.5(a) requires, in part, that each licensee who transports licensed material outside the confines of its plant or other place of use, or who delivers licensed material to a carrier for transport, shall comply NUREG-0940 II.A-23
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| Notice of Violation with the applicable requirements of the regulations appropriate to the 4 mode of transport of the Department of Transportation in 49 CFR Parts 170-189.
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| : 1. Except as otherwise provided in Subpart C of Part 172 (such exceptionsnotbeingapplicablehere),49CFR172.200(a) requires that each person who offers a hazardous material for transportation shall describe the hazardous material on the shipping paper in the manner required by Subpart C of Part 172.
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| Contrary to the above, on the date of the inspection, no shipping papers were available on the licensee's premises and the licensee frequently shipped hazardous materials. In addition, the licensee's logging assistant, who had been in the licensee's employ since October 1987, stated that he had never seen anything that would suffice as shipping papers.
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| This is a repeat violation.
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| : 2. 49 CFR 172.300 requires that each person who offers a hazardous material for transportation mark each package, freight container, and transport vehicle.containing the hazardous material in the manner l required by Sub Except as otherwise provided, 49 CFR 172.301(part D of Part 172.a) requires, in part, that each person
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| ; transportation a hazardous material in a packaging of 110 gallons or less shall mark the package with the proper shipping name and identification number. 49 CFR 172.310(a)(2) requires, in part, that each package of radioactive material which conforms to the requirements for Type A or Type B packaging must be plainly and durably marked on the outside of the package with the words " TYPE A" or " TYPE B" as appropriate.
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| Contrary to the above, on the date of the inspection, neither the l shipping container housing the 5-curie americium-beryllium source, l Serial No. T566, nor the shipping container housing the 2-curie l cesium-137 source, Serial No. CSV-788, had the specified markings.
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| l The licensee's representative stated at the enforcement conference that the containers had not been marked for about 1 year. These materials had been transported during the period January 25, 1985 l
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| to May 27, 1988.
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| : 3. 49 CFR 172.403 requires that each package of radioactive material, unless excepted from labeling, be labeled, as appropriate, with a RADI0 ACTIVE WHITE-I, a RADI0 ACTIVE YELLOW-II, or a RADI0 ACTIVE YELLOW-III label.
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| Contrary to the above, on the date of the inspection, neither the shipping container housing the 5-curie americium-beryllium source, Serial No. T566, nor the shipping container housing the 2-curie cesium-137 source, Serial No. CSV-788, had the specified labeling.
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| NUREG-0940 II.A-24
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| Notice of Violation The licensee's representative stated at the enforcement conference that the containers had not been labeled for about 1 year. These materials had been transported during the period January 25, 1985 to May 27, 1988.
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| 4 49 CFR 173.415(a) re Transportation (00T)Specification quires that each shipper of 7A package a Department maintain of for at least 1 year after the latest shipment a complete documentation for each type of package demonstrating that the construction methods, packaging design, and materials of construction of the package complies with that specification.
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| Contrary to the above, on the date of the inspection, D0T Specification 7A, Type A performance records were not on file for the container used to transport the three cesium-137 sources. The licensee acknowledged that these sources had been transported within the last 4 to 6 weeks.
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| This is a repeat violation.
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| : 5. 49 CFR 173.476(a) requires that each shipper of special form radioactive material maintain on file for at least 1 year after the last shipment a complete safety analysis, including documentation of ;
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| any tests, demonstrating that the special form material meets the requirements of part 173.469 Contrary to the above, on the date of the inspection, the special form material performance test records were not available for the 5-curie americium-beryllium source, Serial No. T566, which had been transported within the previous 4 to 6 weeks. '
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| This is a repeat violation.
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| The above violations have been categorized in the aggregate as a Severity Level III problem. (Supplements IV, V, and VI)
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| Cumulative Civil Penalty $1,000.
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| Pursuant to the provisions of 10 CFR 2.201, Computalog, Inc., (Licensee) is hereby required to submit a written statement or explanation to the Directnr, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation:
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| (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved (4) the corrective steps that will be taken to avoid further violations,and(5)thedatewhenfullcompliancewillbeachieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be NUREG-0940 II.A-25
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| l 1
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| Notice of Violation taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in i the amount of the civil penalty proposed above, in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear l Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty in whole or in part, such answer should be clearly marked as an
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| " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the pena'lty.
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| In requesting mitigation of the proposed penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, the be
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| , should f We factors addressed addressed. Any in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. ,
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| )
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| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and answer to a Notice of Violation) should be addressed to: Director, Office of Enfort.ement, I U.S. Nuclear Regulatory Commission, ATT'4: Document Control Desk, Washington, !
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| D.C. 20555 with a copy to the Regional Aon.!nistrator, U.S. Nuclear Regulatory !
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| Commission, Region IV.
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| FOR THE NUCLEAR REGULATORY COMMISSION YYk Robert D. Martin kt Regional Administrator Dated at Arlington, Texas, this g $ ay of August 1988 NUREG-0940 II.A-26
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| [ 'o,, UNITED STATES NUCLEAR REGULATORY COMMISSION
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| !"' g
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| ~c WASHINGTON D. C. 20555
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| {o a
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| %; * , . * * / NOV la 1988 Docket Nos. 030-13105 and 030-17570 License Nos. 3/-17637-01 and 37-17637-02 EA 88-248 E. L. Conwell & Company ATTN: Ms. Ellin Spitzer President Continental Business Center Front and Ford Streets Bridgeport, Pennsylvania 19405 Gentlemen:
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| ==Subject:==
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| (1)NOTICEOFVIOLATIONANDPROPOSEDIMPOSITIONOFCIVILPENALTIES; (2) ORDER TO SHOW CAUSE WHY LICENSE SHOULD NOT BE MODIFIED (NRC Inspection No. 30-17570/88-02)
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| This letter refers to the NRC inspection conducted at your facility in Bridgeport, Pennsylvania, and at a temporary job site in Conshohocken.
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| Pennsylvania on September 12-13, 1988 of activities authorized by NRC License Nos. 37-17637-01 and 37-1/637-02. The inspection report was delivered to you on September 21, 1988. During the inspection, several violations of HRC requirements were identified, two of which were similar to violations identified during several previous NRC inspections. On September 27, 1988, an enforcement conference was conducted with you and a member of your staff to discuss the vio itions, their causes and your corrective acticns.
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| The violations, ,.ich are described in the enclosed Notice of Violation t i Proposed Imposition of Civil Penalties, consisted of: (1) failure to secure, or areasmaintain at theconstant surveillance Conshohocken of, on field site a nut.
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| September lear gauge 12, being(used 1988 ViolationA); in unrestricted (2) failure by the same individual involved in Violation A to secure the source lock on the gauge when not in use, on both September 12 and 13 (Violation D);
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| (3) transport of the gauge to the job site on both Septeraber 12 and 13,1988 without the gauge being accompanied by adequate shipping papers as required (Violation C); and (4) transmittal of inaccurate information to the NRC, in a {{letter dated|date=September 9, 1988|text=letter dated September 9, 1988}}, in response to a Hotice of Violation issued by the NRC on August 19, 1988 (Violation B).
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| The NkC is particularly concerned that, although the employee responsible for the three violations a' the field site was informed of the violations when they were initially ic ntified by the inspector on Septerrber 12, 1988, appro-priate corrective act';n was not taken and two of the three violations were again identified when the inspector visited the field site the following day.
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| These violations, as ell as the failure to promptly take appropriate corrective r:easures, are additio:ial exemples of a continuirg cecline in regulatory perform-ence by E. L. Conwell & Ccepany. As you incw, two of the violations (unsecured gauges, ano tailure to have proper shipping papers) were ic'entified by the NPC during several inspecticos in the post, vere discus;ed during two previous NUREG-0940 II.A-27
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| i E. L. Conwell & Company 2-enforcement conferences with your Vice-President and General Manager, and resulted in the imposition of $500 and $1000 civil penalties on December 10, '
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| 1985 and August 18, 1987, respectively.
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| Recurrent violations of NRC's regulations cannot be tolerated. When sucn violations recur, particularly at the frequency they have recurred at your facility, the NRC considers revocation of the license. In this case, the NRC seriously considered revocation of your license. However, because of your voluntary imediate suspension of your NRC licensed gauge activities, as described in your September 29, 1988 letter, pending development of a disci-plinary program, retraining of all gauge users, and implementation of an I internal audit program, the NRC has decided that action should not be taken to '
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| revoke your license at this time.
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| Nevertheless, to emphasize the need for increased and improved management attention to activities authorized by your license, so as to ensure these activities are conducted safely and in accordance with the terms of your license, I am issuing the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of One Thousand Nine Hundred Fifty Dollars
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| ($1,950) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions,"
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| 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), Violations A and B are each classified at Severity Level III and Violations C ano D are each classified at Severity Level IV.
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| With respect to Violation A, involving the unsecured gauge, a $1000 civil penalty is proposed. The base civil penalty for a Severity Level III violation is $500. The escalation and mitigation factors in the Enforcement Policy were considered and the base civil penalty amount has been increased by 100% because of your poor enforcement hist'*y in this area, as evidenced by the repetitive nature of the violation.
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| With respect to Violation B, involving the transmittal of inaccurate information to the NRC, a $500 civil penalty is proposed. The est,alation and mitigation factors were considered and no adjustment has been deemed appropriate.
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| With respect to Violations C and D, involving the failure to have adequate shipping papers accompanying a gauge in transit, and failure to secure the source lock on the gauge while not in use, although a civil penalty is not normally proposed for a Severity Level IV violation, a civil penelty is proposed for each of these two Severity Level IV violations. In accordance with NRC's Enforcement Policy, civil penalties are imposed for Severity level IV violations that are similar to previous violations for which the licensee did not take effective corrective action. The base civil penalty amount for a Severity Level IV violation is $150. The Enforcement Policy also provides that if a licensee is aware of a condition which results in an origoing violation and fails to initiate corrective action, each day the coridition exists may be considered as a separate violation subject to a separate additional civil penalty. With respect to Violation C, a cumulative $300 Civil Penalty is oposed because this violdtion is similar to a violaticr identified on a past inspection and occurred on both days of this inspection. With respect to Violation D, a $150 civil penalt" is proposed because the violation occurred on both days of this inspection ' was not sim116r to violaticns of past inspections.
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| NUREG-0940 II.A-28
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| E. L. Conwell & Company In addition to proposing to impose the civil penalties, I have also decided to issue the enclosed Order to show cause why your license should not be modified to prescribe additional requirements, as set forth therein, tb ensure that activities are conducted safely trd in accordance with the terms of your license.
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| You are required to respond to this letter and the enclosed Notice and Order and should follow the instructions specified in the Notice and Order in preparing your response. In your response, you shculd document the specific actions taken to correct the violations and any additional actions you plan to prevent recurrence. After reviewing your response, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further enforcement action is necessary to ensure compliance with NRC regulatory requirements. Furthermore, you should be aware that any additional recurrence of these violations may result in suspension or revocation of your license.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosed Notice will be placed in the NRC's Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
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| Sincerely,
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| /
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| any.s M. Taylor, k J puty Executive Director 1ar Regional erations
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| [
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| ==Enclosures:==
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| : 1. Notice of Violation and Proposed Imposition of Civil Fenalcies
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| : 2. Order To Show Cause Why License Should Nut Be Modified cc w/ encl:
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| Public Document Room (PDR)
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| Nuclear Safety Information Center (NSIC)
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| Commonwealth of Pennsylvania l
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| I NUREG-0940 II.A-29
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES E. L. Conwell & Company Docket No. 030-17570 Front and Ford Streets License No. 37-17637-02 Bridgeport, Pennsylvania EA 88-248 During an NRC inspection conducted on September 12-13, 1988, violations of NRC j requirements were identified. In accordance with the " General Statement of 1 Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C i (1988), the Nuclear Regulatory Commission proposes to impose civil penalties j pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), I 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated !
| |
| civil penalties are set forth below:
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| A. 10 CFR 20.207(a) requires that licensed materials stored in an unre-stricted area be secured against unauthorized removal from the place of storage. 10 CFR 20.207(b) requires that licensed materials in an unrestricted area and not in storage be under constant surveillance and immediate control of the licensee. As defined in 10 CFR 20.3(a)(17), .
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| an unrestricted area is any area access to which is not controlled by {
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| the licensee for purposes of protection of individuals from exposure to l radiation and radioactive materials. '
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| Contrary to the above, on September 12, 1988, licensed material consisting of a Troxler Model No. 3411B nuclear density gauge, containing approximately 8.4 millicuries of cesium-137 and 40 millicuries of americium-241, was located I at the Towers Bridge construction site in Conshohocken, Pennsylvania, an unrestricted area, and the gauge was not secured from unauthorized removal nor was it under constant surveillance and immediate control of the licensee.
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| This is a repeat Severity Level III Violation. (Supplement IV)
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| Civil Penalty - $1,000 B. 10 CFR 30.9(a) requires that information provided to the NRC by the licensee be complete and accurate in all material respects.
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| Contrary to the above, in a {{letter dated|date=September 9, 1988|text=letter dated September 9,1988}}, signed by the licensee's General Manager, in response to a Notice of Violation issued by the NRC on August 19, 1988, information was provided to the NRC that was not accurate in all material aspects. Specifically, the licensee's letter stated that it had obtained and placed with each device a shipping document from the manufacturer that contained certain information required by 10 CFR 71.5(a) and 49 CFR 172.200(a). The letter also stated that this action was completed on September 7, 1988. The letter was not accurate in all material respects in that an inspection of one of the devices (a nuclear density gauge) on September 12 and 13, 1988, revealed that the shipping document described had not been placed with the device.
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| This is a Severity Level III Violation. (SupplementVII)
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| Civil Fenalty - $500 NUREG-0940 II.A-30
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| l Notice of Violation 2 C. 10 CFR 71.5(a) requires that each licensee who transports licensed
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| ' material outside the confines of its facility, or who delivers licensed l material to a carrier for transport,_shall comply with the applicable requirements of the regulations appropriate to the mode of transport of the Department of Transportation in 49 CFR Parts 170-189.
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| 49 CFR 172.200(a) requires that each person who offers licensed material for transportation shall describe the licensed material on the shipping paper in the manner required by Subpart C of Part 172.
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| 49 CFR 172.203(d) requires, in part, that shipping papers for radioactive material include: (1) the name of each radionuclides, (2) the physical and chemical form of the radioactive material, (3) the activity in each package, (4) the category of label applied to each package, and (5) the transport index assigned to each packdge.
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| Contrary to the above, on September 12, 1988 and September 13, 1988, a nuclear density gauge containing licensed material was transported to a temporary job site in Conshohncken, Pennsylvania, and the gauge was not accompanied by a shipping paper that described the licensed material in the manner required by the subpart. Specifically, the shipping paper with the gauge did not provide the transport index, the chemical and physical form of the radioactive material or the category of label applied to the package.
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| This it a repeat Severity Level IV violation. (Supplement V)
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| Cumulative Civil Penalty - $300 (Each day this violation occurred is considered a separate violation and assessed a separate $150 civil penalty.)
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| D. Condition 16 of License No. 37-17637-02 requires that licensed uterial be possessed and used in accordance with statements, representations and precedures contained in an application dated June 18, 1985. Item 10(3)(f) of this application requires that the licensee keep the source lock on nuclear gauges in place when not in use.
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| Contrary to the above, on September 12 and 13,1988, at a field site in Conshohoken, Pennsylvania, the source lock on a nuclear density gauge, when the gauge was not in use, was cot in place.
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| This is a Severity Level IV violation. (SupplementVI)
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| Civil Penalty - $150 Pursuant to the provisions of 10 CFR 2.201, E. L. Corwell & Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. t'uclear Regulatory Commission, within 30 days of the date of this flotice. This reply should be clearly marked as a ,
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| " Reply to a Notice of Violation" and should include for each alleged violation: I (1) admission or denial of the alleged violation, C) the reasons for the i violation if admitted, (3) the corrective steps that have teen taken and the results achieved, (4) the ccrrective steps that will be teLen to avoid further vio!ations, and (5) the date when full compliance wi;: t,e achieved. U tr 6dequate reply is not received within the tire specified in this Totice, ar crder may be issued to show cause why the license sNuld not be modified, NUREG-0940 II.A-31
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| Notice of Violation 3_
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| suspended, or revoked or why such other action as may be proper should not be l taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalties by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, er money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amcunt of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the I civil penalties in whole or in part by a written answer addressed to the Director, Office of Enforcement, Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalties will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil peralty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed ir this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties, such answer may request remission or mitigation of the penalties.
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| In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate pa:'ts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the nrocedure for imposing a civil penalty. !
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| Upon failure to pay any civil penalty due which subsequently has been deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collectdd by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a ;
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| Notice of Violation, letter with payment of civil penalties, and Answer to a r Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, 1 D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406.
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| 1 FLR THE NUCLEAR REGULATORY C0f411SS10N
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| / I N h .
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| /J Taylor Deputy Executive Director
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| / /fcr Pegional Operations j
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| .- i Odted at foCkville, Ldryland I this /S"t'ay of November 1988 i NUREG-0940 I1.A-32 l
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| UNITED STATES NUCLEAR REGULATORY COMMISSICN E. L. Conwell & Company Docket Nos, 030-13105 and 030-17570 Front and Ford Streets L1 ense Nos. 37-17637-01 and 3717637-02 Bridgeport, Pennsylvania EA 88-248 ORDER TO SHOW CAUSE WHY LICENSE SHOULD NOT BE f10DIFIED I
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| E. L. Conwell & Company (licensee), Bridgeport, Pennsylvania, is the holder of Byproduct Naterial Licenses Nos. 37-17637-01 and 37-17637-02 issued by the Nuclear Regulatory Commission (the Commission or NRC). The licenses authorize the licensee, in part, to possess and use byproduct nuclear material in sealed sources (for use in nuclear gauges) to measure the properties of materials in accordance with the conditions specified in the licenses. The licenses were most recently renewed on October 20, 1983 (License No. 37-17637-01) and February 5,1987 (License No. 37-17637-0?), and are due to expire on October 31, 1988 and January 31, 1992, respectively.
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| II On September 12-13, 1988, an unannounced radiation safety inspection of licensed activities was performed at the licensee's facility in Bridgeport, Pennsylvania, and at a temporary job location in Conshchocken, Pennsylvania.
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| During the inspection at the field site on September 12, 1988, the NRC found that a Troxler nuclear density gauge, containing milliturie quantities of cesium-137 and arnericium-241, was being used at the field site, and the gauge, which was not secured, was not under ccr stant surveillance and ir:rediate control of a licensee employee as required. :r: addition, the NRC fourd that the source lock on the gauge was not in place (i.e. , Los not lctied in the safe NUREG-0940 II.A-33
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| store position) when the gauge was not in use, and that the gauge was not accompanied by adequate shipping papers as required. Furthermore, when the inspector visited the same field site on the following day, he again found that the gauge was not locked in tne safe store position when not in use, and again was not accompanied by the appropriate shipping papers as required.
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| These failures constitute violations of NRC requirements. i III These violations raise significant regulatory concerns regarding the adequacy of nanagement control of, and the degree of management attention to, NRC licensed activities, oiven the fact that (1) two of the three violations i recurred within the same two day period, and (2) one of these two violations, involving a lack of adequate shipping papers, as well es the violation involving the failure to maintain constant surveillance or immediate control of unsecured gauges, had been identified during several previous NRC inspections.
