ML20072U212

Submits Followup to 910408 Rept Re 910116 Shipment of Small Quantity of Radioactive Matl.Shipment Should Have Been Labeled W/Radioactive Yellow-2 Label Instead of Radioactive Matl,Limited Quantity Label.Procedures Revised

ML20072U212
Person / Time
Site:	Oregon State University
Issue date:	04/12/1991
From:	Andrea Johnson Oregon State University, CORVALLIS, OR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9104190054
Download: ML20072U212 (5)

Text

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IMDINMON CINII;R Oni:GON STA'It Usivrusity Radiation Center Al(o Cervalls Oregon 97331 SW3

'lelephone $03 737 2Mt Ib $03 737 NHO April 12,1991 Document Contre! Desk U.S. Nuclear Regulatory Commission Washington, D.C. 20555

Subject:

Oregon State University TRIGA Reactor (OSTR), Licenso No. R 106, Docket No.

50 243; written report filed by the OSTR as a follow up to telephone conversat!ons with USNRC stalf.

Gentlemen:

On April 8,1991, A. G. Johnson, Director of the OSU Radiation Contor, tolophoned Mr. Al Adams, OSTR Project Manager at U.S. Nuclear Regulatory Commission (NRC) headquarters to discuss an event involving the shipment of a small quantity of radioactivo motorial, which occurred on January 16,1991, in addition, on April 5,1991, Dr. Brian Dodd, Reactor Administrator at the OSTR, contacted Mr. Wondell Carriker, Roscarch and 1 Special Programs Administration, US Department of Transportation, Washington, D.C. to report the event to the USDOT. Relativo to reporting,it should also be noted that on April 5 A. G. Johnson attempted to contact Mr. Adams at NRC headquarters, and Mr. Phil Qualls and Mr. Leroy Nordorhaug who are the OSTR contact personnelin the NRC's Rogion 5 offico. None of those individuals were availablo on April 5 and thus the first NRC telephone contact was made with Mr. Adams on April 8,1991. {

The purposo of the tolophone calls to the DOT and the NRC was first to describe the event to the agenciss and then to determino whether or not there woro formal reporthy requiromonts for Iabeling and shipping paper discrepancios which woro detected af ter tho-fact for a shipment of 140 Ci of radioactivo material which went from the OSTR to another licenseo. The DOT representativo indicated that their regulations had no clear reporting requirements for the event describod, and Mr. Adams telephoned A.G. Johnson on April 8 to report that there did not appear to be any 6pplicablo NRC reporting requirements for such on event. However,in kooping with the OSTR policy of open communication with the NRC on matters which wo believe to be of mutualinterest, we have decided that it would be appropriate to submit a report of the event.

In addition to verbal notification of NRC headquarters, tolophone colla were also completed to the NRC's Region V Offico, to the Oregon Department of Energy, to the Oregon Radiation Control Section, to the carrior (Federal Express) and to the recipient of the shipment, Renssolaer Polytechnic Institute (RPl). In the latter caso, the notification s

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USNRC 2- April 12,1991 was made to the RPI Radiation Safety Officer, which is where the package was shipped.

Notifications to the specified organizations were made on April 8 and April 10,1991.

A description of the event itself, including our analysis of its cause: corrective actions and measures implemented or planned to prevent or reduce the possibility of reoccurrence; lessons learned; and specific conclusions regarding the event are allincluded as part of this report, Furthermore, the information submitted in this report, including the corrective /

preventative actions, has been reviewed and opproved by a quorum of the OSTR Reactor Operations Committee (ROC). -

BACKGROUND INFORMATION The Oregon State University Radiation Conter routinely ships small quantities of radioactive material to other licensed users on the OSU campus and to users at other locations throughout the country. All shipments are made in full accordance with applicable regulations of the US Department of Transportation and the State of Oregon.

Normally, the quantitles of radioactive material shipped are in the microcurio rango and fall into the DOT " Limited Quantity" category. The remainder of the shipments are USDOT

• Type A Quantitles" and normally require a White I or a Yellow ll radioactive matoriallabel.

Upon very rare occasion, the Radiation Center may ship a package requiring a Yellow lli radioactive materiallabel.

As part of the Radiation Center's program for shipping radioactive material, training sessions are conducted for each individual authorired to make such shipments. Upon completion of the training, individuals have their name entered on a list of certified radioactive material shippers. To retain this certification, individuals must participate in an j annual retraining program. l Another part of the shipping program includos quarterly audits of all shipments. One ,

such audit is n*? formed by the OSU Radiation Safety Of ficer, while a separate quarterly audit of shipm from the OSTR is performed by the ROC. 1 The R$diation Center also has several different types of containers which have been tested to meet USDOT container Specification 7A. Records of these container tests me maintained permenently on file at the Radiation Center.

Detailed written procedures for packaging and shipping radioactivo material are also part of.the Radiation Center's shipping program. These procedures are available to all

individuals authorized to make such shipments and are reviewed for accuracy at least annually by the OSTR Reactor Operations Committee,  !

1 DESCRIPTION OF OCCURRENCE AJD_POSSIBLE CAUSES i As noted previously, part of the Radiation Center's program for shipping radioactivo materialincludes a quarterly audit which is performed by the OSU Radiation Safety Of fmer.

