IR 05000170/1988004: Difference between revisions

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{{Adams
{{Adams
| number = ML20196A484
| number = ML20247E797
| issue date = 11/23/1988
| issue date = 03/22/1989
| title = Insp Rept 50-170/88-04 on 881026-28 & 1107.Violation Noted. Major Areas Inspected:Facility Operations,Organization, Reviews & Audits,Operator Requalification Training, Surveillance Activities & Allegation Followup
| title = Discusses Insp Rept 50-170/88-04 on 881026-28 & 1107 & Forwards Notice of Violation & Proposed Imposition of Civil Penalty in Amount of $2,500
| author name = Linville J, Williams J
| author name = Russell W
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
| addressee name =  
| addressee name = Irving G
| addressee affiliation =  
| addressee affiliation = ARMED FORCES RADIOBIOLOGICAL RESEARCH INSTITUTE
| docket = 05000170
| docket = 05000170
| license number =  
| license number =  
| contact person =  
| contact person =  
| document report number = 50-170-88-04, 50-170-88-4, NUDOCS 8812060019
| document report number = EA-88-289, NUDOCS 8904030241
| package number = ML20196A474
| package number = ML20247E802
| document type = INSPECTION REPORT, NRC-GENERATED, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| document type = CORRESPONDENCE-LETTERS, NRC TO RESEARCH INSTITUTION/LABORATORY, OUTGOING CORRESPONDENCE
| page count = 14
| page count = 4
}}
}}


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    ; March 22, 1989 Docket No. ~50-170 License No. R-84 L EA 88-289 l'
U.S. NUCLEAR REGULATORY COMMISSION
l'  Defense Nuclear Agency Armed. Forces Radiobiology Research Institute ATTN: Colonel George Irving, III, USAF, USC Director Bethesda, Maryland 20014 Gentlemen:
SUBJECT: NOTICE OF VIOLATION AND PROPOSED. IMPOSITION OF CIVIL PENALTY (NRC Inspection Report No. 50-170/88-04)
  .This refers to the NRC inspection conducted on October 26-28 and November 7, 1988 at your facility in Bethesda, Maryland of activities author. ed by License N R-8 The report of the inspection was forwarded to you on November 28, 198 During the inspection, several violations of NRC requirements were identified, including multiple examples of some of these violation This also refers to the letter, dated December 2, 1988, sent'to you by the Area Director of the United States Department of Labor's (DOL) Wage and Hour office in Baltimore, Maryland. In that letter, the Area Director issued a DOL finding that one of your employees was discriminated against at your. facility for raising allegations of safety violations. After reviewing the D0L-findings, as well as your letter dated January 19, 1989 which provides your basis for this employee action, the NRC supports the D0L finding that'a discriminatory act occurred. This discriminatory action constitutes another violation of NRC requirements. On January 5, 1989, an enforcement conference was conducted with you and members of your staff to discuss the violations, their causes, and your corrective action The violations, which are described in the enclosed Notice, represent a programmatic deficiency in the control of operations in that management did not adequately respond to potential safety issues raised.by an employee. The violations include: (1) failure to perform written safety evaluations to assure that changes made at the facility, as described in the safety analysis report, did not involve unreviewed safety questions; (2) failure to adhere to procedural requirements on several occasions; (3) failure to ensure that some of your licensed operators satisfactorily completed the required requalification program; and (4) discrimination, in violation of 10 CFR 50.7, against an employee who raised safety concern The NRC is concerned that, although this employee identified a number of technical deficiencies at the facility and informed appropriate levels of CERTIFIED MAIL RETURN RECEIPT REQUESTED OFFICIAL RECO'tD COPY CP PKG AFFRI 3/17 - 0001. /17/89
        %/Y 8904030241 890322    #I R ADOCK 0500 0


==REGION I==
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l l Docket / Report N /88-04 License No, R-84 Licensee: Armed Forces R Miobiology Research Institute Bethesda, Maryland 20014 Facility Narne: Armed Forces Radiobiology Research Institute l
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Inspection at: Bethesda, Maryland j Dates: .
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October 26 - 28 and November 7, 1988 Inspectors: J. H. Williams, Project Engineer J. Gadzala, Reactor Engineer D. T. Wallace, Operations Engineer l
Defense Nuclear Agency  -2-management and supervision on September 13, 1988, action was not taken to investigate and correct the deficiencies until the matter was brought to your attention on October 13, 1988. Even then, the deficiencies were not acknow-ledged by your managers,. rather, a discriminatory action was taken against the individual, which could have a " chilling effect" on other employees who might be inclined to raise safety issues to' management or the NR These violations demonstrate the need for increased and improved management attention to facility operations to ensure that (1) deficiencies, when they exist, are promptly identified and corrected, and (2) individuals who identify these concerns feel free to raise them to management without fear of reprisa To emphasize this need, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, 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 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 have been categorized in the aggregate at Severity Level II The base civil penalty amount for a Severity Level III violation or problem is
Reviewed by:
$2,50 The escalation and mitigation factors of the Enforcement Policy were considered and found to be offsetting. The NRC attaches great importance to comprehensive licensee programs for detection, correction, and reporting of problems that may constitute violation of regulatory requirements. In considering the identification and reporting factor, we noted that your programs failed to identify the violations as they occurred, and once  l identified by an employee, your managers failed to immediately investigate and  s correct the deficiencies. It was not until after the employee refused to withdraw the allegations that this matter was brought to your attention and you initiated notification of the NRC and an internal investigation by the Inspector General. Even then, the full scope of the deficiencies were not fully understood by your staff and specific corrective actions were not undertaken until after the subsequent NRC inspection identified various items as violations. Therefore, a 50% escalation is applied for this factor. Your corrective actions, though not initially prompt, were found to be extensive and thorough. We believe that those actions outlined in your letters of February 14. and March 1,1989, provide a good foundation for assuring an effective solution to the facility's recent problems, and therefore, provide a basis for mitigating the proposed civil penalty by 50%. Therefore, on balance, no adjustment to the base civil penalty is appropriate.
  [r J( . W1111ams, oject Engineer
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      ' dafe Approved by: . gfg_ N _  // ,7f/
U. C. O nvi}14, C tef, '/ ' ' dfte Reactor Pro M d'Section/2A, Division of Reactor Projects l
Summary Inspection on October 26-28 and November 7, '988 Areas Inspected: Routine, unannounced inspection by three region-based inspectors [Whours) of facility operations, organization, reviews and audits, operator requalification training, surveillance activities and allegation followup.