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| These previous inspections resulted in enforcement conferences being conducted with the licensee on November 19, 1985 and July 22, 1987, and civil penalties of $500 and $1,000 being proposed for these violations on December 10, 1985 and August 18, 1987, respectively.
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| IV In addition to these three violations, the NRC also fcund that in a {{letter dated|date=September 9, 1988|text=letter dated September 9, 1988}}, frcm the licensee's General Manager to the NRC NUREG-0940 II.A-34
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| Region I, inaccurate information was provided to the NRC. The letter was sent to the NRC in response to a Notice of Violation issued on August 19, 1988 for two violations identified during an inspection in June, 1988, including a vio-lation involving the failure to include all of the required information on shipping papers. The letter stated that on September 7, 1988, the licensee had obtained and placed with each device a shipping document from the manufac-turer which contained the transport index, chemical and physical form of radioactive material,_ and the category of label applied to the package. The statement was inaccurate in that an inspection of one of the devices on September 12 and 13, 1988, revealed that the shipping document described in the licensee's letter, dated September 9, 1988, was not with the device. This is a violation of 10 CFR 30.9.
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| V The licensee's continued failure to adhere to NRC requirements (as evidenced by the recurrence of previously identified violations), as well as the submittal of inaccurate information to the NRC, demonstrates that additional actions are needed, in addition to those currently imposed by the license, to increase and improve management attention to licensed activities so as to ensure that these activities are conducted safely and in accordance with NRC requirements. The NRC recognizes that the licensee, in a {{letter dated|date=September 29, 1988|text=letter dated September 29, 1988}}, informed the NRC that subsequent to the enforcement conference, it (1) suspended use of the gauges until the provisions of the license have been reviewed with all certified technicians, and (2) established e disciplinary procedure for failure NUREG-0940 II.A-35
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| to comply with its prescribed procedures. Nonetheless, I have determined that the measures proposed by the licensee do not sufficiently address the underlying causes of the violations and that additional requirements are necessary to ensure that your licensed activities are conducted safely and in accordance with the terms of your license. Specifically, I have determined that the license should be modified to require that (1) the duties and responsibilities of the Radiation Safety Officer be more clearly defined, (2) a training program be established for gauge users, (3) a program of field audits of nuclear gauge users be implemented, and (4) a defined disciplinary program be developed and implemented'for those nuclear gauge users who fail to comply with license requirements, as steps to preclude recurrence of these violations.
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| VI Accordingly, in view of the foregoing, and pursuant to Sections 81, 161b, 1611, 1610, and 182 of the Atomic Energy Act of 1954, as ameaded, and the Commission's regulations in 10 CFR Section 2.202 and 10 CFR Part 30, IT IS HEREBY ORDERED THAT THE LICENSEE SHALL:
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| A. Within 30 days of the date of this order, submit to the Regional Administrator, Re I, a description of how the designated Radiation Safety Officer (Lu. .<ill implement his responsibilities to:
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| NUREG-0940 II.A-36
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| : 1. Ensure that radioactive materials are handled, and iicensed activities are conducted, in accordance with the terms of the license and NRC requirements;
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| : 2. Provide appropriate training, and periodic retraining, to all individuals handling licensed raaterials or performing licensed activities, including training concerning appropriate NRC requirements and the conditions of the license;
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| : 3. Perform appropriate audits of licensed activities at both the permanent facilities and temporary field sites, at a minimum at intervals not to exceed three months, for each individual who used a nuclear gauge during any of those three months, to verify that all personnel are adhering to the conditions of the license; and l
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| 4 Advise all employees of the disciplinary policy that will be utilized for individuals who do not adhere to the conditions of the license.
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| B. Within 30 days of the date of this Order, submit to the Regional Administrator, Region I,
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| : 1. A detailed description of the specific trainin~g to be provided to all empicyees, and specific checklist (s) that the R50 will use in performirg the querterly audits; NUREG-0940 II.A-37
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| : 2. A description of the disciplinary program that the licensee intends to follow to ensure that individuals are held accountable whenever f4RC requirements are violated, and verification that the terms of the disciplinary program have been communicated to all licensee employees.
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| C. Maintain records of all training, retraining, and audits, for at least three years.
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| The Regional Administrator, Region I, may, in writing, relax, rescind, or terminate any of the above provisions upon good cause shown.
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| VII l
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| i The licensee may show cause why this Order should not have been issued and i should be vacated by filing a written answer under oath or affirmation within 1
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| 30 days of the date of this Order which sets forth the matters of fact and law on which the licensee relies. The licensee may answer as provided in 10 CFR l 2.202(d) by consenting to this Order. If the license fails to answer within the specified time or consents to this Order, this Order shall be final without further Order.
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| VIII The licensee, or any other persor cdversely offected by tt.is Order, ray request a hearing within 30 days after issuance of this Order. Any answer to this NUREG-0940 II.A-38
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| Order or any request for hearing shall be submitted to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555.
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| Copies shall also be sent to the Assistant General Counsel for Enforcement at the same address and to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406.
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| If a person other than G licensee requests a hearing, that person shall set fcrth with particularity the canner in which the petitioner's interest is adversely affected by the Order and should address the criteria set forth in 10 CFR 2.714(d). Upon the failure of the licensee, or any other person adversely affected by this Order to answer or request a hearing within the ,
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| specified time, this Order shall be final without further proceedings.
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| If a hearing is requested by the licensee or a person whose interest is adversely affected, the Commission will issue an Order designating the time and place of any hearing. If a hearing is held, the issue to be considered at such a hearing shall be whether this Order should be sustained.
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| FOR THE NUCLEAR RECULATORY COMMISSION ne amIsM. Taylor, eputy Executive Director for Regional Operations :
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| Dated at Rockville, Maryland thisI P day of November 1988 NUREG-0940 II.A-39
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| '"'8 UNITED STATES y- '', NUCLEAR REGULATORY COMMISSION
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| $ ;f REGION IV
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| % S11 RYAN PLAZA DRIVE. SUITE 1000
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| , ARLINGTON. TEXAS 79011 f
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| OLT 27 588 Docket No. 30-19278 l License No. 35-19815-01 EA 88-231 Davis Great Guns Logging Digital Division ATTN: Dale Davis President Room 416 107 N. Market Wichita, Kansas 67202 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 30-19278/88-01)
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| This refers to the inspections conducted on August 17 and 24, 1988 at your facility in Tulsa, Oklahoma. A Confirmation of Action Letter (CAL) was sent to you on August 19, 1988 and confirmed your agreement to suspend your use of certain licensed radioactive sources until your program was brought into compliance with NRC requirements. You were permitted to resume all licensed activities on August 24, 1988 following a reinspection of your program. The results of the August 17, 1988 inspection, in which several violations of NRC requirements were identified by our inspector, were provided to you in an
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| . inspection report dated September 9, 1988, and were discussed with you at an enforcement conference in our offices on September 15, 1988.
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| As a result of our discussions with you at the enforcement conference and subsequent discussions with other NRC personnel, we have dropped from consideration two of the apparent violations that were included in the Septewber 9,1988 inspection report. We have determined that there is no en siration date associated with your 00T-7A Type A shipping container performance test records and that the record-keeping requirement in 10 CFR 20.205 does not apply to the receipt of packages containing less than 20 curies.
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| CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-40
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| OCT 271988 Davis Great Guns Logging i The violations which remain are described in more detail in the enclosed Notice l of Violation (Notice) and involve: inadequate control of licensed material; l failure to identify and post radiation areas in your facility; failure to l conduct semiannual equipment inspections and conduct visual checks, of logging equipment; and failure to maintain records of the use of licensed material and training.
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| Violation A in the Notice, involving your failure to maintain adequate controls of licensed material, is of significant concern to the NRC. However, we also view it and the remaining eight violations collectively as an indication of a breakdown in the management of your NRC-licensed activities and a need to focus greater attention on the requirements associated with your license. To remedy these shortcomings, the NRC urges you to develop effective audit programs designed to ensure that you are in fact complying with all NRC requirements.
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| In addition, we note that you attributed these violations, in part, to serious health problems experienced by your corporate radiation safety officer. It is incumbent on you to obtain suitable replacements should key personnel become unavailable.
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| ( To emphasize the importance of conducting your licensed activities in accord
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| ; with NRC's radiation safety requirements, I have been authorized, after consul-l tation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the er.cic:;ed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Five Hundred Dollars l ($500) for the violations described in the enclosed Hotice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions,"
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| 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violations described l
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| in the enclosed Notice have been categorized in the aggregate at a Severit,t Level III. The base value of a civil penalty for a Severity Level III violation is $500. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| NUREG-0940 II.A-41
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| i OCT 271988 Davis Great Guns Logging The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. c Sinc ,
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| l Robert D. Martin Regional Administrator
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| ==Enclosure:==
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| Notice of Violation and Proposed Imposition of Civil Penalty cc: Oklahoma and Kansas Radiation Control Program Directors i
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| l l
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| NUREG-0940 II.A-42
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| OLT 271988 NOTICE OF VIOLATION l
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| AND PROPOSED IMPOSITION OF CIVIL PENALTY Davis Great Guns Logging Docket: 30-19278 Digital Division License: 35-19815-01 Tulsa, Oklahoma EA 88-231 During an NRC inspection conducted on August 17, 1988, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuanttoSection234oftheAtomicEnergyActof1954,asamended(Act),
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| 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| A. 10CFR39.31(b)(1) requires,inpart,thatthelicenseestorelicensed material in a container or package which must be locked and physically secured to prevent tampering or removal of licensed material from storage by unauthorized personnel.
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| Contrary to the above, on August 17, 1988, the NRC inspector performed a radiation survey and found a 2-curie cesium-137 sealed source, Serial No. CSV-A68, in an unlocked and unsecured shipping package in a shop area which was often unattended and which had an entrance from a public parking area. The shipping package. lid could have been easily removed thus exposino the unshielded source. The source had been unsecured in this manner for approximately 5. days, and the licensee's management was unaware of the situation.
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| B. 10 CFR 39.61(c) requires, in part, that the licensee shall provide safety reviews for logging supervisors and logging assistants at least once during each calender year.
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| Contrary to the above, the NRC inspector determined that the annual safety review for logging personnel had not been performed in calendar year 1987 C. 10 CFR 39.43(b) requires, in part, that each licensee shall have a program for semiannual visual inspection and routine maintenance of source holders, logging tools, injection tools, source handifng tools, storage containers, transport containers, and uranium sinker bars to ensure that the required labeling is legible and that no physical damage is visible.
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| Contrary to the above, on August 17, 1988, the NRC inspector detemined l that the licensee had no such program in that no semiannual inspections of the subject logging equipment were performed for the period July 14, 1987, to August 17, 1988, i
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| NUREG-0940 II.A-43
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| OCT 271988 Notice of Violation D. License Condition 14 states:
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| "Except as specifically provided otherwise in this license, the licensee shall conduct its program in accordance with the statements, representations, and procedures contained in the documents, including any enclosures, listed below. The Nuclear Regulatory Connission's regulations shall govern unless the statements, representations, and procedures in the licensee's application and correspondence are more restrictive than the regulations.
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| : a. Letter dated September 10, 1987
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| : b. Letter dated January 14, 1988
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| : c. Letter dated May 13, 1988"
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| : 1. Section III.B.2 of the licensee's operating and emergency procedures manual, which was revised by {{letter dated|date=May 13, 1988|text=letter dated May 13, 1988}}, requires that if the dose rate in an area is greater than 2 mR/h, the area is considered " restricted" and shall be posted with signs stating " CAUTION - RADIATION AREA."
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| Contrary to the above, on August 17, 1988, the NRC inspector performed a radiation survey and determined a dose rate greater than 2 mR/h at about 6 inches from the edge of the storage well before the unsecured source was deposited in the well and greater than 2 mR/h at about 1 foot after the source was secured in the storage well and there were r.a markings, barriers, or signs that indicated this storage area was a radiation area.
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| : 2. Section I.B.3(d) of the licensee's operating and emergency procedures manual, which was revised by {{letter dated|date=May 13, 1988|text=letter dated May 13, 1988}}, requires that records of instruction provided to ancillary personnel at the time of initial employment and annually thereafter be retained for 3 years.
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| Contrary to the above, on August 17, 1988, the NRC inspector determined that the records for 10 CFR 19.12 training for initial training and annual retrain'ng of employees were not maintained by the licensee for the period May 13, 1988, to l
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| August 17, 1988. The licensee affirmed that the training had 3een done during this period, but records were not kept.
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| l E. 10 CFR 39.43(a) requires that each licensee shall visually check source holders, logging tools, and source handling tools, for defects before each use to ensure that the equipment is in good working condition and that required labeling is present. If defects are found, the equipment must be removed from service until repaired, and a record must be made listing: the date of check, name of inspector, equipment involved, defects found, and repairs made. These records must be retained for 3 years after the defect is found.
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| NUREG-0940 II.A-44
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| OCT 271988 Notice of Violation Contrary to the above, on August 17, 1988, the NRC inspector determined that the licensee had found such defects but had not maintained the records required by 10 CFR 39.43(a) for the period, July 14, 1987, to August 17, 1988. The licensee affirmed that the daily visual checks before equipment was used were being performed, but the licensee's mar,agement failed to assure the maintenance of the records required by 10 CFR 39.43(a).
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| F. 10 CFR 39.39 requires, in part, that each licensee shall maintain records for each use of licensed material showing: (1) the make, model number, and a serial number or a description of each sealed source used; (2) in the case of unsealed licensed material used for subsurface tracer studies, the radionuclides and quantity of activity used in a particular well and the disposition of any unused tracer materials; (3) the identity of the logging supervisor who is responsible for the licensed material and the identity of logging assistants present; and (4) the location and date of use of the licensed material.
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| Contrary to the above, on August 17, 1988, the NRC inspector determined that the licensee had not maintained the records required by 10 CFR 39.39 for two test wells drilled by the licensee on its premises in November 1987 for calibration and testing of its manufactured logging tools.
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| G. 10 CFR 39.33(c)(1) requires, in part, that the licensee's survey instruments be calibrated at intervals not to exceed 6 months and after instrument servicing.
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| Contrary to the above, on August 17, 1988, the NRC inspector determined that several survey instruments were calibrated at intervals exceeding 6 months. One instrument, G. E. Smith, Model 500A, Serial Number 2576, which the licensee's representative stated was being used, had not been calibrated between February 5, 1987 and November 15, 1987.
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| H. 10 CFR 20.205(d) requires, in part, that each licensee shall establish and maintain procedures for safely opening packages in which licensed material is received.
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| Contrary to the above, on August 17, 1988, the licensee was unable to show that such procedures were established and maintained in that the licensee's representative was not aware of any such procedures and was unable to locate and produce a copy of same.
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| The above violations are considered collectively as a Severity Level III violation (SupplementsIV,V,andVI).
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| Cumulative Civil Penalty - $500 (assessed equally among the violations).
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| Pursuant to the provisions of 10 CFR 2.201, Davis Great Guns Logging, Digital Division is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 1
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| NUREG-0940 II.A-45
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| OCT 271988
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| )
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| l Notice of Violation days of the date of this Notice. This reply should be clearly marked as a ,
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| " Reply to a Notice of Violation" and should include for each alleged violation:
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| (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved (4) the corrective steps that will be taken to avoid further violations,and(5)thedatewhenfullcompliancewillbeachieved. If an adequate reply is not received within the time specified in this Notice, an order may be is3ued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Connission, with a check, draf t, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time I specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an
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| " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice (3) show in whole error in thisorNotice, in part,or(2)) demonstrate (4 show extenuating other reasons why the circumstances, senalty should not be imposed. In addition to protesting the civil penalty in w1 ole or in part, such answer may request remission or mitigation of t'te penalty.
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| In requesting mitigation of the proposed penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, , shouldthe befive factors Any addressed. addressed in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty and answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, NUREG-0940 II.A-46
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| i l
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| OCT 271988 Notice of Violation I U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Comission, Region IV, 611 Ryan Plaza Drive, Suite 1000, Arlington, Texas 76011.
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| FOR THE CLEAR REGULATORY COMMISSION
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| / a
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| / _
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| Robert D. Martin Regional Administrator Dated at Arlington, Texas, This 27th day of October 1986.
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| l l
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| NUREG-0940 II.A-47 I
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| l..
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| l, UNITED STATES So nic jf % NUCLEAR HEGULATORY COMMISSION y ' ,; nEclONtil 799 ROOSEVELT RO AD 0 - g f CLEN E LLYN. lLLf NOIS 60137
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| %,; . je" )
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| ***++ OCT 2 71989 Docket No. 999-90003 General License (10 CFR 31.5).
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| EA 88-255
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| ' Ford Motor Company ATTN: Mr. D. A. Greschaw Radiation Health Administrator Central Laboratory 1500 Century Drive
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| ==Dearborn,==
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| Michigan 48120 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 999-90003/88139[DRSS])
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| This refers to the inspection conducted on September 7, 1985, at the Ford Motor Company's Van Dyke Plant in Sterling Heights, Michigan. . The inspection was conducted in response to your. August 16, 1988 telephone notification of the loss of a generally licensed nuclear gauge. The report of the inspection was forwarded to you by {{letter dated|date=October 3, 1988|text=letter dated October 3, 1988}}. An enforcement conference was conducted by telephone on October 4 1988, between l Mr. C. F. Norelius and others of my staff and you and other members of Ford i l
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| Motor Cuapany to discuss the event, its causes, and your corrective act1ons to prevent recurrence.
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| The violation described in the enclosed Notice involves the improper disposal of a generally licensed device containing byproduct material. The NRC recognizes that gauge No. 4037LA was exempted from leak test and inventory requirements; however, it appears that Ford Motor Company employees knew that the gauge could not be located for over a year before proper searches and notifications were initiated. Part of the reeson for the inadequate searches and failure to promptly notify the corporate Raolation Safety Offic appears to be a lack of understanding as to the significance of losing such a device.
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| Increased training of your staff concerning the potential hazards of these devices needs to be implemented.
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| 1 To emphasize the importance of maintaining adequate control over gauges ;
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| containing radioactive material, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Five Hundred Dollars ($500) for l
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| CERTIFIED MAIL i' RETURN RECEIPT REQUESTED NUREG-0940 II.A-48 ;
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| Ford Motor Company 2 007 27 1989 the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violation described in the enclosed Notice has been categorized as a Severity Level III violation.
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| The escalation and mitigation factors in the Enforcement Policy were considered, and no adjustment has been deemed appropriate. The actions you undertook to correct the situation were considered as a mitigating factor; however, these actions were balanced against the length of time the violation continued prior to notification of the NRC. The length of time which existed between the loss of the gauge and actions on the part of Ford Motor Company personnel to recover the gauge significantly reduced the probability for successful recovery of the device.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget, as required by the Paperwork Reduction Act of 1980, Pub. L., No. 96-511.
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| Sincerely, C.
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| kh N M9 A. Bert Davis Regional Administrator
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| ==Enclosures:==
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| 1
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| : 1. Notice of Violation and Proposed Imposition of Civil Penalty
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| : 2. Inspection Report No. 999-90003/88139[DRSS]
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| See Attached Distribution NUREG-0940 II.A-49
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| ' NOTICE OF VIOLATION i Aho I PROPOSED IMPOSITION OF CIVIL PENALTY Ford Motor Company Docket No. 999-90003 Sterling. Heights, Michigan General License (10 CFR 31.5)
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| EA 88-255 During an NRC special safety inspection conducted on September 7,1988 at Ford Motor Company's Van Dyke Plant in Sterling Heights, Michigan, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act),
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| 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:
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| 10 CFR 31.5(c)(8) requires that any person who acquires, receives, possesses, uses or transfers byproduct material in a device pursuant to a general license shall transfer or dispose of the device containing byproduct material only by trarsfer to persons holding a specific license pursuant to Parts 30 and 32 of this chapter or from an Agreement State to receive the cavice.
