ML20196L402

Enforcement Actions:Significant Actions Resolved.Quarterly Progress Report,January-March 1988

ML20196L402
Person / Time
Issue date:	06/30/1988
From:	NRC OFFICE OF ENFORCEMENT (OE)
To:
References
NUREG-0940, NUREG-0940-V07-N01, NUREG-940, NUREG-940-V7-N1, NUDOCS 8807070438
Download: ML20196L402 (315)

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NUREG 0940

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Enforcement Actions: "

Significant Actions Resolved '

Quarterly Progress Report

January - March 1988-o U.S. Nuclear Regulatory y

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A year's subscription v.nsists of '4 issues for

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NUREG-0940 Vol. 7, No.1 l Enforcement Actions:

Significant Actions Resolved Quarterly Progress Report January - March 1988 Manuscript Completed: June 1988 Date Published: June 1988

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Office of Enforcement U.S. Nuclear Regulatory Commission Weshington, DC 20555

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ABSTRACT This compilation summarizes significant enforcement actions that have been resolved during one quarterly period (January - March 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 m?nagers 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 111

CONTENTS P_ag ABSTRACT..................................................................

INTRODUCTION...........................

111

.... ............................... 1 SUMMARIES................................... ............................... 3 I. REACTOR LICENSEES A. Civil Penalties and Orders Arkansas Power and Light Company, Little Rock, Arkansas (Arkansas Nuclear One, Unit 1 I

EA 8 7- 6 2 . . . . . . . . . . . . . . . . . . . . . ) . . . . . . . . . . . . . . . . . . .

Arkansas Power and Light Company, Little Rock, Arkansas (Arkansas Nuclear One, Units 1 and 2 EA 8 7 - 9 0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .) . . . . . . . . . . . .

Commonwealth Edison Company, Chicago, Illinois (Dresden Nuclear Power Station Unit 2 EA 87-207......................,.......)........................I.A-22 Consumers Power Company, Jackson, Michigan (Big Rock Point Nuclear Power Plant EA 87-202..........................)...........................I.A-28 Duke Power Company, Charlotte, North Carolina (McGuire Nuclear Plant Unit 2 E A 8 7 - 19 2 . . . . . . . . . . . . . ., . . . . . . . .) . . . . . . . . . . . . . . . . . . . . . . . . . . .

Florida Power and Light Company, Juno Beach, Florida (Turkey Point Nuclear Plant Units 3 a 4)

EA 87-179...................,..........nd ........................I.A-34 Houston Lighting and Power Company, Houston, Texas (South Texas Project, Unit 1 j EA 87-236...................).................................I.A-37 Houston Lighting and Power Company. Houston, Texas (South Texas Project, Unit 1 EA 87-240...................)..................................I.A-39 f Northeast Nuclear (Millstone Nuclear Energy Power StationCompany), Hartford, Connecticut

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EA 87-198.....................................................I.A-44 '

Northern States Power Company, Minneapolis, Minnesota (honticello Nuclear Generatin Station)

EA 87-147....................g .................................I.A-47 NUREG-0940 v

CONTENTS (Continued)

Page REACTORLICENSEES(Continued) ,

1 Omaha Public Power District, Omaha, Nebraska (Fort Calhoun Station)

EA 87-200.....................................................I.A-59 \

Omaha Public Power District, Omaha, Nebraska (Fort Calhoun Station)

EA 87-210.....................................................I.A-64 The Cleveland Electric Illuminating Company, Cleveland, Ohio (Perry Nuclear Power Plant, Unit 1)

EA 87-206.....................................................I.A-72 The Detroit Edison Company, Newport, Michigan (Enrico Fermi Nuclear Power Plant, Unit 2)

E A 8 7 - 2 3 2 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A - 30 Toledo Edison Company, Toledo, Ohio (Davis-Besse Nuclear Power Station, Unit 1)

EA 87-219.....................................................I.A-85 University of Virginia, Charlottesville, Virginia EA 87-155.....................................................I.A-88 B. Severity Level III Violation, No Civil Penalty Alabama Power (Farley Nuclear Company), Birmingham, Alabama Plant EA 88-33..................................................... .I.B-1 Gulf States Utilities, St. Francisville, Louisiana l (RiverBendStation) i EA 87-229......................................................I.8-7 l 1

Long Island Lighting Company, Wading River, New York (Shoreham Nuclear Power Station)

EA 8 7 - 17 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . B - 1 1 l

1 II. MATERIALS LICENSEES A. Civil Penalties and Orders i Beckley Appalachian Regional Hospital, Beckley, West Virginia EA 8 7 - 15 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A - 1 BP Oil, Inc., Marcus Hook, Pennsylvania E A 87 - 17 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A - 21 l l

l i NUREG-L940 vi

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CONTENTS (Continued)

MATERIALS LICENSEES (Continued)

Kermit Butcher, Elkins, West Virginia EA 8 7 - 9 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A - 3 7 Case Western Reserve University, Cleveland, Ohio EA 87-226....................................................II.A-49 Combustion Engineering, Inc., Windsor, Connecticut EA 8 7 - 19 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A - 61 Radiation Sterilizers, Inc., Menlo Park, California EA 8 7 - 2 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A - 6 9 Sequoyah Fuels Corporation, Oklahoma City, Oklahoma EA 8 7 - 10 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A - 9 2 The Head Corporation, Dayton, Ohio EA 87-215...................................................II.A-116 Tidewater Memorial Hospital, Tappahannock, Virginia E A 8 7 - 12 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A - 121 United Hospital Center, Clarksburg, West Virginia I E A 8 7- 214 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A- 14 0 Wego Perforators, Inc., Ada, Oklahoma EA 87-140...................................................II.A-146 1

Wheeling Hospital, Inc., Wheeling, West Virginia E A 8 7 - 7 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A- 151 1 B. Severity Level III Violation, No Civil Penalty Keystone Portland Cement Company, Bath, Penns i EA 87-230....................................ylvania .................II.B-1 l

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NUREG-0940 vii

l ENFORCEMENT ACTIONS: SIGNIFICANT ACTIONS RESOLVED January - March 1988 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 1987. On April 12, 1987, the Office of Inspection and Enforcement was abolished as a result of the NRC staff reorganization. Enforcement actions are issued by the Deputy Executive Director for Regional Operations (DEDRO) and the Regional Administrator. The Director, Office of Enforcement, may act for the DEDR0 in the absence of the DEDR0 or as directed. Prima rily emphasized are those actions involving civil penalties and Orders that have been issued by the Director of the Office of Inspection and Enforcement (now DEDR0 or Director, Office of Enforcement) and the Regional Administrators.

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 engaged 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.

A brief summary of each significant enforcement action that has been resolved in the first quarter of 1988 can be found in the section of this report entitled "Sumaries." Each sumary provides the enforcement action (EA) number to identify the case for reference purposes. The supplement number refers to the activity area in which the violations are classified according I

to guidance furnished in the U.S. Nuclear Regulatory Comission's "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, l Appendix C (1987). Violations are categorized in terms of five levels of soverity to show their relative importance within each of the following activity areas:

l Supplement I - Reactor Operations Supplement II - Facility Construction Supplement 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 or 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.

Part II.A contains civil penalty or Order actions involving materiale licensees.

NUREG-0940 1

Part II.B includes a copy of a Notice of Violation that has been issued to a materials licensee for a Severity Level III violation, but for which no civil penalty was assessed.

Actions still pending on March 31, 1988 will be included in future issues of this publication when they have been resolved.

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SUMMARIES I. REACTOR LICENSEES A. Civil Penalties and Orders Arkansas Power and Light Company, Little Rock, Arkansas (Arkansas Nuclear One, Unit 1) EA 87-62, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued on June 25, 1987 based on a violation in which one pressurizer code safety valve was found inoperable in that its lift setpo!nt was approximately 500 psi above that specified in the bases for the pertinent Technical Specification. The base penalty was mitigated by 50% because of good performance in the main-tenance area. The licensee responded on September 18, 1987 and after consideration of the response, an Order Imposing a Civil Penalty was issued on January 26, 1988. The licensee paid the civil penalty on March 22, 1988.

Arkansas Power and Light Company, Little Rock, Arkansas (Arkansas Nuclear One, Units 1 and 2) EA 87-90, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $75,000 was issued on July 2,1987 based on seven examples of breaches in vital area barriers and two examples of sleeping security guards. The civil penalty was increased by 50%

because of the licensee's poor prior perfonnance in the security area and the multiple examples of the violations. The licensee responded on August 3,1987 and after consideration of the response, an Order Imposing a Civil Penalty was issued on February 4,1988. The licensee paid the civil penalty on March 4, 1988.

Comonwealth Edison Company, Chicago, Illinois (Dresden Nuclear Power Station, Unit 2) EA 87-207, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued on February 11, 1988 based on an event in which the licensee exceeded the specified time limits for two Technical Specifications associated with containment deinerting.

The licensee responded and paid the civil penalty on March 15, 1988.

Consumers Power Company, Jackson, Michigan (Big Rock Point Nuclear Power Plant) EA 87-202, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued on December 2,1987 based on a violation involving failure to maintain control of access to a vital area of the plant. The base civil penalty was mitigated by 50% because of the licensee's prior good enforcement history. The licensee responded and paid the civil penalty on January 4, 1988.

NUREG-0940 3

l Duke Power Company, Charlotte, North Carolina (McGuire Nuclear Plant, Unit 2) EA 87-192, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued on January 29, 1988 based on an event in which the containment shield / divider barrier was found to be inoperable. This condition which existed for over four years could have allowed higher than calculated containment pressure following a loss-of-coolant accident. The base civil penalty was ,

decreased by 50% because of the unusually prompt and extensive corrective actions taken once the licensee identified the problem.

The licensee responded and paid the civil penalty on February 26, 1988.

Florida Power and Light Company, Juno Beach, Florida (Turkey Point Nuclear Plant, Units 3 and 4) EA 87-179, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $150,000 11, 1988 based on was issued on February (1) multiple failures two Severity Lavel III violations to maintain positive access control, involving) and (2 the improper storage of Safeguards Infonnation. The base civil penalty for the violation relating to access control was increased by 100% because of the multiple examples and the licensee's poor prior enforcement history.

The licensee responded and paid the civil panalty on March 14, 1988.

Houston Lighting and Power Company, Houston, Texas (South Texas Project, Unit 1) EA 87-236, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued on March 9,1988 based on violations of the licensee's commitments concerning the physical security program, including multiple examples of violations relating to access control, training and qualification of security force members, proper marking of Safeguards Information, and testing and maintenance of security equipment. The licensee responded and paid the civil penalty on March 31, 1988.

Houston Lighting and Power Company, Houston, Texas (South Texcs Project, Unit 1) EA 87-240, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $75,000 was issued on February 11, 1988 based on two events in which the licensee failed to satisfy Technical Specification requirements. In the first, the licensee identified that all three cold leg injection valves in the high head safety injection system were shut in an operational mode in which they were required to be open. In the second event, the licensee reported all four channels of the low pressurizer safety injection actuation setpoint were set below the Technical Specification limits.

The base penalty was increased by 50% because the first problem existed for a significant duration and corrective action for a prior event should have prevented the second problem. The licensee responded and paid the civil penalty on February 19, 1988.

1 NUREG-0940 4

1 Northeast NuclearPower (Millstone Nuclear Energy Company),

Station Hartford, EA 87-198, Connecticut Supplement III A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued on December 14, 1987 based on several violations of commitments made in the licensee's physical security plan, including violations relating to the failure to maintain the integrity of vital an clear One.

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 bt effective without further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection.

I In the event the licensee requests a hearing as provided above, the issue j to be considered at such hearing shall be whether the proposed civil penalty

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should be imposed, in whole or in part.

FOR THE NUCLEAR REGULATORY CCHMISSION a s M. Tay r, Deputy Executive Director or Regional Operations Dated at Bethesda, Maryland, this 26th day of January 1988.

NUREG-0940 I.A-10

APPENDIX EVALUATION ANC CONCLUSIONS On June 25, 1987, a Notice of Violation and Proposed Imposition of Civil Penalty (NOV) was issued for the violation identiiied during an NRC inspection.

Arkansas Power and Light Company responded to the Notice on September 18, 1987.

In the response the licer.see admits that the violation occurred as stated, but argues that certain factors provide a basis for full mitigation of the proposed civil penalty. The NRC's evaluation and conclusion regarding the licensce's arguments are as follows:

Restatement of Violation Technical Specification 3.1.1.3 requires that both pressurizer code safety valves be operable when the reactor is critical. With one pressurizer code safety inoperable, either restore the valve to operable status within 15 minutes or be in Hot Shutdown within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. The associated basis for this technical specification states that the lift set point for the safety valve shall be set at 2500 psig i 1 percent tolerance for error.

Contrary to the above, on December 21, 1986, pressurizer code safety valve PSV-1002 was found inoperable, a condition that likely existed since September 1985 and during which time the reactor was critical. The valve lift setpoint cas at least 500 psi above the required 2500 psig i i percent setpoint.

This is a Severity Level III violation (Supplement !).

Civil Penalty - $25,000.

Summary of Licensee's Response The licensee concluded that the high lift setpoint likely occurred as a result of pressurizer code safety valve maintenance performed during an outage in September 1985, although its investigation of the activity did not identify specific personnel errors or procedural discrepancies.

The licensee presented background information in its response that each of the two pressurizer code safety valves is rated for total relief capacity of the system and that during the period from September 1985 to December 1986, reactor coolant system overpressure protection was maintained with the one remaining operable pressurizer code safety valve. Background information was also provided describing the methods for testirg the setpoints of the pressurizer

code safety valves.

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a NUREG-0940 I A-11 l 1

Appendix The licensee further described in its response a sequence of events that began on September 24, 1986, when ANO-2 experienced a reactor trip. During the post trip review of the transient, plant computer data indicated that one of the pressurizer code safety valves lifted prematurely. In-situ tests were conducted that confirmed that both ANO-2 pressurizer code safety valve setpoints were slightly below Technical Specification limits. Subsequently, in-situ testing of the recently installed Unit 1 pressurizer code safety valve was al.so conducted. Upon finding the setpoint on this Unit 1 valve to be slightly low, a test was performed on the other Unit 1 pressurizer code safety valve which had been in service since September 1985. This test revealed a very high setpoint, and the valve was adjusted and retested satisfactorily.

The licensee indicated that this pressurizer code safety valve with the high setting had been refurbished and tested by the licensee onsite, while the other pressurizer code safety valves with the lower settings had been set and tested by an off site vendor. Because results of the preliminary investigation could not rule out mechanical failure, the licensee decided to replace the valve with the higher setting with a spare pressurizer code safety valve.

The licensee described the short-term root cause investigation, and because the results of the short-term investigation were inconclusive, the licensee contracted a third party to assist with the investigation efforts. After describing the detailed efforts of the third party investigation, the licensee concluded that no factor was identified which would have resulted in the anomalous condition. Therefore, the licensee stated that "the reason for the violation is unknown".

The licensee discussed the corrective steps that have been and will be taken.

These included the replacement of the safety valve in December 1986, even though the valve setpoint had been adjusted within tolerance. The licensee also pointed to program improvements made prior to the finding of the inoperible valve and not as a result of the event. As a result of the event, procedure changes are being made to increase Quality Control involvement in safety valve testing and maintenance (pressurizer and main steam system code safety valves), development of management guidelines for handling safety-related equipment found to be in an abnormal condition, and an additional Quality Assurance program review based on the results of the root cause investigation.

NRC Evaluation of Licensee's Response The licensee's response did not dispute the classification of the violation as a Severity Level III or the findings related to pressurizer code safety valve maintenance and testing documentation and procedural deficiencies discussed in NRC Inspection Report 50-313/87-05 and in the Notice of Violation and Proposed imposition of Civil Peralty dated June 25, 1987. The licensee's root cause investigation, though extensive, did not identify a specific factor which t would have resulted in the high lift setpoint.

Based on the licensee's description of the event, the licensee's actions appear to be acceptable. The actions include short-term corrective actions associated i

NUREG-0940 I.A-12

Appendix with the pressurizer code safety valve high setpoint condition, including plant cooldown to replace the pressurizer code safety valve in December 1986, safety valve disassembly for inspection, site records and industry experience review, specific site and vendor procedures review, review of work performed in September 1985, and discussions with personnel.

The licensee's description of the short-term and long-term corrective actions regarding the program and procedure improvements associated with the pressurizer code safety valves, the main steam system code safety valves, and other safety-related equipment to improve the overall performance of safety-related activities are acceptable, and were necessary to correct the identified problems.

l Sumary of Licensee's Request for Mitigation of Civil Penalty The licensee requested full mitigation of the proposed civil penalty based on the facts that the condition was identified because of its initiative to investigate a maintenance prcblem, the condition was promptly reported, corrective actions had been taken to address related issues prior to identifi-cation of the condition, maintenance and ouality program improvements were already underway due to management initiatives already in place, there was adequate margin of capacity with one safety valve operable, and the funds expended investigating possible generic implications have elinineted the need to impose a monetary penalty.

NRC Evaluation of Licensee's Request for Mitigation ,

l fn accordance with the NRC's General Staterent of Policy and Procedure for  !

Enforcement Actions, the following matters are apprepriately considered in determining whether to mitigate (or escalete) a civil penalty:

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1. Prompt Identification and Reporting {

The NRC staff acknowledges that once the licensee became aware of the problem it was promptly reported. However, because of the duration of the problem and the fact that proper QC checks would have provided the licensee opportunities to identify the problem earlier mitigation under l this factor is not appropriate.

l 2. Corrective Action to Prevent Recurrence I

! The licensee's corrective action to prevent recurrence is not considered extensive in view of the significance of the identified problems. The NRC expects its licensees to aggressively pursue correction of identified findings. These actions were particularly necessary because the licensee's previous corrective actions regarding similar problems (SALP Category 2 in l maintenance during 1984-1985) were not fully effective. After re-adjustment of the pressurizer code safety valve to within tolerance, the licensee elected to cool down the unit and replace the valve since the short-term investigation did not rule out mechanical failure as a cause for high setpoint. The NRC staff considers this action by the licensee to be prudent and conservative but expected, due to the importarce of the NUREG-0940 1.A-13

Appendix reactor system code safety valves to protect the integrity of the reactor coolant system, a fission product boundary. Further, the expenditure of funds deemed appropriate by the licensee to investigate possible generic implications of such a significant problem is considered, by the NRC staff, to be part of the necessary corrective actions.

3. Past Performance The base civil penalty was originally mitigated by 50% due to generally good past performance in the maintenance area as demonstrated by some improvement in the SALP ratings from Category 3 to Category 2. The NRC staff believes that further mitigation for improving performance would be inappropriate given that performance level is still categorized as satisfactory.

4. Prior Notice of Similar Events Escalating factor only.

5. Multiple Occurrences Escalating factor only.

NRC Conclusien The NRC staff concludes that in order to emphasize the importance of providing appropriate controls during plant operations and maintenance including verificaiton of safety valve operability, it is not appropriate to fully mitigate the civil penalty. Acccrdingly, the proposed civil penalty in the artcunt of Twenty-five Thousand Dollars ($25,000) should be imposed.

NUREG-0940 1.A-14

jd 4 UNITED STATES c' , 'g NUCLEAR PEGULATORY COMMISSION te -

l REolONIV kI 4 til RYAN PLAZA DRIVE, SUITE 1000 o,, , ARLINGTON, TEXA5 M011 M 2 1967 Docket Nos. 50-313 50-368 License Nos. DPR-51 NPF-6 EA 87-90 Arkansas Power & Light Company ATTN: Mr. Gene Campbell Vice President, Nuclear Operations P. O. Box 551 Little Rock, Arkan.as 72203 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 50-313/86-39; 50-368/86-39 and 50-313/87-07;50-368/87-07)

This refers to the inspections conducted on December 8-11, 1986, and February 25, 1987, at Arkansas Nuclear One, Russellville, Arkansas. During the inspection of December 8-11, 1986, the NRC inspector identified several security violations and reviewed items identified by the licensee. An enforcement conference to discuss these matters was held on February 12, 1987. .