I Results: Four apparent violations were identified associated with; (1) failure l to perform safety reviews (see Sections 3.3 and 6.2), (2) inadequacy of and l failure to follow procedures (see Section 5), (3) failure to monitor effluent I releases (see Section 3.4), and (4) failure to adhere to the requalification I
training program (see Section 7). Three unresolved items are discussed related to (1) assignment of responsibilities in the absence of the Reactor Facility Director (see Section 6.3), (2) the impact of omitting information on license renewals (see Section 7), and (3) NRC review of the reactor console safety evaluation (see Section 8). Weaknesses were noted in documenting operations in enough detail to allow the reconstruction of events at a later date and I
timeliness of safety reviews. Operator professionalism was considered a I strength as was the questioning attitude displayed by the Safety Comitte estjeg  ,
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gDR ADOCK 05000170 :
PNU L
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OETAILS    , Persons Contacted Col G. W. Irving, III  Director, AFRRI
    * M. L. Moore  Chairman, Radiation Sources Department
    * Maj J. R. Felty  Reactor Operations Supervisor
    * Maj L. A. Alt  Radiation Sources Program Manager
    * SFC W. W. Reed  Senior Reactor Operator SFC P. Cartwright  Senior Reactor Operator
    * SFC G. F. Talkington  Senior Reactor Operator
    * T. J. O'Brien  Radiation Protection Officer, SHD A. Munno    Senior Reactor Operator W. Ting    Senior Reactor Operator
    * Lt Col A. A. Elliott, J Air Force Observer
    * CMSGT D. J. Bragg, J Air Force Observer Interviews and discussions were conducted with other members of licensee staff as necessary to support inspection activit * Attended the exit interview on October 28, 1938, Followup on Outstanding Items 2.1 (Closed) Emergency Training Program (84-01-04)
The licensee was to consider strengthening the Emergency Training Program by implementing eight suggestions. Review of this item revealed that the eight suggestions have been considered, and have been incorporated into the Emergency Training Progra .2 (Closed) Review and Tracking of As-Built Orawings (86-01-02)
Operators were unable to locate up to date, as-built drawings of I    the facilit Review of this item revealed that drawings of the l    facility are available to the operator Efforts have been made
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by the facility to acquire more recent drswings, however these efforts have not yet resulted in a complete set of detailed and current as-built drawing Although drawings are available to the operators, management is expected to take the necessary steps to acquire detailed as-built drawings. This effort is being tracked under Unresolved Item 87-01-02.
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 requirement FFICIAL RECORD COPY CP PKG AFFRI 3/17 - 0002. /17/89 w____ - _ _ __ _ _ _ _ _ - - _ . .___ __ _ _ _ - _


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Defense Nuclear Agency  -3-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 Roo 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. 96-51


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Sincerely, Origin,.I Signed B7
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      'y;ILL1h T. EU3 SELL William T. Russell Regional Administrator Enclosure:
l Armed Forces Radiobiology
Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl:
. Research Institute  3 2.3 (0 pen) Vp to Date As-Built Drawings (87-01-02)
M. L. Moore, Reactor Facility Director State of Maryland 0FFICIAL RECORD COPY    CP PKG AFFRI 3/17 - 0003. /17/89
As discussed in paragraph 2.2 above, detailed current as-built i
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drawings are not available to operators. Although r.everal requests have been made to the site unit assigned to provide such drawings, these requests have not been answered with deliver / of the requested drawing . Operations Review (NRC Inspection Manual Module 40750)
3.1 Facility Tour The inspectors examined the facility by having an operator walk through the "Daily Operational Start-up Checklist." The operator demonstrated a good knowledge of the facility. Areas were generally clean and well maintained although some debris was observed from l  construction activities. The inspectors examined the preventive l  maintenance program by checking the work done on the air compressor.