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| Contrary to the above, during the Spring of 1987, the licensee disposed of a Weston Controls 5310 generally licensed gauge containing approximately one curie of americium-241. The transfer and disposal of the aevice was not made to persons holding a specific license pursuant to Parts 30 and 32 of this chapter or fror,an Agreement State to receive the device.
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| This is a Severity Level III violation (Supplement IV).
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| Civil Penalty $500.
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| Pursuant to the provisions of 10 CFR 2.201, Ford Motor Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation:
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| (1) admission or denial of the alleged violation; (2) the reasons for the !
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| violation if admitted; (3) the corrective actions that have been taken and the results achieved; (4) the corrective actions that will be taken to avoid further violations; and (5) the date when full compliance will be achieved.
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| If an adequate reply is not received within the time specified in this Notice, an Order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, th % response shall be submitted under oath or affirmation.
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| NUREG-0940 II.A-50
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| f Notice of Violation 2 OCT 2 71989 Within the same time as provided for the response required under 10 CFR 2.201, the Licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draf t, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an Order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may:
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| (1) deny the violations listed in this Notice in whole or in part; (2) demon-strate extenuating circumstances; (3) show error in this Notice; or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, in whole or in part, such answer may request remission or '
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| mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the five factors described in Section V.B of 10 CFR Part 2, Appendix C (1988), could be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been deter.:ned in accordance with the applicable provision of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137.
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| FOR THE NUCLEAR P.EGULATORY COMMISSION t
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| 0 (
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| h7S *<"
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| A. Bert Davis Regional Administrator 1
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| Dated a Glen Ellyn, Illinois !
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| this y day of October 1988 I NUREG-0940 II.A-51 1
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| p" "'%c UNITED STATES y?
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| gx $ NUCLEAR REGULATORY COMMISSION f REGION IV 01 RYAN PLAZA ORIVE, SUITE 1000
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| * ARLINGTON, TEXAS 76011 SEP 201988 l
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| l Docket No. 30-20865 i License No. 35-21497-01 l EA 87-205 l Payne and Payne, Inc.
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| Acnw Road and Highway 177 Post Office Box 427 Shawnee, Oklahoma 74801 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 30-20865/87-01)
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| This refers to the inspection conducted on September 25, 1987, at your facility in Shawnee, Oklahoma. The results of tk'- inspection were provided to you in NRC inspEcticn report 30-20865/87-01 aated October 22, 1987 During this 1 inspection, the NRC inspector identified apparent violations that were subse- l quently discussed with you at an enforcement conference on October 28, 1987, 1 in NRC Region IV's offices in Arlington, Texas.
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| The violations identified during the 1987 inspection which are discussed in j more detail in the enclosed Notice of Violation, include: (1) failure to calibrate radiation survey instrum.ents at the proper intervals, (2) failure to submit personnel monitoring devices for evaluatio.i at the proper intervals, (3) failure to perform radiation surveys of areas in which radioactive materials are stored, (4) failure to test sealed sources of radioactive material for leakage at the proper intervals, (5) failure to label transportation containers of radioactive materials in accordance with U.S.
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| Department of Transportation requirements, (6) failure to carry proper shipping documents with shipments of radioactive materials, (7) failure to enter into an agreement with the well owner or operator designating responsibilities in the event a source becomes lodged or is irretrievable, and (8) failure to maintain records of physical inventories of sealed sources.
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| At the October 28, 1987 Enforcement Conference, you stated that the violations identified in NRC Inspection Report No. 30-20865/87-01 had been corrected. Our subsequent inspection on May 11, 1988 confirmed your statements. Nonetheless, the fact that these violations occurred remains significant because collectively it is indicative of a breakdown in the management of your NRC-licensed programs.
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| Meeting these requirements is essential to an effective radiation safety program.
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| CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-52
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| i l
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| I l
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| Payne and Payne, Inc. The NRC is extremely concerned because you acknowledged during the enforcement conference that you had made a conscious decision to violate some of the NRC's requirements due to your fir.ancial situation. Willful violations of the NRC's regulations cannot be tolerated. This is because the NRC inspection program is one of audits. We cannot continuously inspect licensees. Thus we must depend on the integrity of licensees to conduct activities in good faith. When a licensee willfully violates requirements, suspension of a license is considered and in this case we gave serious consideration to suspension of your license.
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| However, because of your candor at the enforcement conference, your immediate corrective action following the September 25, 1987 inspection, your demonstrated willingness to come into and maintain compliance with the requirements of your license, and because you were candid with our inspector, we decided that suspension and/or revocation action would not be taken.
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| Nevertheless, to emphasize the significance in which the NRC views deliberate violations, the importance of an effective radiation control program and the need for lasting improvements in management controls over licensed activities, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Thousand Six Hundred Dollars ($1,600) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate at a Severity Level II. These violations would have been classified at Severity Level III; however, the severity level was increased because of your admitted willful violation of requirements that are important to radiation safety. I The base value of a civil penalty for a Severity Level II violation is $800.
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| The escalation and mitigation factors in the Enforcement Policy were considered.
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| In this case, the base civil penalty amount has been increased by 100% due to multiple examples of some violations and duration.
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| l You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to preven. recurrence. Your response should specifically address your continuing commitment to complying with regulatory requirements regardless of the associated financial costs. Without such assurance, NRC cannot permit Payne and Payne, Inc. to continue in licensed operations. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. Suspension of your license will be considered should future inspections identify similar violations.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| NUREG-0940 II.A-53
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| _A
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| P.ayne and Payne, Inc. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork .7. $Jction Act of 1980, Pub. L. No. 96-511.
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| Sincerely, N ~' M -
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| Robert D. Ma. istrafar egional Admin
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| ==Enclosure:==
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| Notice of Violation and Proposed Imposition of Civil Penalty cc: Oklahoma Radiation Control Program Director 1
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| i l
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| NUREG-0940 II.A-54
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Payne and Payne, Inc. Docket No. 30-20865 Shawnee, Oklahoma License No. 35-21497-01 EA 87-205 During an NRC inspection conducted on September 25, 1987, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C i (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act),
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| 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| A. License Condition 18 requires that the licensee possess and use licensed material in accordance with statements, representations, and procedures contained in the license application dated October 18, 1983; and letters dated December 1, 1983, and April 4, 1984
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| : 1. Item 11 of the license application requires that radiation survey instruments be calibrated at intervals not exceeding 6 month .
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| Contrary to +he above, as of September 25, 1987, the licensee's only survey instrument, Serial No. 15363, was found to have been last calibrated on February 25, 1986.
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| : 2. Item 12 of the license application requires that personnel monitoring devices worn by individuals be evaluated monthly.
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| Contrary to the above, as of September 25, 1987, personnel were wearing film badges dated September 1986. Records confirmed that personnel monitoring devices had not been returned for evaluation since that date.
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| : 3. Part D.1 of the operating procedure submitted with the license application requires that radiation surveys of the storage area be performed monthly and the results be maintained in the survey files.
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| Contrary to the above, as of September 25, 1987, the licensee had not performed monthly radiation surveys of the radioactive source storage area since March 22, 1984 B. License Condition 13 requires that sealed sources of licensed material be tested for leakage and/or contamination at intervals not exceeding 6 months.
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| NUREG-0940 II.A-55
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| Notice of Violation l Contrary to the above, as of September 25, 1987 the licensee's 2-curie cesium-137 source, Serial No. CSV-G91, and 3-curie americium-beryllium source, Serial No. 992, had not been tested for leakage since September 30, 1986. Utilization records confirmed that these sources were used during '
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| the period from March 30, 1987, until September 24, 1987 C. 10 CFR 71.5(a) requires each licensee who transports licensed material outside of the confines of its plant or other place of use, or who delivers licensed material to a carrier for transport, shall comply with the applicable requirements of the Department of Transportation regulations appropriate to the mode of transport in 49 CFR 170-189.
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| : 1. Unless excepted from labeling, 49 CFR 172.403 requires, in part, that each package of radioactive material be labeled, as appropriate, with a RADI0 ACTIVE WHITE I, a RADI0 ACTIVE YELLOW-II, or a RADI0 ACTIVE YELLOW-III label.
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| Contrary to the above, as of September 25., 1987, transportation containers housing source Nos. 992, 3 curies of americium-beryllium, and CSV-G91, 2 curies of cesium-137, were transported without affixing ,
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| the appropriate label.
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| This is a repeat violation.
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| : 2. Except as otherwise prov Med in Subpart C of 49 CFR 172, 49 CFR 172.200 requires 'M each person who offers a hazardous material for transport action shall describe the hazardous material on the shipping paper in the manner required by Subpart C.
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| Contrary to the above, from March 22, 1984, until September 25, 1987, shipping papers describing the hazardous materials (radioactive material) offered for transportation were not prepared by the licensee.
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| D. 10 CFR 39.15(a) requires that the licensee perform well logging with a sealed source only after entering into an agreement with the employing well owner or operator. The agreement must identify who will meet certain requirements specified in 39.15(a).
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| Contrary to the above, as of September 25, 1987, the inspector found that no such agreement had been made since July 14, 1987, the eff::ctive date of this requirement. The licensee's records confirmed that well logging work had been performed during this time period.
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| E. License Condition 16 requires that records of physical inventories of all sealed sources received and possessed under the license be maintained for 2 years from the date of the inventory. Such records shall include the quantities and kinds of byproduct material, location of sealed sources, and the date of the inventory.
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| NUREG-0940 II.A-56
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| Notice of Violation Contrary to the above, on the date af the inspection, such records of physical inventories were not available for the period of September 25, 1985, to September 25, 1987.
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| The above violations have been categorized in the aggregate as a Severity Level II problem (Supplements V and VI).
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| Civil Penalty $1,600 (assessed equally among the violations).
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| l Pursuant to the provisions of 10 CFR 2.201, Payne and Payne, Inc., is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U..,. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violution" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the Jesults achieved (4) the corrective steps that will be taken to avoid further violations, and (5) the j date when full compliance will be achieved. If an adequate reply is not l received within the time specified in this Notice, an order may be issued to I show cause why the license should not be modified, suspended, or revoked or why i such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted I under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to de Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by .a written answer addressed to the Director, Office of Enf orcement, U.S. Nuclear Regulatory Comission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Liceiisee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, the should be five factors addressed. Anyaddressed in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may j incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.
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| NUREG-0940 II.A-57
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| l Notice of Violation Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of_10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region IV.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| , cr-9F"
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| /N R'obert D. Ma _ ~
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| Regional Administ or Dated at Arlington, Texas, this 20th day of September 1988.
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| i l
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| l NUREG-0940 II.A-58
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| I l
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| l
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| / % UNITED STATES y ~
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| c NUCLEAR REGULATORY COMMISSION g ~ ,1 WASMNG TON, D. C. 20555
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| '....*# 00 7 g 3 jggg Docket No. 30-1983S License No. 35-21144-01 EA No. 88-189 Penn Intpection Company ATTN: Wade Penn Route 3, Box 311 Chickasha, Oklahoma 73018 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N0. 30-19836/88-01) AND ORDER MODIFYING LICENSE, EFFECTIVE IMME.01ATELY AND ORDER TO SHOW CAUSE This refers to the inspection conducted on May 31, 1988 at your facility in Chickasha, Oklahoma, to the information provided by Oak Ridge Associated Universities on August 2,1988, and to our discussions with you and your Radiation Safety Officer (RS0) at an enforcement conference in our offices on August 11, 1988. The results of the inspection were provided you in a report cated August 4, 1988.
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| The enclosed Notice of Violation and Proposed Imposition of Civil Penalty lists five violations of NRC requirements, four of which are directly associated with a May 12, 1988 incident involving an employee of Penn Inspection Company who was using licensed radioactive materials to perform radiography. The fifth violation, your failure to observe this radiographer since he had not participated in radiography activities in more than three months, appears to have been a contributing factor.
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| On May 12, a radioactive source being used to perform radiography could not be returned to its shielded position using the remote cranking device. Your radiographer, ignoring good radiation protection practices as well as the conditions of your NRC license, manually freed the source and returned it to its shielded storage device. Although it does not appear that a radiation overexposure occurred, based on reenactments of the incident and medical evaluation, this individual's actions created a high potential for an overexposure, did not reflect an adequate understanding of radiation safety requirements and procedures to be followed in the event of an emergency and demonstrated a careless disregard for NRC requirements important to radiation safety. Therefore, I have determined that it is in the interest of public health and safety to issue the enclosed Order Modifying License, Effective Immediately and Order to Show Cause which prohibits the use of this individual as d radiographer. Th1s Order supersedes the Confirmation of Action Letter issued on June 3, 1988.
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| CERTIFIED MAIL PETURN RECEIPT REQUESTED NUREG-0940 II.A-59
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| Pern Inspection Company The violations in the enclosed Notice include: failure to utilize personnel radiation monitoring devices when performing radiography operations, failure to have access to, and failure to follow emergency procedures, failure to straighten the source tube prior to conducting radiography, and failure to observe and record the performance of a radiographer who had not participated in radiographic operations in more than three months. Althcugh we are not in-cluding d citation for your radiogra'pher's inaccurate statements to our inspector because of the circumstances in this case, we urge you to ensure that your employees understand the importance of providing accurate information to the NRC.
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| To emphasize the importance of ensuring that individuals in your employ who use radioactive materials understand their responsibilities to meet all radiation safety requirements associated with your NRC license, I am issuing the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Twenty-five Hundred Dollars ($2,500) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988)
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| (Enforcement Policy), the violations described in the' enclosed Notice have been categorized in the aggregate at a Severity Level III.
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| The base value of a civil penalty for a Severity Level III violation is $5,000.
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| The NRC Enforcement Policy allows for reduction of a civil penalty under certain circumstances. In this case, the base civil penalty is reduced by 50 percent because your prior compliance history has been good. However, further reduction was not considered appropriate because of the seriousness of the incident on May 12.
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| i Ycu are required to respond to this letter and should fo' low the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrer.ce. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject I to the clearance procedures of the Office of Management and Budget as required I by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. l Sincerely,
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| 'M L2 s"fI. Taylo Deputy Executive
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| / Director for Regional Operations
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| | |
| ==Enclosures:==
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| | |
| Notice of Violation and Proposed Imposition of Civil Penalty and Order Modifying License cc: Oklahoma Radiation Control Program Director NUREG-0940 II.A-60
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Penn Inspection Company Docket: 30-19836 Chickasha, Oklahoma 73018 License: 35-21144-01 EA: 88-189 During an NRC inspection conducted on May 31, 1988, violations of hRC requirements were identified. In accordance with the " General Statement of l
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| Policy),and (1988 Procedure the Nuclear for NRC Regulatory Commission Enforcement Actions,"
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| proposes to impose 10 CFR Partpenalty a civil 2, Appendix C ,
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| pursuant to Section 234 of the Atomic Energy Act of 1954, as amended; i 42 U.S.C. 2282; and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
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| A. 10 CFR 34.33(a) requires, in part, that the licensee not permit any individual to act as a radiographer unless at all times during radiographic operations each such individual wears a direct reading pocket dosimeter and either a film badge or a thermoluminescent dosimeter.
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| Contrary to the above, on May 12, 1988, an individual acted as a radiographer for the licensee and did not wear a direct reading packet dosimeter and either a film badge or a thermoluminescent dosimeter while conducting radiographic operations at a fabricating company in Arkla, O klahoma.
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| : 8. License Condition 16 states, in part, that the licensee shall possess and use licensed material in accordance with statements, representations, and procedures contained in application dated August 3, 1982, as amended September 2, 1982. '
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| : 1. Section XII.A. of the Operating and Emergency Procedures contained in the application states, in part, that each radiography crew working in the field shall have access to the Operating and Emergency Procedures (i.e., will be carried on each job site).
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| Contrary to the above, on May 12, 1988, a radiographer conducted radiographic operations at a job site in Arkla, Oklahoma and later told the NRC inspector that he did not have access to the Operating and Emergency Procedures. Althuugh the procedures may have been in the radiographer's vehicle, the radiographer stated he had no knowledge of that.
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| : 2. Section XIII of the Operating and Emergency Procedures contained in the application states, in part, that it is the responsibility of each radiographer to become thoroughly familiar with these procedures and to follow them explicitly when emergency situations arise including immediately contacting the Radiation Safety Officer.
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| Section XIII.B. states that if there is any question as to whether a given situation constitutes an emergency, then emergency procedures are to be followed.
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| NUREG-0940 II.A-61
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| l l
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| )
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| Notice of Violation ]
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| Contrary to the above, on May 12, 1988, during an event in which the radiography source would not retract into the radiography camera, a malfunction which was clearly an emergency situation in accordance with Section XIII.C. of the Operating and Emergency Procedures, a radiographer ,
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| attempted resolution by unsafe and unconventional tactics and did not j follow the above referenced procedures, which, among other requirements, j required him to immediately contact the Radiation Safety Officer.
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| : 3. Section IX.D.9 of the Operating and Emergency Procedures contained in the application requires that the source transfer tube be straightened as a step. for making an initial exposure with the crank-out device. (This procedure minimizes the potential for source l hang-up in the source transfer tube.) l Contrary to the above, on May 12, 1988, a radiographer made an initial exposure with the crank-out device while the source transfer tube had an )
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| almost 90 bend approximately 6 to 8 inches from the exposure device. As t a result, when the radiographer attempted to retract the source into the camera, the source became stuck in the source transfer tube.
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| C. 10 CFR 34.11(d)(2) requires that an applicant have an inspection program that requires, in part, that if a radiographer has not participated in a radiographic operation for more than 3 months since the last inspection, that individual's performance must be observed and recorded the next time the individual participates in a radiographic operation.
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| Contrary to the above, on May 12, 1988, the licensee failed to perform an inspection to observe and record the actions of a radiographer involved in performing radiographic operations. as required by the licensee's inspection program. The radiographer .ad not performed radiographic operations for the licensee since October 1987.
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| Collectively the above violations have been categorized in the aggregate as a
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| ' Severity Level III problem. (Supplement VI)
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| Cumulative Civil Penalty - $2,500.00 (assessed equally among the violations).
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| Pursuant to the provisions of 10 CFR 2.201, Penn Inspection Company is hereby required to sub'ait a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of
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| * 2 Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| NUREG-0940 II.A-62
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| | |
| Notice of Violation Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violatioris listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalt Section V.C of 10 CFR Part 2, Appendix C (1988)y, the,five
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| , should factors addressed be addressed. Any in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil per:alty.
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| Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, 1 D.C. 20555 with a ccpy to the Regional Administrator, U.S. Nuclear Regulatory i Commission, Region IV, 611 Ryan Plaza Drive, Suite 1000, Arlington, Texas 76011. I FOR THE NUCLEAR REGULATORY COMMISSION j \ M~
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| J 1es M. Taylo , Deputy Executive Director for Regional Operations Dated at Rockville, Maryland this (,TA-day of October 1988.
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| NUREG-0940 II.A-63 !
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| l UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of Penn Inspection Company Docket No. 30-19836 Route 3, Box 311 License No. 35-21144-01 f Chickasha, Oklahoma EA No. 88-189 ORDER MODIFYING LICENSE, EFFECTIVE IMMEDIATELY AND ORDER TO SHOW CAUSE I
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| Penn Inspection Company (licensee) is the holder of byproduct material license No. 35-21144-01 (license) issued by the NRC, which authorizes the licensee to possess iridium-192, cobalt-60, and cesium-137 in sealed sources for use in industrial radiography. The license, scheduled to expire on September 30, 1987, remains in effect pending NRC action on a license renewal application dated August 27, 1987.