As a result of the enforcement conference, a follow-up inspection was conducted I on February 25, 1987, to clarify issues and examine additional items identified by the licensee.

Violation I.A involvss seven examples of inadequate vital area barriers that were identified by the licensee. These violations included six examples of l openings (greater than 96 square inches with the shortest side greater than 6 inches) that had existed since the plant was built and one example of an inadequate barrier opening caused by a rusted vent in a ventilation duct that occurred some time during the operation of the plant. Violation 1.B involves two examples where the licensee identified security officers being found asleep at a compensatory post.

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. To emphasize the need for increased management oversight and control of the security program particularly in regard to vital area barrier integrity, 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," 10 CFR Part 2, Appendix C (1987)

(Enforcement Policy), Violations !. A and I.B described in the enclosed Notice CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.A-15

_ . . _ . . . _ . ~ _ _ _ _. . . _. _. _ _. ._

i l J1. 21987 Arkansas Power & Light Company l have been classified as a Severity Level Ill problem. The base value of a civil penalty for a Severity Level !!! violation is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered. The base civil penalty amount har. been increased by 50 percent because of your poor i past performance in the area of security and the multiple occurrences of the violations. The civil penalty has not been reduced based on self identification because of the associated failure to make required reports set forth in Violation II.A.

Violations !!.A and B described in the enclosed Notice of Violation are of lesser significance and are classified as Severity Level IV violations. l i You are required to respond to this letter and should follow the instructions i 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 i Notice, including your proposed corrective actions and the results of future 1 inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.

The material enclosed herewith contains Safeguards Information as defined by 10 CFR 73.21 and its disclosure to unauthorized individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as amended. Therefore, the 4 material will not be placed in the Public Document Room.

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TheTesponses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as ret;uired

] by the Paperwork Reduction Act of 1980, Pub. L. No.96-511.

Sincerely, 1

4 o I obert D. Martin Regional Administrator '

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Enclosures.

l Notice of Violation and Proposed Imposition of Civil Penalty i l

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cc: Arkansas Radiation Control Program Director

[Non-SafeguardsPortionsonly]

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l NUREG-0940 1.A-16

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UNITED STATES

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3 NUCLE AR REGU,l,ATORY COMMISSION 2 usmoros. o. c. rom

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j FEB 0419N In Reply Refer To:

l Dockets: 50-313/86-39 50-368/86-39 50-313/87-07 50-368/87-07 EA 87 90 Arkansas Power & Light Company ATTN: Mr. Gene Campbell Vice President Nuclear Operations Post Office Box 551 Little Rock, Arkansas 72203 Gentlemen:

SUBJECT:

ORDER IMPOSING CIVIL !!OhETARY PENALTY This refers to your letter dated August 3,1987, in response to the Notice of Violation and Preposed Imposition of Civil Penalty sent to you by our letter dateo July 2, 1987. Cur letter and Notice described violations, one of which was identified by AP&L, during an inspection conducted during the periods December 8-11, 1986, and February 25, 1987, of activities at the Arkansas Nuclear One Station.

To emphasize the reed for ircreased management oversight and control of the l security program, a civil penalty of Seventy-Five Thousand Dollars ($75,000)  !

was proposed. I In your response, you admitted that violations !.A. I.B and !!.A occurred as I stated and requested that violation !!.B be "handled as an open item" Decause the circumstances of the violation stemed from confusion over your corrective actions to violation 50-313/85-26-03; 50-368/85-27-03. You also requested that the civil penalty for violations !.A and I.B be mitigated to Twenty-Five l Thousand Dollars ($25,000).

)I After consideration of your response, we have concluded, for the reasons given l' in the Appendix attached to the Order Imposing Civil Penalty, that the civil penalty proposed for violations I. A and !.B should not be mitigated.

I Accordingly, we hereby serve the enclosed Order on Arkansas Power and Light j Company imposing a civil monetary penalty in the amount of Seventy-Five i Thousand Collars (575,000). However, we have concluded in regard to Violation l

'  !!.B that confusion and misunderstanding concerning your compensatory measures did occur, and we are withdrawing this violation and correcting the appropriate records to reflect this action. We will review the effectiveness of your corrective actions for violations !.A, !.B and !!.A during a subsequent inspection.

l CERTIFIED MAIL

, RtiuRN RECEIPT REQUESTED NUREG-0940 1.A-17 i

Arkansas Power and Light Company 4 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 crder will l i

be placed in the NRC's Public Document Room.

The material contained in the Appendix to the Order contains Safeguards Information as defined by 10 CFR Part 73.21 and its disclosure to unauthori:ed i individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as l amended. Therefore, this Appendix will not be placed in the Public Document l Room.

Sincerely,

/

JamesM.Tayh,DeputyExecutiveDirector fbrRegionalOperations

Enclosures:

As Stated cc:

Arkansar P.adiation Control Program Director (Non-Safeguards Portions Only) l l

l i

l l

I 1

l NUREG-0940 I,A-18

UNITED STATES NUCLEAR REGUCATORY CCMMISSION In the Matter of Arkansas Power & Light Company Docket Nos. 50-313 and 50 368 Arkansas Nuclear One, Units 1 and 2 License Nos. OPR-51 and NPF-6 EA 87-90 ORDER IMPOSING CIY!L MONETARY PENALTY Arkansas Power & Light Company (licensee) is the holder of facility Operating Licenses No. DPR-51 issued by the Nuclear Regulatory Comission (hRC) on May 21, 1974 and No NPF-6 issued by the NRC on September 1,1978. The licenses authorize the licensee to operate Arkansas Nuclear One, Units 1 and 2 in acccrdance with the conditions specified therein.

A special inspection of the licensee's activities was conducted on December 8-11, 1986, and February 25, 1987. The results of this inspection indicated that the licensee had not conducted its activities in full compliance with NRC requirerents. A Notice of Violation and Preposed Imposition of Civil i Penalty was served upon the licensee by letter dated July 2, 1987. The Notice statec the nature of the violations, the provisions of the NRC's reovirements that the licensee had violated, and the amount of the civil penalty proposed for the violations. The licensee responded tp the Notice of Violation and Proposed Imposition of Civil Fenalty by letter dated August 3,1987. l l

After consideration of the licensee's response and the statements of fact, explanation, and argument for mitigation of the Civil Penalty contained therein, the Deputy Executive Directer for Regional Operations has determined NUREG-0940 I.A-19

62 as set forth in the Appendix to this Order that the violations for which a civil penalty was assessed occurred as stated and that the penalty proposed for the violations designated in the Notice of Violation and Proposed i Ir. position of Civil Penalty should be imposed.

IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act) 4? U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY >

ORDERED THAT:

The licensee pay a civil 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 raailed to the Director, Office of Enforcement L.S. Nuclea? Regulatory Comission, ATTN: Document Control Desk Washington, D.C. 20555.

The licensee ray 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 shall be addressed to the Direct 8r, Office of Enforcement, U.S.

Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. i J 1 20555, with a cepy to the Regional Administrctor, U.S. Nuclear Regulatory Commission Region IV.

If a hearing is requested, the Comission will issue an Order designating the time and place of the hearing. If the licensee fails to request 4 hearing

)

within 30 days of the date of this Order, the provisions of this Order shall be

'l NUREG-0940 1.A-20

3,-

effective without further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection.

Having admitted that violations 1.A and I.B occurred as set forth in Section I of the Notice of Violation and Proposed Imposition of Civil Penalties, in the event the licensee requests a hearing as provideo above, the issue to be

, considered at such hearing shall be whether, on the basis of such violations, 1

this Order should be sustained.

FOR THE NUCLEAR REGULATORY COMMISSION

/ 1

./ ames M. Tay1 Deputy Executive Director

/

V for Regional Operations l

Dated at Bethesda, Maryland, )

this 4 day of February 1988.

NUREG-0940 I.A-21

so m ato UNITED STATES g ?g NUCLEAR REGULATORY COMMISSION

$ $ REGION lit E f 799 ROO5tvtLT ROAO corn tuvs. itunOis som

• ...+

FEB i ' IE.

Docket No. 50-237 License No. OPR-19 EA 87-207 Commonwealth Edison Company ATYN: Mr. James J. O'Connor President Post Office Box 767 Chicago, IL 60690 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORT NO. 50-237/87005(ORP)

This refers to the NRC inspection, conducted during the period December 1, 1986 through January 8, 1987, at the Dresden Nuclear Power Station, Unit 2, of activities authorized by NRC Operating License DPR-19, and to the circumstances associated with the failure to follow Technical Specifications relating to shutdown of Unit 2 following the deinerting of primary containment. This matter, which was discovered by the licensee on November 29, 1986, and was reported to the NRC on a timely basis, resulted in two violations of_NRC regulatory requirements. The details are presented in the subject inspection report which was sent to you by letter dated January 16, 1987. On January 19, 1988, we held an enforcement conference with members of your staff during which the violations, the root causes, and your corrective actions were discussed.

The violations, which are discussed in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty, resulted from a failure to have an effective system for keeping track of when a Limiting Condition for Operation (LCO) is entered and its time limit expires. As a result, a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> time limit for deinerting primary containment prior to shutdown was exceeded. When station management became aware that the 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> limit had been exceeded, it decided to continue at power while a high pressure coolant injection pump (HPCI) fast start test was conducted. This resulted in the LCO time limit being exceeded by almost five hours before the reactor was manually scrammed.

On January 23,,1987, a management meeting was held between Commonwealth Edison Company (CECO) personnel and the NRC Region III staff to discuss this event. It was Ceco's position that when the Technical Specification LCO limit was exceeded NUREG-0940 I.A-22

Commonwealth Edison Company 2 FEE i 1985 the provisions of Technical Specification 3.0.A could be invoked, thereby, making an additional 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> available for shutting down the reactor. During j the January 23rd management meeting and again during the enforcement conference, l the NRC staff restated its position that Technical Specification 3.0. A can be applied only when the circumstances are such that they are not specifically provided for in Technical Specification LCOs and that it is not appropriate to combine the shutdown time allocation of two Technical Specification limits.

l As a result of this occurrence, an investigation was conducted (see attached i synopsis) by the NRC Region III Office of Investigations to determine if Ceco may have willfully violated Technical Specification LCOs. This investigation concluded that CECO personnel inadvertently exceeded the deinerting LCO, and that CECO personnel or management did not willfully operate Dresden, Unit 2, in violation of Technical Specifications.

To emphasize the importance of tracking the expiration of Technical LC0 time

~

limits and ensuring the implementation of appropriate Technical Specifications, 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 accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR, Part 2, Appendix C (1987)

(Enforcement Policy), the violations described in the enclosed Notice have beers categorized in the aggregate as a Severity Level III problem. The base value of a civil penalty for a Severity Level III problem is 550,000. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate.

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, the NRC will determine whether further 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, l Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.

l 4

NUREG-0940 I.A-23

. - , . . . -- ~. . __ . . _- - - - --

4 Commonwealth Edison Company 3 FEB' 1 i 1980 The responses directed by this letter and the. enclosed Notice are not subject to the clearance procedure of the. 0f fice 'of Management and Budget as required by the. Paperwork Reduction Act of 1980, Pub. L., No.96-511.

Sincerely, i C\

d bd h W A. Bert Davis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Synopsis of Investigation Report No. 3-87-002

3. NRC Inspection Report No. 50-237/87005(DRP) cc w/ enclosures:

Cordell Reed, Senior Vice President D. Butterfield, Nuclear Licensing Manager J. Eenigenburg, Plant Manager DCD/DCB (RIOS)

Licensing Fee Management Branch Resident Inspector, RIII Richard Hubbard J. W. McCaffrey, Chief, Public Utilities Division i

l l

l l

l l

NUREG-0940 I.A-24 .

_ - - _ ~. . _ _ _ - - _ _ _ _ _ _. . . . .

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY l' Commonwealth Edison Company Docket No. 50-237 Dresden Nuclear Power Station License No. DPR-19 Unit 2 EA 87-207 During an inspection conducted during the period December 1, 1986 through January 8,1987, 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 (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:

A. Technical Specification (TS) Limiting Condition for Operation (LCO) 3.7.A.5.a requires that the primary containment atmosphere be reduced to less than four percent oxygen with nitrogen gas during reactor power operation with reactor coolant pressure above 90 psig, except as specified in TS 3.7.A.5.b which provides that deinerting may commence 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> prior to a shutdown.

Dresden Operating Procedure 1600-9, Revision 4, Nitrogen Make-up to Primary Containment, states that "the containment atmosphere shall be reduced to less than four % oxygen with nitrogen gas . . . and up to 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> before taking the reactor out of the RUN mode."

Contrary to the above, at 1220 hours0.0141 days <br />0.339 hours <br />0.00202 weeks <br />4.6421e-4 months <br /> on November 28, 1986, during power operation and with reactor coolant pressure above 90 psig, the licensee commenced deinerting procedures. Although the oxygen concentration was greater than four percent, the reactor continued operating until it was manually scrammed at 1703 hours0.0197 days <br />0.473 hours <br />0.00282 weeks <br />6.479915e-4 months <br /> on November 29, 1986, a deinerting period of 28 hours3.240741e-4 days <br />0.00778 hours <br />4.62963e-5 weeks <br />1.0654e-5 months <br /> and 43 minutes.

B. Technical Specification Limiting Condition Tor Operation 3.7.A.7.a.

requires that differential pressure between the drywell and suppression chamber be maintained at equal to or greater than 1.00 psid, except as specified in TS 3.7.A.7.a(1), which provides that the differential may be relaxed 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> prior to a reactor shutdown, and TS 3.7.A.7.a(2) is not applicable here.

Contrary to the above, at 1220 hours0.0141 days <br />0.339 hours <br />0.00202 weeks <br />4.6421e-4 months <br /> on November 28, 1986, a two inch equalizing line between the drywell and the torus was opened, thereby reducing the differential pressure to less than 1.00 psid. The reactor continued to operate in this configuration until 1703 hours0.0197 days <br />0.473 hours <br />0.00282 weeks <br />6.479915e-4 months <br /> on November 29, 1986, a period cf 28 hours3.240741e-4 days <br />0.00778 hours <br />4.62963e-5 weeks <br />1.0654e-5 months <br /> and 43 minutes, when the reactor was manually scrammed.

NUREG-0940 I.A-25 l

FEB 1 i 1980 Notice of Violation 2 Collectively, the above violations have been evaluated as a Severity Level III problem (Supplement I).

Civil Penalty - 550,000.00 (assessed ecually between the violations).

Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison 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:

(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 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 the 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 shcivn. Uader the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath of affirmation.

Within the same time as provideo for the response required above under 10 CFP. 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, 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 require 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 (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 M 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph number) to avoid repetition. The attention of the Licensee is directed to other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.

NUREG-0940 I.A-26

Notice of Violation 3 FEB 11 1985 Upon fcilure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.200, 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.

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, DC 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137, and a copy to the NRC Resident Inspector at Dresden.

Sincerely, (iDdh -

A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois this // " day of January 1988 i

NUREG-0940 I.A-27

ga UNITfo STATES

+

s aseg

,, NUCLEAR REGULATORY COMMISSION

[ S nearoN m 3 j He nooseveLT noAo

,f ottN eLLYN. ILLINoll 40137 DEC 0 21987 Docket No. 50-155 License No. OPR-6 EA 87-202 Consumers Power Company ATTN: Dr. F. W. Bu.ckman &

Vice President Nuclear Operations 212 West Michigan Avenue Jackson, MI 49201 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY

[NRC INSPECTION REPORT NO. 50-155/87025(ORSS)]

This refers to the special safeguptds inspection conducted during the period September 28 through October 2,1987, at the Big Rock Point Nucitar Power Plant. The inspection was in response to your discovery of an opening in a vital area barrier which could have allowed unauthorized and undetected access from the protected area.

Our inspection effort determined that this opning has existed since the plant was originally constructed and that prior to this being discovered by one of )

your employees, you had at least three other occasions to identify it. The violation, the cause, and your corrective actions were discussed during an enforcement conference in the Region III office between you and other members of your staff, and Dr. Carl Paperiello and other members of the Region III staff on October 21, 1987.

The violation in the enclosed Notice of Violation and Proposed Imposition of l Civil Penalty is considered significant due to the fact that it represents a lack of security management assertiveness to assure adequacy of your program as evidenced by the fact that you failed to adequgtely identify the breach in the vital area which has existed since plant construction.

To emphasize that effective controls be implemented to assure the adequacy i of vital are6 barriers, 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 Twenty-Five Thousand Dollars ($25,000) 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) (Enforcement Policy), the violation described in the enclosed Notice has been categorized at a Severity Level III.

NUREG-0940 I.A-28

l Consumers Power Company 2 DEC011987 1

The base amount of a civil penalty for a Severity Level III violation or I problem is $50,000. In assessing the proposed civil penalty your prior good  !

enforcement history, including your Category I ratings in Safeguards in the l Systematic Assessment of Licensee Performance (SALP), was balanced against your failure to identify the violation over a long period of time in spite of several specific opportunities to do so and your prior notice of similar events. Therefore, the amount of the civil penalty was set at Twenty-Five Thousand Dollars ($25,000).

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.

The material enclosed contains Safeguards Information as defined by 10 CFR 73.21 and its disclosure to unauthorized individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as, amended. Therefore, with the exception of the cover letter, this material will not be placed in the 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 of 1980, Pub. L. No.96-511.

Sincerely, Original cigned by

'A., Bert Davis A. Bert Davis Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty (UNCLASSIFIED SAFEGUARDS INFORMATION)

See Attached Distribution NUREG-0940 I.A-29

u UNITED sT ATES NUCLEAR REGULATORY COMMIS$10N O'ga afo ,m'o,$

4 REGloN H j'

j 101 MARIETTA STREET, NW.  ;

t ATLANT A GEORGI A 3o323 l k

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m2 m Docket No. 50-370 License No. NPF-9 EA 87-192 Ouke Power Company ATTN: Mr. H. B. Tucker, Vice President Nuclear Production Department 422 South Church Street Charlotte, NC 28242 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT HOS. 50-369/87-35 AND 50-370/87-35)

This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by W. Orders at the McGuire Nuclear. Plant on August 24 - September 4, 1987. The inspection included a review of the circumstances surrounding the inoperability of the Unit 2 missile shield / divider barrier and the degradation of the Unit 1 missile shield. The report documenting this inspection was sent to you by letter dated October 9,1987. As a result of this inspection, a significant failure to comply with NRC regulatory requirements was identified, and accord-ingly, NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on November 6, 1987. The letter, summarizing this Conference was sent to you on December 3, 1987. Since the letter, further evaluations of your analysis of the possible consequences of the missing bolts have been made by the NRC. We do not necessarily agree with your analysis of the event's significance. However, given the fact that you recognize this as a significant issue and corrective actions have been taken, debate about the possible consequences of an event would serve no useful purpose.

The violation described in the enclosed Notice of Violation involved a failure to maintain the operability of the Unit 2 missile shield. The events that resulted in this violation included operation of McGuire Unit 2 in Modes 1-4 with hold-down bolts missing in the control rod drive mechanism missile shield /

containment divider barrier. The missile shield was found to be inoperable on August 14, 1987, and had been inoperable since3Harch 1983. The root cause of this event was an inadequate procedure which did not contain suf ficient informa-tion to ensure proper installation of the missile shield blocks for both Units 1 and 2.

To emphasize the need to have detailed and accu. ate procedures covering safety-related 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 Twenty Five Thousand Dollars ($25,000) for the vielation described in the enclosed Notice.

CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.A-30

Duke Power Company Ji\N ^ a fn accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), the violation has been categorized as a Severity Level III violation. The base civil penalty for a Severity Level III violation is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered and a 50 percent reduction was deemed appropriate because of the unusually prompt and extensive corrective actions taken. The individual who discovered the problem should be commended for identifying such a significant concern which had been overlooked on other occasions. However, further mitigation is not warranted because of opportunities for identification when the shield barriers were fully accessible for inspection and the duration of the violation prior to discovery.

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 fature inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In addition to your corrective actions regarding the specific matters identified in the enclosed Notice, we encourage your pursuit of the Unit 1 civil structures study and your plans to perform a similar study on Unit 2 during the next refueling cutage. We are interested in following the progress of these studies, with the expectation that any remaining safety-related civil structure deficiencies will be identified and promptly corrected.

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 of 1980, PL No.96-511.

Should you have any questions concerning this letter, please contact us.

Sincerely, s ,

J. Nelson Grace Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enc 1:

T. L. McConnell, Station Manager i NUREG-0940 I.A-31

E.

NOTICE OF VIOLATION AND PROPOSED IMPOSITI0ii 0F CIVIL PENALTY Ouke Power Company Docket No. 50-370 McGuire 2 License No. NPF-17 EA 87-192 i During the Nuclear Regulatory Commission (NRC) inspution conducted on August 24- l September 4, 1987, 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 (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, PL 96-295 and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:

Technical Specification (TS) 3.6.5.5 requires in Modes 1-4 that the equipment hatches betweer the containment upper and lower compartments be operable and closed. With a personnel access door or equipment hatch inoperable or open except for personnel transit entry, the ACTION requirement of T.S. 3.6.5.5 requires the door or hatch to be returned to operable status or closed (as applicable) within one hour or the unit must be in at least hot standby within the next six hours and cold shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

Contrary to the above, the reactor vessel missile shield / divider barrier, an equipment hatch, was inoperable from March 1983 to August 14, 1987.

During this period the unit was operated in Modes up to Mode I without complying with the ACTION requirement of T.S. 3.6.5.5.

This is. a Severity Level III violation (Supplement I) applicable to Unit 2 oniv Civil Penalty - $25,000.

Pursuant to the provisions of 10 CFR 2.201, Duke Power Company is hereby required to submit a written statement or explanation to the Nuclear Regulatory Commission, ATTN: Document Control Oesk, Washington, DC 20555, with a copy to the Regional Administrator, Region II, and a copy to the NRC Resident Inspector, McGuire Nuclear Station, 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: (1) admission or denial of the violation, (2) the reason for the violation if admitted, have been taken and the results achieved, (4) thef 3) the corrective corrective stepswill steps which which be taken to avoid further violations, and (5) 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 why such other action as may be proper should not be taken, dithin the same time as provided for the response required above under 10 CFR '2.201, Duke Power Company may pay the civil penalty by letter addressed to the Director, l 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 cumulative amount of Twenty-Five Thousand Dollars ($25,000) or may proust imposition of the civil NUREG-0940 I.A-32

1 l

l Notice of Violation JAN 2 91988 penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement. Should Duke Power Company fail to answer within the time specified, an order will be issued imposing the civil penalty. Should Duke Power Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer 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.

En 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 the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Duke Power Company's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedures for imposing a civil penalty.

Upon failure to pay any civil 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.

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 Regional Administrator, Region II and a copy to the NRC Resident Inspector at McGuire.

FOR THE NUCLEAR REGULATORY COMMISSION J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia this49dday of January 1988 NUREG-0940 I.A-33

l nstop UNIT E D ST ATES I o NUCLEAR REGULATORY COMMISSION p n RE0lON il e C 101 MARIETTA STREET. N.W.

N ATLANTA,0EORol A 30323

%".....} FEB 111988 f l

Docket Nos. 50-250 and 50-251 License Nos. OPR-31 and OPR-41 EA 87-179 Florida Power and Light Company ATTN: Mr. C. O. Voocty Group Vice President Nuclear Energy Department P. O. Box 14000 Juno Beach, FL 33408 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NOS. 50-250/87-38, 50-251/87-38, 50-250/87-47, AND 50-251/87-47)

This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by Mr. D. Thompson at the Turkey Point facility on August 24-28, 1987 and Ms. O. Masnyk on November 16-20 and 23-24,1987. These physical security inspections included a review of records and reports, the security system power supply, compensatory measures, access control, and the physical protection of safeguards information. The reports documenting these inspections were provided to you by letters dated September 24 and December 16, 1987. As a result of thess inspections, significant failures to comply with NRC regulatory  ;

requirements were identified, and accordingly, NRC concerns relative to the  :

inspection findings were discussed during Enforcement Conferences held on I October 28 and December 21, 1987. Letters summarizing these Conferences were sent to you on November 18 and December 31, 1987.

The violations described in Section I of the enclosed Notice of Violation and Proposed Imposition of Civil Penalties involved six failures to maintain positive access control. The first three of these violations involved the licensee's failure to control access of personnel to the protected area, to the Unit 4 containment personnel hatch, and to the Unit 3 containment equipment hatch. The fourth violation described in this Section of the enclosed Notice involved the reported event of a security officer admitting to sleeping while on duty, and the fifth violation involved the entry of an individual into the protected area without being issued a picture badge. This violation is significant because a guard force supervisor directed a member of the guard force to disregard security requirements. The last violation described in this Section involved a guard acting as a compensatory measure leaving his post.

These violations are indicative of a need for more aggressive management involvement to assure that each Florida Power and Light Company (FPL) employee NUREG-0940 1.A-34

FEB i 1 1988 Florida Power and Light Company who has a need to enter protected or vital areas is fully trained concerning the objectives and requirements of the security program and is made fully aware l that security is the responsibility of all employees not just the security force. Additionally, the violations described in Section I of the enclosed Notice are similar to violations contained in notices sent to you by letters dated April 21 and July 28, 1987. Although we acknowledge that FPL has imple-cented a Security Enhancement Program, it has repeatedly failed to address current problems as evidenced by the repetitive nature of these violations and by number of violations in the area of access control. The security force members continue to demonstrate an inability to perfore their security duties.

The violation described in Section II of the enclosed Notice involved the failure to properly mark, protect, and recognize safeguards information. This violation is of particular concern because the documentation collectively disclosed security systems for protection of safety-related vital equipment, physical security system vulnerabilities, and security force response actions and capabilities. Additionally, this violation demonstrates a lack of management knowledge of NRC requirements and an apparent weakness in employee training relative to the protection of safeguards information.

To emphasize the need for the guard force to implement the security program by strict adherence to their duties and responsibilities and for increased management review and attention to the protection of safeguards information, 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 Penalties in the amount of One-Hundred fifty Thousand Dollars ($150,000) for the violations described in the enclosed Notice. The violations described in the enclosed Notice have been categorized in accordance with the "General Statement of Polic Appendix C (1987) y and Procedure for NRC Enforcement Actions," 10 CFR Part 2, (EnforcementPolicy).

The violations described in Section I of the enclosed Notice involving six failures to maintain positive access control have been categorized in the aggregate as a Severity Level III probles. The base value of a civil penalty for a Severity Level III problem is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered, and the base civil penalty amount has been increased by one hundred percent due to your continued poor performance in the area of concern, to the repetitive nature of the violations, and to the number of violations in the area of access control.

The violation described in Section II of the enelosed Notice involving the failure to properly mark, protect, and recognize safeguards information has '

been categorized as a separate Severity Level III violation. The escalation and mitigation factors in the Enforcement Policy were considered, and no mitigation of the base civil penalty amount has been deemed appropriate for this violation.

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. The repetitive nature of the violations NUREG-0940 I.A-35

Florida Power and Light Company II1988 described in Section I of this Notice and the failure of previous corrective ceasures to prevent them is of significant concern to the NRC, please give l particular attention in your response to the identification of the root causes of these problems and your corrective actions to prevent recurrence. After i reviewing your response to this Notice, including your proposed corrective  !

actions and the results of future inspections, the NRC will determine whether i further NRC enforcement action is necessary to ensure compliance with NRC l regulatory requirements. l l

In accordance with 10 CFR 2.790(d) and 10 CFR 73.21, safeguards activities and l security measures are exempt from public disclosure; therefore, the enclosure I to this letter will not be placed in the NRC Public Document Room. I The responses directed by this letter and its enclosure are not sub1ect 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. l Sincerely, J. Nelson Grace Regional Administrator

Enclosure:

Notice of Violation and Proposed Impcsition of Civil Penalties (Safeguards Information) cc w/ enc 1:

J. S. Odos, Vice President Turkey Point Nuclear Plant C. J. Baker, Plant Manager Turkey Point Nuclear Plant L. W. Bladow, Plant QA Superintendent J. Arias, Jr. , Regulatory and Compliance Supervisor NUREG-0940 I.A-36

( M# 8, UNITED STATIS l y /; NUCLEAR REGULATORY COMMISSION

! h ', - REGION IV

.. til RYAN PLAZA DRIVE SulTE 1000

?,, ARLINGTON, TEXAS 79011 i

! MAR 91988 Docket No. 50-498 License No. NPF-71 EA 87-236 Houston lighting and Power Company ATTN: J. H. Goldberg, Group Vice President, Nuclear Post Office Box 1700 Houston, Texas 77001 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 50-498/87-52, 50-498/87-54, 50-498/87-59, and 50-498/87-66)

This refers to NRC inspections conducted on August 24-28, September 8-11, September Project, Unit21-25,(October 1 STP-1) near Bay 5-9,City, and Texas October by 19-23, 1987, personnel at the of the NRCSouth Texas Region IV office. The inspections included reviews of the Plant Security Plan and its implementation. During these inspections, NRC personnel reviewed violations, most of which were licensee identified, concerning failure to provide positive personnel access control including 19 examples identified in 5 separate areas, inadequate vital area barriers (2 examples), failure of security personnel in watchperson class to possess a required high school diploma or equivalency examination, failure of explosive detectors to function properly, failure of watch standers to complete required training, failure to properly mark HL&P letters containing Safeguards Information, improper use of the computer monitoring system for intrusion detection and personnel access control, and failure to perform an adequate test of the peiimeter "E" field. An enforcement conference to discuss these matters was held in the Region IV offices on January 19, 1988. These events were of concern to NRC in that they indicated a lack of attention to detail and the need for improvement of management controls over the secur:ty program. It has been noted tiat l since these inspections were conducted, improvements have been noted in the dreas identified above.

To emphasize the need to improve adherence to the Physical Security Plan, 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 violations described in the enclosed Notice.

CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 1.A-37

Houston Lighting & Power Company 1., accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy),

the violations described in the enclosed Notice has been categorized as Severity Level III. The base value of a civil penalty for a Severity Level III violation is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate.

It should be noted that due to the nature and number of these violations, a significantly higher civil penalty could have resulted, with each example being I treated as a separate violation. However, a higher civil penalty was not l issued due to the fact that the licensee identified most violations, the j status of the plant during the time that the violations occurred, and the fact that an act of radiological sabotage while in this status could not have l produced a significant radiological release. l l

You are required to respond to this letter and should follow the instructions I specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken ar.d 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.

The material enclosed herewith contains Safeguards Information as defined by 10 CFR Part 73.21 and its disclosure to unauthorized individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as amended. Therefore, the material, will not be placed in the Public Document Room, i 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, l

Robert D. Martin  :

Regional Administrator l l

Enclosures:

Notice of Violation and Proposed Imposition of Civil Penalty cc: Texas Radiation Control Program Director NUREG-0940 I.A-38

. c# % UNITED STATES l f,  ; NUCLEAR REGULATORY COMMISSION

~

REoloN IV t, j f 611 RYAN PLAZA DRIVE, SUITE 1000 0,, ,, ARLINGTON. TEXAS 76011 FEB f I 1988 Docket: 50-498 License No: NPF-71 EA 87-240 Houston Lighting & Power Company ATTN: J. H. Goldberg, Group Vice President, Nuclear P.O. Box 1700 Houston, Texas 77001 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS 50-498/87-71 and 50-498/88-06)

This refers to the inspection conducted during the period November 1-30, 1987, l at the South Texas Project, Unit 1 (STP-1) near Bay City, Texas, and during the period January 5-11, 1988, in the Region IV office by personnel of the NRC Region IV office. During this inspection, NRC personnel reviewed two events that involved the failure to satisfy Technical Specification requirements. On November 2,1987, the licensee identified that all three cold leg injection valves in the High Head Safety Injection System were shut while in hot shutdown. Two of the three valves are required to be open in this mode. On November 24, 1987, the licensee reported that all four channels of the low pressurizer pressure safety injection actuation setpoint had been set lower than Technical Specification requirements. These events were documented in Licensee Event Reports 87-12 and 87-17, and NRC review of these events is documented in NRC Inspection Reports 50-498/87-71 and 50-498/88-06, respectively. Following a review of the events, an enforcement conference was held on December 30, 1987, in the Region IV office in Arlington, Texas.

Violation A in the enclosed Notice of Violation and Proposed Imposition of 1 Civil Penalty involves a significant failure to satisfy Technical Specification l requirements for operable Emergency Core Cooling System (ECCS) flow paths during plant operation in Mode 4 All three High Head Safety Injection cold leg injection valves were closed. This condition would have prevented automatic injection into the ECCS if required ih an emergency. 't is significant that this condition existed for 51 hours5.902778e-4 days <br />0.0142 hours <br />8.43254e-5 weeks <br />1.94055e-5 months <br /> prior to discovery even though Main Control Board alarms and indications were available and indicated an off normal status for each train of the High Head Safety Injection System during the above period of time.

CERiiFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.A-39

-= .-

Houston Lighting and Power Violation B involves the significant failure to satisfy Technical Specification requirements for instrument setpoint valves for the Pressurizer P,ressure-Low Trip Setpoints. All four channels of the low pressurizer pressure safety injection activation setpoints were set below (less conservative) Technical Specification requirements. Thus, the plant entered Mode 3 on November 22, 1987, with all four channels inoperable. This error would have resulted in delayed activation of the safety injection sequence when required during an emergency. 'It is significant that this setpoint had been changed as a result of an engineering analysis by the vendor, and the licensee requested a Technical Specification change as a result of the analysis. Two NRC Inspection Reports (50-498/87-27 and 50-498/87-39) also discussed this change and suggested further verification of instrument setpoints. Notwithstanding this attention and the fact that this is one of the most important setpoints in the plant, the failure still occurred.

While the NRC recognizes that the reactor core has not been operational and no decay heat was present, these two events are viewed as serious in that they called into question Houston Lighting and Power's readiness to begin power operation of STP-1. Each of the violations could have been prevented by proper monitoring of control room indications and a proper understanding of Technical Specification requirements. Had these problems continued to exist subsequent to power operations the significance of them would have been much greater.

Because of these events, NRC Region IV performed additional operational inspec-tions and dedicated additional inspection resources to evaluate the STP-1 operational programs. These inspections focused on individuals and the under-standing of their role in assuring the proper operation of the facility and of Technical Specification requirements. The immediate issues involved are now fully resolved and the NRC staff will follow up your long term corrective actions during future inspections.

To emphasize the need to improve adherence to Technical Specification require-ments, 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 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 (1987) (Enforcement Policy),

the violations described in the enclosed Notice have been categorized at a Severity Level I11. The escalation and mitigation factors in the Enforcement Policy were considered. The base civil penalty amount has been increased by 50 percent because the first violation existed for a significant duration where opportunity to identify and correct the violation was readily available, and because appropriate corrective action for prior events should have presented the second violation.

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 NUREG-0940 1.A-40

l Houston Lighting and Power 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 i necessary to ensure compliance with NRC regulatory requirements.

fn 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 of 1980, Pub. L. No.96-511. ,

Sincerel ,

/ ,

/

t-obertIIMartin l[dh Regional Administrator  ;

Enclosure:

Notice of Violation and Proposed imposition of Civil Penalty cc:

Texas Radiation Control Program Director J

NUREG-0940 1.A-41

NOTICE OF VIOLATION A't0 PROPOSED IMPOSITION OF civil PENALTY Houston Lighting & Power Company Docket: 50-498 P. O. Box 1700 Operating License: NPF-71 Houston, Texas 77001 EA No.: 87-240 i

During NRC inspections conducted on November 1-31, 1987, and January 5-11, f 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 (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. 2287, and 10 CFR 2.205. The violations and associated Civil Penalty are set fe Lh below:

A. Technical Specification 3.5.3.lc, requires a minimum of two operable ECCS flow paths to the RCS for Mode 4 of plant operations. ACTION requirement a of TS 3.5.3.1 requires that with less than two operable flow paths restore the minimum flow paths within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> or be in COLD SHUT 00WN within the next 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br />.

Contrary to the above, the plant was operated in Mode 4 from October 31 to November 2, 1987, without two operable ECCS flow paths. All three High Head Safety Injection (SI) cold leg injection valves were closed during this entire period.

B. Technical Specification Table 3.3 4, Item 1.e recuires the pressurizer pressure-low setpoint to be set at equal to or greater than 1869 psig with an allowable value of equal to or greater than 1861 psig. Technical Specification Table 3.3-3, item 1.e requires the pressurizer pressure-low trip function to have a minimum of three safety injection trip channels operable prior to entering Mode 3 of plant operation.

Contrary to the above, the plant entered Mode 3 on November 22, 1987, with all four pressurizer pressure-low trip channels inoperable due to being l set to trip at 1850 psig, an incorrect, nonconservative setting. 1 Collectively the above violativ.1s have been categorized in the aggregate as a Severity Level til violation. (SupplementI)

Cumulative Civil Penalty - $75,000 (assessed equally between the violations).

Pursuant to the provisions of 10 CFR 2.201, Houston Lighting & Power Company 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 1 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 alleged violation: (1) admission or denial of the alleged violation, (2) the reason for the violation if admitted, (3) the corrective steps which have been taken and the results achieved (4) the corrective steps which will be taken to avoid furtherviolations,and(5)thedatewhenfullcompliancewillbeachieved. If an adequate reply is not received within the time specified in this Notice, an NUREG-0940 1.A-42

l l

l l

1 Notice of Violation j

I order may be issued to show cause why the license should not be modified, I suspended, or revoked or why such other action as may be proper should not be l taken. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath of affirmation.

i dithin 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. Should the Licenee 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 tc.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 cr mitigation of the penalty.

In requesting mitigation of the proposed penalt Section V.B of 10 CFR Part 2, Appendix C (1987)y, thebe

, should five factors addressed addrested. 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 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.

The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Enswer to a Notice of Violation) should be addressed to: Director Office of Enforcement, 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, and a copy to the NRC Resident Inspector, at South Texas Project.

FOR THE N,UCLEAR REGULATOR COMMISSION

/

A c /b hetU ~

Robert D. Martin Regional Administrator Dated at Arlington, Tejas, this day of g , 1988.

NUREG-0940 I.A-43

pasee,

+8 o UNITED STATES

[ ' ,i NUCLEAR REGULATORY COMMISSION Q

j d

REGION 1 M1 PARE AVENUE k.....,o# KINO oP PRUS$1A. PENNSYLVANIA 1M00 14 DEC 1987 Docket Nos. 50-245; 50-336; 50-423 License Nos. OPR-21; OPR-65; NPF-49 EA 87-198 Northeast Nuclear Energy Company ATTN: Mr. E. J. Mroczka Senior Vice President - Nuclear Engineering and Operations Group P. O. Box 270 Hartford, Connecticut 06141-0270 Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSE 0 IMPOSITION OF CIVIL PENALTY (NRC Combineo Inspection Nos. 50-245/87-22; 50-336/87-20; 50-423/87-18 and NRC Insoection Nos. 50-423/87-21; This refers to the NRC physical security inspection conducted between August 31 and September 4,1987, and to the routine resident inspection conducted between September 22 and November 2, 1987 at the Millstone Nuclear Power Station, Waterford, Connecticut. During the security inspection, violations of physical security requirements were identified. During the resident inspection, the NRC inspectors reviewed the circumstances associated with two examples of a viola-tion of physical security requirements which occurred on October 16 and October 29, 1987 respectively, one of which was identified and reported to the NRC by a member of your staff. The inspection reports were sent to you on October 2, 1987 and November 24, 1987, respectively. On November 3, 1987, an enforcement conference was conducted with you and members of your staf f to discuss the violations, their causes, and your corrective actions.