l Licensee records indicated that PM was performed twice in 1937 and
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three times in 1938. Equipment appeared to be well maintained and I  clearly labeled. No leaks or abnorrnal operation were observed.
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l  Postings as required by 10 CFR 19 were observed. No deficiencies l were identified.
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l Defense Nuclear. Agency        -4-DISTRIBUTION:
l 3.2 Reactor Operators The inspectors observed several Reactor Operators during the course of reactor startups and pulse operations. The operators demonstrated proper control room decorum and formality. A positive attitude was conveyed. Operator professionalism is considered a strength.
Region I Docket Room (with concurrences)
 
Management Assistant,.DRMA (w/o enc 1)
l 3.3 Logs and Records The following records were reviewed to evaluate operations:
  . Robert J. Bores,. DRSS              :
Reactor Operator Log (1936 present)
DRP Section Chief              !
Malfunction Log (1985 - present)
PDR~
Gas Stack Monitor Historical Log (1937 - present)
SECY CA HThompson, DEDS JMTaylor, DEDR JLieberman, OE WTRussell, RI LChandler, OGC              l RBernero, NMSS RCunningham, NMSS Enforcement: Coordinators RI, RII, RIII,'RIV, RV FIngram, GPA/PA-BHayes, OI              ;
Reactor Console Strip Chart Record (March 1936)
FHerr, OIA VMiller; SPA /SP EJordan, AE0D WTroskoski, OE              l OE:Chron-              ;
Meter calibration records
OE:EA DCS l
 
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Armed Forces Radiobiology Research Institute  4
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i A general weakness was noted in recording adequatr; details for non-routine events to allow reconstruction of the events. An example '
was the March 6, 1986 failure of the linear channel pen during a reactor startup. When this event was discussed, the licensee stated that during this startup, a digital voltmater was used in the neutron monitoring circuit in lieu of the failed pen. The inspector found that a safety evaluation had not been performed to analyze the use of this digital voltmeter in the linear channel. This is an apparent violation of 10 CFR 50.59 (88-04-01). The digital voltmeter, which appears to be commonly used, was also found to be out of calibration since August 30, 198 Additional examples of inadequate documentation include the various Gas Stack Monitor failures described in sections 3.4 and 5, Operator Log entries for installation of the various neutron detectors, and '
placing equipment required by Technical Specifications to be operating, out of service (section 5).
 
3.4 Effluent Monitoring During a review of the Gas Stack Monitor (GSM) Historical Log, the inspector noted that there was no hourly report printout from the GSM for August 1, 1988, to document effluent samples for that day's operation The morning checklist which directs checking the GSM was completed at 6:36 a.m., but the morning 1 minute printout from the GSM is dated 01/01/061 at 02:02 which indicates a malfunction. The Operator's Log showed that nine reactor operations occurred that day during the period from 6:46 a.m. to 3:20 Cognizant operators stated that upon completing operations, the GSM electronics were found to have malfunctioned, neither measuring nor storing effluent data. No log entry or other record was made to note this. This is an apparent violation of Technical Specification 3. (b) which requires that gaseous effluents be sampled and measured during reactor operations (SS-04-02). In addition Technical Specif t-cation 1.21 (b) requires that any violation of a Limiting Condition for Operation (LCO) be reported to the NRC and this was not don Section 5 contains additional information regarding this even Although environmental monitoring dosimeters had not yet been read following this event, a backup system to the GSM was in operation during this period. That system, the Reactor Deck Continuous Air Monitor System, is also required by Technical Specifications and would have provided a warning of any unusual effluent releases.
 
! Surveillance Activities The following surveillance requirements were selected from the Technical Specifications for review:
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Armed Forces Radiobiology Research Institute  5 Description  Frequency Control rod worth (4.1)  Annual Control rod visual inspection (4.1)  Annual Clean / inspect pulse rod drive (4.1) Semiannual Measure delta k/k at 100 kW and 1 MW (4.1) Annual Measure control rod drop time (4.2.1) Semiannual Power level channel calibration (4.2.2) Annual Fuel temperature channel calibration (4.2.3) Annual Shield door / plug / dolly interlock check (4.2.4) Annual Fuel element inspection (4.2.5)  Annual /500 pulses Measure water conductivity (4.3)  Weekly Check ventilation damper mecharum (4.4) Monthly Channel test radiation monitoring system (4.5) Quarterly Calibrate radiation monitoring system (4.5) Annual The inspector verified that the selected surveillance items had been completed as required. The licensee uses a compact folder containing index cards to document surveillance items and specify procedures to be used. The file cards have clearly labeled tabs and are cross referenced for ease of acces No deficiencies were identifie . Procedures The inspector reviewed Reactor Cperations Procedures I through VII Deficiencies were identified in the adminstration of procedures and sufficient instances of failure to follow procedures were found to indicate an underlying sense of complacency towards procedural complianc Specific examples of the deficiencies include:
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GSM malfunctions on 7/26/88 and again on 8/1/88 were not recorded in the Malfunction log as required by Procedure II There was no record of the GSM hourly printout for 8/1/58 in the GSM Historical Log as required by Tabs I and K of Reactor
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Operations procedure VI!!.
 