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| I II On May 28, 1988, a physician at Grady Memorial Hospital in Chickasha, Oklahoma, reported to NRC Region IV that an individual had sought medical evaluation on that day for a potential overexposure to radiation. The individual Michael L. Moon (radiographer), claimed that he had been performing industrial radiography work for Penn Inspection Company and that he had used his hands to ,
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| free a radioactive source that had become stuck in an unshielded position, thus exposing himself to a potentially high radiation exposure. NRC immediately contacted the licensee to discuss this information. Based on this telephone conversation, the licensee agreed to suspend licensed radiographic operations in areas of NRC jurisdiction until NRC concurred on resumption of these )
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| I activities. This action was documented in a Confirmation of Action letter j dated May 31, 1988. On fiay 31, 1988, the NRC conducted a special inspection !
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| NUREG-0940 II.A-64 I
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| of activities being carried out by the licensee under the terms of its NRC license prompted by the May 28, 1988 reported potential overexposure. It was later concluded, based on reenactments of the incident durimi the inspection that the radiographer described and based on subsequent medical evaluation, that it was unlikely that the radiographer had been subjected to a radiation exposure in excess of NRC-established limits. However, the inspection disclosed that on May 12, 1988, the date of the incident, several of the radiographer's actions were in violation of NRC requirements and, on the whole, were an indication that the radiographer was not adeouately knowledgeable of NRC regulations and license requirements. Specifically, the inspection disclosed that on May 12, 1988, the radiographer failed to use personnel radiation monitoring devices while performing industrial radiography, failed to maintain access to and to follow Penn Inspection Company's Operating and Emergency Procedures, and failed to straighten the source transfer tube as required before making an initial radiographic exposure. Each of these failures is a violation of NRC requirements and each contributed to making the incident on flay 12 a serious event in terms of its potential for a radiation overexposure.
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| Following this incident, the radiographer did not report the seriousness of the incident to either company officials or the NRC. As a result of the inspection, and discussions with a licensee's representative on June 2, 1988, the NRC allowed resumption of licensed radiographic operations based on licensee's agreement to not allow the radiographer to perform or assist in those operations and to cooperate with the NRC specified physician by providing the radiographer l
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| l for cytogenetic studies related to the potential overexposure. This agreement was documented in a Confirmation of Action {{letter dated|date=June 3, 1988|text=letter dated June 3, 1988}}.
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| NUREG-0940 II.A-65
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| III After consideration of the facts, the NRC has concluded that the radiographer's actions on May 12 displayed a careless disregard for NRC requirements important to radiation safety. In addition, his failure to report the seriousness of this incident, either to officials of the Penn Inspection Company or to the NRC, was irresponsible. In total, Mr. Moon did not display the understanding of NRC regulations and license requirements that is required for radiographer by 10 CFR Pai 5 A " radiographer" as defined in Section 34.2 of 10 CFR Part 34 is any individual who performs or who, in attendance at the site where the sealed source or sources are being used, personally supervises radiographic (9erations and who is responsible to the licensee for assuring compliance with the requirements of the Commission's regulations and conditions of the license.
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| Based on Mr. Moon's actions as stated above, there is no longer reasonable assurance that he can be relied upon to comply with Commission requirements concerning his use of licensed material during radiographic operations or personally supervising the use of licensed material in radiographic operations.
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| Therefore, I have d?termined pursuant to 10 CFR 2.202 that the public health, safety and interest require that the license should be modified, as described i
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| below, effective imediately, and that no prior notice is required.
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| IV Accordingly pursuant to Sections 81, 161(b) and (i) of the Atomic Energy Act of 1954, as amended (Act), and the Commission's regulations in 10 CFR 2.20E and Parts 30 ano 34, IT IS HEREBY ORDERED, EFFECTIVE IliMEDIATELY THAT:
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| NUREG-0940 II.A-66
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| NRC License No. 35-21144-01 is modified to prohibit Mr. Michael L. Moon from acting as a radiographer without specific NRC approval.
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| The Regional Administrator, Region IV, or his designee may relax or rescind any of the above provisions for good cause.
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| V The licensee or Mr. Moon may show cause why this Order should not have been issued and should be vacated by filing a written answer under oath cc affirmation within 30 days of the date of this Order which sets forth the matters of fact and law on which the licensee or Mr. Moon relies. The licensee or Mr. Moon may answer as provided in 10 CFR 2.202(d) by consenting to this Order. If the ensee fails to answer within the specified time or consents to this Order, this Order shall be final unless Mr. Moon shows cause why the Order should not have been issued or requests a hearing.
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| VI The licensee or any other person adversely affected by this Order may within 30 days of the date of this Order request a hearing. A request for a hearing shall be addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555. A copy of the hearirg request shall also be sent to the Assistant General Counsel for Enforcement, Office of l
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| General Counsel, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, and to the Regional Administrator, Region IV, 611 Ryan Plaza Drive, Suite 1000, NUREG-0940 II.A-67
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| T Arlington, Texas 76011. If a person other than the Licensee requests a hearing, that person shall set forth with particularity the manner in which the petitioner's interest is adversely affected by this Order and should address the criteria set forth in 10 CFR 2.714(d).
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| If a hearing is requested, th6 Commission will issue an Order designating the time and place of the hearing. If the Licensee fails to request a hearing within 30 days of the date of this Order , the provisions of this order shall be effective without further proceedings. AN ANSWER TO THIS ORDER OR A REQUEST FOR HEARING SHALL NOT STAY THE IMMEDIATE EFFECTIVENESS OF THIS ORDER.
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| In the event the Licensee or any oth, person requests a hearing as provided above, the issue to be considered at such hearing shall be whether this Order should be sustai..(:d.
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| FOR THE NUCLEAR REGULATORY C0tiMISSION NY J ies M. Taylo eputy Executive Director for Regional Operations Dated at Rockville, Maryland, this(o % ay d of October 1988.
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| I NUREG-0940 II.A-68
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| L l
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| - /g. .% 'o, UNITED STATES E'
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| ; NUCLEAR REGULATORY COMMISSION j 5 j REGION I eeee*
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| / 475 ALLENDALE ROAD KING OF PRUSSIA, PENNSYLVANIA 19400 October 28, 1988 Docket No. 70-01718 License No. SNM-1531 EA 88-188 Shadyside Hospital ATTN: Mr. Henry Mordoh President 5230 Centre Avenue Pittsburgh, Pennsylvania 15232 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection Report No. 70-01718/87-01 and Office of Investigations Report No. 1-87-01P.)
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| This letter refers to the NRC safety inspection conducted on April 15, 1987 of activities authosized by NRC License No. SNM-1531, and to the subsequent investigation conducted by the NRC Office of Investigations (01). The inspec-tion report, and synopsis of the OI investigation report, were forwarded to you on July 19, 1988. During the inspection and investigation, a violation of NRC requirements was identified. On July 29, 1988, an enforcement conference was conducted in the NRC Region I office with Mr. David Martin and other members of your staff during which the violation, '.ts causes, and your corrective actions were discussed.
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| The violation, which is described in the enclosed Notice of Violat an and Proposed Imposition of Civil Penalty (Notice), involved the failure to recover and return a nuclear pacemaker to the manufacturer upon the death of an individual. The pacemaker accompanied a deceased individual to a funeral home after he died. It should also be noted that as a result of your failure to recover and return the nuclear pacemaker to the manufacturer, the pacemaker I
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| was disposed of by the funeral home in the normal trash, a method of disposal not authorized by the license or NRC regulations.
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| Although a member and/or a former member of your staff apparently contacted the pacemaker manufacturer and requested that an appropriate shipping container for the return of the pacemaker be sent to the funeral home, Shadyside Hospital did not assure that the pacemaker, for which it still had responsibility, was returned to the manufacturer, as required by your license. Furthermore, inaccurate information was provided te the NRC in an undated letter signed by your then Assistant Administrator and received in Region I on January 2,1986. The letter indicated that the pacemaker had been returned to the manufacturer, when, in fact, the pacemaker had remained at the funeral home, where, after several months, it was discarded in the normal trash.
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| These events demonstrate that Shadyside Hospital did not exercise adequate control of, or attention te, the activities authorized by its license. The NRC is CERTIFIED MAIL liETURN RECEIPT REQUESTED NUREG-0940 II.A-69
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| Shadyside Hospital particularly concerned that any reasonably timely follow-up effort to contact the manufacturer or the funeral home could have prevented the improper disposal.
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| Therefore, to emphasize the importance of maintaining adequate management control of all licensed materials and activities, I have been authorized, after consultation with the Commission, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Two Thousand Five Hundred Dollars ($2,500) for the violation set forth in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC i
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| Enforcement Actions," 10 CFR Part 2, Appendix C (Enforcement Policy)(1988), l the violation set forth in the Notice has been classified at Severity Level III. The base civil penalty for a Severia Level III violation is $2,500. The escalation and mitigation factors were ccn.idered and no adjustment has been deemed appropriate. ,
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| In addition, with respect to tL transmittal of inaccurate information to the NRC in 1986, the NRC emphasizes that all information provided to the NRC must be complete and accurate. Submittal of such information in the future will constitute a violation of 10 CFR 30.9 which became ef fective on February 1, 1988, and escalated enforcement action will be considered.
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| )
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| You are required to respond to this letter and should follow the instructions in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. In addition, your response to this letter should describe the changes that have been made and actions that have been or will be implemented to ensure licensed activities are conducted in accordance with the license, and information submitted to the NRC is complete and accurate.
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| After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject l to the clearance procedures of the Office of Management and Budget as required i by the Paperwork Reduction Act of 1980, PL 96-511. '
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| Sincerely, w'n1. k p William T. Russell Regional Administrator
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| ==Enclosure:==
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| Notice of Violation and Proposed Imposition of Civil Penalties cc's: See next page NUREG-0940 II.A-70
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Shadyside Hospital Docket No. 70-01718 Pittsburgh, Pennsylvania License No. SNM-1531 EA 88-188 During an NRC inspection conducted on April 15, 1987 at the licensee's facility in Pittsburgh, Pennsylvania, and a subsequent investigation by the NRC Office of Investigations, a violation of NRC requirements was identified.
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| In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1984, as amended ("Act"), 42 U.S.C. 2282 and 10 CFR 2.205.
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| The particular violation and the associated civil penalty are set forth below:
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| Condition 15 of License No. SNM-1531 requires that upon the death of a patient the nuclear pacemaker be recovered and returned to the manufacturer.
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| Contrary to the above, upon the death, in December 1985, of an individual who had previously been inlanted with a nuclear pacemaker at Shadyside Hospital, the pacemaker was not recovered by the licensee and returned to the manufacturer.
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| This is a Severity Level III violation. (Supplement IV)
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| Civil Penalty - $2,500 Pursuant to the provisions of 10 CFR 2.201, Shadyside Hospital (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply.
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| to a Notice of Violation" and should include for each alleged violation:
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| (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an i order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C.
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| 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should NUREG-0940 II.A-71
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| Notice of Violation the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violation (s) listed in this Notice in whole or in part,
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| '?) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigai. ion of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 replyo 'y specific reference (e.g.,
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| citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2<205, regarding the procedure for imposing a civil penalty.
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| Upon failure to pay any civil penalty due which subsequently has been deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Corr.ission, ATTN: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I.
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| FOR THE NUCLEAR REGULATORY COMMISSION w>n . k hi1 d ator Dated a1 King of Prussia, Pennsylvania thispg7aay of October 1988 NUREG-0940 II.A-72
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| i-
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| /pe nag %,
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| UNITED STATES g NUCLEAR REGULATORY COMMISSION
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| [ WASHINGTON, D. C. 20655 i j
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| ' \*****} OCT 121988 1
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| Docket No. 030-14827 License No.- 34-18309-01MD EA 88-194 (Blue Ash Facility)
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| Docket No. 030-15166 License No. 34-18484-01MD EA 88-242 (Columbus Tacility)
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| SYNCOR International Corporation ATTN: Mr. Monte Fu Chairman of the Board Post Office Box 2185 20001 Prairie Street Chatsworth, California 91313-2185 Gentlemen:
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| i SUCJECT: ORDER MODIFYING LICENSES (EFFECTIVE IMMEDIATELY)
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| Enclosed is an Order, effective immediately, which: (1) confirms your commitments regarding-the Blue Ash, Ohio facility documented in our Confirmatory Action Letter No. RIII-CAL-88-0026 (Enclosed) issued September 2, 1988; (2) confirms your commitments regarding the Cclumbus, Ohio facility documented in our Confirmatory Action Letter No. RIII-CAL-88-0027 (Enclosed) issued September 9, 1988; and (3) requires you to assess the adequacy of implementation of licensed activities of your Blue Ash and Columbus, Ohio facilities and to assess the adequacy of your corporate oversight at a sampling of other SYNCOR facilities. This action has been taken because of the unacceptably large number of improperly tagged or labeled radiopharmaceuticals distributed from your Blue Ash facility, the failure of your staff at the Blue Ash and Columbus facilities to properly perform quality control, including testing and recordkeeping, and the failure to properly implement certain aspects of the Blue Ash facility radiation safety program.
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| You are required to respond to the enclosed Order, and in preparing your response, you should follow the instructions specified in the Order.
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| In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosed Order will be placed in the NRC's Public Document Room.
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| NUREG-0940 II.A-73
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| l- j I
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| i i
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| SYNCOR Cor[.. oration J The respon',e directed by the enclosed Order is not subject to the clearance procedures of the Office of Management and Budget as required by.the Paperwork' Reduction Act of 1980, PL 96-511.
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| Sincerely,
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| ~ [
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| J
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| __- f Deputy es M. Taylo Q Executive Director forRegional[ Operations -
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| | |
| ==Enclosures:==
| |
| Order Modifying l License (Effective Immediately)
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| Confirmatory Action Letter No. RIII-CAL-88-0026 Confirmatory Action Letter No. RIII-CAL-88-0027 cc w/ enclosures:
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| Michelle Loos, Manager Blue Ash Facility i John Hatch, Manager Columbus Facility Jack L. Coffey, Corporate RSO 5! REG-0940 II.A-74
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| l r
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| /* ,.
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| NUCLEAR RECuLATORY COMMtssl0N unio m j j ,,eacessvsLTnoao
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| =, ,t oss. a60s . e66mois sein
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| ..<.* $EP 4 2 1998 Syncer International Corporation License No. 34-18309-01MO ATTN: M~r. Monte Fu EA 88-194 Chairman af the Board fost Office Box 2185 20001 Prairie Street Chatsworth, CA 91313-2185 Gentlemen: ,
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| This refers to a telephone conversation between you, Ms. Michelle Loos, and Mr. C. E. Norelius of this office on September 2,1988, regarding activities at your facility at Blue Ash, Ohio. The subject cf this conversation related to numerous occurrences of improperly labeled compounds that have been distributed by the Blue Ash facility to local hospitals. The information discussed and agreed to during this conversation supersedes the requirements that were set forth in your letter to Mr. A. B. Davis dated July 22, 1988, and subsequently referenced in License Condition No. 23 of NRC License No. 34-18309-01ML.
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| Based on this conversation it is our understanding that you will implement the following actions: .
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| A. Require that two individuals independently perfom the following activities:
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| : 1. Verify the perfomance of all tests and assays of radiophartnaceuticals and labelling of products and product packages as required by your NRC license and as listed below in Item C;
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| : 2. Complete ecch verification prior to further distribution of material; l
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| : 3. Document each verification by signature; and
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| : 4. Maintain documentation of each verification.
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| One of the individuals shall be listed on an NRC or Agreement State license, or shall possess equivalent qualifications, and shall not be currently affiliated with your Blue Ash facility. ]
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| B. Submit telephonically, to the NRC Region !!! office with written confirmation within 5 days, the name and qualifications of the individuals who will perfom the verifications specified above. Approval of these individuals shall be obtained prior to further distribution of material.
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| CONFIRMATORY ACTION LETTER NUREG-0940 II.A-75
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| Syncor In'ternatioral Corporation 2 SEP a 2 19o9 C. Additional activities to be verified: ;
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| 1.- Molybderum breakthrough test; i
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| : 2. Alumina breakthrough test;
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| : 3. Labeline efficiency test for technetium-99m prepared ]
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| ra diopharmaceuticals; 4 Activity measurement; and
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| : 5. Proper Poduct and product package label.
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| D. Within ore week, inform all clients of the Blue Ash facility that misedministrations of NRC licensed materials must be reported by the hospital to the NRC.
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| If our understand *ng of the above is not correct please contact this office by telephone immediately. Issuance of this Confirmatory Action Letter does not preclude the issuence of an Order requiring implementation of the above comi tments .
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| Sincerely,O di73dA "
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| A. Bert Davis Regional Administrator cc: Michelle Loos, Manager, ,
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| B_lue Ash facility Frank Comer, Corporate RSO DCD/DCB (RICS) l i
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| CONFIRMATORY ACTION LETTER NUREG-0940 II.A-76 i
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| SEPc9'iP Syncor Interna tional Corporation License No. 34-18484-01PD
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| -ATTN: Mr. Monte Fu EA 88-242 Chainnan of the Board Post Office Box E185 20001 Prairie Street Chatsworth, CA 91313-2185 Gentlemen:
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| - This refers to a telephone c:nversation be?. ween you- and Mr. C. E. Norelius of this office on September 9,19E8, regardir; activities at your facility in Colurbus, Ohio. The subject of this convers, tion related to the failure to--
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| perform QA/QC tests on radicpharTraceuticals distributed from this facility during Sep tember 5-8, 1988, and two occurrences of erroneous information entered into the QA/QC entry log indicating that chromatography tests were perfortned en September 6,1988, when these tests were not performed.
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| Based on this conversation it is our understanding that you will implement the followirg acticas:
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| A. The pharmacy manager will perform a daily audit of the CC/QA records and program to ensure trat all tests and assays are being performed properly. This audit will include the followir; tests.
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| : 1. Molybdenum breakthrough test;
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| : 2. Alumina breakthrough test;
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| : 3. Labeling efficient / test for technetium-99m prepared radiopharm2ceuticals; 4 Activity measurement; ard
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| : 5. Proper product and product package label.
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| B. The corporate staff will perform a weekly audit c' the above activities and submit a weekly written repcrt of its f'edir;s to this office.
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| l c: :::PA :o :c-*:N LE TEc l
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| NUREG-0940 II.A-77
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| .;: t i 4. .a . h . . ; .c . : . ::.n " ; ; ; ;;.:. . ;;;. , ;
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| Syncor . Interna tional 2 SEP 0 91998 Corporation If our understanding of the dbove is not correct please contact this office by telephone irrnediately. Issuance of this Confirmatory Action Letter does not preclude the issuance of an Order requiring implementation of the above commitments.
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| Sincerely, A. Bert Davis Regional Administrator cc: John Hatch, Manager, Columbus Facility Frank Comer, Corporate RSO DCD/DCB (RIDS) bcc: J. Clifford, DEDR0 J. Lieberman, OE L. Chandler, 0GC H. Thompson, NMSS R. Cunningham, NMSS i
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| )
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| NUREG-0940 II.A-78 i' - - - - - - - - - - - - . - - - - - - - - - - - - - - - - - - _ - - - - _ - - - - - - - _
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| 1 UNITED STATES NUCLEAR REGULATORY COMMISSION ,
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| In the Matter of SYNCOR. Corporation ) License No. 34-18309-01MD.