The violations, which are described in the enclosed Notice, included multiple examples of inadequate protected and vital ares barriers, two examples of visitors being in the protected area without an escort, improper implementa-tion of compensatory measures, as well as other degradations of the physical i security program. The NRC is concerned that several of these conditions, the l

' majority of which were identified by the NRC, hpd existed for an extended period anJ should have been obvious to knowledgbable and attentive personnel.

However, these conditions were not detected by your staff even though security personnel make frequent patrols of the entire facility, and security super-vision, including the contractor, perform periodic walkdowns of security equipment and periodic eva'luations of the security program.

These violations, as well as the f ailure to promptly identify and correct them, ,

were caused, in part, by inadequate review of plant design, failure to ade- l quately instruct individuals in their responsibilities with respect to security, a lack of understanding of the purpose of security patrols, and an apparent 1

1 NUREG-0940 1.A-44

Northeast Nuclear Energy Company 2 complacency toward security program requirements. The violations represent a significant lapse in attention to and control of the physical security program at Millstone.

The NRC recognizes that Northeast Nuclear Energy Corporation has recently experienced significant losses in knowledgeable corporate and site security personnel which may have contributed to the multiple f ailures in your security program. However, these f ailures can also be attributed to (1) excessive delays in permanently filling vacancies in the NRC approved interim security organization established in late 1985, and (2) failure to instruct several individuals who rotated through these vacancies in their responsibilities and authorities. These deficiencies represent a serious problem requiring expeditious resolution. Furthermore, although the NRC also recognizes that the licensing of Unit 3 has required considerable attention and staffing, as you indicated at the enforcement conference, it does not excuse or mitigate this degradation of the security program.

To emphasize the importance of preventing such lapses in the future, 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 T.enty-five Thousand Dollars ($25,000) 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 (1987)

(Enforcement Policy), the two violations described in Section A of the enclosed Notice have been categorized in the aggregate as a Severity level Ill problem, The base civil penalty amount for a Severity Level Ill violation or problem is

$50,000. The NRC considered complete mitigation of tne civil penalty based on your prior good enforcement and SALP history. However, the penalty has been mitigated by only 50*. because the violations involved multiple examples of barrier degradations and were identified by the NRC.

Several other violations are described in Section 8 of the enclosed Notice, including the two examples of failure to escort two visitors while within the protected area. Although this violation has also been classified at Severity Level Ill, the civil penalty for this violation has been mitigated in its entirety because of (1) your prior good enforcement history, (2) the fact that the more significant example was identified by your staff and reported to the NRC, and (3) your corrective action. The other violations in Section 8 have been categorized as Severity level IV and V violations and therefore were not assessed a civil penalty.

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 t actions you plan to prevent recurrence. As part of that response, you should l address actions to be taken to assure that supervisory vacancies in the I security program are promptly filled with trained and qualified individuals. l Af ter reviewing your response to this Notice, including your proposed corrective l

actions and the results of future inspections, the NRC will determine whether i further NRC enforcement action is necessary to ensure compliance with NRC l regulatory equirements.

NUREG-0940 I.A-45

Northeast Nuclear Energy Company 3 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.

Further, in your response to this letter and Notice, you should place all Safeguards Information in enclosures, so as to allow your letter (without enclosures) to be picced in the Public Document Room.

The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Of fice of Management and Budget as required by the Paperwork Reduction Act of 1980, P. L. No.96-511.

Sincerely, William T. Russell Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty (Contains Safeguards Information (SGI))

cc w/enci (w/o Safeguards Information):

W. D. Romberg, Vice President, Nuclear Operations S. E. Scace, Station Superintendent D. O. Nordquist, Manager of Quality Assurance R. M. Kacich, Manager, Generation Facilities Licensing Gerald Garfield, Esquire Public Document Room (PDR) local Public Document Room (LPOR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector (w/SGI)

State of Connecticut I

NUREG-0940 I.A-46

m asou UNITED STATES NUCLEAR REGULATORY COMMISSION p REOloN 111 g

5 , no moolavsLv noao

% GLEN ELLYN. ILUNO15 00 m

/

'"** OCT EIc l

Docket No. 50-263 l License No. DPR-22 EA 87-147 Northern States Power Company ATTN: Mr. C. E. Larson Vice Prasident, Nuclear Generation 414 Nicollet Mall Minneapolis, MN 55401 1

Gentlemen: l l

SUBJECT:

NOTICE OF VIOLATION AND PROPOSE 0 IMPOSITION OF CIVIL PENALTY

[NRC INSPECTION REPORT NO. 50-263/87009(DRS)]

This refers to the special safety inspection conducted during the period ,

June 17-18 and July 6,1987 at the Monticello Nuclear Generating Station.

The inspection was in response to two licensee reported events which occurred on June 7 and 14, 1987 involving the inadvertent tripping of a Class IE 480 volt load center output breaker. The results of the inspection were sent to you by letter dated July 20, 1987. The violation, the cause, and your corrective actions were discussed during an enforcement conference on July 27, 1987 in the Region III office between you, Mr. Dennis Gilberts, and other members of your staff and myself and other members of the Region III staff.

The violation in the enclosed Notice of Violation and Proposed Imposition i of Civil Penalty is considered significant because it caused the unit to be operated for eleven months while an unreviewed safety question existed.

The violation involved the failure to establish and implement a procedure for conducting design change con vol reviews to evaluate the effect of modifications in the area of electrical coordination. Thus, when solid s*. ate trip devices with ground fault protection were installed into load center breakers feeding ,

essential buses, an electrical coordination review was not performed. Therefore, I it was not recognized that for certain faults tpe solid state trip device could function before the individual component protection (fuse) could isolate the nonsafety-related load. An unreviewed safety question was created in that faults in nonsafety-related components during a postulated design basis event (i.e. grounding due to moisture intrusion) could cause the common-mode failure of multiple essential electrical buses and thus, increase the consecuences of the accident. The loss of multiple essential buses and their associated Engineered Safety Features components is a condition which was not considered in the design of the facility. A safety evaluation had not been performed for the solid state trip devices with ground fault protection.

I NUREG-0940 I.A-47

Northern States Power Company OCT 5 1987 1

To emphasize that effective controls be implemented for the evaluation of plant modifications to preclude creating unreviewed conditions, I have tean authorized, after consultation with 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 for the violations described in the enclosed Notice. In acccrdance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy),

the violations described in the enclosed Notice have been categorized a Severity Level III problem. The base value of a civil penalty for a Severity Level III violation is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered. Although your prior performance in the general area of concern has been good, based on your enforcement history involving modifications and your SALP Category 1 ratings in maintenance and modifications, the duration of the violation and its significance preclude any consideration for mitigation of the civil penalty.

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. As part of this response, you should also address your prograrr to assure that changes to previously approved modifications are properly evaluated. 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.

The respon:es 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.

Sincerely, 4 A. Bert Davis j Regional Administrator

Enclosure:

Notice )f i Violation and Proposed I Imposition of Civil Penalty See Attached Distribution NUREG-0940 I.A-48

L l

l l

I NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Northern States Power Company Docket No. 50-263 Monticello Nuclear Generating Station License No. DPR-22 EA 87-147 An NRC special safety inspection conducted during the period June 17-18 and-July 6,1987 identified violations of NRC requirements. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions",

f 10 CFR Part 2, Appendix C (1987), the Nucitar Regulatory Commission proposes t 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:

10 CFR Part 50, Appendix B, uriterion V states, in part, that activities affecting quality be prescribed by documented instructions, procedures,_

or drawings, of a type appropriate to the circumstances.

Contrary to the above, from August 1986 to July 1987, activities involving the review and performance of electrical coordination to determine the effects of changes to the electrical power system on other portions of the system were not prescribed by electrical design change control procedures.

As a result, when the electrical distribution system was modified by replacing trip devices in load center circuit breakers for essential buses eith devices having ground fault protection, the potential for loss of an essential bus due to a fault in a nonsafety-related component was created.

This is a Severity Level III violation (Supplement 1). '

Civil Penalty - $50,000.

Pursuant to the provisions of 10 CFR 2.201, Northern States Power 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 vio".ation, (2) the reasons for the violation if admitted, (3) the corrective steps that hTve 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.

NUREG-0940 I.A-49

OCT 5 1987 Notice of Violation 2 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 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 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 writtan answer addressed to the Director, Office of Enforcement, U.S. Eaclear Regulatory Comission. 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 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 nc; be imposed. In addition to protesting the civil penalty, such answer may request remirsion or mitigation of the penalty.

In requesting mitigation of the proposed penalty, the 1987 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 the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the License 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. 2282.

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 r 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, NUREG-0940 1.A-50

K..-ice of Violation 3 OCT 5 1987 U.S. Nuclear Regulatory Commission, for the appropriate Region, and, if applicable, a copy to the NRC Resident Inspector, at the facility which is the subject of this Notice, t

FOR THE NUCLEAR REGULATORY COMMISSION

/

A. Bert Davis- f Regional Administrator Dated at Glen Ellyn, Illinois this f day of October 1987.

t HUREG-0940 1.A-51

,( p %9(0, , UNITED STATES y g NUCLEAR REGULATORY COMMISSION 3 l W ASHINGTON O. C. 20555

/

Docket No. 50-263 FEB 101900 License No. OPR-22 EA 87-147 Northern States Power Company ATTN: Mr. C. E. Larson Vice Pr'esident Nuclear Generation 1 414 Nicollet Mall  !

Minneapolis, Minnesota 55401 Gentlenen:

SUBJECT:

ORDER IMPOSING A CIVIL MONETARY PENALTY This refers to your letter dated Noveltber 4,1987, in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you by our letter dated October 5,1987. Our letter and Notice described a violation involving an unreviewed safety question which was categorized as a Severity Level 111 violation. The event was reported to the NRC as a result of investigations by the licensee into events on June 7 and 14,1987, involving the inadvertent tripping of a Class IE 480 volt load center output breaker.

To emphasize that effective controls be implemented for the evaluation of plant modifications to preclude creatino unreviewed safety questions, a civil penalty of Fifty Thousand Dollars ($50,000) sas preposed.

In your response you admitted the violation and requested complete mitigation of the proposed civil penalty in accordance with the factors contained in the Enforcement Policy.

Af ter consideration of your response, we have concluded for the reasons given in the Appendix attached to the enclosed Order Imposing Civil Monetuy Penalty that you did not provide an adequate basis for mitigation of the proposed civil penalty. Accordingly, we hereby serve the enclosed Order on Northern amount States of Fifty PowerDollars Thousand Company (imposirg)a

$50,000 . We willcivil monetary review penalty in the the effectiveness of your corrective actions during a subsequent inspection.

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 enclosures will be placed in the NRC's Public Docurrent Room.

Sincerely, M

/J s M. Tay1 , Oeputy Executive Director  ;

, for Regional Operations  ;

Enclosures:

As stated NUREG-0940 I.A-52

l l

UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of Northern States Power Company Docket No. 50-263 (Monticello) Licensee No. DPR-22 EA 87-147 ORDER IMPOSING CIVIL MONETARY PENALTY I

Northern States Power Company (licensee) is the holder of Operating License No. DPR-22 issued by the Nuclear Regulatory Comission (hRC/Comission) on January 19, 1971. The license authorizes the licensee to operate the Monticello plant in accordance with the conditions specified therein.

II A sg.ecial inspection of the licensee's activities was conducted during the period June 17-18 and July 6, 1987. The results of this inspection 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 was served upon the licensee by letter dated October 5, 1987.

The Notice states the nature of the violation, the provision of the NRC's requirements 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 November 4,1987 admitting the violation, but requesting ccmplete mitigation of the proposed civil penalty. I 1

l l

NUREG-0940 I.A-53 l

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 the penalty proposed for the violation designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be imposed.

IV in view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1.954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT:

The licensee pay a civil monetary 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 nailed to the Director of Enforcement, U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. 20555.

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 of Enforcement, NUREG-0940 I.A-54

l U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk Washington, D.C. 20555, with a copy to the Regional Administrator, Region III, and a copy to the NRC Resident Inspector, Monticello plant.

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 by that time, the matter may be referred to the Attorney General for collection.

In the event the licensee requests a hearing as provided above, the issue ,

to be considered at such hearing shall be whether the proposed civil penalty should be imposed in whole or in part.

FOR THE NUCLEAR REGULATORY CCMMISSION Ja

- h s M. TayJ6r, Deputy Executive Director i

for Regional Operations Dated at Bethesda, Maryland this / 9 day of February 1988.

l 1

NUREG-0940 I.A-55 i i

Appendix Evaluations and Conclusions On October 5,1987, a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for a violation of 10 CFR Part 50, Appendix B, Criterion Y. Northern States Power Company responded to the Notice on November 4, 1987. In its response, the licensee agreed that the violation occurred, but stated that it believed total mitigation of the proposed civil penalty was warranted because of its prompt identification and reporting of the violation, prompt and extensive corrective actions, its prior good enforcement history, and other considerations.

Restatement of Violation 10 CFR Part 50, Appendix B, Criterion V states, in part, that activities affecting quality be prescribed by documented instruction, procedures, or drawings, of a type appropriate to the circumstances.

Contrary to the above, from August 1986 to July 1987, activities involving the review and performance of electrical coordination to determine the effects of changes to the electrical power system on other portions of the electrical power system were not prescribed by electrical design change control procedures.

As a result, when the electrical distribution system was modified by replacing trip devices in load center circuit breakers for essential buses with devices having ground fault protection, the potential of loss of an essential bus due to a fault in a nonsafety-related component was created.

Sumary of Licensee's Response The licensee acknowledges the occurrence of the violation, but requests the proposed civil penalty be completely mitigated. The licensee's arguments concerning mitigation are based on the following:

1. Prorpt Identification and Reporting The licensee states that the grnund fault coordinatien problem was discovered by plant personnel and promptly reported to the NRC. The licensee further states that even though the problem existed for 11 months, there were only two opportunities to discover the breaker coordination problem prior to its identification by the licensee.

2. Corrective Action to Prevent Recurrence The licensee states that prompt and extensive corrective actions were taken as a result of the event, including consideration of other '

potential coordination problems in other, unrelated, plant modifications. ,

it is further argued that the corrective actions were on the initiative '

of plant personnel and were broad in scope.

3. Past Perfonnance The licensee states that only one event involving inadequate design control was identified in the prior two years and that SALP ratings in this area have been consistently above average.

i NUREG-0940 I.A-56

l i

i Appendix 4. Prior Notice of Similar Events The licensee states there was no prior notice of this problem.

5. Multiple Occurrences The licen.see states that this is the first occurrence of this type at Monticellb.

6. Other Considerations The licensee clarifies a point in the Notice concerning the existence of procedures. The licensee states that procedures did exist for electrical coordination studies for changes to the electrical power system. The licensee acknowledges that a procedure for the review of the coordination of Motor Control Center (MCC) loads did not exist.

The event was considered to be an isolated event. While the licensee admits that the failure to provide adequate ground fault coordination when circuit breaker trip devices were replaced was a serious error, it believes that the impact on plant safety due to this failure was small.

NRC Evaluation of Licensee's Response Regarding prompt identification end reporting, the NRC agrees that the licensee identified the problem, but not until the issue was disclosed by the June 7 and June 14, 1987 events which required the licensee to investigate.

The coordination problem occurred when the licensee failed to properly evaluate the effects of replacing existing electrical circuit breakers with solid state trip devices which had ground fault protcction not previously provided. An electrical coordination review was not perfonned at the time of replace:nent and is considered the first opportunity to identify the problem.

Of the next two opportunities to discover the problem, the licensee failed to I

take advantage of the first chance because the fault was meggered and not continuity tested which would have identified the problem. The fault on June 14 was identified only after the containment fan cooler motor tripped on high current, not as a result of planned testing or maintenance. Overall, the fact that the licensee eventually identified the violation is balanced by the fact that the licensee failed to take advantage of opportunities to identify the problem earlier. Therefore, mitigation was not considered appropriate for this factor. l l

With respect to corrective actions the NRC acknowledges that the licensee took l corrective actions that should prevent recurrence, but does not believe that auch actions were unusually prcmpt and extensive in response to the significance I of the event. The NRC staff points out that the corrective actions were I necessarily broad in scope and additional electrical coordination problems i had been identified which delayed start-up of the plant. The NRC considers that the corrective actions taken were appropriate to the significant nature of the problem identified and therefore considers mitigation for the corrective actions taken unwarranted.

NUREG-0940 I.A-57

Appendix The NRC recognizes the licensee's good enforcement history in the area of maintenance and modifications and considered mitigation of the base civil penalty for this factor. However, the NRC notes declining performance in the area of engineering which was the cause of the violation cited in this enforce-ment action and also a violation (Severity Level III) given in December 1986 for deficiencies in the Standby Liquid Control System. The significance of the violation .in the current enforcement action is also increased hecause of the fact that the problem existed for 11 months prior to its discovery. It is considered significant that during this time, under certain conditions, the potential existed for ground faults in nonsafety-related equipment to cause the loss of essential motor control center loads. Consideration of mitigation '

of the base civil penalty because of the licensee's enforcement history in the area of maintenance and modifications is balanced by the declining performance in the engineering area and the duration for which the violation existed while the plant operated in condition which could have had a significant impact on the availability of safety systems. Therefore, neither mitigation ror escalation is deemed appropriate.

Regarding other considerations, the NRC recognizes that the plant had procedures for electrical coordination studies; however, as the licensee  ;

admits, there was no procedure for electrical coordinatinn studies for Motor l Control Center (MCC) loads. As discussed earlier, the NRC believes that the event was significant in that verinus safety systems were affected by the coordination problem.

NRC Conclusion The NRC has reviewed Northern States Power Company's response to the proposed imposition of civil penalty and arguments for mitigation of the base civil penalty. The NRC concludes that an adequate basis for mitigation of the civil penalty was not provided by the licensee. Consequently, the proposed civil penalty in the amount of $50,000 should be imposed.

NUREG-0940 I.A-58

et "" *% UNITED STATIS y

• NUCLEAR REGULATORY COMMISSION REGION IV

$ f k ,., / 411 RYAN PLAZA DRIVE. SUITE 1000 ARUNGioN. TEXAS 79011 R I 9 l988

, Docket No. 50-285/87-21 l License No. DPR-40 EA 87-200 l

Omaha Public Power District ATTN: R. L. Andrews, Division Manager Nuclear Production 1623 Harney Street Omaha, Nebraska 68102 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-285/87-21)

This refers to the inspection conducted on September 14-18, 1987 at the Ft.

Calhoun Station, by personnel of the NRC Region IV office. Du r i .... this inspection, NRC personnel identified several violations that were discussed at an enforcement conference on October 15, 1987, at the NRC Region IV office in Arlington, Texas.

The violations identified during the inspection include the failure to lock the door to a very high radiation area and the failure to follow health physics proc (dures and technical S~.ifications when entering a very high radiation area. Subsequent to th' spection, two additional violations have been identified. These inc* second unlocked very high radiation ar6a door and the failure to issue r ensee Event Report (LER) for the initial unlocked very high radiatic, . door. The two incidents of unlocked doors to very high radiation area re significant in view of a prior incident of an unlocked door for which you were cited for on May 22, 1986 as a Severity Level 111 violation without a civil penalty. The staff recognizes that you identified the second failure to lock a very high radiation area door on the day before the enforcement conference. However, the staff is concerned that, though the incident was not required to be reported until after the conference, the incident was not promptly brought to the attention of the NRC notwithstanding that tie purpose of the conference was to addresp control of high radiation areas. It was not until towards the end of the conference, af ter discussion of the corrective actions taken or planned and as a result of questioning, that the incident was disclosed.