On Friday, March 29 the OSU Radiation Safety Officer terformed the routino quarterly _

. . i USNRC 3- April 12,1991 audit of shipments mado during the first quarter of 1991 and identified a discrepancy in a radioactive material shipment made on January 10,1991. The discrepancy is described below:

On January 16,1991, the Radiation Center's Radiation Protection Technologist packaged a shipment containing 140 pCl of iron 59 (Fe 59) for shipment to Renssoleer Polytechnic Institute (RPl). The radioactivo material was contained in thin geologic samplos which had boon irradiated in the OSTR thermal column, and the majority of the radioactivity at the timo of shipmont is  !

belloved to have been due to flux monitors present with the samplos. The shipment was modo from OSTR License R 106 to RPI's Now York Stato License NYS 1035. The 140 pCl of radioactivity was well within the DOT limit for a Limited Quantity shipment, but the material was actually packaged in a container mooting USDOT Specification 7A, which qualifies the container to carry a Type A Quantity of radioactive material. The maximum radiation levelin contact with the packago was 4 mrom/hr, while the radiation level at 1 motor (i.e., the transport index) was O mrem /hr. The packago was distinctly labeled Radioactive Material, Limited Quantity n.o.s., UN 2010, which was consistent with the quantity of radioactivo material being shipped, but was not consistent with the maximum radiation level at contact with the package. Considoring the 4 mrem /hr present on the packago surface, the packaga should have boon labeled with a Radioactive Yellow ll label and classified as Radioactivo Material, n.o.s., UN 2982. In addition, the shipping papers which accompanied the ,

package reflected the fact that the package was classified and labelod as a '

Limited Quantity, and consistent with this laboling the papers indicated that the package was industrial, strong and tight rather than Specification 7A. As a l reminder, a USDOT Specification 7A package was actually used to make the shipment, but the shipment was not being considered a Type A Quantity. All other DOT requirements applicable to the shipment were mot, and after the packtDo was prepared it was transferred to Federal Express for shipment to

- RPl. The shipment arrived without incident at its intended destination. ,

The individual who prepared this shipment for the OSTR was cortified to ship radioactivo material and is a very capable and conscientious member of the i Radiation Center's staff. Thero are no indications that the discrepancies occurred due to carolossness on the part of the individual involved. The person making the shipment had successfully shipped a large number of radioactive material packages from the Radiation Centor, and af ter discussing the matter i' with the individual, we can only conclude that the mistake was duo simply to human error. We have every confidence that this employoo will recognize the significanco of this occurrence and will benefit from tho additional training and l other follow up activities associated with this event. 1 I

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USNRC 4- April 12,1991 CORRECTIVE SUCH AN EVENT ACTIONS AND MEAS 3).flES TAKEN TO PREVENT THE REOQCURRERCLQI The Contor's program for shipping radioactive materialis very rnuch a part of our day to day operation and we believe that it must be carried out in a safe and professional mannor. As indicated previously, the Radiation Contor conducts a formal training program associated with the authority to ship radioactive materials. The training involves many dif ferent topics including the writton shipping procedures, practical shipping oxorcisos, and other factors designed to assuro full compliance with all USDOT and Stato of Oregon requirements. However,in view of the event described in this report, the Contor has implemented two additional actions which we believe will significantly help to provent the rooccurrence of any further discropancy during the shipment of radioactivo material. The two correctivo measures are as follows:

1. The Radiation Conter procedure for transfor, packaging, and transport of radioactivo material has boon revised to require an indopondent review by a second individual of all packages and shipping papers before they are offered for shipment, The review will be conducted by an individual cortified to ship radioactivo material, but the reviewer will not be the same individual who packaged the shipment and prepared the shipping papers.

2. All Radiation Contor staff members certified to packago and ship radioactivo matorial participated in a special retraining program conducted on April 9,1991. During this training session the event being reported was reviewed along with the now requirement for a secondary review of shipping papers and packages. Other aspects involved in the shipping of radioactivo material were also reviewod.

LESSONS LEARNED The concept of performing a second independent review of logs and checklists is common throughout the research reactor community. Based on this event,it would appear that an independent review of radioactive material packages and shipping papers prior to actual shipment would be a wise addition to all shipping proceduros which do not currently requiro such a review, CONCLUSIONS The quantity of radioactivo materialinvolved in this event was quito small and the associated radiation levels were very low. Consequently, the discrepancies identified are primarily regulatory in naturo. Furthermore, safety 'vas not an issuo in this occurrence.

Nevertholoss, the OSTR staff regrets that this event took placo and wishes to assure the NRC, the DOT and the State of Oregon that safety and compliance with regulatory requirements arn of the utmost importanco in all aspects of our program. We also wish to mako it clear thet we are fully committed to implomonting the previously identified correctivo actions in order to prevent a rooccurrence of this event.

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USNRC 5- April 12,1991 In conclusion, we would like to summarize for your consideration soveral key factors relating to our report.

1. The amount of radioactive material shipped (140 pCl) was well within the I DOT's curie limit for a

• Limited Quantity" shipment. l l

2. The radioactivo material was packaged in a container mooting USDOT container Specification 7A, which was a fully appropriate container for the radioactive material shipped.

3. The primary discrepancies were in the labeling of the packago and in the previously identified errors on the accompanying shipping papers; however, '

those latter errors were consistent with the labeling discrepancy.

4. The maximum radiation lovel at the package surface was only 4 mrom/hr and at 1 meter was O mrom/hr. Thus, there were no radiation safety Isoues associated with handling or transport of the package.

5. All other USDOT regulatory requirements applicable to this shipment woro complied with in full.

6. There does not appear to be any clear requirement for reporting this type of event. However, this report is being submitted to maintain open communications with the NRC and other regulatory agenclos which have jurisdiction over our program.

Should there be questions rogarding the information in this report or should you require more information, please let me know. It is our intent that this report be as complete and helpful as possible.

Yours sincoroly, i

A. G. h son Direct '

. ogydd/ntc/1 16.91 cc: NRC Region V NRC Al Adams ODOE David Stewart Smith State of OR, Radiation Control Section-Martha Dibblee SEB BD JFH TVA SMC DSP RHF i

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