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| ' 5225 Creek Road ) Docket No. 030-14827 Blue Ash, OH 45242 ) EA 88-194 SYNCOR Corporation. ) License No. 34-18484-01MD 3075-3027 East 14th Avenue ) Docket No. 030-15166 Columbus, OH 43219 ) EA 88-242 ORDER MODIFYING LICENSES (EFFECTIVE IMMEDIATELY)
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| I SYNCOR Corporation (SYNCOR), 5225 Creek Road, Blue Ash, OH 45242, is the holder of a specific byproduct material license issued by the Nuclear Regulatory Commission (the "Commitsion" or "NRC") pursuant to 10 CFR Part 30.
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| License No. 34-18309-01MD was originally issued to Pharmatopes Corporation on December 12, 1978, and was last renewed in its entirety on January 9,1984.
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| This license was due to expire on January 31, 1988; however, the NRC issued a {{letter dated|date=January 7, 1988|text=letter dated January 7,1988}}, acknowledging timely receipt of the ' Licensee's rene;,al application. Therefore, this license is currently active. This k
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| license authorizes, among other things, the use of molybdenum-99/ technetium-99m (Mo-99/Tc-99m) generators for the production of technetium-99m sodium pertechnetate for use with reagent kits in the preparation and distribution of radiopharmaceuticals to authorized recipients.
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| l l
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| II l SYNCOR Corporation (SYNCOR), 3025-3027 East loth Avenue, Columbus, OH 43219, is the holder of a specific byproduct n.aterisl license issued by the Nuclear Regulatory Comission (the "Ccmmission" or "NRC") pursuant to 10 CFR Part 30. .;
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| NUREG-0940 II.A-79 I
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| ___ _-._.__._-_.-._._.._.l
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| License No. 34-18484-01MD vos originally issued to Pharmatopes, Inc. on July 24,1979, and was last renewed in its entirety on April 24, 1986. The license expires on April 30, 1991. The license authorizes, among othcr things, the use of molybdenum-99/ technetium-99m generators for the production of technetium-99m sodium pertechnetate to be used to prepare technetium-99m tagged radiopharmaceuticals. The license also authorizes the distribution of radiopharmaceuticals to authorized recipients.
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| III On April 29 and May 9, 1988: the NRC Region III Office received notification of several misadministration of radiopharmaceuticals utilized in diagnostic procedures.that occurred on April 28, 1988, at hospitals in Southwest, Ohio.
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| The radiopharmaceuticals had been distributed from the SYNCOR facility at Blue Ash, Ohio.
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| On July 6-8, 1988, NRC Region III performed an inspection at the Blue Ash j facility and on August 19, 1988, NRC Region III Office of Investigations (01) initiated an investigation into this matter. Those activities disclosed.that l l
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| the Blue Ash facility had distributed 17 patient doses to client hospitals consisting of free technetium (Tc)-99m sodium pertechnetate improperly labeled as Tc-99m tagged to methylene diphosphonate (MDP), a bone imaging agent. This resulted in 14 diagnostic misadministration at seven hospitals on April 28, 1988 (Appendix B to this Order). In addition to the improper labels, ti,e inspection determined that tagging efficiency tests of compounded radiophar-naceuticals like Tc-99m/MDP were not always performed.
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| NUREG-0940 II.A-80
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| I
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| )
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| On July 13. 1988, NRC Region III issued Confirmatory Action Letter No. RIII-1 CAL-88-019 to SYNCOR confirming the commitments of the Blue Ash facility manager to: (1) immediately report certain misadministration events to NRC Region III and the licensee's affected clients; (2) expand the quality control {
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| program to include introduction of test samples into the production testing operation; and (3) implement double verification of satisfactory quality control test completion.
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| On July 22, 1988, SYNCOR requested an amendment to the Blue Ash facility license to include the provisions of Confirmatory Action Letter No. RIII-CAL-88-019, Items 1-4. Those provisions were incorporated on August 29, 1988, into License Condition No. 23 through Amendment No. 16 to the Blue Ash facility license.
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| In addition to the concerns described above regarding the 14 misadministration that occurred on April 28, 1988 (Appendix B to this Order), the inspection and the subsequent 01 investigation disclosed several other apparent violations of the Blue Ash facility radiopharmaceutical production requirements and radiation protection program. The identified apparent violations are listed in Appendix A to this Order. 1 i
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| IV On August 30 and 31, 1988, NRC Region III conducted interviews at a sampling of seven clients of the Blue Ash facility and identified numerous occurrences of improperly tagged or labeled radiopharmaceuticals being provided to these NUREG-0940 II.A-81
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| _4 facilities within the past 15 months. The specific problems cssociated with the distributed radiopharmaceuticals are listed in Appendix B ta this Order.
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| Each of these improperly tagged or labeled doses resulted in diagnostic misadministration or in unnecessary organ and whole body doses during the J procedures. Many of these occurrences could have been prevented had appro-priate quality control testing been performed as indicated by the testing records,-i.e., the percent tagging test could have indicated only free Tc99m pertechnetate in the vial. This testing is particularly important because the nuclear pharmacy distributes multiple doses to clients from a single preparation of a radiopharmaceutical and the clients place reliance on the pharmacy to ensure the radiopharmaceutical is properly prepared. The dose is directly administered to the patient by the client.
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| As a result of these findings, on September 2, 1988, NRC Region III issued Confirmatory Action Letter No. CAL-RIII-88-026 to SYNCOR Blue Ash, confirming
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| 'the commitments of the Chairman of the Board and the Blue Ash facility manager l
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| i to perform independent verification of satisfactory completion of all cuality control program and NRC required tests and assays prior to distribution of radiopharmaceuticals. The Blue Ash facility is currently operating under )
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| i these restrictions.
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| V On September 8 and 9, 1988, NRC conducted an inspection at the S.YtfC'OR Columbus, ,
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| 1 Chio facility. That inspection disclosed that on September 5 through 7, 1988, i NUREG-0940 II.A-82 !
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| .1
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| 5 the instrumentation utilized to perform tagging efficiency tests was out of service and testing was not performed on radiopharmaceuticals distributed on those days.
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| As a result of these findings, on September 9, 1988, NRC Region III issued Confirmatory Action Letter No. RIII-CAL-88-027 to SYNCOR Columbus, confirming the commitments of the Chairman of the Board to perform daily audits by the Columbus facility pharmacy manager and weekly audits by the corporate staff to assure all tests and assays at the Columbus facility are performed properly.
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| VI
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| *s a result of the inspections and investigation described above, the NRC has concluded that the Blue Ash facility distributed improperly tagged or labeled radiopharmaceuticals and the Blue Ash and Columbus facilities failed to perform tests on radiopharmaceuticals. In addition, records were inadequate to reflect i the actual tests performed. Clinical use of improperly tagged or labeled 3 radiopharmaceuticals will cause: (a) additional unnecessary radiation exposures to patients because the tests must be repeated or the material is concentrated in parts of the body where it was not prescribed; (b) delays in obtaining diagnostic information; and/or (c) difficulty in interpreting the test results.
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| I Accurate records of the quality control tests are essential to permit pharmacy and corporate management to audit compliance with the testing requirements and l follow-up on identified deficiencies. In addition to these concerns, the Blue Ash facility apparently failed to implement several radiation protection requirements including dose calibrator accuracy testing, semiannual testing for NUREG-0940 II.A-83
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| )
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| l
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| ]
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| operation of the fume hood, leak testing of a sealed source, calibration of a survey meter to within 20 percent, and maintenance of radioactive waste disposal survey records. These are described in Appendix A tn this Order.
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| Furthermore, on February 8,1988, the NRC Region I office conducted an inspection at the SYNCOR Allentown, Pennsylvania facility. That inspection resulted in the issuance of a Notice of Violation on June 22, 1988, which included one Severity Level III violation involving failure to properly label radiopharmaceuticals and a second aggregated Severity Level III violation involving failure to properly implement the radiation protection program at the Allentown facility. The multiple example labeling violation caused 14 diagnostic misadministration and one of the aggregated radiation protection program violations concerned a radiation overexposure to c radiation worker.
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| The cover letter transmitting that Notice emphasized that the NRC was concerned with the lack of management oversight of licensed activities. The NRC also issued Information Notice No. 88-53 to all manufacturers and distributors of radiopharmaceuticals for human use, nuclear pharmacies and medical licensees, to heighten their sensitivity to the NRC's concern regarding labeling errors.
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| In sumary, the pervasiveness of SYt!COR's problems including the unacceptably large number of improperly tagged or labeled radiopharmaceuticals distributed from your Blue Ash facility, the failure of your staff at the Blue Ash and Columbus facilities to properly perform quality control including testing and recordkeeping, and the failure to properly implement certain aspects of the Blue Ash facility's radiation safety program, together with the problems which previously occurred at the Allentown facility, demonstrates a lack of control NUREG-0940 II.A-84
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| i l
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| i l
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| i 1
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| of licensed activities, raises questions regarding the adequacy of corporate oversight and presents an immediate health and safety concern. Consequently, without further regalatory action, I lack the reasonable assurance thet licensed activities will be conducted in accordance with the Commission's requiremerits I
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| and have therefore determined that the public health and safety require that this Order be irnmediately effective.
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| VII Accordingly, pursuant to Sections 81, 161b, 1611 and 1610 of the Atomic Energy Act of 1954, as amended, and the Commission's regulations in 10 CFR Parts 2, 30, and 32, IT IS HEREBY ORDERED EFFECTIVE IMMEDIATELY THAT:
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| A. 1. License No. 34-18309-01MD is modified to include the following condition:
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| SYNCOR shall maintain in effect at the Blue Ash Facility the provisions of Confirmatory Action Letter flo. RIII-cal.-88-0026, issued on September 2, 1988.
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| : 2. License No. 34-18484-01MD is modified to include the following condition:
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| SYNCOR shall maintain in effect at the Columbus Facility the provisions of Confirmatory Action Letter No. RIII-CAL-88-0027, issued on September 9, j 1988.
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| l l
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| B. SYNCOR shall, within 10 days of the date of this Orcer. submit to the Regional Administrator, NRC Region Ill, a plan for assessment of its activities for assuring that it meets regulatory requirements and that it NUREG-0940 II.A-85 ,
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| l
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| eliminates the distribution of improperly tagged or labeled radio-pharmaceuticals at each of its facilities. This assessment shall be managed at the corporate level and the plan shall identify those individuals who will be conducting the assessment and their qualifications.
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| Persons performing the assessment shall not be employees of the pharmacy or supervisors of-the activities being assessed.
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| The assessment shall be initiated within 15 days of NRC approval of the plan and completed within 45 days of NRC approval.
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| The assessment shall include, but not be limited to: licensed activities at the Blue Ash and Columbus facilities and at least 50% of the other SYNCOR facilities licensed by the NRC, the selection of which shall have prior Region III approval, to assess:
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| : 1. The qualifications, training and commitment of SYNCOR'S employees to perform licensed activities including radiopharmaceutical preparation, evaluation, and distribution tasks.
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| : 2. The adequacy of the number of SYNCOR staff assigned to perform licensed technical activities.
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| : 3. The adequacy of procedures, including manufacturer's instructions, for the preparation and distribution of radiopharmaceuticals and i I
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| the uniformity of implementation of those procedures. l NUREG-0940 II.A-86
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| i 1
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| .g-
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| : 4. The adequacy of the quality control (QC) program and procedures for ensuring that proper radiopharmaceuticals are dispensed from the pharmacy.
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| : 5. The adequacy of the types of QC records and labeling utilized in the production and distribution of radiopharmaceuticals.
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| : 6. The validity of records maintained over the last 15 months to satisfy QC and NRC requirements.
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| .7. The adequacy of the licensee investigation and action in_ response to any product deficiencies identified through internal and external (client) sources, including root cause determination, 1
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| corrective actions, and notification. Interviews should be conducted with cognizant client personnel as part of this investigation.
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| : 8. The root cause of all incidents over the last 15 months involving distributed radiopharmaceuticals that were not as prescribed. .
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| : 9. The adequacy of the corporate oversight of operation of the SYNCOR facilities' licensed programs.
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| Based on its findings, SYNCOR shall, in its report, identify programmatic l weaknesses and planned program improven:ents and corrective action necessary to assure proper control of licensed activities.
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| NUREG-0940 II.A-87
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| 1 D. SYNCOR shall submit its report within 30 days of completing the assessment to the Regional Administrator, NRC Region III; to the Director, Office of Enforcement; and to the Director, Office of Nuclear Materials Safety and Safeguards.
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| E. The Regional Administrator, Region III, may for good cause relax or rescind any of the above requirements upon written request by the licensee.
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| VIII The licensee or any other person adversely affected by this Order may request a hearing within 30 days of the date of issuance of this Order. Any request for a hearing shall be submitted to the Director, Office of Enforcement, U.S.
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| Nuclear Regulatory Commission, ATIN: Document Control Desk, Washington D.C.
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| 20555, with copies to (1) the Assistant General Counsel for Enforcement, Office of the General Counsel, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, and (2) the Regional Administrator, Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, Illinois 60137. If a person other than the licensee requests a hearing, that person shall set forth with particularity the manner in which the person's interest is adversely affect by this Order and should address the criteria set forth in 10 CFR 2.714(d). Upon 1
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| the failure of the licensee to answer or request a hearing within the specified '
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| time, the Order shall be final without further proceedings. A Request for Hearing shall not stay the Immediate Effectiveness of this Order.
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| NUREG-0940 II.A-88 ,
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| 1
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| If a hearing is requested, the Commission will issue an Order designating the time and place of any hearing. If a hearing is held, the issue to be considered at the hearing s. il be whether this Order shall be sustained.
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| FOR THE NUCLEAR REGULATORf COMi1ISSION
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| /
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| kh I' J mes M. Tay1 , Deputy Executive Director for Regional Operations Dated at Rockville, Maryland this /:Giday of October 1988 Attachments: Appendices A and B NUREG-0940 II.A-89
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| APPENDIX A APPARENT VIOLATI0ks IDENTIFIED DURING THE INSPECTION AND INVEST!0ATION OF LICENSED ACTIVITIES AT THE SYNCOR BLUE ASH FACILITY Apparent violations identified during the July and August inspections and investigations includes, but are not necessarily limited to the following:
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| : 1. Dose calibrator accuracy tests performed on March 17 and May 21, 1988, did not include the use of a barium-133 reference standard.
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| : 2. Records were not maintained of surveys of radioactive waste disposal activities performed on August 8, 1987.
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| : 3. Semiannual testing for proper operation of the fume hood used for storage or radioactive materials was not performed since October 21, 1987.
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| : 4. Semiannual sealed source leak testing of the nominal 148 microcurie barium-133 sealed source was not performed since March 1986.
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| : 5. A Bicron 2000 survey instrument was not calibrated in June 1988 to read within twenty percent of the known values for monitoring Tc-99m radiation fields.
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| : 6. Radiopharmaceuticals were dispensed on October 8, 1987, April 28, 1988, and June 9, 1988, with the incorrect pharmaceutical form listed on the dose container. ;
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| : 7. The " Prepared Radiopharmaceutical Data Sheet" for radiopharmaceuticals prepared in-house on April 28, 1988 and on other occasions did not include the correct chemical form of the radionuclides.
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| : 8. Alumina breakthrough tests were not performed on each eluate of the generators as required by the instructions furnished by the manufacturer.
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| : 9. In the preparation of Tc-99m/MDP on April 28, 1988, using MDP-SQUIBB l Technetium Tc-99m Medronate Kits, the procedure specified by the j manufacturer requiring injection of sodium pertechnetate Tc-99m into '
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| the reaction vial was not followed. Instead, the sodium pertechnetate Tc-99m and the contents of several reaction vials were injected into '
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| a separate " Super Kit" vial.
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| i NUREG-0940 II.A-90
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| l APPENDIX 8 EXAMPLES OF IMPROPLRLY LASELED OR TAGGED RADIOPHA MACEUTICALS PRODUCED AND DISTRIBUTED BY THE SYNCOR BLUE ASH FACILITY '
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| Date Description 6-12-87 Two doses of Tc-99m/HDP provided to Deaconess Hospital with inefficient tag *.
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| 6-27-87 One dose of Tc-99m/HDP provided to Deaconess Hospital with inefficient tag *,
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| 9-28-87 One dose of Tc-99m/HDP provided to Deaconess Hospital with inefficient tag *.
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| 10-2-87 Two doses of Tc-99m/HDP provided to Deaconess Hospital with inefficient tag *.
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| 10-6-87 One dose of Tc-99m/HDP provided to Deaconess Hospital with inefficient tag *.
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| 10-8-8/ One dose of free Tc-99m labeled as Tc-99m/MAA provided to Bethesda North Hospital. i 12-5-87 One dose of Tc-99m/MAA labeled as Tc 99m/
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| Chlorotec provided to Bethesda North Hospital.
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| 2-17-88 One dose of Tc-99m/HDP provided to Deaconess Hospital with inefficient tag *,
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| 4-15-88 Four doses of free Tc-99m labeled as Tc-99m/MDP provided to Bethesda North Hospital.
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| l 4-15-88 Two doses of free Tc-99m labeled as Tc-99m/MDP provided to St. Luke Hospital.
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| *While tagging efficiency is not regulated by the NRC, and a small amount of breakdown of the tag will occur with time, the frequency of inefficient tag ,
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| on Tc-99m/HDP produced and distributed by the Blue Ash facility with quality control test records indicating a high tagging efficiency is cau.5e for concern.
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| The inefficient tag resulted in unnecessary organ dose to the patient.
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| r NUREG-0940 II.A-91 i
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| APPENDIX B (continued)
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| Date Description 4-15-88 Two doses of free Tc-99m labeled as Tc-99m/MDP provided to Jewish Hospital.
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| 4-18-88 Two doses of free Tc-99m labeled as Tc-99m/MDP provided to St. Luke Hospital.
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| 4-28-88 Five doses of free Tc-99m labeled as Tc-99m/MDP provided to Bethesda North Hospital.
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| 4-28-88 Two doses of free Tc-99m labeled as Tc-99m/MDP provided to Epp Memortal Hospital.
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| 4-28-88 Two doses of free Tc-99m labeled as Tc-99m/MDP provided to St. Elizabeth South Harpital.
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| 4-28-88 Two doses of free Tc-99m labeled as Tc-99m/MDP provided to St. Luke Hospital.
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| 4-28-88 One dose of free Tc-99m labeled as Tc-99m/MDP provided to Jewish Hospital.
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| 4-28-88 One dose of free Tc-99m labeled as Tc-99m/MDP provided to Mercy North Hospital.
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| 4-28-88 One dose of free Tc-99m labeled as Tc-99m/MDP provided to Mercy South Hospital.
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| 6-9-88 Two doses of Tc-99m/DTPA labeled as Tc-99m/MAA provided to Bethesda Oak Street Hospital.
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| 1 I
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| NUREG-0940 II.A-92
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| /* 'o g UNITED STATES
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| ! NUCLEAR REGULATORY COMMISSION I WASHINGTON, D. C. 20555
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| \...../Docket No. 030-01391 AUG f 41987 License No. 12-01087-07 EA 87-150 l Veterans Administration Edward Hines, Jr. Medical Center ATTN: Mr. John Fears Director Hines, IL 60141 Gentlemen:
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| ==SUBJECT:==
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| ORDER TO SHOW CAUSE WHY LICENFs SHOULD NOT BE MODIFIED (EFFECTIVE IMMEDIATELY)
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| Enclosed is an Order, effective immediately, which: 1) removes Dr. Maynard Freeman's authority to use or supervise the use of licensed material at Edward Hinas, Jr. Medical Center, Hines, Illinois; 2) requires independent quarterly audits of your Radiation Safety Program; 3) requires you to the and report corrective actions for identified deficiencies, and
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| : 4) implements the provisions of the Confirmatory Action Letter of January 12, 1987.