I Collectively, the violations irdicate a declining trend in radiation protection l control that is also reflected by the reduced rating in the applicable category of the last SALP report for your facility. In this particular cate, there was a lack of coernitment by your employees, including health physics (HP) personnel CERTIFIED Mall I RETURN RECEIPT RE0 VESTED l

)

l NUREG-0940 I.A-59 i

aA- -- 4 ~_,---,---=,1 L

- 4 ,.,

Omaha Public Power District to adhere to procedures and technical specifications. These deficiencies i demonstrate that (1) employees and HP personnel must have a better understanding I of their roles and of HP practices and procedures, and must pay greater l attention to detail in performing their duties; and (2) site maragement must i assure that the radiation protection program is properly implemented. l To emphasize the need to improve radiation protection control, I have been authorized, after consultation with the Director, Office of Enforcement, and i

'the Deputy Executive Director for Regional Operations, to issue the enclosed 1 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," 10 CFR Part 2, Appendix C (1987)

(Enforcement Policy), the violations described in the enclosed Notice have been categorized as a Severity Level 111 problem, The base value of a civil penalty ,

for a Severity Level !!! violation or problem is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered and the base civil penalty amount has been increased by 50% because of your prior similar violation in May 1986.

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, your response should address what actions .vou plan to take to assure that discussions with the NRC staff are complete and that material information is brought forward in a more open and candid manner. 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. i 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 of 1980, Pub. L. No.96-511.  ;

Sincerel , '

< ./N Robert D. Martin Regional Administrator Enciosure:

1 Notice of Violation and Proposed Imposition i of Civil Penalty l cc: Nebraska Radiation Control Program Diractor NUREG-0940 I.A-60 4

- - - , . , - - - - - - . - - - - - - r - - - , , - - - , -- - - ,--- - -,,+r- - , - - - - --

NOTICE OF VIOLATION ,

AND PROPOSED INPOSITION OF CIVIL PENALTY l Omaha Public Power District Docket No. 50-267 '

Omaha, Nebraska License No. DPR-34 EA 87-200 l

l During an NRC inspection conducted on September 14-18, 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 (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty oursuant 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:

1. Violations Assessed a Civil Penalty A. Technical Specifiestion 5.11.2 requires that entrance into each high radiation area in which the intensity of radiation is greater than a

1000 mrem /hr (very high radiation area) shall be controlled Sy tiv use of locked doors to prevent unauthorized entry.

1. Contrary to the above, at approximately 10:00 a.m. on September 9, 1987, the doot 'he ncrt fuel storge port heat exchanger, pump, and filter n u (Room No. 5), s very aigh radiation area, was unloct~

4

) 2. Contrary to the above, at approximately 2:30 p.m. on October 14, i 1987, the door to Room No. 11 in the Auxiliary Building, a very j high radiation area, was unlocked.

These are repeat dolations.

l Technical Specification 5.11, Radiation Protection Program, requires B.

that procedures for personnel radiation protection shall be prepared consistent with the requirements of.10 CFR Part 20 and adhered to for all operations involving personnel radiation exposure. The FCS Radiation Protection Manual provides procedures to implement the requirements of Technical Specification 5.11. Section 3.1.7.2.b of

the Manual, provides that an individual permitted to enter a very high radiation area shall be provided continuous health physics coverage by a technician who is equipped with a radiation dose rate instrument.

l I

NUREG-0940 1.A-61

. i

Omaha Public Power District 1987 an auxiliary building Contrary to the above, equipment operator enteredon September Room No. 5 9,(a ver,y high radiation area) wRhou obtaining continuous health ph3 sics coverage by a technician equipped with a radiation dose rate instrument.

Collectively the above violations have been categorized as a Severity Level III problem (Supplement IV).

Cumulative Civil Penalty - $75,000 (assessed equally between the violations).

II. Violation Not Assessed a Civil Penalty 4

10 CFR 50.73 requires, in part, that the holder of'an operating license for a nuclear power plant shall sub_mit a Licensee Event Report (LER) for-any condition prohibited by the plant's Technical Specifications within 30 days after the discovery of the event. Technical Specification 5.11.2

. states, in part, that each high radiation area in which the intensity of I radiation is greater than 1000 mem/hr (very high radiation area) shall be l

provided with locked doors to prevent unauthorized entry.

l Contrary to the above, the licensee failed to submit an LER within 30 days for a condition prohibited by the Technical Specifications, i.e., a very high radiation area consisting of Room No. 5 which had a door unlocked on September 9, 1987.

This is a Severity Level IV violation (Supplement IV).

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 "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 resultsachieved(5)thedatewhenfullcompliancewillbeachieved.(4) violations, and the corrective s 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 snould 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 i

2.201, the Licensee may pay the civil penalty by letter addressed to the -

t Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a I check, draft, or money order payable to the Treasurer of the United States in j the amount of the civil penalty proposed above, or the cumulative amount of the -

NUREG-0940 I.A-62

Omaha Public Power District ,

l civil penalties, if more than one civil penalty is proposed, or may protest i 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 Notict 'f Violation" and ma): (1) deny the violations listed in this Notice-in (2) demonstrate extenuating circumstances, (3) show error in whole sr in this Noticc, or part[4) show otter reasons why the penalty should not be imposed.

In addition to protesting the civil penalte in whole or in part, such answer may request remission or mitigation of the pnalty.

In requesting mitigation of the pruposed penalt Section V.B of 10 CFR Part 2, Appendix C (1987)y, , shouldthe five factorsAny be addressed. addressed in critten 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, thii 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 '.ct, 42 U.S.C. 2282c.

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, and a copy to the NRC Resident Inspector, at the facility which is the subject of this Notice.

FOR THE NUCLEAR REGULATORY COMMISSION

/

/ 61 Robert D. Martin Regional Administrator Dated at Arlington, Texas, this gNay of January 1988.

i HUREG-0940 I.A-63

l 0"*  % UNIT 1D STATIS j y [*; NUCLEAR REGULATORY COMMISSION ,

5 f Atoio" ;v til RYAN PLAZA DRIVE, Sufft 1000 I ARLt40 TON,itXA$ 78011 FE8 2 21988 Docket No. 50-285 License No. DPR-40 EA 87-210 Omaha Public Power District ATTN: R. L. Andrews, Divistor. Manager.

Nuclear Productien 1623 Harney Street Omaha, Nebraska 68102 Gentlemen:

SUBJECT:

NOTICE OF VIO'.ATION AND PROPOSED IMPOSITION OF CIYil PENALTY (NRC INSPECTION REPORT 50-285/87-27)

This refers to inspections conducted during the periods of September 23 through October 2, 1987, and November 2-6, 1987, of activities authorized by NRC Operating License DRP-40 for the Fort Calhoun Station by personnel of the NRC Region IV office. Theinspectionsincludedreviewsoftheeventsthat resulted in the inoperability of Emergency Diesel Generator (EDG) 2 due to the introduction of water into the Instrument Air System on July 6 and a separate occurrsnce on August 25, 1987. As a result of these inspections, it was found that certain of your activities were in violation of NRC requirements.

Accordingly, an enforcement conference was held in the Region lY office on October 29, 1987, to discuss the issues related to these events. On October 23, 1987, NRC Inspection Report 50-285/87-27 was issued to provide details of l the initial inspection perforined September 23 through October 2,1987, and NRC i inspection Report 50-285/87-30 was issued on December 10, 1987, to provide details of the followup inspection performed November 2-6, 1987, by a special review team ' rom the NRC's Region lY office.

Inadequate evaluation and testing of a plant modification as well as inadequate procedures led to a situation where an emergency diesel generator was rendered inoperable because of the intrusion of water into the instrument air system.

Additionally, once the water intrusion was discovered it was not adequately corrected, properly classified as a Notice of Unusual Event (NOVE) or properly reported to the NRC. Collectively, the sequence of events outlined above indicate a significant failure of your management control systern to ensure activities that affect quality were properly conducted at the Fort Calhoun Station. This failure resulted in the plant being operated in an unanalyzed condition where a potential comon mode failure condition existed.

To emphasize the need to improve your management control 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 One Hundred Seventy-Five Thousand Dollars ($175,000) for the violations described in the enclosed iiotice. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1987)

(Enforcement Policy), the two violations and the one problem described in the enclosed Notice have each been categorized at Severity Level III. The base NUREG-0940 I.A-64

1 Omaha Public Power District ED value of a civil penalty for a Severity Level III violation is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered, t

The base civil penalty amount for Violation A has been increased by 50% because of poor enforcement history in the area of concern, i

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 forralizing your corrective actions, l you should be aware that the three Severity Level III problems arising out of the inspections are a clear indication of a need to take strong and effective corrective actions in the area of your management controls. After reviewing your response to this Notice, including your propored corrective actions and the results of future inspections, the NRC will determine whether more stringent

enforcement action is necessary to ensure lasting corrective action in this area.

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 res sonses directed by this letter and the enclosed Notice are not subject to tie clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction of 1980, Pub. L. No.96-511.

Sincerely, Robert D. Martin Regional Administrator

Enclosure:

Appendix - Notice of Violation and Proposed Imposition of Civil Penalty 4

cc w/ enclosure: .

! W. G. Gates, Manager l Fort Calhoun Station i

> P. O. Box 399 Fort Calhoun, Nebraska 68023 l

Harry H. Voigt, Esq. )

LeBoeuf, Lamb, Leiby & MacRae 1333 New Hampshire Avenue, NW Washington, DC 20036 Kansas Radiation Control Program Director

Nebraska Radiation Control Program Director NUREG-0940 I.A-65 1

3 J

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Omaha Public Power District Docket No. 50-285 1623 Harney Street License No. DPR-40 Omaha, Nebraska 68102 EA 87-210 During NRC inspections conducted during the periods of September 23 through

. October 2,1987, and November 2-6, 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 (1987), the Nuclear Regulatory Comission proposes to impose a civil penalty pursuant to Section 234 oftheAtomicEnergyActof1954,asamended(Act),42U.S.C.2282,and 10 CFR 2.205.. The particular violations and associated civil penalties are set forth below:

Design Evaluation A. 10 CFR 50.59(a) allows the holder of a license to make a change in the facility as described in the safety analysis report (SAR) without prior Commission approval unless it involves a change in the technical specification or involves an unreviewed safety question. A proposed  ;

change involves an unreviewed safety question: (1) if the probability of occurrence or the consequences of an accident or malfunction of -

equipment important to safety previously evaluated in the SAR may be increased, (2) if a possibility for an accident or malfunction of a different type than any evaluated previously in the SAR may be created,

or (3) if the margin of safety as defined in the basis for any Technical Specification is reduced.

10CFR50.59(b) requires,inpart,thatthelicenseemaintainrecordsof changes in the facility to the extent that such changes constitute changes-in the facility as described in the SAR. These records shall include a written safety evaluation which provides the bases for the determination that the change does not involve an unreviewed safety question.

Section 9.12 of the Fort Calhoun Station Updated Safety Analysis -

j Report (USAR) describes,inpart,thatthecompressedairsystemprovides e compressed air to the instrument air header for pneumatic controls and the s actuation of valves, dampers, and similar devices, and states that the .

system has a design basis of a maximum instrument air dew point of -20'F.  !

Contrary to the above, the licensee failed to perform an adequate evaluation, i

as required by 10 CFR 50.59(a), to determine if'an unreviewed safety question existed when Modification MR-FC-83-182 was installed on May 22, 1985 to connect the Instrument Air System to the Fire Protection System. Although the licensee completed a 10 CFR 50.59 evaluation to determine the effect I of the modification on the Fire Protection System, it failed to evaluate the effect of the modification on the Instrument Air System and the potential j

{

j t f

4 NUREG-0940 I.A-66  !

Notice of Violation for introduction of water from the Fire Protection System into the Instrument Air System. The introduction of water into the Instrument Air System could result in a connon mode failure through flooding of the Instrument Air l System, which supplies the motive force for equipment or components in redundant trains of safety-related equipment. The intrusion increased the probability of the malfunction of safety-related equipment, and components because moisture caused the system to not meet the design bases for a dew point maximum limit of -20'F which is specified in Section 9.12 of the Fort Calhoun Station USAR. The unreviewed safety question existed until the Instrument Air / Fire Protection System interface was disconnected in October 1987.

ThisisaSeverityLevel!!! violation (SupplementI). l Civil Penalty - $75,000.

Design Implementation and Classification / Reporting Bol. 10 CFR Part 50, Appendix B, Criterion XI and Section 8.4 of the OPPD Quality Assurance Plan requires, in part, that a test program be established to assure that all testing required to demonstrate that components will perform satisfactorily in service is identified and performed in accordance with written test procedures.

Contrary to the above, on May 22, 1985, the licensee installed check valves in the Instrument Air System to ensure that water from the Fire Protection System did not enter the Instrument Air System, but failed to establish a test program that would assure that the check valves would perform satisfactorily in service. Subsequently, on July 6, 1987, the check valves failed to perform their intended function, resutting in the j introduction of fire water into the Instrument Air System.

B.2. 10 CFR Part 50, Appendix B, Criterion V and the OPPD Quality Assurance Plan, Section 2.1 require, in part, that activities affecting quality be prescribed by documented instructions of a type appropriate to the circumstances. i

a. Procedure ST-FP-5, "Fire Protection-Auxiliary Building Sprinkler Systems Testing," specifies how the licensee is to test the dry-pipe fire system in the emergency diesel generttor rooms.

Contrary to the above, Procedure ST-FP-5 failed to provide adequate instructions for the performance of surveillance testing activities on the dry-pipe system in the emergency diesel generator rooms.

Procedure ST-FP-5 did not provide specific step-by-step instructions for returning the dry-pipe system to the normal lineup after comple-tien of the surveillance test. Consequently, water from the Fire Protection System was introduced into the Instrument Air System during the performance of the test on July 6, 1987.

j b. Procedure AOP-17 ' Loss of Instrument Air," Revision 2, dated July 2, l 1986, requires the licensee to provide instructions to operations

, personnel for the mitigation of a plant transient due to the effect l

of the loss of instrument air on 14 different safety-related systems.

i NUREG-0940 I.A-67 l

FE8 2 21988 Notice of Violation  ! Contrary to the above, Procedure AOP-17 failed to provide adequate instructions to operations personnel in that the procedure did not adequately address the effect of loss of instrument air for each of the safety-related systems specified. For example, the procedure did l not address the effect of the loss of instrument air of the radiator

> exhaust dampers on the emergency diesel generators. Furthermore it 4

didnotprovidespecificinformationregardingthebackupcapability(

of the accumulators installed on specific safety-related equipment  ;

the procedure stated that level indication for the safety injection and refueling water tank would be lost, when in fact, the tank level indication is available up to 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> after the loss of instrument i air).  !

) B.3. Technical Specification 2.7 states, in part, that the reactor shall not be heated up or maintained at temperatures above 300'F unless both diesel generators are operable. Additionally, Technical Specification 2.7 states that if one diesel generator becomes inoperable it may remain inoperable e for up to seven days provided the other diesel is started to verify operability, shutdown and controls are left in automatic mode and tnere are no inoperable safeguards components associated with the operable diesel generator.

The Definitions section of the Technical Specification states, in part, ,

that a component shall be operable "when it is capable of performing itsspecifiedfunction(s). Implicit in this definition shall be the  :

assumption that all necessary... auxiliary equi f

forthecomponent...toperformitsfunction(s)pmentthatarerequi*ed are also capable of performing their related support function (s)...."

] Contrary to the above, the reactor was maintained at temperatures above j 300'F for greater than seven days while Emergency Diesel Generator (EDG) 2

was inoperable. On July 6 and August 25, 1987 water entered the

]

InstrumentAirSystemrenderingtheairaccumulatorassociatedwithair driven motor for the EDG 2 radiator exhaust damper inoperable, thus rendering EDG 2 inoperable. EDG 1 was not started to verify operability.

This condition existed until discovered during a surveillance test on EDG 2 performed September 23, 1987.

1 B.4. Fort Calhoun Station Technical Specification 5.8.1 requires that arocedures

]- be established, implemented, and maintained that meet or exceed tie minimum requirements of ANSI N18.7-1972 (Sections 5.1 and 5.3).

l ANSI N18.7-1972, Section 5.1.6.1 states that maintenance which can affect i the performance of safety-related equipment shall be in accordance with

! written procedures and Section 5.3.5(3) states that instructions shall be

! included (or referenced) for returning equipment to normal operating l

! status, giving special attention to systems that can be defeated by  !

leaving valves, breakers, or switches mispositioned.

l Contrary to the above, at the time of the NRC inspections, even though mispositioning of an instrument air isolation valve led to the August 25, 1987 water intrusion event, the licensee had not provided a procedure 2

NUREG-0940 1.A-68

i FEB 2 2128 Notice of Violation or instruction to ensure proper positioning of valves, breakers, or switches prior to returning the Instrument Air System to norr.a1 operating status.

l B.S.10 CFR 50.47(b)(4) states, in part, that the onsite emergency response plan for nuclear power reactors must contain a standard emergency classification and action level scheme. The licensee's l Procedure EPIP-05C-1, "Emergenc requirements of 10 CFR 50.47(b)y(4). Classification," implements the Section !Y.2 of EPIP-05C-1 states, in part, that the shift supervisor shall evaluate the condition and determine the applicable einergency classification. Note 1.a of Section IV.d defines a notification of unusual event (NOVE) as events in progress or which have occurred which indicate a potential degradation of the level of safety of the plant.

Contrary to the above, the shift supervisor failed to detennine the applicable emergency classification and declare a NOVE when an event occurred which indicated a potential degradation of the level of safety of the plant. On July 6, 1987, an unknown amount of water from the Fire Protection System was introduced into the Instrument Air System and resulted in a potential comon mode failure condition.

B.6.10 CFR 50.72 states, in part, that each nuclear power reactor licensee shall notify the NRC Operations Center via the Emergency Notification System, within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />, of any event or condition during operation that results in the condition of the nuclear power plant being in an unanalyzed condition that significantly compromises plant safety.

10 CFR 50.73 states, in part, that the holder of an operating license for a nuclear power plant shall submit a Licensee Event Report (LER), within 30 days af ter the discovery of any event where the plant is in an unanalyzed condition that significantly compromises plant safety.

Contrary to the above, the licensee failed to notify the NRC Operations Center within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> and failed to submit an LER within 30 days, of an

' event that resulted in an unanalyzed condition that significantly compromised plant safety. On July 6,1987, an undetermined amount of water was introduced into the Instrument Air System and resulted in a potential comon mode failure condition. The plant was in an unanalyzed condition in that the licensee did not determine the capability of the Instrument Air System to provide the motive force for operation of redundant safety-related equipment and components for at least two days after the water from the Fire Protection System was introduced into the Instrument Air System.

These violations are considered in the aggregate to be a Severity Level !!!

problem (Supplement 1).

Civil Penalty - $50,000 (assessed equally among the violations).

1 Corrective Action C. 10 CFR Part 50, Appendix B, Criterion XVI and Section 10.4 of the OPPD Quality Assurance Plan require, in part, that measures shall be established to assure that conditions adverse to quality are promptly

NUREG-0940 1.A-69

fEB 2 % lsod Notice of Violation identified and corrected. In the case of significant condhions adverse to quality, these measures must assure that the cause of the condition is deterinined and corrective action is taken to preclude repetition.

Contrary to the above, water from the Fire Protection System was introduced into the Instrument Air System on July 6,1987, and the licensee failed to determine the cause of the condition adverse to quality and failed to take corrective action to preclude repetition such that:

1. After introduction of water into the Instrument Air System on July 6, 1987, the licensee did not perform dew point measurements of air in the system to verify that the system complied with the design bases for the dew point maximum limit.