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Procedure I, Conduct of Experiments, requires completion of a Reactor Use Recuest (RUR) prior to irradiation of materials.
 
l    Af ter review of the reactor log, a Memorandum for the Record dated 6/21/88 and interviews it was concluded that an experiment was conducted on 10/9/85 without completion of an RUR.
 
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e Armed Forces Radiobiology
  . Research Institute   6
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The GSM pump was turned off on 6/3/87 due to apparent malfunction (smell of smoke) without being recorded in the Malfunction Log (Procedure III).
 
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L a rator's Log #78 (3/10/87 - 6/17/87) and the Activated Materials Log were not reviewed by the Reactor Facility Director as required by TAB A of procedure VIII and TAB A of procedure I respectivel Interviews with the staff revealed that equipment required during reactor operations is occasionally taken out of service without any formal method to alert the operator of this fact. An example occurred when the Gas Stack Monitor pump was turned off on June 3, 1987, between a series of reactor operations. This practice has the effect of invalidating the startup checklist which is performed to ensure that required equipment is in service prior to reactor operation It illustrates an inadequacy in procedural control that increases the potential for reactor operation outside the bounds required in the Technical Specification This inadequacy in procedural control and the previous examples of procedural non compliance have been classed as a single apparent violation of Technical Specification 6.3 which eequires the licensee to have (and comply with) written procedures adequate for safe operation (88-04-03).
 
Issuance, approval, and operator notification of procedures appears wea A specific example is the Pulse Operation procedure using the Cerenkov detector. The procedure was not issued until a month after the April 1933 installation of the detector. Operator review of the procedure is dated October 1933, and the preimplementation Reactor and Radiation Facility Safety Committee (RRFSC) review is still pendin During a tour of the facility on October 26, 1988 tne inspector noted that the procedure for gas stack monitor operations posted at the monitor had no information on it to identify the revision number, date, or any other markings to ascertain it was the current procedure. This concern was discussed with the licensee and actions were taken to correct the proble . Organization and Administration 6.1 Reactor and Radiation Facility Safety Committee (RRFSC)
The composition, qualifications, functions and authority of the RRFSC are defined in section 6.2 of the Technical Specifications. The inspector reviewed the minutes for meetings conducted in 1986 thrcugh 1988 as well as annual audit re orts for this period. In all cases the requirements associated with quorum and frequency were net. The RRFSC meeting minutes documented the review of audit reports, procedure changes, and safety reviews. The supporting documentation of the RRFSC meeting was noted to have improved in 198 No deficiencies were identified,
 
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Armed Forces Radiobiology
. Research Institute  7 6.2 Safety Reviews Based upon discussions with licensee personnel it was determined that when the new reactor console was installed in a monitoring only mode of operation in early April, 1988, the licensee      ;
exchanged the pulse ion chamber in Safety Channel Number 2 with a      '
Cerenkov detector. This review by the inspector was prompted by an allegation indicating a failure to perform a safety evaluation prior to use of the Cerenkov detecto The inspector examined current and early versions of the Safety Analysis Report (SAR), the 10 CFR 50.59 evaluation for the new reactor console, and other reports provided by the licensee to determine if use of a Cerenkov detector was described or evaluated from a safety standpoint. One early version of the SAR indicated the      ,
Cerenkov detector would be evaluated during initial startup. No information was available on these startup tests. The licensee      ,
had a drawing showing the Cerenkov detector in the nuclear instrumentation system but this was not part of the SAR, nor was there any information provided to indicate that a safety       +
evaluation was mad .
The licensee stated they had used the Cerenkov detector in the past and believed it to be described in the SAR. However, the 50.59 evaluation dated May 11, 1988, for the new reactor console ftates with respect to SAR changes; "the phrase 'three ion chambers' has been changed to 'two ion chambers and a pulse detector' to allow a Cerenkov detector or an ion chamber to be used for pulse operation." It was also noted that the SAR described a scram input from the pulse ion chamber which was not described in the Technical Specifications and had been eliminated from use apparently without a safety evaluation. The elimination of the pulse ion chamber scram input is another example of an apparent violation of 10 CFR 50.59 (88-04-01).
 
The capability and adequacy of the Cerenkov detector and the effects of various parameters on its performance could not be determined based upon the information available to the inspector. No written safety evaluations exist to document the suitability of the Cerenkov detecto This is yet another example of an apparent violation of 10 CFR 50.59 which requires a written safety evaluation to provide the basis for a determination that a change to the facility does not involve an unreviewed safety question (88-04-01).
 