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| If you desire, the NRC will meet with you to discuss these matters further.
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| You are required to respond to the enclosed Order, and in preparing your response, you should follow the instructions specified in the Order.
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| In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2 Title 10. Code of Federal Regulations, a copy of this letter and the enclosed Order will be placed in the NRC's Public Document Room.
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| The response directed by the enclosed Order is not subject to the clearance procedures of tt;e Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
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| Sincerely,
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| \
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| /
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| .,Fyf ~
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| f J. s M. Tay1 , Deputy Executive rector for Regional Operations
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| ==Enclosure:==
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| Order to Show Cause Wh* icense Should Not be Modified (Effective Imediately) cc w/ enc bsure: Dr. Maynard Freeman Edwat * 's, Jr. Medical Center 1' State of a' .nois CERTIFIED MAIL RETURN RICEIPT REQUESTED '
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| NUREG-0940 II.A-93
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| 4 1
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| UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of )
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| )
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| VETERANS ADMINISTRATION ) Docket No. 030-01391 EDWARD HINES, JR. MEDICAL CENTER ) License No. 12-01087-07 Hines, Il 60141 ) EA 87-150 ORDER TO SHOW CAUSE WHY LICENSE SHOULD NOT 8E MODIFIED, EFFECTIVE IMMEDIATELY I
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| Edward Hines, Jr. Medical Ccater (Veterans Administration) Hines, Illinois, (licensee / hospital) is the holder of specific byproduct material license of broad scope No. 12-01087-07 (the license) issued by the Nuclear Regulatory Commission (Comission/NRC) pursuant to 10 CFR Parts 30, 33 and 35. The license authorizes the licensee to use: 1) byproduct material listed in Groups I through VI of Schedule A, Section 35.100 of 10 CFR 35 (under the new revised 10 CFR Part 35 this material is identified in Subparts D, E, F, and G) for diagnostic and therapeutic procedures; 2) any byproduct material between Atomic Nos. 1 and 83, inclusive, and 3) xenon-133 for blood flow and pulmonary function studies. The license was originally issued on October 15, 1958, was most recently renewed on September 24, 1985, and expires on September 30, 1990.
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| II From December 16, 1986 through January 22, 1987, and April 16 through June 30, 1987, NRC inspections and investigations were conducted at Edward Hines, Jr.
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| Medical Center, Hines, Illinois. As a result of these inspections and investigations, violations of NRC requirements were identified. The NRC has established that three misecoinistrations occurred during the week of l
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| NUREG-0940 II.A-94 L.
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| August 4-8, 1986. The first and third misadministration (Paragraphs C. and E.,
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| below).were not reported to the NRC as required. The second misadministration ]
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| (Paragraph D., below) occurred, but was not required to be reported to the NRC beccuse the material involved, ga111um-67, is not regulated by the NRC. However, it appears that, with regard to the first and second misadministration, the Assistant Chief, Nuclear Medicine Service (NMS) was informed that these mis-administrations had occurred, and took actions to conceal the fact that the misadministration had occurred and to impede the NRC investigation into whether misadministration had occurred during that time frame.
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| Specifically, based on sworn interviews conducted by the NRC's Office of Investigations (01) between April 16 and June 30, 1987, and on interviews during a special inspection by NRC Region III inspectors conducted December 16, 1986 through January 22, 1987, it appears that the following occurred:
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| A. On August 14, 1986, NRC Region III received an anonymous allegation that three diagnostic misadministrstions occurred at Edward Hines, Jr. Medical Center during the week or August 4-8, 1986, and were not reported to the NRC as required by 10 CFR 35.43. I/ It was further al'?ged that Dr. Maynard L. Freeman, Assistant Chief, NMS, was notified of the three misedministrations by the Acting Chief Technologist for that week (the Assistant Chief Technologist), but took no action to ensure that those M The Commission's regulations have since been revised. The requirements for reporting misadministration are presently set forth in 10 CFR 35.03.
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| I NUREG-0940 II.A-95
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| I events were reported. It has been established that Dr. Freeman was aware of the reporting requirements for diagnostic misadministration. The NRC-subsequently verified that these misadministration did occur, and at least two of the misadministration were made known to Dr. Freeman shortly after they occurred.
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| B. On October 29, 1986, the Director, Edward Hines, Jr. Medical Center, ordered an investigation into the three alleged misadministration.
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| The V.A. Investigatory Board concluded that only one of the three events may have involved a misadministration but that a definite conclusion could not be drawn in that case. A subsequent NRC investigation determined that the V.A. investigation reached erroneous conclusions because, among other
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| -matters, a nuclear medicine technologist subsequently admitted to NRC investigators, under oath, that he had made a false statement to the V.A. Investigatory Board.
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| C. On August 4, 1986, a patient who was scheduled for a bone scan was injected with a brain scanning agent. The patient was subsequently injected with the bone scanning agent. Although Dr. Freeman was informed by the Assistar.t Chief Technologist that a misadministration may have occurred, he failed to take the sters necessary to have the misadministration reported to the NRC as was then required by 10 CFR 35.43. When questioned about the event by the V.A. Investigatory Board and by NRC investigators, Dr. Freeman stated that the event did not involve a misadministration because he had verbally instructed the nuclear medicine technologist who administered the injecticn NUREG-0940 II.A-96
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| | |
| f to inject a brain scanning agent rather than a bone scanning agent. The NRC investigation determined that this was a false statement, as no such instruction was actually given. The Assistant Chief Technologist testified that there was no discussion of a brain scan being appropriate before the injection was given. The attending physician testified that he had originally requested a non-specified scan, that during a telephone discussion with the nuclear medicine department it was determined that a bone scan would be performed, and that when the attending physician received the results of the scan he assumed that a bone scan had been performed. The nuclear medicine technologist testified that a brain scanning agent was injected by mistake and, when he realized that a mistake had been made, a bone scanning agent was then injected. The nuclear medicine technologist further testified that he had never been instructed by Dr. Freeman to perform a brain scan rather than a bone scan.
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| In addition, the nuclear medicine technologist further testified that he had falsely stated to the V.A. Investigatory Board that he remembered Dr. Freeman telling him to inject a brain scanning agent because Dr. Freeman had previously stated to the Chief of the Nuclear Medicine Department in the presence of the technologist that he had given such an '
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| instruction, and the technologist feared to contradict Dr. Freeman.
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| Dr. Freeman also falsely stated to the V.A. Investigatory Board that he had ordered the technologist to perform a brain scan. Finally, the Chief Technologist testified that in his presence Dr. Freeman renoved and destroyed a dose calibration ticket indicating that a bene scan had been given.
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| NUREG-0940 II.A-97
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| D. On August 4, 1986, a patient received a gallium-67 dose which had been intended for another patient. Dr. Freeman was informed by the Assistant !
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| I Chief Technologist that a misadministration had occurred. Dr. Freeman subsequently obtained a written prescription to perform a gallium scan on the misadministered patient from a physician who was acting in the place l of the patient's attending physician without informing the acting physician that the injection had already been administered. Both the acting physician and the attending physician indicated that the normal practice I
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| of the hospital would be to request that approval prior to, not following, I the-injection. The attending physician testified that she could not find any evidence in the patient's file that she had ordered a gallium injection co be administered to this patient on August 4. While this misadministra- l tion did not require reporting under to 10 CFR 35.43 because ga11ium-67 is not regulated by the NRC, these events indicate that Dr. Freeman attempted to conceal the fact that a misadministration had occurred, and shed doubt on Dr. Freeman's credibility and ability to ensure the i safe conduct of licensed activities.
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| E. On August 6, 1986, a patient scheduled for a gallium-67 scan received i a bone scan that was scheduled for another patient. This constituted a misadministration which was not reported to the NRC as required.
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| F. Following these events, prior to the NRC investigation, it appears that Dr. Freeman attempted to influence the testimony of a witness. Specifically, NUREG-0940 II.A-98
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| | |
| in November 1986, Dr. Freeman telephoned the Assistant Chief Technologist and suggested that she respond to the questions of NRC investigators by saying that she could not recall what had occurred.
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| G. Previous NRC inspections and this investigation have shown that greater management attention was required to correct recurring violations, such as failure to properly maintain records, perform surveys, and train employees. On January 12, 1987, the NRC issued a Confirmatory Action Letter that addressed these violations of procedures. By accepting the Confirmatory Action Letter, the licensee has committed to complying with the requirements of that Letter. These requirements are incorporated in paragraph IV B-E of this Order, with an expansion of the requirement for a periodic audit program.
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| III Licensees must adhere strictly to radiation safety requirements so that the medical use of NRC-licensed material does not create a radiation hazard to workers and members of the public. The proper and competent performance of licensee employees is essential to ensuring the safe conduct of licensed activities. 10 CFR Part 35 of the Comission's regulations establishes requirements applicable to human use of byproduct materials, including, at the time of these occurrences, the reporting of diagnostic misadministration under 10 CFR 35.43.
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| NUREG-0940 IL A-99 l
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| I Dr. Freeman testified that he had approved reports for previous misadministration, and that he knew of the reporting requirements. The evidence indicates that )
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| Dr. Freeman was aware that diagnostic misadministration had occurred on at least two occasions and that he was required to ensure that one of these misadministration was reported to the NRC. However, he failed to ensure that that misadministration was reported. In addition, it appears that Dr. Freeman made a false statement to the V.A. Investigatory Board and NRC investigators, destroyed evidence, improperly obtained additional evidence, and attempted to impede the NRC investigation by influencing the testimony of a witness, all in order to conceal the fact that these misadministration had occurred. These actions demonstrate that there is no longer reasonable assurance that l Dr. Freeman can be relied on to comply with Commission requirements in ta performance or supervision of licensed activities or that the licensee will comply with Commission requirements while Dr. Freeman is conducting or supervising licensad activities as an authorized user at Edward Hines, Jr.
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| Medical Center.
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| In addition, NRC inspections over the last several years and this investigation disclosed that licensee's management and staff failed to implement and adequately control the licensee's program for administration of radiopharmaceuticals to patients. Specifically, the licensee failed to: (1) report misadministration; (2) properly control dose administration records; (3) effectively train nuclear !
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| medicine staff; (4) verify procedure orders; and (5) provice accurate information to the V.A. Investigatory Board and the NRC.
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| l i
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| NUREG-0940 II.A-100 1
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| | |
| IV Therefore, I am issuing this Order. I have determined pursuant to 10 CFR 2.201(c) that no prior notice is required and pursuant to 10 CFR 2.202(f) and 2.204 that the public health, safety and interest require that this Order should be inanediately effective.
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| Accordingly, pursuant to Sections 81, 161(b), (1), and (o), 182, and 186 of the Atomic Energy Act of 1954, as amended, and the Comission's regulations in 10 CFR 2.202 and 2.204 and 10 CFR Parts 30 and 35, IT IS HEREBY ORDERED EFFECTIVE IMMEDIATELY THAT:
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| A. License No. 12-01087-07 is amended by adding the following condition:
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| On receipt of this Order, Dr. Maynard L. Freeman shall be removed from all licensed activities and shall thereafter not serve in any position involving the performance or supervision of any licensed activities (e.g., as an authorized user) including the supervision of any nuclear medicine technologists.
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| B. The licensee shall hold in-service classes at least annually for all Nuclear Medicine Service personnel to assure a complete understanding of regulations, policies, and procedures relating to misadministration reporting procedures. The licensee shall keep records of this training.
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| NUREG-0940 II.A-101
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| C. The licensee shall use and maintain records to provide precise tracking and comprehensive documentation of dosage measurement and administration.
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| D. The'licenree shall assure that all prescriptions for nuclear medicine.
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| l procedures are: (1) in writing; (2) reviewed by a nuclear medicine !
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| l physician; and (3) verified by the technologist prior to administration l of the dose to a patient, except where this would jeopardize emergency l
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| l patient care.
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| E. Within 30 days of the date of this Order, the licensee shall: (1) retain an independent organization to perform quarterly audits of the nuclear medicine department, and (2) submit to the Regional Administrator, NRC Region III, for approval, a description of the organization retained, including the name(s) and resume (s) of the individual (s) who will perform i
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| the audits. The requirement for independence of the organization may be satisfied by use of VA personnel who have not been associated in any way with V.A. Edward Hines, Jr. Medical Center.
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| These audits shall be conducted to evaluate the effectiveness of the radiation safety program in assuring adherence to NRC requirements and safe performance of licensed activities. These audits shall include as a minimum:
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| : 1. assessment of management control and oversight of the program; NUREG-0940 II.A-102
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| : 2. evaluation of the adequacy of staffing levels, training and I l
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| qualification of personnel involved in licensed activities, understanding of the procedures concerning misadministration and reporting, and implementation of the preram;
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| : 3. observation and evaluation of the performance of personnel engaged in licensed activities; and
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| : 4. assessment of the quality and accuracy of records required to be maintained concerning licensed activities.
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| The first independent audit shall be conducted within one month of the date of this Order. The results of each audit shall be simultaneously provided to the Hospital Director and the Director, Division of Radiation Safety and Safeguards (DRSS), NRC Region III, within two weeks of completion of the audit. Within 30 days of receipt of the results of each audit, the hospital shall previde to the Director, DRSS NRC Region III, a description of the corrective actions taken for each recommendation by the independent party and justification for any recommendation not accepted.
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| The Regional Administrator, Region III, may relax or terminate any of these conditions for good cause shown.
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| V Dr. Freeman may show cause why Condition A of this Order should not have been issued and should be vacated by filing a written answer under oath or affirmation NUREG-0940 II.A-103
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| l l
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| within 30 days of the date of this Order which sets forth the matters of fact I l
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| and law on which he relies. Dr. Freer.an may answer as provided in 10 CFR 2.202(b) by consenting to Condition A of this Order. If Dr. Freeman fails to answer within the specified time, Condition A of this Order shall be final without further proceedings, unless the licensee shows cause why Condition A should not have been i issued or requests a hearing as to Condition A.
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| The licensee may show cause why this Order should not have been issued and should 1
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| be vacated by filing a written answer under oath or affirmation within 30 days of the date of this Order which sets forth the matters of fact and law on which the licensee relies. The licensee may answer as provided in 10 CFR 2.202(b) by consenting to this Order. If the licensee fails to answer within the specified time, this Order shall be final with respect to Conditions B-E without further proceedings and shall be final with respect to Condition A unless Dr. Freeman shows cause why Condition A should not have been issued or requests a hearing.
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| The licensee or any other person adversely affected by this Order may request l
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| a hearing within 30 days after issuance of this Order. Any answer to this l Order or any request for hearing shall be submitted to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555. Copies shall also be sent to the Assistant General Counsel for Enforcement at the same address and to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, Illinois 60137. If a person other than the licensee requests a hearing, that person shall set forth with particularity the manner in which the petitioncr's interest is adversely affected by the Order and should address the criteria set forth in NUREG-0940 II.A-104
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| | |
| 10 CFR 2.714(d). Upon the failure of the licensee and any other person adversely affected by this Order to answer or request a hearing within the '
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| specified time, this Order shall be final without further proceedings. AN ANSWER TO THIS ORDER OR A REQUEST FOR HEARING SHALL NOT STAY THE IMMEDIATE EFFECTIVENESS OF THTS ORDER.
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| If a hearing is requested, the Comission will issue an order designating the time and place of any hearing. If a hearing is held, the issue to be considered at such hearing shall be whether this Order should be sustained.
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| FOR THE NUCLEAR REGULATORY COMMISSION
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| /
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| XL i a s M. Taylor, eputy Executive Director or Regional Operations Dated at; Bethesda, Maryland, thispytiay of August 1987 )
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| NUREG-0940 II.A-105
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| . . i..L' ALJ-88-2 UNITED STATES OF AMERICA NUCLEAR REGULATORY _ COMMISSION 88 OCT -7 P4 :39 Administrative Law Judge d5 : --
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| o0 N "i
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| Morton B. Margulies ,
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| SGVED OCT 111988 In the Matter of Docket No. 30-1391-SC
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| )
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| EDWARD HitL5, JR. MEDICAL CENTER ) ASLBP No. 88-565-01-SC
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| )
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| (Veterans Administration) October 7, 1988 ORDER (Approving Agreement to Terminate Proceeding and Terminating Proceeding)
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| On October 1, 1988, the parties to'th.is enforcement proceeding, the NRC Staff and Dr. Maynard L. Freeman, filed with the Administrative Law )
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| Judge (1) an Agreement to Terminate Proceeding that had been accepted by both parties; and (2) a joint motion requesting the Judge's approval of the Agreement and the entry of an order terminating this proceeding, ;
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| with a proposed Order.
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| I have reviewed thf Agreement under 10 C.F.R. 9 2.203 to determine whether approval of the Agreement and consequent termination of this proceeding are in the public interest. Based upon the review, I am satisfied that approval of the Settlement Agreement and termination of this proceeding based thereon are in the public interest. The terms of the Agreement satisfy the interests of the public and parties without the need for a hearing.
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| Accordingly, I approve the Settlement Agreement attached hereto and incorporated by reference into this Order. Pursuant to 10 C.F.R.
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| NUREG-0940 II.A-106
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| i 2.203, this proceeding is terminated on the basis of the attached Agreement.
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| b Morton B. Margulies (J ADMINISTRATIVE LAW JUDGE Dated at Bethesda, Maryland this 7th day of October, 1988.
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| ATTACHMENT AGREEMENT TO TERMINATE PROCEEDING On August 24, 1987, the NRC issued to the Veterans Administration, Edward Hines, Jr. Medical Center (Hines Hospital) an " Order to Show Cause Why License Should Not be Modified Effective Imr.ciately" (Order).
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| 52 Fed. Reg. 32,623 (1987).
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| Hines Hospital is the holder of a specific byproduct material license of broad scope No. 12-01087-07 originally issued by the NRC on October 15,.1958, pursuant to 10 C.F.R. Parts 30, 33 and 35. (The license was most recently renewed on September 24, 1985, and expires on September 30,1990.) As a result of the Order, the license was amended effective imediately, inter alia, by addino the following condition:
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| On receipt of this Order, Dr. Maynard i.. Freeman shall be removed from all licensed activities and shall thereafter not serve in any position involving the performance ur supervision of eny licensed activities (e.g., as an authorized user) including the supervision of any nuclear medicine technologists.
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| The Order issued against Hines Hospital was based on alleged violations of NP; requittments allegedly determined during inspections and NUREG-0940 II.A-107
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| | |
| investigations conducted at Hines Hospital from December 16, 1986 through June 30, 1987. Mines Hospital did not challenge the Order.. However, Dr. Maynard L. Freeman, through his first attorney, challenged the Order by filing on September 22, 1987 a Response to the Order. Dr. Freeman also filed an Answer to the Order, a Request fnr a Hearing Pursuant to the Order, and a Request for Hearing Pursuant to 10 C.F.R. 9 2.714(d). Dr.
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| Freeman, through his first attorney, also requested the NRC to defer action on his request for a hearing pending conclusion of a meeting with him and the NRC's continued evaluation of Dr. Freeman's response. That meeting and evaluation did not result in any relaxation of the Order by the Staff. By {{letter dated|date=January 25, 1988|text=letter dated January 25, 1988}}, then Counsel for Dr. Freeman requested that the hearing process go forward. That regt:ast bd to the designation of the Administrative Law Judge (ALJ) on February 18, 1988.