, 2. Even after water was introduced into the Instrument Air System through the connection that maintained the portion of the fire Protection System in the emergency diesel generator rooms as a dry-pipe system, the licensee cleaned and inspected the associated check valves to verify proper operation and reinstalled the interconnection between the Fire Protection and Instrument Air systems. By reinstalling the interconnection, the licensee reestablished, in its original configuration, the condition that had led to the introduction of water into the Instrument Air System.

3. Af ter the introduction of water into the Instrument Air System, the licensee did not perform a review to determine whether other instrument air / pressurized water interfaces existed in the system. Subsequently, on August 25, 1987, another event occurred in which water was introduced into the Instrument Air System through an interf ace with a p*;nt water system,

4. Af ter the introduction of water into the instrument Air System, the licensee comenced a formal program for performing blowdowns to remove the water and/or moisture from the Instrument Air System.

However, the licensee f ailed to blowdown some accumulators to verify that water and/or moisture was not present. For example, water was foundintheaccumulatorfortheEmergencyDieselGenerator(EDG)2 radiator exhaust damper during an investigation performed after EDG 2 failed its surveillance test on Septembe/ 23, 1987 ThisisaSeverityLevel!!! violation (Supplement 1).

Civil Penalty - $50,000.

Pursuant to the provisions of 10 CFR 2.201, Omaha Public Power District (Licensee)isherebyrequiredtosubmitawrittenstatementorexplanationto 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 "Reply to a Notice of Violation" and should include for each alleged violation:

(1)admissionordenialoftheallegedviolation,(2)thereasonsforthe 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 way 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 I.A-70

l I

FEB 2 21553 l

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.

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 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 cumulative amount of the civil penalties or may protest imposition of the civil penalties in whcle or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission. 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 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 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 penalties, the five factors addressed in Section V.B of 10 CFR Part 2. Ap>endix C (1987) should be addressed. Any written answer in accordance wit) 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.

The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalties, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document 8 Control Desk, Washingten, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Comission, Region IV, and a copy to the NRC Resident Inspector, Ft. Calhoun Station.

FOR THE UCLEAR REGULATORY COMMISSION N f(f "

Robert D. Martin Regional Administrator Dated at Arlington, Texas, this J21 ay of February 1983 NUREG-0940 I.A-71

m 88% UNITED ST ATES y

+ 'g NUCLEAR REGULATORY COMMISSION

?> REGION W 8 noaoosevett neao 3

otes attvs. itumois m n m ,1 a I

Docket No. 50-440 Licensee NO. NPF-58 EA 87-206 l 1

The Cleveland Electric Illuminating Company ATTN: Mr. Alvin Kaplan Vice President Nuclear Group Post Office Box 5000 Cleveland, Ohio 44101 ,

Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-440/87013(DRS))

This refers to an NRC inspection conducted during the period July 13 through

='

Neverder 10, 1987, of activities authorized by NRC Operating License No. NPF-58 at the Perry Nuclear Power Plant (PNPP). That inspection reviewed implementation of the requirements for assuring environmental qualification (EQ) of electrical equipment at PNPP and violations were identified by the NRC.

An enforcement conference was held between Mr. A. Kaplan, Dr. C. Paperiello, '

and others of our respective staffs on November 10, 1987, during which the violations, their root causes, and your corrective actions were discussed.

The report of the inspection and enforcement conference was sent to you by letter dated December 17, 1987.

i

The violations described in the enclosed Notice of Violation and proposed Imposition of Civil Penalty (Notice) concern the failure on the part of the

PNPP engineering and maintenance personnel to ensure that electrical equipment important to safety was: (1) qualified for its intended service by testing l and/or analysis; (2) installed in the configuration qualified by test and/or l dnalysis; and (3) maintained to preserve its qualification. It appears that j these violations were due to a lack of management and programmatic controls to ensure that your engineering staff: (1) assured that equipment was properly qualified; (2) verified that equipment was properly installed in the field; and (3) assured coordination with your maintenance organizations so maintenance was l i

performed on equipment in a manner that would sustain its qualification. The NRC recognizes that the deficient conditions may not have been to such a degree as to impair a system's ability to perform its intended function. However.

l the programmatic nature of these violations are cause for significant regulatory  !

concern and therefore the violations have been considered in the aggregate as i a Severity Level III problem.

NUREG-0940 I.A-72

l l

I The Cleveland Electric 2 Illuminating Company FEB 11 %

To emphasize the importance of implementing adequate management and programmatic controls to ensure the initial and continuing qualification of equipment important to safety, I have been authorized, after consultation with the ,

l Director, Office of Enforcement and the Deputy Executive Director for Regional t Operations, to, issue the enclosed Notice of Violation and Proposed Imposition ,

of Civil Penalty in the amount of Twenty-Five Thousand Dollars (525,000) for- 1 l the violations described in the enclosed Notice. In accordance with the "General Statement of Policy and Procedures for NRC Enforcement Actions,"

10 CFR, Part 2, Appendix C (1987) (Enforcement Policy), the violations described in the enclosed Notice have been categorized as a Severity Level III l problem. The base value of a civil penalty for a Severity Level III violation or problem is $50,000. The Enforcement Policy allows for reduction of a civil penalty under certain circumstances.

l The civil penalty for these violations has been reduced by 50 percent due  !

to your unusually prompt and extensive corrective actions in response to the '

identification of these problems. You promptly initiated action to resolve i the specific equipment and documentation deficiencies identified by the inspectors and broadened your actions to address programmatic concerns i' including: (1) a walkdown of all equipment requiring sealing from moisture intrusion and a similar walkdown of all Limitorque operators to assure the absence of grease relief shipping caps; (2) expansion of the content and application of EQ training to address the inspection findings; (3) a complete reverification of EQ maintenance requirements to assure that they are either correctly reflected in specific procedures or properly controlled through the

• work planning procedures; and (4) computerized listing of equipment requiring EQ consideration in work planning. The other escalation and mitigation factors have been considered and no further adjustment has been deemed appropriate.

The enforcement action being taken in this case is based on the normal enforcement policy of 10 CFR, Part 2, Appendix C (1987). Because Perry Unit I was granted operating license af ter the November 30, 1985 EQ deadline, the enforcement policy for EQ violations for operating reactors, provided in

~

Generic Letters 85-15 and 86-15, was not considered applicable.

You are required to respond to this letter and should follow the instruction specified in the enclosed Notice when preparing your response. In your 1

' 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 3

whether further 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 i

will be placed in the NRC Public Document Room, 1

l ,

l

, NUREG-0940 I.A-73

._.__s__ -

_ _ . _ _ , . , -y _ ___y . -

4 The Cleveland Electric 3 FEB i 1 1985 Illuminating Company i

i The responses directed by this 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 Act of 1980, Pub. L. , No.96-511.

Sincerely, b

A. Bert Davis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition Civil Penalty

2. NRC Inspection Report No. 50-440/87013(DRS) cc w/ enclosures:

F. R. Stead, Manager, Perry Plant Technical Department M. D. Lyster, Manager, Perry Plant Operations Department Ms. E. M. Buzzelli, General Supervising Engineer, Licensing and Compliance Section DCD/DCB (RIDS)

Licensing Fee Management Branch Resident Inspector, RIII Harold W. Kohn, Ohio EPA Terry J. Lodge, Esq.

James W. Harris, State of Ohio Robert M. Quillin, Ohio Department of Health State of Ohio, Public Utilities Commission l

l i

l l

i

(

NUREG-0940 1.A-74 l l

l

1 NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY I

l Cleveland Electric Illuminating Company Docket No. 50-440 )

Perry Nuclear Power Plant, Unit 1 License No. NPF-58 EA 87-206 During the NRC inspection conducted during the period July 13 through November 10, 1987, violations of NRC requirements were identified. In

, accordance with "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 ??'1, and 10 CFR 2.205.

The particular violations and associated civil penalty are set forth below:

1. 10 CFR 50.49 (a) requires each holder of a license to operate a nuclear power plant to establish a program for qualifying safety-related electric equipment, nonsafety-related electric equipment whose failure could prevent the satisfactory fulfillment of a safety function, and certain

, post-accident monitoring equipment. .

10 CFR 50.49 (f) requires that each item of electric equipment important to safety be qualified by test and/or analysis.

Contrary to the above, as of November 10, 1987, equipment which the licensee determined had to be qualified was not properly qualified due to test and/or analysis deficiencies, as demonstrated by the following examples:

A. Valcor solenoid valves were not properly qualified because the  !

thermal aging was based on a process fluid other than that actually used in operation (Test Report No. NEOC-30735).

B. PYC0 temperature elements (Model No. 102-9039-11) were not properly qualified because repairs were made to the equipment (torquing the cover) during quslification testing (File No. E-301-C03-01). ,

C. ITT General Controls electrohydraulic actuators were not properly qualified because they were installed inside containment while the

, qualification testing was performed to a set of less severe accident j conditions representing conditions outside containment (File No. ,

, E-245-00-001). '

! D. ASCO solenoid valves were not properly qualified because thermal aging was based on a process fluid other than that actually used in ,

operation.

Also, the thermal aging evaluation was based on partial thermal aging i in the test program combined with aging as a result of the design basis ,

event exposure. Thermal aging is required to be performed prior to .

the event exposure (File Nos. E-641-001-01, E-641-000-01 and E-607-001-01). !

4 i

j NUREG-0940 I.A-75 -

Notice of Violation 2 FEB ii tget E. Marathon 1600, Buchanon 200, and GE EB-5 terminal blocks were not properly qualified because insulation resistance readings during qualification testing were taken at voltages lower than that which would be actually experienced in operation (6 volts vs. 480 or 120 l

volts) (File No. E-565-000-04).

12, 10 CFR 50.49(f) requires that each item of electrical equipment important l to safety be qualified by testing and/or analyses of an identical item of I equipment under identical conditions, or a similar item or under t ir.il a r

• conditions with a supporting analysis to show that the equipment to be qualified is acceptable. i l

Contrary to the above, as of Novenber 10, 1987, equipment which the licensee determined had to be qualified was not properly qualified by testing and/or  ;

analyses of an identical or similar item or under identical or similar I conditions in that discrepancies existed between the tested / analyzed and "

the installed configuration without supporting .,r. lyses, as demonstrated by '

the following examples:

i A. Target Rock Solenoid Valve No. 1E12-F0758 (Model No. 77JJ-006 SOV)

• was found installed with three bolts missing from the solenoid housing while the tested configuration was with all eight bolts installed, r B. Limitorque Actuator IP51-F652 had a T drain installed such that '

condensate which might collect during an accident could short the  ;

electrical internals while the tested configuration had the T drain  ;

properly located to allow proper drainage.

C. Thirty-five Limitorque Actuators (including IP51-F652) were found installed with plastic shipping caps on the gr.ese relief valves while the tested configuration was with those caps removed.  ;

D. Limitorque actuators, addressed under File E-568-000-00 and located inside containment, were installed without the suppression poc' swell deflector plates changing the environment the actuator would  ;

experience post-LOCA from the tested environment. '

a

E. PYC0 Thermocouple No. IE31N001A was found installed with a loose I housing cover while the tested configuration required a 50 ft-lb <

torque to be applied to the housing cover for adequate sealing. l i

F, WEED Resistance Temperature Detectors, Series 611, including l 1023N050A and B were found with loose housing covers while the j tested configuration required the covers to be hand tight plus l 1h turns to provide adequate sealing.

1 i

NUREG-0940 I.A-76 i

Notice of Violation 3 FEB !t 19 86 l ZII.10 CFR Part 50, Appendix B, Criterion V, as implemented by the licensee's l Quality Assurance Program, requires that activities affecting quality be l prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances.

Contrary to the above, as of November 10, 1987, the maintenance procedures for equipment which the licensee determined had to be qualified were not appropriate to the '.ircumstances in that they did not ir.clude the EQ maintenance requirements specified by the equipment vendor, as demonstrated by the following examples:

A. 0-ring replacement was not required in the ma'ntenance procedure each time the housing cover was removed fron. PYC0 temperature elements.

B. 0-ring inspection, application of radiation resistant sealant, and torquing the cover housing were not required in the maintenance procedure for WEED thermocouples each time the cover was removed.

C. 0-ring replacement and application of Dow 55M silicone grease to the body and housing cover threads and Nebula 1000 grease to the housing pipe plug threads were not required n the maintenance procedure for Rosemont transmitters each time the housing cover was removed and as necessary.

D. Replacement of the actor junction box cover gasket was not required in the maintenance procedure for MSIV blower motors 1E32-C001, 1E32-C002B and 1E32-C002F whenever the cover was removed. The failure to specify this caused invalidation of equipment qualification when Work Order 86-05531 required removal the cover of IE32-C001, but did not require gasket replacement.

E. Seal and gasket replacement was not required in the maintenance procedure for Target Rock solenoid valves each time.the housing cover was removed.

Collectively, thesc viciatiens have been categorized as a Severity Level III problem (Supplement I).

Cumulative Civil Penalty - 525,000 (assessed equally among the violations).

Pursuant to the provisions of 10 CFR 2.201, Cleveland Electric Illuminating 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 NUREG-0940 I.A-77 4

Notice of Violation 4 FEB it 1988 l

l l 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 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 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 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 of the United States in the amount of 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 Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part; (2) demonstrate extenuation 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 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 scparately from the etnement or explanation in reply pursuant to 10 CFR 2.201, but may inccrporate 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.

NUREG-0940 I.A-78

Notice of Violation 5 FEB i t 198C 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, OC 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Poad, Glen Ellyn, Illinois, 61037, and a copy to'the NRC Resident Inspector at the Perry Nuclear Power Plant.

FOR THE NUCLEAR REGULATORY COMMISSION

[(h M A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois this /% day of February 1988 NUREG-0940 I.A-79

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Docket No. 50-341  ;

1 License No. NPF-43 I EA 87-232 The Detroit Edison Company ATTN: B. Ralph Sylvia Group Vice President Nuclear Operations 6400 North Dixie Highway Newport, MI 48166 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-341/87049(DRP))

This refers to the special NRC inspection conducted during the period September 11 through November 25, 1987, at the Enrico Fernii Nuclear Power Plant, Unit 2, of activities authorized by NRC Operating License No. NPF-43.

That inspection examined the circumstances surrounding the event that disclosed a design problem in the single failure protection for the 72CF bus autor.atic throwover function. This matter, which was discovered by you on September 8,1987, and was reported to NRC on a timely basis, resulted in one violation of NRC regulatory requirements. The details are contained in the subject inspection report which was sent to you by letter dated December 17, 1987. On December 22, 1987, an enforcement conference was held between Dr. C. J. Paperiello and other members of my staf f and you and members of your staf f during which the violations, the root causes, and your corrective actions were discussed.

The violation, which is described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty, resulted from a f ailure to properly design the automatic throwover function for bus 72CF. As the design was implemented, coth divisions of the low pressure coolant injection system would be inoperable in the event of the failure of Division 1 DC control power following a large break loss of coolant accidept coupled with a loss of offsite powei. The Fermt 2 Updated Final Safety Analysis Report, Section 8.3.1.1.4, describes the design of the automatic throwover function as satisfying the "no single failure" criterion. This design problem resulted in substantial degradation of the plants ability to respond to that type of accident.

The violation emphasizes the importance of proper system design to ensure minimum availability of safety equipment. I have been authorized, af ter )

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 Twenty Five Thousand Dollars ($25,000) for the violation described in the enclosed Notice. In 1.A-80 NUREG-0940

i The Detroit Edison Company 2 FEB 11 1980 l

accordance with the "General Statement of Policy and Procedure for NRC  !

Enforcement Actions," 10 CFR, Part 2, Appendix C (1987) (Enforcement Policy), '

the violation described in the enclosed Notice has been categorized at Severity Level III. The base value of a civil penalty for a Severity Level III violation is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered and the civil penalty has been mitigated 50 percent to recognize your prompt and extensive corrective actions. Although further mitigation for self identification was not deemed appropriate, you are encouraged to pursue all technical problems in a similar timely and thorough manner.

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. You should also describe your basis for having confidence that other significant electrical design problems have not gone undetected. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further enforcement action is necessary to ensure compliance with NRC regulatory requirements, ln 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 response directed by this 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 Act of 1980, Pub. L., No.96-511.

Sincerely, A. Bert Davis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. NRC Inspection Report No. 50-341/87049(ORP)

See Attached Distribution I

NUREG-0940 I.A-81 '

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Detroit Edison Company Occket No. 50-341 Enrico Fermi Nuclear Power Plant License No. NPF-43 Unit 2 EA 87-232 An NRC special inspection conducted during the period September 11 through November 25, 1987, resulted in identification of a violation of NRC requirements.

In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR, Part 2, Appendix C (1987), the Nuclear Regulatory Conmission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2281, and 10 CFR 2.205. l The particular violation and associated civil penalty are set forth below:

10 CFR 50, Appendix B, Criterion III, "Design Control," as-implemented by the licensee's approved quality assurance program, requires that measures be established to assure that the design basis specified in the license application for systems that mitigate the consequences of postulated accidents is correctly translated into drawings.

Section 8.3.1.1.4 of the Fermi 2 Updated Final Safety Analysis Report, a part of the license application, describes the design basis for the 72CF bus automatic throwover function as satisfying the "no single failure" criterion. Bus 72CF is necessary for the operation of both divisions of the residual heat removal system in the post-accident core cooling mode to mitigate the consequences of a loss of coolant accident.

Contrary to the above, between July 15, 1985, the time of operating license issuance, and October 6, 1987, the design basis for the 72CF bus automatic throwover function to satisfy the "no single failure" criterion was not correctly translated into drawings. The as-drawn (reference Drawing No. 617212573-11, Revision L) and as-built configuration for that automatic throwover function would have allowed the failure of the Division -

1 DC control power following a loss of coolant accident with loss of offsite power to prevent throwover. This would render inoperative both divisions of the post-accident core cooling mode of the residual heat removal system.

This is a Severity Level III violation (Supplement I).

Civil Penalty - ($25,000)

Pursuant to the provisions of 10 CFR 2.201, Detroit Edison Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN:

l NUREG-0940 I.A-82 l

FEB 11 198S Notice of Violation 2 Document Control Desk, Washington, D.C. 20555, within 30 days of the date of this Notice. This reply should be clearly marked as a "Reply to a Notice of i Violation" and should include for each alleged violation: (1) the reason for I the violation if admitted; (2) the corrective steps that have been taken and the results achieved; (3) the corrective steps which will be taken to avoid further violations; (4) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in the 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.

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, draf t, or money order payable to the Treasurer of the United States in the amount of 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 Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuation circumstances, (3) show error in this

! Notice, or (4) show other reasons why the penalty should not be imposed. In I

addition to protesting the civil pen' 'j, 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 (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 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.

NUREG-0940 1.A-83

Notice of Violation 3 FEB 11 1988 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, DC 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, Illinois 61037, and a copy to the NRC Resident Inspector at the Fermi Nuclear Power Plant.

FOR THE NUCLEAR REGULATORY COMMISSION h

$0> 0.d A. Bert Davis 5

Regior.a1 Administrator j Dated at Glen Ellyn, Illinois this JJC day of February 1988 l

l NUREG-0940 I.A-84

pm Riog UNITED STATES d  % NUCLEAR REGULATORY COMMISSION g y, REGION 111 5'

0, '

E l 199 ROOSEVELT RO AD CLEN ELLYN, ILLlNOIS 60137 g * *m**' /

OEC 181987 Docket No. 50-346 License No. NPF-3 EA 87-219 i Toledo Edison Company I

ATTN: Mr. Donald Shelton l

Vice President Nuclear Edison Plaza 300 Madison Avenue Toledo, OH 43652 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-346/87028(ORSS))

This refers to the inspection conducted caring the period of October 21-30, 1987, at the Davis-Besse Nuclear Power Station, Unit 1, Oak Harbor, Ohio. The inspection was in response to a licensee-identified event involving potential access to vital area barriers. An enforcement conference to discuss the event, causes, and corrective actions was held in the Region III office on November 19, 1987.