Additionally, some other safety evaluatiors did not appear to be performed in a timely manner. For example the safety evaluation for the new reactor console was not submitted to the RRFSC until the console was already in piece, and it did not address the additional nuclear instruments prior to their installatio It is reco;ni:ed that the console and additional instrumentation was not used to cperate the reactor,
 
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Armed Forces Radiobiology
. Research Institute  8 6.3 Organizational Structure l  The inspectors reviewed the AFRRI organizational changes relating to
)  the reactor facility and compared these changes to technical specif1-
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cation requirements. The creation of the Radiation Sources Department headed by the Psactor Facility Director (RFD) enabled the Department Chairman to be responsible for both the administrative and technical aspects of reactor operations The Reactor Division is within the Radiation Sources Departmen The inspector noted that the organizational changes were approved by the RRFSC on August 14, 1987 and after further changes, again on December 18, 1987. Minutes of the December 18, 1987 RRFSC meeting indicate that the Reactor Operations Supervisor (ROS) and Reactor
,  Division Chief should be two separate positions and that changes
;  in the organization should be made in the SAR and technical
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specifications The annual report for 1987 discusses these changes, The annual report states thit a dual chain now exists under the Department Head, with the P'JS reporting to the Department Head /RF0 on matters that pertain to reactor operations, and the Reactor Division Chief reporting to the Department Head /RF0 on administrative matters, Technical Specification 6.1.1 states that organizational changes can be made as long as the RF0 has direct responsibility to the Director of AFRRI for operation, safety and emergency contro There is no Technical Specification requirement that the Reactor Division Chief and the ROS be two separate positions, although the RRFSC recommended this arrangemen As a result of an allegation that the designation of the Acting RF0 was not in accordance with technical specification requirements, the inspector examined licensee practice in this area. Techacal Specification 6,1,2 states that the RF0 shall be respo...ible for administration and operation of the Reactor Facility and for determination of applicability of procedures, experiment authorization, and maintenance operations. During the absence of the RFD, the ROS shall have these responsibilitie Documentation in certain memoranda, organizational charts, the Safety Analysis Report and Annual Reports indicate a definite awareness of the requirements in technical specification 6,1, However, discussions and memoranda indicate that in many cases during the absence of the RFD, his responsibility was assigned to the senior person in the departeent or division. This iteru is considered unresolved pending licensee clarification of the responsibilities of the ROS in the absence of the RF0 (88-04-05).
 
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Armed Forces Radiobiology
. Research Institute  9 6.4 Reporting The inspector discussed with the licensee an internal memo describing an event of March 23, 1988 should be reported and addressed to NRC as required by the technical specifications. A copy of the memo was provided to NR It was noted that Annual Reports to the NRC for 1985, 1986 and 1987 all stated that liquid radioactive effluents released were estimated on a quarterly basis to be less than 25*4 of the allowable amounts t,nder 10 CFR 20. The inspectors asked to see the basis for the estimate and was told that there are no liquid releases from the AFRRI reactor facility and therefore no dat Section 3.4 of this inspection report discusses a failure to report an LCO violatio . Operator Training A review of licensed operator training (r* qualification training) was conducced in order to deterinine whether the facility has successfully implemented its NRC approved requalification progra Improvements to the requalification program are currently being implemented by the Training Coordinator. These improvements are intended to strengthen the requalification program by improving scheduling control, tracking of attendance, and establishing "performance based training". Because these measures have not been fully implemented, the effectiveness of the measures cannot be verified. However, the measures are recognized as being positive factors inter.ded to improve requalification program qualit The inspector verified that all licensed operators have been administered the annual written, oral and operating exams required by 10 CFR 55.59 (a)(2). Documentation of the annual oral and operating examinations included only a signed statement that these examinations had been performe No clarifying information sue.h as examination coverage, strengths or weaknesses was available for any operator. Such clarifying information is needed to identify strengths and weaknesses that are an important source of data that can be used to improve the requalification program. Although adequate documentation of these examinations existed in the operator files, the thoroughness of the operating and oral examination documentation is a program weahnes A review of lecture training revealed that between 1986 and 19SS, approximately twenty-two of thirty-nine schedu'ed lectures were cancelled by management and not rescheduled, resulting in a substantial amount of the requalification lecture eaterial not bei covered as required. Examples of training lectures that were cancelled by management and not perfor.med at a later date include:
 
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  * "Calibration Procedures,"
   * "Plant Instrumentation and Control Systems,"      >
  * "Plant Protection Systems and Physical Security,"
  * "Preview of Annual Shutdown"
  * "Reactor Facility Update,"
  * "Nuclear Reactor Kinetics,"
  * "Biological Effects of Radiation," and
  * "Operating Procedures."
 
In addition, of those requalification lectures that were performed, attendance by-the operators was poor, resulting in every licensed operator missing be-tween two and seventeen of the lectures during the 1986-1988 cycle. No makeup of the missed lecture material was performed as required by the AFRRI Requalification Program. Members of management apparently condoned laxity regarding the requalification training program since all licensed operators, including management, missed a substantial amount of the training, Apparently, other concerns outweighed management's commitment to the requali-fication program, resulting in scheduled lectures frequently being cancelle Management stated that a review would be performed to determine those opera-tors who are deficient in requalification training and that remedial training would be performe The improved scheduling method was a means through which management stated that full compliance with the requirements could be achieve Failure to perform requalification training lectures and ensure proper attendance is an apparent Violation of 10 CFR 55.59(c) (88-04-06).
 
In addition, the ur. completed requalification training was not noted on the NRC Form 398's which were submitted during 1983 for five licensed operators applying for license renewals. Facility management must certify on the Personal Qualifications Statement (NRC Form 393) that the licensed operator has met all the requirements of the requalification program. The impact of these omissions on the license renewal applications is an Unresolved Item (23-04-07).
 