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| By Orders dated May 24, 1988 and June 23, 1988 respectively, the ALJ granted the Staff's motions of May 23, 1988 and June 22, 1988, respectively, to extend a temporary stay of the proceeding which had been originally granted by the ALJ, over the objections of Dr. Freeman, on April 29, 1988, to and including June 24, 1988 and July 15, 1988, respectively. On July 13, 1988 the ALJ granted a joint motion of the Staff and Dr. Freeman for a further extension of the temporary stay of this proceeding to and including August 31, 1988.
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| By {{letter dated|date=June 13, 1988|text=letter dated June 13, 1988}} Staff Counsel advised the ALJ that Dr.
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| Maynard L. Freeman had tendered his resignation to Hines Hospital. Staff Counsel further advised that Hines Hospital had accepted Dr. Freeman's resignation. Dr.. Freeman states that his resignation was tendered for reasons unassociated with these proceedings. Dr. Freeman's last day of NUREG-0940 II.A-108
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| | |
| official duties at the Hines Hospital was May 31, 1988. As a result of Dr. Freeman having ceased performing duties at Hines Hospital, and,.
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| further, since he is no longer physically present at said hospital, it is the NRC Staff's position that the condition imposed on the Hines Hospital license is moot since it can have no practical effect on Dr. Freeman.
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| Dr. Freeman, however, vigorously disputes this position and argues that notwithstanding his departure from Hines Hospital, he is entitled to contest the validity of the underlying basis for the conditions applicable to him set out in the August 24, 1987 Order. However, the parties believe it is in the public interest to terminate this proceeding without further litigation and, therefore, the NRC Staff and Dr. Maynard L. Freeman hereby agree as follows:
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| : 1. Based on this Agreement, except as specified in the second sentence of this paragraph, Dr. Freeman hereby withdraws his requests for a Hearing pursuant to the Order and pursuant to 10 C.F.R. ! 2.714(d) which requests were filed on Scotember 22, 1987.
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| In the event the NRC initiates a future proceeding, the subject matter of which includes expressly or implicitly the conditions of the Order of August 24, 1987, that were applicable to Dr. Freeman, the Staff agrees not to interpose any objection to any request for a hearing by Dr. Freeman based on this withdrawal, or interpose laches, estoppel, waiver, or any equitable type defense or the passage of time as they relate to the underlying ba is of the August 24, 1987 Order.
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| : 2. The Staff agrees to provide, pursuant to Dr. Freeman's request for production, the following NRC documents:
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| NUREG-0940 II.A-109
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| : a. Office of Investigations (OI) Report of Investigation No.
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| 3-87-003 (Edward Hines, Jr., Veterans Administration Medical Center)-Alleged Willful Failure to Report Diagnostic Misadministration and Alleged Willful Material False Statements-Dated Nove...ber 4, 1987 and Exhibits 1-33 Attached thereto;
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| : b. OI Report of Investigation No. 3-87-0035 (Edward Hines, Jr., Veterans Administration Medical Center)-Alleged Material False Statements-Dated March 29, 1988 and Exhibit 1 attached thereto. [This Report has only one Exhibit].
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| : 3. The NRC Staft agrees to provide copies of the foregoing documents without cost to Dr. Freeman. The documents will be provided to Counsel for Dr. Freeman on or before October 31, 1988.
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| It is understood by Dr. Freeman that the delay in providing the documents in question is necessitated by the fact that the NRC Staff must review the documents in order to remove, if necessary, the home address, home telephone numbers, and any other information which may be exempt from release by virtue of the Privacy Act or any other provicion of law, of any persons mentioned or discussed in the documents in question. Dr. Freeman agrees to the removal of such information and recognizes that such action on the part of the NRC is necessary to protect the privacy of any such persons mentioned or discussed in the documents in question and to comply with the Privacy Act.
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| : 4. For a period of one year from the date of this agreement, Dr.
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| Freeman agrees to voluntarily advise, in writing, the NRC in the NUREG-0940 II.A-110 u_ _ _________
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| 1 event he is employed in any activity, regulated by the NRC or which would be regulated by the NRC but for an agreement with a state pursuant to section 274 of the Atomic Energy Act of 1954, as amended.
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| The notice required by this provision shall state the name and address of his employer and a brief description of his duties and be mailed or sent to the Director, Office of Enforcement, U.S. Nuclear Regult. tory Comission Washington, D.C. 20555. In the event that Dr.
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| Freeman shall engage in an activity r.'ouiring NRC authorization, regulation or licensing, then the filing of any application for a license or approval as an authorized user shall be deemed to satisfy this requirement.
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| : 5. The NRC Staff and Dr. Freeman shall jointly move the ALJ for an Order approving this Settlement Agreement and terminating this proceeding. This Agreement shall become effective upon approval by the ALJ.
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| )
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| fr iL JA?
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| er' /
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| o e) Dr. Maynard L. eeman V I Bernard M. Bordenitk Dated: N/ , 1988 Seen and approved:
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| mur u/h -et Dr. Maynaro L. Freeman NUREG-0940 II.A-111
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| | |
| / UNITED STATES I
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| ~
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| E NUCLEAR REGULATORY COMMISSION E REGION 11
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| ? - af 101 MARtETTA ST., N.W.
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| .g,, ATLANTA. GEOMGIA 30323 SEP 3 01988 Docket No: 030-28616 License No: 45-23524-01 EA 88-204 Wise Appalachian Regional Hospital ATTN: Mr. John Grah, Administrator Wise, VA 24293 Gentlemen:
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| | |
| ==SUBJECT:==
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| NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N0. 45-023524-01/88-01)
| |
| This refers to the inspection conducted by Mr. M. Elliott at the ,:se Appalachian Regional Hospital on July 14, 1988. The inspection included a review of licensed activities to include im;, lamentation of your Radiation Safety Program. The report documenting this inspection was sent to you by {{letter dated|date=August 4, 1988|text=letter dated August 4,1988}}.
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| As a result of this inspection, numerous failures to comply with NRC regulatory requirements were identified, and NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held at your facility on August 10, 1988. The letter summarizing this Conference was sent to you on August 18, 1988.
| |
| The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty involved a failure to: 1) label syringes or syringe shields containing radiophamaceuticals; 2) label vial radiation shields that contain a vial of radiophamaceuticals; 3) issue written pemission to a visiting authorized user and to obtain a copy of an NRC license which listr. the visiting physician as an authorized user; 4) post a restricted area; 5) conduct a quarterly Radiation Safety Comittee meeting; 6) perfom a formal annual review of the radiation-safety program; 7) provide in-service and initial training to ancillary personnel; 8) perform quarterly dose calibrator linearity tests; 10) perform l waste surveys; 10) calculate adequate survey results and to record established l " trigger levels" on area survey records; 11) perfom wipes of the final source container upon receipt of packages containing radioactive material; 12) properly record molybdenum concentration test results; and I?) post required documents or a notice of where they might be examined. The events or circumstances that resulted in these violations are included in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty.
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| The inspection findings indicate a breakdown in your Radiation Safety Program due to a lack of management control and attention, which contributed to the deteriorattLn of the program. Such a breakdown led to the increased potential for possible misadministration or unnecessary exposure to radiation and radioactive materials. Furthermore, it is evident that had the Radiation Safety Officer been more involved with t.he day-to-day administration and oversight of the program, such a breakdown may have been precluded. We note that the administrator, who is new to the hospi'.al, appears comitted to taking action to address these concerns.
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| NUREG-0940 II.A-112
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| | |
| Wise Appalachian Regional Hospital SEP 3 01988 To emphasize the need for proper management control over the Radiation Safety Program. I have been authorized, af ter consultation with the Director, Office of Entvecement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Thousand Two Hundred Fifty Dollars ($1,250.00) fer the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a ' Severity Level III problem.
| |
| The base value of a civil penalty for a Severity Level III violation or problem is $2,500.00. The NRC Enforcement Policy allows for reduction of a civil penalty under certain circumstances. In this case, the base civil penalty amount has been reduced by 50 percent because of your prompt and extensive corrective actions to prevent recurrence. Actions were taken by a licensee's representative to immediately start correcting the violations identified by the inspector before the end of the inspection. The licensee's new administrator obtained the services of a health physics consultant to assist and' audit the radiation safety program and to establish procedures for correcting all the violations identified during the inspection prior to the enforcement conference. These actions indicate a renewed connitment and understanding of the importance of an effective and detailed Radiation Safety Program.
| |
| You are required to respond to this letter and the enclosed Notice and should follow the instructions specified therein when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
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| Should you have any questions concerning this letter, please contact us.
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| Sincerely,
| |
| . A-J. Nelson Grace Regional Administrator Enclosur2:
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| Notice of Violation and Proposed Imposition of Civil Penalty NUREG-0940 II.A-113
| |
| | |
| NOTICE OF VIOLATION AND PROPOSED IMPOSITIDT 0F CIVIL PENALTY Wise Appalachian Regior,al Hospital Docket No. 030-28616 Wise, VA 24293 License No. 45-23524-01 EA 88-204 During an NRC inspection conducted on July 14, 1988, violations of NRC require-ments were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions " 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act) 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
| |
| A. 10 CFR 35.60(b) states that to identify its contents, a licensee shall conspicuously label each syringe or syringe shield that contains a syringe with a radiopharmaceutical. The label must shoW the radiopharmaceutical name or its abbreviation, the clinical procedure to be performed, or the patient's name.
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| Contrary to the above, since April 1, 1987, the effective date of this regulation, until the date of the inspection, the licensee failed to label the syringes or syringe shields containing a radiopharmaceutical.
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| B. 10 CFR 35.61(b) states that to identify its contents, a licensee shall conspicuously label each vial radiation shield that contains a vial of a radiopharmaceutical. The label must show the radiopharmaceutical name or its abbreviation.
| |
| Contrary to the above, since April 1,1987, the effective date of this regulation, until the date of the inspection, the licensee failed to label each vial shield that contains a vial of a radiopharmaceutical.
| |
| C. 10 CFR 35.27(a) states in part that a licensee may permit any visiting authorized user to use licensed material for medical use under the terms of the licensee's license for sixty days each year if the visiting authorized user has the prior t.itten permission of the licensee's management, and, if the use occurs on behalf of an institution, the institution's Radiation Safety Committee; and, if the licensee has a copy of a license issued by the Comission or an Agreement State.
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| Contrary to the above, as of May 1988, the licensee failed to issue any written permission or obtain a copy of a license listing Dr. Ramakrishnan, a visiting physician, as an authorized user. Dr. Ramakrishnan routinely used licensed material when Dr. Gopalah, the licensee's authorized user, was absent or when nuclear medicine scans were needed on weekends.
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| D. 10 CFR 20.203(e)(1) states in part that each area or room in which licensed material in an amount exceeding 10 times the Appendix C quantity (100 microcuries for technetium-99m) is used or stored shall be conspicuously posted with a sign or signs bearing the words: " CAUTION RADI0 ACTIVE MATERIAL (S)."
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| NUREG-0940 II.A-114 i
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| Notice of Violation Contrary to the above, as of the date of the inspection, the licensee had not posted a sign, as described above, in the nuclear medicine scan room, in which amounts of technetium-99m exceeding 10 times the Appendix C limits were used, so that it can be viewed when entering from an adjacent ultra sound department.
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| E. License Condition 15 states in part that the licensee shall possess and use licensed material in accordance with statements, representations, and procedures contained in the application dated March 29, 1985, and a letter with attachment thereto dated May 1, 1985, and May 22, 1985.
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| : 1. Item 7 of the application requires the Radiation Safety Committee follow the duties in Appendix B, Regulatory Guide 10.8, Rev. 1 (October, 1980) and meet once per calendar quarter.
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| Item 8 of Appendix B requires that the Committee maintain written records of all Committee meetings, actions,' recommendations, and decisions.
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| Contrary to the above, written records were not maintained for meetings which may have occurred from January 1 to March 31, 1988, a calendar quarter.
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| : 2. Items 1.a., 1.b., 2.c(3), and 3.a(1) of the ALARA program contained in the application state in part that the management, the Radiation Safety Committee, and the Radiation Safety Officer will perfonn a formal annual review of the radiation safety program, including ALARA considerations. This shall include reviews of operating procedures and past exposure records, inspection, etc., and consultations with the radiation protection staff or outside consultants.
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| Contrary to the above, the licensee failed to perform a formal annual review, as described above, since December 11, 1985.
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| : 3. Item 12 of the application and Item c. of the {{letter dated|date=May 1, 1985|text=letter dated May 1, 1985}}, state in part that initial and recurrent in-service training will be given to ancillary personnel whose duties require their presence in the department. This will include security personnel.
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| Frequency of training will be at least annually.
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| Contrary to the above, the licensee failed to provide in-service training to housekeeping and security personnel since December 11, 1985.
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| : 4. Item 10 of the application states in part that dose calibrator linearity tests shall be performed at installation and quarterly thereafter.
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| Contrary to the above, the licensee failed to perform dose calibrator linearity tests during the first and second quarters of 1986 and during the fourth quarter of 1987.
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| NUREG-0940 II.A-115
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| Notice of Violation ! 5. Item 18 of the application states in part that solid waste will be l held for decay until radiation levels, as measured in a low background area with a low-level survey meter and with all shielding removed, have reached background levels.
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| 10 CFR 20,201(b) requires'that each licensee md e such surveys as may be necessary to comply with all sections of Cart 20. As defined in
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| , 10 CFR 20.201(a), " survey" means an evaluation of the radiation I
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| hazards incident to the production, use, release, disposal, or presence of radioactive materials or otht.r sources of radiation under a specific set of conditions.
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| 10 CFR 20.401(b) states in part that eat.h licensee shall maintain records in the same units used in Part 20, showing the results of surveys required by $20.201(b) and disposals made under 120.302.
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| Contrary to the above, from May 29, 1985 to April 19, 1986, the licer.see failed to keep records of disposals of waste held for decay, a method of disposal approved by 620.302, and to perfonn surveys on the waste held for decay before the waste was disposed of in the normal trash.
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| : 6. The {{letter dated|date=May 22, 1985|text=letter dated May 22, 1985}}, requires the licensee to calculate the efficiency of the survey meter (cpm /dpm). The survey meter reading (cpm) corresponding to 200 dpm will determine the " action level" above which decontamination will be employed.
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| Contrary to the above, as of the date of the inspection, the licensee failed to calculate the efficiency of the survey meter and document the 200 dpm action level or the survey meter reading (cpm) corresponding to 200 dpm action level.
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| : 7. Item 14 of the application states in part that the licensee shall, upon receipt of packages containing radioactive material, wipe the external surface of the final source container, assay, and record the amount of removable activity.
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| Contrary to the above, since December 11, 1985, until July 14, 1988, the licensee failed to perform wipes of the final source container for packages containing radioactive material received.
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| F. 10 CFR 35.204(c) states in part that a licensee who must measure molybde-num concentrations shall record the ratio of the required measurements expressed as microcuries of molybdenum per millicurie of technetium.
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| Contrary to the above, since April 1,1987, the effective date of this regulation, until July 14, 1988, the licensee failed to record the ratio of the required measurements in the units expressed above.
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| G. 10 CFR 19.11 requires a licensee to post current copies of certain documents near or in a licensed activity location. These documents include 10 CFR Part 19,10 CFR Part 20, the license complete with amendments, NUREG-0940 11.A-116
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| Notice of Violation referenced documents, and operating procedures. If pesting,is not practicable, the licensee may post a notice that describes the documents and where they may be examined.
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| Contrary to the above, as of the date of the inspection, neither the documents nor a notice of where the documents could be examined was posted.
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| These violations have been evaluated in the aggregate as a Severity Level III problem (Supplement IV and VI).
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| Cumulative civil penalty - $1,250.00 (assessed equally among the violations).
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| Pursuant to the provisions of 10 CFR 2.201, Wise Appalachian Regional Hospital (licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, within 30 days of the date of this Notice. This reply should be clearly marked as a
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| " Reply to a Notice of Violation" and should include for each violation:
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| (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.
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| Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances. (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed.
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| In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.
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| In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing NUREG-0940 II.A-117
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| | |
| Notice of Violation page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty.
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| Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282.
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| The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323.
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| FOR THE NUCLEAR REGULATORY COMMISSION I
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| M J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia i
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| this 30 % day of September 1988 NUREG-0940 II . A-118
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| II.B. MA1ERIAL LICENSEES, SEVERITY LEVEL Ill VIOLATION, NO CIVIL PENALTY NUREG-0940
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| eN
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| [ " ';
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| UNITED STATES NUCLEAR REGULATORY COMMISSION
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| $ o REGION I E
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| f0 476 ALLENoALE ROAD
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| ,9g KING oF PRusstA. PENNSYLVANIA 19406 June 22, 1988 Docket No. 030-19768 License No. 37-21092-01MD EA 88-53 Syncor Corporation ATTN: Mr. Monty Fu Chairman of the Board Post Office Box 2185 20001 Prairie Street Chatsworth, California 91313-2185 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 30-19768/88-01)
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| This letter refers to the NRC inspection conducted on February 8,1988, at your facility in Allentown, Pennsylvania to review the circumstances associated with a violation identified by your staff and reported to the NRC. The violation involved a cumulative radiation exposure in excess of the regulatory limit to the right hand of one of your radiopharmacists during the fourth calendar quarter of 1987. The report of the inspection was forwarded to you on February 26, 1988.
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| During the inspection, other violations of NRC requirements were identified, including: (1) failure to adequately train and monitor the individual who received the exposure; (2) failure to perform required bioassays on at least ten occasions; (3) failure to perform a required calibration check of the dose calibrator; and (4) labelling of containers of radioactive material with the wrong radiopharmaceutical name. On March 11, 1988, we held an enforcement conference with you and members of your staff to discuss the violations, their causes, and your corrective actions.
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| One of the violations, involving the mislabelling of radiopharmaceuticals, occurred on six separate occasions between October 10, 1986 and December 30, 1987, resulting in fourteen misadministration at your clients' medical facilities. Although corrective actions were taken after each mislabeling incident, these actions, which involve retraining of personnal with emphasis on reading and double checking the color and name on the kit label prior to pre-paring a radiopharmaceutical, apparently were not effective, as these incidents recurred. The labeling errors described in Section I of the enclosed Notice of Violation represent a significant failure to control licensed material and are of significant concern because once the radiopharmaceutical is mTslabeled, the user cannot avoid a resulting misadministration.
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| NUREG-0940 II.B-1
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| Syncor Corporation 2 This violation demonstrates the need for assuring that prepared radiopharma-ceuticals are laceled properly, since mislabeled products may result in multiple diagnos:.ic misadministration at your clients' facilities, and these misadmin-istrations result in unnecessary radiation doses to patients who are members of the pneral public. Although the staff recognizes that ir the past, similar violations hae been Categorized at Severity Level V, this violation represents a :ignificant regulatory concern and, therefore, after consultation with the Comhission, the violation in Section I has been categorized at Severity Level III in a:cordance with the " General Statement of Policy and Procedure for NRC Enfo cement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy).
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| A civil ,r: .dtv was considered for this case in view of similar labeling errors at other Syncor facilities. However, a civil penalty will not be proposed because (1) upon notification of the misadministration by your clients' medical facilities, you promptly notified all of your other clients to prevent further administrations of the mislabeled product, (2) you informed the NRC of the mislabeling incidents, (3) your prior enforcement history at the Allentown facility has been good, and (4) this is a substantial departure from previous NRC practice. However, any similar violations in the future may result in civil penalties.