The violation is considered significant because a potential for unauthorized, undetected access was created when mainter,ance workers removed material frow,a vital area barrier without taking adequate compensatory measures. The primary cause of this violation appears to be the failure of the maintenance staff to notify security prior to the initiation of physical modifications to the plant, a notification that would have provided an opportunity to review the implications of such work and take timely and appropriate compensatory measures. A secondary and contributing factor in this violation was the failure of the security organization to identify the weakness during the ,

periordic patrols of the area or to respond appropriately to the first report i by a maintenance worker that there might be a problem, even though it was brought to the attention of a security su:ervisbr. These events suggest that the security organization failed to carry out its responsibilities in identifying and correcting vulnerabilities that may allow uncontrolled access tc, vital areas of the plant.

To emphasize that ef fective controls be i plemented to assure the adequacy of vital area barriers, I have been authe-ized, after consultation with the Director, Of fice of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclose:: Notice of Violation and Proposed l CERTIFIED P.All RETURN RECEIPT REQUESTED NUREG-0940 I.A-85

Toledo Edison Company 2 DEC 181987 Imposition of Civil Penalty in the amount of Twenty-five Thousand Dollars

($25,000) 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) (Enforcement Policy), the violation described in the enclosed Notice has been cap gorized at a Severity Level III.

The base value of a civil penalty for a Severity Level III violatien is

$50,000. 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 of your prompt and extensive corrective ections once tha event was identified. These corrective actions included: (1) installation of barriers on the af fected areas; (2) vital area barrier walkdown; (3) revision j of a present procedure and implementation of a new procedure to improve control '

of work activities affteting security; (4) increased awareness of personnel; and (5) participation of security personnel in modification meetings.

Further mitigation is not warranted for licensee-identification and reporting in this case because the licensee had several opportunities to identify the violation prior to finally doing so. The violation existed for forty-six days before identification. A cimilar violation was discovered elsewhere in the l plant two days earlier and should have led to the identification of this violation. Furthermore, a maintenance worker had notified a member of the security force that a problem could exist, but no compensatory measures were taken.

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 plant to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of f uture inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements.

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.

Further, in your response to this letter and Notice, you should place all Safeguards Information in enclosures, so as to allow your letter (without l enclosures) to be placed in the Public Document Room. I l

NUREG-0940 I.A-86 l l

1

Toledo Edison Company 3 DEC 181W7 l

l T9e responses directed by this letter and the accompanying Notice are not s;bject to the clearance procedures of the Of fice of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.

Sincerely, A. Bert Davis Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty (JNCLASSIFIED SAFEGUARDS INFORMATION) cc w/ enclosure:

L. Storz, Plant Manager

~NRR/ORIS/SGB NRR/b?IS/ SIB cc w/ enc:osure, w/o UNCLASS1?IED SAFEGUARDS INFORKATICN:

DCD/DCB ( AIDS)

Licensing Fee Kinagement Branch Harold W. Kohn, Ohio EPA James W. Harris, State of Ohio Robert M. Quillin, Ohio Department of Health State of Ohio, Public Utilities Commission i

l NUREG-0940 I.A-87 i l

1 l

UNITED STATES

/ga att *o

~,^

NUCLEAR REGULATORY COMMIS$10N REGloN ll 3*

101 MARIETT A STREET, N.W..

t ATLANTA,GEoRotA 30323 s' **"*

• J l 00T 26 887 i

1 Docket No. 50-62 License No R-66 ,

EA 87-155 University of Virginia ATTH: Dr. Edgar A. Starke, Jr., Dean School of Engineering and Applied Science Thornton Hall Charlottesville, VA 22903 Gentlemen:

SUoJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-62/87-03)

This refers to the Nuclear Regulatory Comission (NRC) inspection conducted by F.10. Wright, P. T. Burnett, and J. Caldwell at the University of Virginia Pool Reactor on July 6-8 and 15-17,1987. The inspection included a review of the events associated with the significant potential for overexposures _of personnel in the neutron radiography facility which was identified by members of your staff and reported to the NRC on July 2, 1987. The report documenting this inspection was sent to you by our letter dated August 6, 1987. As a result of this inspection, 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 at your facility on August 13, 1987. A sumary of the Enforcement Conference was sent to you by our letter dated September 4,1987.

The violations described in Section I of the enclosed Notice of Violation and Proposed imposition of Civil Penalty involved (1) failures to perfom the surveys necessary to identify a high radiation area and to take appropriate actior to properly post and control access to the area and (2) failure to provide written procedures for the installation, operation, modificaticr. and surveillance of experimental facilities. Although the highest radiation exposure received by any individual was 270 mrem, which was less than the NRC limit, the NRC is concerned that these violations, collectively, caused a significant potential for personnel exposures in excess of NRC Limits. Radiation levels up to 180 rem per hour could have been encountered in the blockhouse had the wa*.er shield been fully drained. These .iolations also demonstrate the need for improvements in the administration and control of facility modifica-tions to ensure the safe performance of licersed activities and adherence to the h:: requirements.

With rispect to these violations, we are c: :erned c,er an apparent lack of management auth.ority to ensure that operation of your facility is conducted in a safe manner. Technical Specification 6.1.1 states that the Chaiman, Depart-ment c f Nuclear Engireering, has the overall responsibility for management of CERTIFIED MAIL  ;

RLIUD RECLIPT REQUESTED NUREG-0940 I.A-88

l l

University of Virginia OCT 261987 the facility. Technical Specification 6.1.2 states that the Reactor Facility Director has overall responsibility for facility operation. Our inspections in the area of health physics and operations have revealed that, in the recent past, when activities have been under the managerial control of the Reactor Facility Director, only minor health and safety problems have existed. But, it appears that where that control has not been fully exercised, as in this particular instance when experimental facilities were modified, adherence to I regulatory requirements involving health and safety decreases. We believe that the Chairman, Department cf Nuclear Engineering, has not given full authority to the Reactor Facility Director to control experimental facilities and their use and this was a contributing factor to this problem. Consequently, in your response to the Notice of Violation and Imposition of Civil Penalty, you should discuss management control of all aspects of facility operations.

To emphasize the need for adequate control of high radiation areas and manage-ment control of facility design and modifications made for the purpose of performing experiments, 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 Two Thousand Five Hundred Dollars ($2,500) for the violations described in Section I of the enclosed Notice. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions,"

10 CFR Part 2, Appendix C (1987) (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 problem or violation is $2,500. The escalation and mitigation factors in the Enforcement Policy were considered, and no adiustment of the base civil penalty amount has been deemed appropriate in this case. Any mitigation that may have been warranted for your prompt investigation of the circumstances surrounding this event and your prompt and extensive corrective actions to preclude its recurrence at the neutron radiography blockhouse is offset by the lack of broader corrective action to assure that a similar problem does not occur in other aspects of the operation of the facility.

The violation described in Section II of the enclosed Notice involved failures to conduct a safety evaluation of facility modifications in accordance with 10 CFR 50.59. This violation has been categorized as a Severity Level IV violation.

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 inspec-tions, the NRC will detennine whether further NRC enforcement action is neces-sary to ensure compliance with NRC regulatory requirements.

In accordance with Section 2.790 of the NRC's "Rules of Practice," Part 2, i Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room.

NUREG-0940 I.A-89

- . - . - ~.

University of Virginia OCT 261987 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, J. N 1 on Grace Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty 4

NUREG-0940 I.A-90

NOTICE OF VIOLATION AND PROPOSED IMPOSITIUTOF CIVIL PENALTY University of Virginia Docket No. 50-62 Pool Reactor License No. R-66 Charlottesville, VA 22901 EA 87-155 During the Nuclear Regulatory Commission (NRC) inspections conducted on July 6-8 and 15-17, 1987, violations of NRC requirements were identified. In accordance i with the "General Statement of Policy and Procedure for NRC Enforcement Actions,"

l 10 CFR Part 2 Appendix C (1987), the Nuclear Regulatory Comission proposes to i impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of i I 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: l I. Violations Assessed a Civil Penalty A. 10 CFR 20.201(b) requires that each licensee make or cause to be made such surveys as may be necessary for the licensee 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.

10 CFR 20.201(a) defines survey as 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.

10 CFR 20.202(b)(3) defines a high radiation area as an area, acces- l sible to personnel, in which there exists radiation originating in whole or in part within licensed material at such levels that a major portion of the body could receive in any one hour a dose in excess of 100 millirem.

10 CFR 20.203(c)(1) requires a licensee to post each high radiation area with a conspicuous sign or signs bearing the radiation caution symbol and the words: Caution, High Radiation Area.

10 CP 20.203(c)(2) requires each entrance or access point to a high radi; u an area to be equipped with a control device to reduce the radiation exposure that an individual may receive to a dose below 100 millirems in I hour upon entry br equipped with a control device which shall energize a conspicuous visible or audible alann signal in such a way as to alert an individual entering the area of the activity or be maintained locked except during periods when access to the area is required with positive control over each individual entry.

Contrary to the above, as of July 2,1987, the licensee did not make or cause to be made surveys necessary to identify a high radiaticn area ir the neutron radiograph," fEc'lity, did not take appropriate action to ensure the area was properly posted with a conspicuous sign or signs bearing the radiation caution symbol and l the words: Caution, High Radiation Area, and access to all of the entrances to the high radiation area in the neutron radiography facility was not controlled by any of the described methods. An individual could have been exposed to a dose rate of 8 rem per hour.

NUREG-0940 1.A-91

Notice of Violation 8. Technical Specification 6.3 requires, in part, that written procedures, reviewed and approved by the Reactor Safety Connittee, shall be in effect and followed for: (1) startup, operation, and shutdown of the reactor; (2) installation and removal of experiments and experimental fecilities; (3) periodic surveillance (including test and calibration) of reactor instrumentation and safety systems; and (4) preventive and corrective maintenance operations that could have an effect on reactor safety.

Contrary to the above,

1. In 1982, the neutron radiography facility, an experimental facility, was installed without written procedures.

2. Procedures were not adequate, in that, between 1983 and June 1987, the neutron radiography facility was operated without written procedures.

3. In June 1987, modifications were installed to the neutror radiography facility without written procedures.

4. Prior to July 2,1987, written procedures were not in effect for surveillance testing of the neutron detector in the neutron radiography block house access control system.

Collectively, these violations have been evaluated in the aggregate as a Severity Level III problem (Supplement IV).

Cumulative civil penalty $2,500 - (assessed equally between the violations).

II. Violation Not Assessed A Civil Penalty 10 CFR 50.59(a)(1) states, in part, that the holder of 3 license authori-zing operation of a utilization facility may make changes to the facility as described in the safety analysis report (SAR) without prior Comission approval unless the proposeo tange involves ar unreviewed safety question.

10 CFR 50.59(b)(1) states, in part, that the licensee shall maintain records of changes in the facility made pursuant to this section to the extent that these changes constitute chahges in the facility as described in the SAR. These records must include a written safety evaluation which provides the bases for the detertnination that the change does not involve an unreviewed safety questier.

Safety Analysis Report, Secti:a 5.1, states that the two 8-inch neutron beam ports are to be filled with ccncrete plugs when not in use.

Contrary to the above, in 1W., the l'ceane rade a change to the t'14ty as described in the SAR, by renoving the concrete plugs from a neutron beam port and constructing a block house at the beam port to compensate for the removed plugs, without preparing a writter safety evaluation to determine that the change did not involve an unreviewed safety question.

This is a Severity Level IV violation (Supplement I).

NUREG-0940 I.A-92

Notice of Violation Pursuant to the provisions of 10 CFR 2.201, University of Virginia (licensee) is hereby required to submit a written statement or explanation to the Director, O7fice of Enforcement, U.S. Nuclear Regulatory Comission, 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 l corrective steps that have been taken and the results achieved, (4) the correc-tive steps that will be taken to avoid further violations, and (5) the date l 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 l

Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under

! oath or affinnation.

Within the same time as provided for the response required above under 10 CFR 2.2U1, the licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, with a check, draft, l or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative arrount 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 Comission. Should l the licensee fail to answer within the time specified, an order imposing the l civil penalty will be issued. Should the licensee elect to file an answer in '

accordance with 10 FFR 2.205 protesting the civil penalty, in whole or in part, such answer should oe 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) shew error in this Notice, or j (4) show other reasons why the penalty should not be imposed. In addition to {

protesting the civil penalty, such answer may reouest 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 (1987), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statenent or explanation in reply pursuart 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 pena'ty, unless compromised, remit-ted, or mitigated, may be collected by civil actice pursuant to Section 234c of the Act, C ..S.C. 228:c.

The responses to the Director, Office of Enforcerent, noted above (Reply to a Notice of Violation, letter with paynent of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, NUREG 0940 I.A-93

Notice of Violation U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Comission, Region II.

FOR THE NUCLEAR REGULATORY COMMISSION J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia this#6dayofOctober1987 NUREG-0940 I.A-94

8 'o UNITED STATES l'

3/'

3 E NUCLEAR REGULATORY COMMISSION WASHING TON, D. C. 20555

• ,. 1

%, ...../

MAR 0 81988 l

Occket No. 50-62 License No. R-66 EA 87-155 University of Virginia ATTN: Dr. Edgar A. Starke, Jr., Dean School of Engineering ard Applied Science Thornton Hall Charlottesville, VA 22903 Gentlemen:

SUBJECT:

ORDER IMF0 SING A CIVIL MONETARY PENALTY (NRC INSPECTION REPORT NO. 50-62/87-03)

This refers to your letter dated November 18, 1987, in response to the Notice of Yiolation and Proposed Imposition of Civil Penalty sent to you by our letter dated October 26, 1987. Our letter and Notice describe several violations identified as a result of an NRC inspection. To emphasize the need for adequate control of high radiation areas and management control of facility design and modifications made for the purpose of performing experiments, a civil penalty of Two Thousand Five Hundred Dollars ($2,500) was proposed.

In your respense dated November 18, 1987, you denied the occurrence of Violations I.B.2 and I.B.4, and you admitted the cccurrence of the remaining violations. You also requested remission or mitigation of the proposed civil penalty.

In ycur November 18 response you admit Violation I.A but state that contir.uous ocnitoring of the blockhouse modification was not required because beanport shield integrity ceuld be verified by visual inspection of the water level position in the see-through water lines of the beamport fill / drain system.

Interviews with experimenters working on the bicckhouse modification showed that many of the experimenters did not know how to interpret various fluid levels in the water lines of the beamport fill / drain system. In addition, the sight tube for the beamport fill / drain system has located outside the blockhouse and would not have provided any alarm to changing shield conditions to persons working inside the blockhouse. Consequently, continuous monitoring of the blockhouse modification was required.

At the time of the enforcement conference, the NRC was not aware of the broad scope of corrective actions that were in the development stages, such as the guidelines issued for experirents conducted at your reector facility. After consideration of your response, including the evaluation of new informatien submitted after the NRC inspection on July 6-8, and 15-17, 1987, we have concluded fer the reasons given in the Appendix attached to the enclosed Order i Imposing Civil Monetary Penalty that Violation I.B.4 occurred as stated in the I l

l NUREG-0940 I.A-95

University of Virginia Notice of Violation and Proposed In. position cf Civil Peralty dated Cctcher 26, 1987, that Violation I.B.2 should te withdrawn and that mitigation of the proposed civil penalty of $2,500 by 50 percent % warranted due to your extensive corrective actions ano the withdrawal of Violation I.B.2. Acccrdingly, we hereby serve the Enclosed Order on the University of Virginia imposing a civil monetary penalty in the artcunt of One Thousand Two Hundred Fifty Collars

($1,250). We will review the effectiveness of your corrective actions during a subsequent inspection.

i In accordance with Section 2.790 of the NRC's "Rules of Practice", Part 2, l

Title 10, Code of Federal Regulations, e ccpy of this letter and the enclosure '

will be placed in the NRC's Public Document Room, Sincerely,

/

g-

\

JamesM.

i Taylor /f Executive Directer

, Deputy

/ for Regional Operations

Enclosure:

Order !raposing Civil Ponetary Penalty with Appendix l

NUREG-0940 I.A-96

l l

UNITED STATES l NUCLEAR REGULATORY COMilISSICt; j i

In the Matter of Occket No. 50-62 UNIVERSITY OF VIRGINIA License t'n. R-66 Charlottesville, VA EA 87-155 ORDER IFFOSING CIVIL FONETARY PENALTY I

The University of Virginia (licensee) is the holder of Operating Licerse No. R-66 issued by the Nuclear Regulatory Comission (NRC/Comission) cn June 24, 1960, and renewed on September 30, 1982. The license autheri:es the licensee to possess and operate the reactor as a utilization facility in accordance with the conditions specified therein.

II A special inspection of the licensee's activities pertaining to the events associated with a significant potential for overexposure of personnel in the neutron raciography facility was conducted on July 6-8, and 15-17, 1987. The results of this inspection indicatea that the licensee had not conducted its activities in full ccmpliance idth NRC requirements. A written Notice of Violation and Preposed Imposition of Civil Penalty was served upen the licensee by letter dated October 26, 1987. The L'otice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had viclated, and the amount of the civil penalty proposed for the violaticns. The licensee responded to the Notice of Violatior ard Proposed Imposition of Civil Penalty by letter dated November 18, 1987. In its response, the licensee denied Violations I.B.2 end I.B.4, admitted the remaining violations, and requested mitigation of the proposed civil peralty.

I 1

NUREG-0940 I.A-97

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 hes determined as set forth in the 1

Appendix to this Order that violation I.B.2 should be withdrawn, that the  ;

remaining violations occurred as stated in the Notice of Violation, and that a portion of the penalty proposed for the violations designated in the Notice of l violation and Proposed Imposition of Civil Penalty should be mitigated for the reasons stated in the /ppendix to the Order.

IV in view of the foregoing and pursuant to Section ??4 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:

The licersee pay a civil penalty in the amount of One Thousand Two Hundred Fifty Dollars ($1,250) 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 Connission, ATTN: Document Control Desk, Washington, DC 20555.

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 shall be addressed to the Director, Office of Enforcement, 1

NUREG-0940 I.A-98

U.S. Nuclear Regulatory Cormiissien, ATTN: Document Control Desk Washington, DC 20555, with a copy to the Regional Administrator, Regicn II.

If a hearirg is requested, the Cortission will issue an Order designating the time and place of the hearing. If the licensee falls 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 paynent has not been made by that time, the matter may te referred to the Attorney General for collection.

ln the event the licensee reouests a hearing as provided above, the issues to be considered at such hearing shall be:

(a) whether the licensee was in violation of the Comission's requirements Ls set forth in the Notice of Violation and Proposed Imposition of Civil Fenalty as amended in the attached Appendix, and (b) whether, on the basis of such violation, this Order should be sustained.

FOR THE NUCLEAR REGULATORY COMMISSION

~

w -

//t i James M. Taylor eputy Executive

/ Director for ' Regional Operation Dated at Bethesda, Maryland this 8th day of March 1988 NUREG-0940 I.A-99

APPENDIX EVALUATIONS AND CONCLUSICNS On October 26, 1987, a Notice of Violation and Proposed irrposition of Civil Penalty (h0V) was istucd for violations identified during a routine NRC inspection. The University of Virginia responded to the Notice on November 18, 1987. The licensee denied the occurrence of Violations I.B.2 and I.B.4 and admitted the occurrence of the remaining violations. The licersee also requested full remission or mitigation of the proposed civil peralty amount.