!
l Modifications Modifications to the AFRRI facility were reviewed by the inspector in or-
. der to determine if the Reactor and Radiation Facility Safety Committee l  (RRFSC) had reviewed each modification, and whether an adequate Safety l  Analysis had been conducted.
 
Safety Evaluations for the following modifications were reviewed:
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   ' Control Room Windows    * Radiation Area Monitor Readuuts
Holody/p / tim   Linvill      . nger Kdne 2/ 7/89 p
  * Reactor Building Roof    "Gas Stack Monitor
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  *0verpressure Relief Valve     ' Air Supply For Dampers
2/l/89     2/1489     2/p/89 2/g /89 RI: RA      OGC   [6E DE s A19an Russell      Chandler 2/ /89 f. Lieberman 2/ /89 Thompson 2/ /89 y h. ([ b')ldlU 4 3 2/q/89 p 89 0FFICIAL RECORD COPY
  * Reactor Cooling Tower     "Exposure Room Monitoring
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  "Primary Water Makeup System    "Reactor Control Room Air Conditioner i
CP PKG AFFRI 3/17 - 0004. g 03/17/89    hg ;
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Armed Forces Radiobiol';y Research Institute  11    l l
Each of the above modifications was verified to have been approved by    l the RRFSC. A brief review of the Safety Evaluations indicated that    !
indepth analyses had been conductea for each modification,    i A brief review was conducted on the new reactor control console. A    l Safety Evaluation for the console, datad May 11, 1938, describes the instrumentation and control of the system as well as features expected to    ,
improve the overall operability of the reacto !
i The facility contracted ORI Inc. of Alexandria, Virginia, to conduct an independent review of the new console Safety Evaluation. ORI agreed that no unreviewed safety questions existed for the new pane Facility management stated that a plausible five dollar ramp accident over a two second interval was evai led by General Atomics with the    l conclusion that this scenario is encorrpassed in the existing safety    [
analysis for the facilit The adequacy and the appropriateness of the 50.59 safety evaluation of    l the new reactor control console is unresolved pending an NRC review    '
  (88-04-04).
: Allegation Followup (RI-83-A-0102)      y Background        !
l The inspectors investigated several allegations regarding technical    l specification violations, including failure to follow procedures, and    i violations of regulation Allegation
            [
The Reactor Division Chief and Reactor Operations Supervisor are two    I positions being filled by the same person; The designation of Acting RFD is not per Technt:41 Specification 6.1.2. (See section 6.3)    ,
            :
Allegation        !
l The linear channel was not operable during reactor operation in violation    !
of Technical Specification 3.2.1. (See sect w n 3.3)    J A11egai; ion L
The GSM was not operable on June 3,1937, during reactor operations when    j the pump was turned off in the morning. NRC inspectors then onsite were told it was turned of f in the af ternoon af ter completion of reactor operations due to the smell of smok I i
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_ _ _ _ _ _ . _ _ _ _ _ _ _ . _ _ . _ _ . _ _ _ _ _ _ _ _ . . . _ . _ _ _ _ _ . _ _ -. _ _,_ . ]
 