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| The NRC recognizes that the safety significance of the violations described in Section II of the enclosed Notice was low, including the exposure to the radiopharmacist, because the cumulative radiation exposure (21.7 rems) received by the individual was not significantly in excess of the regulatory limit (18.75 rems). Nonetheless, these violations are also of particular concern to tha NRC because they demonstrate a recent lack of adequate management control and oversight of activities at your Allentown facility, which had, in the past, an otherwise good enforcement history. In addition, because the individual who received the radiation exposure was a relatively new employee, we are concerned with the lack of adequate management oversight for this individual's activities.
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| Although his biweekly exposure reports received during the previous calendar quarter indicated decreasing exposure rates, these rates were still higher than normal. The NRC recognizes that you have made significant changes since the inspection to improve oversight of operations, including replacement of both the facility and regional managers and expansion of your training for new pharmacists to provide practical exercises for safe handling of radiopharmaceuticals.
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| Although a violation involving an exposure in excess of the regulatory limit l could individually be classified at Severity Level III in accordanca with Section C.1 of Supplement IV of th- Enforcement Policy, the violations described in Section II of the enclosed Notice have been classified in the aggregate as a Severity Level III problem to focus on the underlying NRC concern, namely, recent inadequate oversight of the radiation safety program at your Allentown facility. A civil penalty normally is considered for a Severity Level III violation or problem. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, I have decided that a civil penalty will not be proposed for these violations because (1) the exposure was identified by your staff and promptly reported to the NRC; (2) the corrective actions were prompt and extensive; and (3) your prior enforcement history at the Allentown facility has been good.
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| NUREG-0940 II.B-2
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| Syncor Corporation 3 Nonetheless, we emphasize that any similar violations in the future may result in additional enforcement action.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. In addition, in responding to Violation I, please identify what action you have taken or plan to take in the future to avoid this problem at not only the Allentown facility, but also your other nuclear pharmacies. After reviewirg your response to this Notice, including your proposed corrective actions and the results of future inspec-tions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL No. 96-511.
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| Sincerely, William T. Russell Regional Administrator
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| ==Enclosure:==
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| Notice of Violation cc w/ encl:
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| Public Document Room (PDR)
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| Nuclear Safety Information Center (NSIC)
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| Commonwealth of Pennsylvania State of California NUREG-0940 11.B-3
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| NOTICE OF VIOLATION Syncor Corporation Docket No. 030-19768 Allentown, Pennsylvania License No. 37-21092-01MD EA 88-53 During an NRC inspection conducted on February 8, 1988, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violations are listed below:
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| I. VIOLATION ASSOCIATED WITH LABELING ERRORS Condition 23 of License No. 37-21092-01MD (superseded amendment) required that licensed material be possessed and used in accordance with statements, representations and procedures in application dated May 28, 1982 and certain specific letters.
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| Item 23 of this application described the required customer container labeling which specifies the name of the radiopharmecutical.
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| Condition 24 of License No. 37-21092-01MD (current amendinent) requires that licensed material be posser. sed and used in accordance with statements, representations and procedures contained in an application dated August 15, 1987.
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| Item 10.13 of this application describes the required customer container labeling, which includes specification of the name of the radiopharmaceutical.
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| Contrary to the above, between September 1986 and February 8, 1988, syringes, vial shields and/or unit dose container shields containing radioactive material were labeled with the wrong radiopharmaceutical name on six separate occasions, which resulted in fourteen misadministration by hospitals.
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| This is a Severity Level III violation (Supplement VI).
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| II. VIOLATIONS ASSOCIATED WITH MANAGEMENT CONTROL A. 10 CFR 20.101(a) requires that no licensee possess, use, or transfer Itcensed material in such a manner as to cause any individual in a restricted area to receive in any period of one calendar quarter a total occupational dose to the hands and forearms in excess of 18.75 reis.
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| Contrary to the above, during the fourth calendar quarter of 1987, a radiopharmacist working in the radiopharmaceutical dispensing area, a restricted area, received a total occupational dose in excess of 18.75 rems.
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| NUREG-0940 11.B-4
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| 2 B. 10 CFR 19.12 requires, in part, that all individuals working in, or frequenting any portion of, a restricted area be instructed in l precautions or procedures to minimize exposure to radioactive materials.
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| Contrary to the above, as of February 8, 1988, a radiopharmacist working in the dispensing area, a restricted area, had not been adequately instructed in precaut' ions or procedures to minimize exposure to radioactive materials in that, although the individual had been shown the kit preparation and dose drawing techniques, the individual was not observed to verify his ability to independently use these techniques, a necessary aspect of the instruction process.
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| C. Condition 24 of License No. 37-21092-01MD requires that licensed material be possessed and used in accordance with statements, representations and procedures contained in an application dated August 15, 1987.
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| : 1. Item 10.10 of this application describes the precautionary measures for handling millicurie quantities of liquid radiciodine and requires that weekly bioassays be performed for individuals who compound iodine-131 capsules.
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| Contrary to the above, between September 1, 1987 and December 14, 1987, radicpharmacists compounded iodine-131 capsules approxi-mately three or four times per week, but during this time, weekly bioassays of the individuals who prepared the capsules were not performed.
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| : 2. Item 10.4 of tnis application requires adherence to the
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| " Procedures for Calibration of Dose Calibrators" contained in !
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| Appendix E of the " Guide for the Preparation of Applications for Nuclear Pharmacy Licenses" d4ted August, 1985. Item 4 of Appendix E requires the assay of at least one reference source to verify the constancy of the dose calibrator before each day the dose calibt; tor is used.
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| Contrary to the above, on at least ten days between September 1987 and February 8, 1988 when the dose calibrator was used for iodine-131 compounding, a reference source was not assayed in the dose calibrator to verify constancy.
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| These violations are categorized in the aggregate as a Severity Level III problem (Supplements IV and VI).
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| Pursuant to the provisions of 10 CFR 2.201, Syncor Corporation (Licensee) is i hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, Region I, within 30 days of the date of the letter transmitting this Notice. This reply should be clearly marked as a NUREG-0940 II.B-5
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| 3
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| " Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted, (2) the corrective steps that have been taken and the results achieved, (3) the corrective steps that will be taken to avoid further violations, and (4) the date when full compliance will be achieved.
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| If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be give to extending the response time for good cause shown.
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| FOR THE NUCLEAR REGULATORY COMMISSION William T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania this J2 #, day of June 1988.
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| NUREG-0940 II.B-6
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| [ea ascoq% , UNITED STATES 8 g[, NUCLEAR REGULATORY COMMIS$10N g , j REGION 1
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| 'v ,/ 475 ALLENOALE ROAD
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| ***** KING OF PRUSstA. PENNSYLVANIA 13406 November 2, 1988 Docket No. 030-18966 License No. 29-19608-01MD EA 88-269 Syncor Corporation ATTN: Mr. Monty Fu Chairman of the Board Post Office Box 2185 20001 Prairie Street Chatsworth, California 9133-2185 Gentlemen:
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| ==Subject:==
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| NOTICE OF VIOLATION (NRC INSPECTION REPOR1 NO. 30-18966/88-001)
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| This letter refers to the NRC inspection conducted on August 11-12 and October 5,1988, at your facility in Fairfield, New Jersey, to review the circumstances associated with a violation involving four misadministration at your clients' medical facilities which were reported to the NRC by members of your staff.
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| The misadministration occurred on four separate occasions between September 21, 1987, and March 25, 1988, and were caused by mislabeling of radiopharma-ceuticals at your Fairfield facility.
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| The NRC hald an enforcement conference with you and members of you" staff on March 11,1988, to discuss an identical violation that occurred curing the s6me time period at your facility in Allentown, Pennsylvania, involving several misadmini'trations caused by labeling errors. During that conference, you presentec an analysis of the cause of the violation ano discussed your proposed correctivt actions to prevent a recurrence at any of your facilities. Since the labeling errors at the Fairfield, New Jersey, facility occurred prior to that enforcement conference, and the violation, causes and corrective actions are identical in nature, the staff has concluded that another enforcement conference to discuss this issue is not warranted at this time.
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| Nonetheless, identification of this violation, when viewed in light of multiple mislabeling errors of a like nature which occurred at your facilities in Pittsburgh, Pennsylvania, in 1987 and m Ash, Ohio, in 1988 (the latter, in part, resulting in an Order Modifyi w License), re-emphasizes the need for assuring that prepared radiopharmaceuticals are labeled properly.
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| These mislabeled products may result in multiple diagnostic misadministration at your clients' facilities, and these misadministration result in unnecessary radiation doses to patients who are members of the general public.
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| The staff recognizes that, in the past, similar violations have been categorized as Severity Level V and have resulted only in the issuance of an NRC Form 591 during the inspection, rather than a subsequent Notice of Violation. In fact, during the August portion of this inspection at Fairfield, a Form 591 was NUREG-0940 II.B-7
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| l Syncor Corporation 2 issued. As you are now aware, via the enforcement action issued on June 22, 1988 to your Allentown facility, such multiple errors are now categorized as Severity Level III violations. As a result, the Form 591 wa'. erroneously i issued and is hereby withdrawn. We apologize for any confusion that resulted I from the issuance of the Form 591.
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| ]
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| Accordingly, this violation, which is described in the enclosed Notice, has I been categorized at a Severity Level III in accordance with the " General Statement of Policy and Procedures for NRC Enforcement Actions", 10 CFR l Part 2, Appendix C (1988) (Enforcement Policy). The violation constitutes a {
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| significant failure to control licensed material and is of significant concern J because once a radiopharmaceutical is mislabeled, the user cannot avoid a I resulting misadministration. Although a civil penalty is normally considered for a Severity Level III violation, a civil penalty is not proposed in this case because the mislabeling at the Fairfield facility occurred prior to the issuance of the NRC Information Notice (88-53) which communicated to all licensees that, in the future, any such violation would be categori7.ed l as a Severity Level III and civil penalties, absent mitigating factors, would )
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| be considered. Further, the NRC recognizes that in this case, your corrective actions were comprehensive. Similar violations in the future may result in the imposition of civil penalties.
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| You are requirid to respond to this letter and should follow the instructions specified in tie enclosed Notice when preparing your response. In your response, you hould document the specific actions taken and any additional actions you plun to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accardance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the enclosed Notice are not subject io the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL No. 96-511.
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| Sincerely, hD William T. Russell Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation
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| : 2. Inspection Report NUREG-0940 II.B-8 i
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| NOTICE OF VIOLATION l Syncor Corporation Docket No. 030-18966 Fairfield, New Jersey License No. 29-19608-01MD EA 88-269 During an NRC inspection conducted on August 11-12 and October 5, 1988, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violation is set forth below:
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| Condition 23 of License No. 29-19608-01MD requires that licensed material be possessed and used in accordance with statements, representations and procedures in an application dated April 25, 1986 and certain specific letters. '
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| Item 10.13 of this application describes the required customer container labeling, which includes specification of the name of the radiopharmaceutical.
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| i Contrary to the above, between September 21, 1987 and March 25, 1988, I syringes, vial shields and/or unit dose container shields containing radioactive material were labeled with the vrong radiopharmaceutical name on four separate occasions, which resulted in four misadministration by hospitals.
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| This is a Severity Level III violation (Supplement VI).
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| Pursuant to the provisions of 10 CFR 2.201, Syncor Corporation (Licensee) is hereby required to submit a written statement or explanation to the U.S.
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| Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C.
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| 20E55 with a copy to the Regional Administrator, Region I, within 30 days of the date of the letter transmitting this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted, (2) the corrective steps that have been taken and the results achieved, (3) the corrective steps !
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| that will be taken to avoid further violations, and (4) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be is<,ued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown.
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| FOR THE NUCLEAR REGULATORY COMMISSION h p'& . . r Pk William T. Russell Regional Administrator DatedatKjngofPrussia, Pennsylvania this 2h day of November 1988.
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| NUREG-0940 II.B-9
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| UNITED STATES
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| [jo ess [0g NUCLEAR REGULATORY COMMISSION y 3 ,. g REGION fit 5 j 799 MOOSEVELT AC AD 0, d GLEN ELLYN. tLLINO15 60137
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| +.,
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| /
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| DEC 1 4 1989 Docket No. 030-0228f1 License No. 24-00624-02 EA 88-244 Trinity Lutheran Hospital ATTN: Mr. Patrick Garrett Chief Executive Officer 3030 Baltimore Avenue Kansas City, Missouri 64108 Gentlemen:
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| ==SUBJECT:==
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| NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 030-02280/88001(DRSS))
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| This refers to the inspection conducted during the period August 18-30, 1988, at Trinity Lutheran Hospital, Kansas City, Missouri, The inspection was in response to a licensee identified event. The violation, its causes, and corrective actions to prevent recurrence were the subject of an enforcement conferece on September 15, 1988, held in the Region 111 Office between you and others of your staff and Mr. C. J. Paperiello and others of the Region III staff.
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| The violation involved a therapeutic misadministration which resulted from a failure to compare the assayed dose to the prescribed physician's dose and the subsequent administration of the dose which was in excess of 10 percent than that prescribed by the physician. This constituted a therapeutic misadministration. The misadministration was promptly identified by the licensee and reported to the NRC as required. The NRC considers violations of License Conditions which result in therapeutic misadministration as significant events.
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| In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violation described l in the enclosed Notice has been classified at a Severity level Ill. A c:vil penalty is considered for a Severity Level III violation. However, after consultation with the Director, Office of Enforcement and the Deputy Execut:ye Director for Regienal Operations, I have decided that a civil penalty will not be imposed in this case because of the following: (1) your prompt identification and reporting of the event; (2) your prior good performance; (3) your prompt and extensive corrective actions which included disciplinary action, revision of procedures, and instructions to the nuclear pharmacy to limit doses sent to the hospital to within 5% of the prescribed dose.
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| You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. in your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this CERTIFIED MAIL RETURN RECElPT REQUESTED NUREG-0940 II.B-10
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| }
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| Trinity Lutheran Hospital DEC ;a iogo Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.
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| In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.
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| The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork R e:ction Act of 1980, PL 96-511.
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| Sincerely, od W A. Bert Davis Regional Administrator
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| ==Enclosures:==
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| : 1. Notice of Violation
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| : 2. Inspection Report No. 030-02280/88001(DRSS) i NUREG-0940 II.B-11
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| NOTICE OF VIOLATION Trinity Lutheran Hospital Docket No. 030-02280 Kansas City, Missouri License No. 24-00624-02 EA 88-244 During an NRC inspection conducted during the period August 18-30, 1988, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1988), the violation is listed below:
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| License Condition 19 requires that all licensed material be possessed and used in accordance with statements, representations, and procedares contained in the application dated July 8, 1982.
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| The application dated July 8,1982, requires that the procedures described in Appendix G of Regulatory Guide 10.8 shall be followed for the safe use of radioactive materials. Regulatory Guide 10.8, Appendix G, describes the following procedures:
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| "6a. Assay each patient dose in the dose calibrator prior to administration. Do not use any doses that differ from the prescribed dose by more than 10 percent.
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| 6b. For therapeutic doses, also check the patient's name, the radionuclides, the chemical form, and the activity vs. the order written by the physician who will perform the procedure."
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| Contrary to the above, on July 29, 1988, a dose differing from the prescribed dose by more than 10 percent wi administered to a patient. The dose administered to the patient was 13.7 millicurie iodine-131 capsule when a 12 milliturie iodine-131 capsule had been prescribed. Additionally, the technician failed to check the activity of the radionuclides as measured by the licensee (15.4 millicuries) to the physician's order (12 millicuries).
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| This resulted in a therapy misadministration as defined in 10 CFR 35.2.
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| This is a Severity Level 111 violation (Supplement VI).
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| Pursuant to the provisions of 10 CFR 2.201, Trinity Lutheran Hospital is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. 20555, l with a copy to the Regional Administrator, Region III, U.S. Nuclear Regulatory Comission, 799 Roosevelt Road, Glen Ellyn, Illinois, 60137, within 30 days of the date of the letter transmitting this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted; (2) the corrective actions that have been taken and the results achieved; (3) the corrective NUREG-0940 II.B-12
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| actions that will be taken to avoid further violatior.s. and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time. If an adequate reply is not received within the time specified in this Notice, an Order may be issued to show cause why the license should not be modified, suspended, or revoked or g why such other action as may be proper should not be taken.
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| FOR THE NUCLEAR REGULATORY COMMISSION i
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| $ ~-a A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois '
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| this v day of December 1988 I
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| 19
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| /
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| s Y
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| il NUREG-0940 II.B-13 - --
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| NRCFOAM335 U s. NUCLEAR KE QULATO2Y COMMisssON I REPONT NUMBE R # Ass,anea er rtDC. eda vor %s , er enri N 12 811
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| '"',"J$'' BIBLIOGRAPHIC DATA SHEET NUREG-0940 1
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| Vol. 7, No. 4 SEE INSTRUCTIONS ON THE REVEHSE 2 TIT LE AND $US TIT LE 3 LE AVE 0 LANK
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| , Enforcement Actions: Significant Actions Resolved
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| ; Quarterly Progress Report 0
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| (October - December 1988) . oATe REPoaT COMPtEno MONTH
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| * EAR y , A v , ,0, ,,, February I 1989 Office of Enforcement Staff a oATi aEPOaT 'sSUEo h MONTH VEAR l February l 1989
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| ! T ,E -o M,No OasA~ ,2 A1,0~ N AME ANo M A,u~a Aoo E ss u,,,,, e. C.,,, , ,oO ,c1 ,As ,oo,v T ,vM E.
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| Office of Enforcement U.S. Nuclear Regulatory Commission . .,~ Oa oa AN r ~UM.E a Washington, DC 20555 10 SPONSORING OHGANb2 ATION NAME AND MAILINo 4dDRES$ Userr u delep Coper ,In TYPE OF REPORT Same as / above Technical b PE RtOD COV E RED Hncies,re dates, I
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| 17 5UPPLEMENT AN Y NOTE 3 l
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| , a As s s n AcT aoo . ora, o, ,,,,,
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| I This compilation summarizes significant enforcement actions that have been resolved during one quarterly period (October - December 1988) and includes copies of letters, Notices, and Orders sent by the Nuclear Regulatory Commission j to licensees with respect to these enforcement actions, It f s anticipated l that the information in this publication will be widely disseminated to
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| )
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| managers and employees engaged in activities licensed by the NRC, so that actions can be taken to improve safety by avoiding future violations similar to those described in this publication.
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| 1 14 DOCUML NT ANALi bts . e R E vvv0ND5 DEscR;PTOR5
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| '5 A V AIL A8 tut V Technical Specifications, Radiographer Quality Assurance Radiation Safety Program, Safety Evaluations Unlimited to $ECURfTv CL AS$f 7ICA?iOO (Tnos onge) l
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| . .nENr,"E Rs *EN E~ao mms Unclassified j iTms report)
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| Unc1assified 17 NUMBE R OF PAGES 18 price
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| ]
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| I l
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| e_ _-_---_ _-_ _ ____ _ - - _ ______ _ - ______r_ ___-__________-
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| l..
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| UNITED STATES 3,, c,,, ,00,,, cu33 ,,y NUCLEAR REGULATORY COMMISSION POSTAGE Er 7EES PAID WASHINGTON, D.C. 20555
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| ,, [""' g, OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300 1
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| _ ____ _ _ _ _ _ _ _ _ _ _ _ . - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _}}
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