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i Armed Forces Radiobiology        l Research Institute      12  l l
              !
Interviews with staff and operators indicated that the Reac ra ';' rations    !
Supery'isor secured the noisy GSM pump at about 9:00 a.m. on s -..    , 1987, l to facilitah a meeting on the reactor deck. He wrote himself a reminder    l in his personal notebook and turned the pump back on af ter the meeting    l (about 10:30 a.m.). A log review indicates that reactor operations were    l conducted from 7:33 - 7:57 a.m., then again from 10:43 a.m. - 1:21 l The second period consisted of two 5 minute runs at 2 kW, followed by a    (
twenty minute run at 960 kW which ended at 1:21 ;
              !
The GSM Historical Log indicates that the GSM was not properly    i sampling during the final run, since the count rate only increased    !
f Nm 1.592+01 cpm at 1:00 p.m. to 2.228+01 cpm at 2:00 p.m. This small    !
increase appears inconsistant with the high power run. The expected    l increase is more aptly shoin in a June 8, 1938 GSM Historical Log    l entry for a similar 100*4 power, 20 minute run f rom 11:01 to 11:2) l The count rate increased more than ten times from 1.482+01 at 11:00    i a.m. to 1.636+02 at 12:00 '
i NRC inspecturs then ensite, state that they noted the secured pump on the GSM at about 2:30 p.m. The Reactor Facility Director (RFD) told them it was secured about half an hour earlier due to the smell of smoke. The putp    ,
was subsequently restarte The RFD had difficulty recalling this event and it is not documented in licensee records. An investigation to obtain the additional information necessary to conclusively substantiate a violation of Technical Specifi-cations is not warranted since t'se weaknesses associ ted with these events are identified in section 5 and a response discussing corrective actions is being requested from the licensee. Environmental dosimetry records indicate normal effluent disebarges during this perio Allegation The GSM was not operable during reactor operations or. July 25 and August 1, 1988. The July 25 malfunction is not recorded in the Malfunction tog as required by local procedure A review of logs and interviews with operators indicates that storm induced electrical surges caused an intermittent memory loss, not a malfuction in the GSM, prior to operations on July 25. The GSM did malfunction on July 26 and August 1, neither of which are recorded in the Malfunction Lo This is discussed further in sectirn 5. Tbt: July 26 malfunction occurred prior to 6:54 a.m. and not during reactor operations. The August 1 eal-function is an apparent violation as discussed in section Allegation Radiation exposure to desteetry personnel was higher than aserag Experieents are run with insuf ficient consideration to ALAR _ _ _ - _ _ _ _ - - . __-_______ ____-___-_-_ -- _ __ _ _ _ __ _ _ . _ _ _ _ _ _ _ _ _ - _ - _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _
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l              l l  Armed Forces RU1obiology          [
Research Institute  13      ;
              ,
f The inspector re :r.ed exposures of the persannel in question and examined    l Reactor Use Req mrts from the standpoint of the ALARA requirement in      :
Technical Speif t, ation 3.8. The requirement is that consideration be given    '
to siternativt operational profiles that might reduce exposures. The      ,
inspector found that ALARA was being considered in running experiments and    [
that exposures wer0 being adequately controlle i Allegation l
    'a exper beent was conducted on October 9,1985 without proper approval,    ,
    (See section 5)        l
    /,11egation I
The xetivated Materials Log was not reviewed annually as require (See ;
section 5)        j Allegation        !
              !
Ne procedure was written for pulse operation wi.~. Cerenkov detecto (See !
section 5)
l A11egstion l
No safety analysis was performed on replacement of Pulse Ion Chamber with Cerenkov detector nor on parallel nuclear instrumentation installed in    ,
conjunction with a new reactor control console. (See section 6.2)      !
              !
Allegation          i
              !
l The 411eger was concerned about licensing a enior Reactor Oprator due to that operator's hearing impediment. Tha alleger does not feel this      .
person etM t the requirements of the AFS statdard for rnedical certificatio r (
The operater in questioi. ' olds a license which contains restrictions that    l l    require the wearieg of a hearing aid when performing licensed duties and    I
.
prohteit assuming the SRO posit'on of Commander, Emergency Response Tea I l    The operator was given an Operatio.3a1 Hearing Evaluation, an Auc.ological    I Evaluation and a standard license related iadical examination. Results of the Operational Hearing Evaluation indicated that the operator is able to l
recognize an abnormal condition indicated by an alarm on either the remote area monitor or the reactor continuous air monitor with the same adeptt.ess that any other oper.ator would exhibi Section 5.4.4 of ANSI /A & 3.4 1983 entitled Medical Certification and l    Monitoring Personnel Requiring Operator Licenses for Nuclear Power Plants, states that: "f' audiometric scores are unacM ptable, qualification may be based upon onst;e deronstration to the satisfaction of the facility eperator of the examinee's ability to safe?y detect, hterm et, and respond to speech and ,ther aucitory signals." Tt e operator's ability to parform thest tasks was ver ified by the Operational Hearing Evaluation.
 
i
 
,
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    .
W
,. .. =:
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9- ,
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Armed Forces Radiobiology
  . Research Institute  14 These factors were all considered during the licensing process and the NRC subsequently issued a restricted license on August 23, 1988. A review
  ,
of the issue maintained the original NRC positio Allegation Snail shells Irradiated on May 12, 1988 were not recorded in the control room core experiment lo A review of the core experiment log shows several May 12 entries appearing in proper chronological order, one of which contains the description "Snail Shells". This entry is consistent with other entries in the log ard appropriately completed. The entry is cross referenced to PUR 83 38. A review of that form also showed no irregularitie . Unresolved Items Unresolved items are items about which more information is required to ascertain whether they are ar.ctotable, a violation, or deviatio Unresolved Items are discussed in sections 2.2, 6.3, 7, and . Exit Meeting (30703)
The scope and findings of this inspection were duscussed with licensee representatives on October 28, 1988. No written inspection material was-provided to the licensee during the inspection.
 
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Latest revision as of 04:12, 16 December 2021

Discusses Insp Rept 50-170/88-04 on 881026-28 & 1107 & Forwards Notice of Violation & Proposed Imposition of Civil Penalty in Amount of $2,500
ML20247E797
Person / Time
Site: Armed Forces Radiobiology Research Institute
Issue date: 03/22/1989
From: Russell W
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To: Irving G
ARMED FORCES RADIOBIOLOGICAL RESEARCH INSTITUTE
Shared Package
ML20247E802 List:
References
EA-88-289, NUDOCS 8904030241
Download: ML20247E797 (4)
v • d • e


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March 22, 1989 Docket No. ~50-170 License No. R-84 L EA 88-289 l'

l' Defense Nuclear Agency Armed. Forces Radiobiology Research Institute ATTN: Colonel George Irving, III, USAF, USC Director Bethesda, Maryland 20014 Gentlemen:

SUBJECT: NOTICE OF VIOLATION AND PROPOSED. IMPOSITION OF CIVIL PENALTY (NRC Inspection Report No. 50-170/88-04)

.This refers to the NRC inspection conducted on October 26-28 and November 7, 1988 at your facility in Bethesda, Maryland of activities author. ed by License N R-8 The report of the inspection was forwarded to you on November 28, 198 During the inspection, several violations of NRC requirements were identified, including multiple examples of some of these violation This also refers to the letter, dated December 2, 1988, sent'to you by the Area Director of the United States Department of Labor's (DOL) Wage and Hour office in Baltimore, Maryland. In that letter, the Area Director issued a DOL finding that one of your employees was discriminated against at your. facility for raising allegations of safety violations. After reviewing the D0L-findings, as well as your letter dated January 19, 1989 which provides your basis for this employee action, the NRC supports the D0L finding that'a discriminatory act occurred. This discriminatory action constitutes another violation of NRC requirements. On January 5, 1989, an enforcement conference was conducted with you and members of your staff to discuss the violations, their causes, and your corrective action The violations, which are described in the enclosed Notice, represent a programmatic deficiency in the control of operations in that management did not adequately respond to potential safety issues raised.by an employee. The violations include: (1) failure to perform written safety evaluations to assure that changes made at the facility, as described in the safety analysis report, did not involve unreviewed safety questions; (2) failure to adhere to procedural requirements on several occasions; (3) failure to ensure that some of your licensed operators satisfactorily completed the required requalification program; and (4) discrimination, in violation of 10 CFR 50.7, against an employee who raised safety concern The NRC is concerned that, although this employee identified a number of technical deficiencies at the facility and informed appropriate levels of CERTIFIED MAIL RETURN RECEIPT REQUESTED OFFICIAL RECO'tD COPY CP PKG AFFRI 3/17 - 0001. /17/89

%/Y 8904030241 890322 #I R ADOCK 0500 0

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Defense Nuclear Agency -2-management and supervision on September 13, 1988, action was not taken to investigate and correct the deficiencies until the matter was brought to your attention on October 13, 1988. Even then, the deficiencies were not acknow-ledged by your managers,. rather, a discriminatory action was taken against the individual, which could have a " chilling effect" on other employees who might be inclined to raise safety issues to' management or the NR These violations demonstrate the need for increased and improved management attention to facility operations to ensure that (1) deficiencies, when they exist, are promptly identified and corrected, and (2) individuals who identify these concerns feel free to raise them to management without fear of reprisa To emphasize this need, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, 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 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 have been categorized in the aggregate at Severity Level II The base civil penalty amount for a Severity Level III violation or problem is

$2,50 The escalation and mitigation factors of the Enforcement Policy were considered and found to be offsetting. The NRC attaches great importance to comprehensive licensee programs for detection, correction, and reporting of problems that may constitute violation of regulatory requirements. In considering the identification and reporting factor, we noted that your programs failed to identify the violations as they occurred, and once l identified by an employee, your managers failed to immediately investigate and s correct the deficiencies. It was not until after the employee refused to withdraw the allegations that this matter was brought to your attention and you initiated notification of the NRC and an internal investigation by the Inspector General. Even then, the full scope of the deficiencies were not fully understood by your staff and specific corrective actions were not undertaken until after the subsequent NRC inspection identified various items as violations. Therefore, a 50% escalation is applied for this factor. Your corrective actions, though not initially prompt, were found to be extensive and thorough. We believe that those actions outlined in your letters of February 14. and March 1,1989, provide a good foundation for assuring an effective solution to the facility's recent problems, and therefore, provide a basis for mitigating the proposed civil penalty by 50%. Therefore, on balance, no adjustment to the base civil penalty is 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 requirement FFICIAL RECORD COPY CP PKG AFFRI 3/17 - 0002. /17/89 w____ - _ _ __ _ _ _ _ _ - - _ . .___ __ _ _ _ - _

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Defense Nuclear Agency -3-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 Roo 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. 96-51

Sincerely, Origin,.I Signed B7

'y;ILL1h T. EU3 SELL William T. Russell Regional Administrator Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl:

M. L. Moore, Reactor Facility Director State of Maryland 0FFICIAL RECORD COPY CP PKG AFFRI 3/17 - 0003. /17/89

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l Defense Nuclear. Agency -4-DISTRIBUTION:

Region I Docket Room (with concurrences)

Management Assistant,.DRMA (w/o enc 1)

. Robert J. Bores,. DRSS  :

DRP Section Chief  !

PDR~

SECY CA HThompson, DEDS JMTaylor, DEDR JLieberman, OE WTRussell, RI LChandler, OGC l RBernero, NMSS RCunningham, NMSS Enforcement: Coordinators RI, RII, RIII,'RIV, RV FIngram, GPA/PA-BHayes, OI  ;

FHerr, OIA VMiller; SPA /SP EJordan, AE0D WTroskoski, OE l OE:Chron-  ;

OE:EA DCS l

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[? Y (L W

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RI:E0 S RI DRP R R -

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Holody/p / tim Linvill . nger Kdne 2/ 7/89 p

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2/l/89 2/1489 2/p/89 2/g /89 RI: RA OGC [6E DE s A19an Russell Chandler 2/ /89 f. Lieberman 2/ /89 Thompson 2/ /89 y h. ([ b')ldlU 4 3 2/q/89 p 89 0FFICIAL RECORD COPY

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CP PKG AFFRI 3/17 - 0004. g 03/17/89 hg ;

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