The NRC's evaluations and conclusions regarding the licensee's arguments are as follows:

I. Restatement of Violations I.B.2 and I.B.4 Technical Specification 6.3 requires, in part, that written procedures, reviewed and approved by the Reactor Safety Committee, shall be in effect l and followed for: (1) startup, operation, and shutdown of the reactor; (2) installation and removal of experiments and experimental facilities; (3) periodic surveillance (including test and calibration) of reactor instrumentation and safety systems; and (4) preventive and corrective maintenance operations that could have an effect on reactor safety.

Contrary to the above,

2. Procedures were not adequate, in that, between 1983 and June 1987, the neutron radiography facility was operated without written procedures.

4. Prior to July 2, ;987, written procedures were not in effect for surveillance testing of the neutron detector in the neutron ,

radicgraphy block house access control system. I Sumary of Licensee's Response to Violation I.8.2 The licensee admitted to not having written procedures to operate the neutron radiography facility; however, the licensee denied the violation.

The licensee contends that the lack cf experimental operating procedures for the neutron radiography facility is not a violation of Technical Specification 6.3, in that Technical Specification 6.3 addresses the safe operation of the reactor and does not cover other aspects of the operation of ancillary experimental facilities such as radiological safety.

NRC Evaluation of Licensee Respense to Violation I.B.?

NRC agrees that Technical Specification 6.3(2) aces not require written operating procedures for cxperimental facilities. Consequently, thic j violation has been withdrawn and NRC records will be adjusted accordirely.

I NUREG-0940 I.A-100 l '

1 . .

1

Appendix Sunriary of Licensee's Respense to Violation I.B.4 The licensee contends that Technical Specif1 cat b n 6.3 decs not apply to the instrurentation utilized in experimental facilities, but to reactcr instrumentatien and safety systems. The licensee states that the boron triflucride (BF neutron counter is not intended to be part of the access I controlsystem$n)ditsfunctionisthatofaredundantmonitoralongwith l the fluid level indicator to indicate beamport draining. The licensec is l of the opinion that written surveillance procedures for the counter are not needed, since its operability is automatically checked with each use of the neutron radiography facility. The licensee also stated that it would strongly consider withdrawing the counter from operation to avoid legal entanglements in ti.e future if the Ccnmission requires surveillance in accordance with written procedures. The licenseo stated that an agreement between the licensee and the inspector had been made not to require calibration of the neutron counter.

NRC Evaluation of Licensee Response to Violation I.B.4 Technical Specification 6.3 requires radiation centrol procedures to be maintained and made available to all operational personnei. The licensee response states that the BF, neutron counter was not part of an access control system. The NRC maintains that the licensee was in fact utilizing the BF ccunter and the light emitting diode (LED) sensor for blockhouse access3 control. In 1982 mcdifications were made by the licensee to the reacter shielding in such a manner as to increase the rediation hazard associated with operation of the facility. The licensee installed the two diverse access control instrumentation systens (one of which is the BF.3 neutron count (.r) thereby restoring the original margin of safety. These systems are required to be periodically tested (although not necessarily "calibrated") for radiation control purposes. Without approved written pcccedures to ensure operability of these systems, operation of the reactor in its nodified configuration is a violation of Technical Specificetion 6.3.

Aaditionally, the licensee response implies that an agrecrent had been made between the inspector and licensee representatives tc censider the BF3 counter as a redundant monitor rot requiring calibratien. The licensee was told by the inspector that calibration of the neutron counter to read dose rates would not be recuired; however, periodic surveillances described in licensee procedures would be required to ensure that the monitor ras functioning properly.

18. Sumary of Licensee's Request for Mitication In its response the licensee agrees with the assignment of a Severity Level III for the violaticns. However, the licensee believes that in view of the cpportune discovery of the violaticos, the irrtdiate reporting of the event to the NRC, the verification of no personnel exposures.above N2C limits, and the extensive corrective actions, consideration of mitigation of the proposec fine is justified.

NUREG-0940 1.A-101

Appendix  ?!RC Evaluation of Licensee's Request for Mitigation The NRC recognizes that the licensee promptly identified and reportnd the event, but does not consider mitigaticn warranted in view of the fact that the discovery of the event was fortuitous. However, in consideratien of the addition 61 broad sccpe corrective actions reported in the. licensce's November 18, 1987, respense and the withdrawal of Violation I.B.2, a sufficient basis is provided for mitigation cf the civil penalty by 50 percent to $1,250.

III. MRC Conclusion The NRC has concluded that violation I.B.2 should be withdrawn and that the remaining violations occurred as stated. In addition, in censideration of the licensee's extensive corrective actions, the civil penalty has been mitigated by 50 percent to $1,250. l l

NUREG-0940 I.A-102

l l

l l

l l

l l

l I.B. REACTOR LICENSEES, SEVERITY LEVEL III VIOLATION, NO CIVIL PENALTY NUREG-0940

I UNITEo STATES

[kn af og'o NUCLE AR REGULATORY COMMISSION y" n REGION 11 y j 101 MARIETTA STREET.N.W.

• ATLANTA. o EoRGI A 30323 k "" * ,/ ,

WAR 101988 Docket Nos. 50-348 and 50-364 License Nos. NPF-2 and NPF-8 EA 88-33 Alabama Power Company ATTN: Mr. R. P. Mcdonald Senior Vice President ]

Post Office Box 2641 Birmingham, Alabama 35291-0400 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION (NRC INSPECTION REPORT NOS. 50-348/88-02 AND 50-364/88-02)

This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by T. R. Collins at the Farley Nuclear Plant on January 4-6, 1988. The inspection included a review of the circumstances surrounding the unauthorized entry into a radiation exclusion area which was identified by your staff and reported to the NRC on January 30, 1987. The report documenting this inspection was sent to you by letter dated February 8, 1988. As a result of this inspection, significant failures to comply with NRC regulatory requirements were identi-fied, and accordingly, NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on February 17, 1988. The letter summarizing this Conference was sent to you on March 2, 1988.

The violations described in the enclosed Notice of Violation involved failures to adequately control access to a high radiation area, failures to comply with procedures for access control to radiation areas including a radiation work permit system, and failure to adequately instruct individuals on the limita-tions and precautions for working in or frequenting a restricted area. The events that resulted in these violations included a contractor providing decontamination support on December 28, 1987, following the fifth refueling outage. One of the rooms requiring decontamination was Room 450 wnich was located in the Unit 1 Auxiliary Building. This room contained high radiation areas and provided the only access to Room 449, where the spent fuel pool demineralizer was located. The "boundary" be obvious nor clearly established. Room 449 and) aween these portion oftwo rooms Room was either 450 were considered to be an exclusion area, defined as an area having radiation fields I greater than 1 res per hour. The entrance to the exclusion area was not locked, although it was barricaded by three yellow and magenta ropes and high radiation area / exclusion area warning signs. A flashing red light was also located at the exclusion area boundary. Radiation fields in the exclusion area ranged from 5 to 240 rem per hour at contact with the spent fuel pool demineralizer and approrimately 150 rem per hour at 18 inches from the surface of the tank.

Moments after a contract decontamination foreman unlocked the door t.o Room 450, a health physics technician entered the room. Subsequently, as a result of miscommunications, two contract decontamination workers entered the room to perform decontamination activities. One worker crossed the exclusion area boundary and worked in an area approximately five feet from the spent fuel NUREG-0940 1.B-1

MAR 10 $88 Alabama Power Company po si demineralizer. After approximately five minutes, this worker observed i.nat his low range dosimeter was offscale and immediately exited the room and reported to a health physics technician.

This event resulted in an unplanned exposure that violated Farley's adminittra-tive dose control of 375 millirem per week. Although the exposure to the worker during the incident was assessed at 455 millirem to the whole body, which is less than che NRC limits, the NRC is concerned that these violations created a significant potential for personnel exposures in excess of NRC limits.

The serious nature of this event indicates the need for improvements in the administration and control of your Radiation Safety Program, in maintaining adequate communications, and of your training program to ensure the safe performance of licensed activities and adherence to NRC requirements.

During the Enforcement Conference, you indicated that the use of the rope barrier, high radiation area warning signs, and a flashing light as a warning device were adequate to control access to the areas of Room 450/449 that were in excess of 1,000 millirem per hour and that these controls were permitted by your Technical Specifications. Technical Specification 6.12.2 does permit access to individual areas with dose rates in excess of 1,000 millirem per hour which are located within larger areas, such as PWR containments, to be con-trolled by roping off this area, conspicuously posting this area, and activating a flashing light as a warning device only if no enclosure exists for purposes of locking and no enclosure can be reasonably constructed around the individual area. It is our position that a lockable barrier could have been constructed at the access to the exclusion area. Therefore, the use of the rope barrier and the flashing light were inappropriate to control access to the exclusion area in Room 450/449.

In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy),

the violations described in the enclosed Notice have been categorized as a Severity level III problem. Normally, a civil penalty is proposed 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 in this case because of your prior good performance in the area nf concern. You received a rating of category 1 for the pist five Systenetic Assessment of Licensee Performance periods, and no escalated enforcement actions were taken for problems in this area during these periods. In addition, during the past two years, only one Severity Level IV violatiqn has been cited involving failure to wear the protective clothing required by the radiation work permit.

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.

I NUREG-0940 I.B-2 l

1

Alabama Power Company MAR 101988 i 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. l l

Should you have any questions concerning this letter, please contact us.  !

Sincerely, J. Nelson Grace Regional Administrator

Enclosure:

Notice of Violation cc w/ encl:

W. O. Whitt, Executive Vice President J. D. Woodard, General Manager -

Nuclear Plant W. G. Hairston, III, Vice President -

Nuclear Support J. W. McGowan, Manager-Safety Audit and Engineering Review S. Fulmer, Supervisor-Safety Audit and Engineering Review NUREG-0940 I.B-3

NOTICE OF VIOLATION Alabama Power Company Docket Nos. 50-348 and 50-364 l Farley Nuclear Plant License Nos. NPF-2 and NPF-8 EA 88-33 During an NRC inspection conducted on January 4-6, 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 (1987), the violations are listed below:

A. Technical Specification 6.12.1 requires in part that each individual or group of individuals permitted to enter a high radiation area in which the intensity of radiation is greater than 100 millirem per hour but less than 1,000 millirem per hour be provided with either a radiation monitoring device which continuously indicates the radiation dose rates in the area or continuously integrates the radiation dose rate in the area and alarms when a preset integrated dose is received, or be accompanied by a health physics qualified individual with a radiation dose rate monitoring device who is responsible for providing positive control over the activities i within the area. l Technical Specification 6.12.2 requires, in part, that in addition to the requirements of Technical Specification 6.12.1, treas accessible to personnel with radiation levels such that a major portion of the body could receive in one hour a dose greater than 1,000 millirem be provided with locked doors to prevent unauthorized entry. Doors shall remain locked except during period of access by personnel.

Contrary to the above:

1. On December 28, 1987, two decontamination workers entered Room 450/449 in the Unit 1 Auxiliary Building, a high radiation area, in which the intensity of radiation was in excess of 100 millirem per hour, without having in their possession one of the required radiation monitoring devices and without being accompanied by a health physics qualified individual who maintained positive control over the workers' activities.

2. As of December 28, 1987, a radiological exclusion area located in Room 450/449, which was accessible to personnel and which had radiation levels such that a major portion of the body could receive in one hour a dose greater than 1,000 millirem, was not provided with locked doors, but was provided with three yellow and magenta ropes, radiological warning signs, and a flashing red light, which were not adequate to prevent unauthorized entry.

B. Technical Specification 6.8.1 requires, in part, that written procedures shall be established, implemented, and maintained covering activities referenced in Appendix A of Regulatory Guide 1.33, Revision 2, 1978.

Regulatory Guide 1.33, Appendix A, Section 7.e(1), states that access control to radiation areas including a radiation work permit (RWP) system should be covered by written procedv as.

NUREG-0940 1.B-4

J Notice of Violation l Plant Procedure FNP-0-RCP-2, Radiation Work Permit, Section 4.1.2, requires !

that a special RWP be issued for specific tasks to be performed that, require entries into exclusion areas.

Plant Procedure FNP-0-M-001, Hei.th Physics Manual, Section 6.3.6, defines radiological exclusion areas as any area, cubicle, etc., with radiation levels generally in excess of I rem per hour at 12 to 18 inches from the surface which in the judgement of the Health Physics Supervisor or Health Physics Manager require precautionary measures to prevent large or unantic-ipated exposure.

l Plant Procedure FNP-0-M-001, Health Physics Manual, Section 4.1.1.7, I states that the individual will know and follow the requirements of the RWP for work being performed.

RWP 87-0010 requires that individuals have a high range dosimeter.

Contrary to the above:

1. On December 28, 1987, a decontamination worker entered a high radiation / exclusion area with dose rates up to approximately 150 rem per hour at 18 inches from the spent fuel pool demineralizer without having a special RWP prior to entry.

2. On December 28, 1987, two individuals entered a high radiation area (Room 450) on routine RWP 87-0010 to perform routine decontamination of articles and equipment without high range dosimeters as required by the RWP.

C. 10 CFR 19.12 requires, in part, that all individuals working in or frequenting any portion of a restricted area shall be kept informed of the storage, transfer, or use of radioactive materials or of radiation in such portions of the restricted area, and shall be instructed in precautions or pic edures to minimize exposure and in the purposes and functions of protective devices employed. The extent of these instructions shall be commensurate with potential radiological health protection problems in t:e restricted area.

Contrary to the above, three contract decontamination employees working in Room 450/449 in the Unit 1 Auxiliary Building (a restricted area) on December 28, 1987, were not adequately instructed in the precautions or procedures to minimize exposure for entry into exclusion areas.

These violations have been evaluated in the aggregate as a Severity Level III problem (Supplement IV).

Pursuant to the provisions of 10 CFR 2.201, Farley Nuclear Plant 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 II, and a copy to the NRC Resident Inspector, Farley Nuclear Plant, 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:

NUREG-0940 I.B-5

l Notice of 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 whi:h will be taken to avoid further violations, and (5) 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 why such other action as may be proper should not be taken. l FOR THE NUCLEAR REGULATORY COMMISSION

, a J. on Grace Regional Administrator Dated at tlanta, Georgia this /4 ay of March 1988 k

l NUREG-0940 I.8-6

l p* *

• 4 UNITED STATES i NUCLEAR RECa'JLATORY COMMISSION fT

%/-

3,g

8 R3GION IV g, $11 RYAN PLAZA DRIVE, SulTE 1000

,, , ARLINoToh. TEXAS 76011 M 4W Oocket No. 50-458 License No. NPF-47 EA 87-229 Gulf States Utilities ATTN: Mr. James C. Deddens Senior Vice President, (RBNG)

Nuclear Licensing Post Office Box 220 St. Francisville, LA 70775 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 50-458/87-28)

This refers to the inspection conducted during the period November 1-21, 1987, of activities at the River Bend Station by personnel of the NRC Region IV office. During this inspection, NRC personnel reviewed the circumstances associated with a violation of NRC requirements involving a misaligned instrument root valve which was identified by the licensee. This violation was discussed in detail at an enforcement conference December 14, 1987, at the NRC Region IV of11ce in Arlington, Texas in which you and your staff provided further details regarding the systems and components affected by the misaligned instrument root valve, the sequence of events leading up to your identification of the problem, analysis of the safety significance, and corrective actions you have implemented or plan to implement.

Violation A in the enclosed Notice of Violation (Notice) involves the failure to maintain the minimum number of channels operable as required by Technical Specifications for reactor trip system initiation, high pressure core spray (HPCS) system initiation, and various system isolation initiation. This was caused when personnel failed to open an instrument root valve for a drywell pressure sensing line which served three pressure transmitters. This valve remained closed from August 1985 to November 17, 1987. With this valve closed, various automatic safety functions initiated by a high drywell pressure signal (i.e., reactor scram, HPCS initiative, and system isolation) were unavailable for short periods of time while required periodic testing was perfDrmed and at other times channel redundancy was lost for these various safety functions. The NRC recognizes that other system initia$lon signals were unaffected and that alarms and indications existed in the control room which could have alerted personnel to a high drywell pressure condition. We also note that this violation and Violation B of the enclosed Notice, while separated by a period of two years, both involved the failure of operations management to ensure that procedures were followed in the perforinance of valve lineups.

In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2. Aopendix C (1987), Violation A described in the enclosed Notice has been classified at a Severity level 111. A civil penalty is considered for a Severity Level !!! violation. However, after CERTIFIED Mall RETURN RECEIPT REQUESTED NUREG-0940 I.B-7

l l

Gulf States Utilities 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 of your prompt identification and reporting of the violation and the unusually prompt and extensive corrective actions, including a detailed evaluation. However, further similar incidents may result in civil penalty action.

While we view this Severity Level III violation as a serious problem requiring  !

strong management action, we also recognize that this problem was identified because of your self-initiated action to verify safety-related valve lineups during this refueling cutage. Without this self-initiated action, this problem may have gone undetected for another refueling cycle or longer. Also, we note ,

that this problem was identified by plant personnel and immediately brought to 1 management and NRC attention and you have encouraged this climate by formally commending the operators who discovered the problem, a practice which the NRC encourages from all licensees.

Two violations (B and C) are also described in the enclosed Notice and have been categorized as Severity Level IV violations. These violations involved the failure to follow procedures while doing an inservice reactor pressure vessel leakage test and for processing an extension for a modification request.

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.

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 of 1980, Pub. L. No.96-511, i Sincer y, g

l obert D. Martin

Regional Administrator

Enclosure:

Notice of Violation cc:

Louisiana Radiation Control Program Director NUREG-0!40 1.B-8

\ . _ _ .

NOTICE OF VIOLATION Gulf States Utilities Docket No. 50-458 River Bend Station License No. NPF-47 EA 87-229 During an NRC inspection conducted on November 1-21, 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 (1987), the violations are listed below:

l l

A. Technical Specifications Limiting Conditions for Operations (LCO) 3.3.1, 3.3.2, and 3.3.3 require that the following minimum channels of Drywell Pressure-High remain operable: two channels per trip system for reactor protection system (RPS) initiation (operational conditions 1 and 2); two channels per trip system for primary and secondary containment and residualheatremoval(RHR)systemisolation(operationalconditions1) 2, and 3); and four channels for high pressure core spray system (HPCS initiation (operationalconditions1,2,and3). With less than the minimum number of channels operable, the associated LC0 action statement requirements include placing the inoperable channel (RPS or isolation actuation) and/or the trip system in the tripped condition within one hour and declaring the HPCS system inoperable.

Contrary to the above, from August 1985 to November 17, 1987 while the plant was operating in conditions 1, 2, or 3, one of two channels in one trip system for RPS initiation, primary and secondary containment isolation, and RHR system isolation were inoperable, and two of four channels for HPCS initiation were inoperable. The channels were inoperable when an instrument root valve (1RCS-V122) for a drywell pressure sensing line was closed, thereby isolating three pressure transmitters, and actions were not taken to meet the action statement requirements.

This is a Severity Level III violation (Supplement I).

B. Technical Specification 6.8.1.d requires that written procedures shall be established, implemented and maintained for surveillance and test activities of safety-related equipment.

Step 7.7.4 of Temporary Procedure (TP) 87-25, "RPV Inservice Leakage Test," Revision 0, which provides instruction for the inservice leakage test on the reactor pressure vessel, requires that the operator secure shutdown cooling by stopping both RHR pumps and closing shutdown cooling isolation valves E12*F053A, E12*F0538, E12*F008 and E12*F009.

Contrary to the above, on November 19, 1987, step 7.7.4 of TP 87-25 was improperly signed off by the responsible shift supervisor due to confusion in the procedures, although the required valve manipulations for E12*F008 and E12*F009, described among other items in step 7.7.4, had not been performed. l This is a Severity Level IV violation (Supplement I). I NUREG-0940 I.B-9

i L

Notice of Violation C. Technical Specification, 6.8.1.a requires that procedures shall be established, implemented, and maintained for activities recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Paragraph 9 of Appendix A to Regulatcry Guide 1.33 delineates procedures for control of modification work.

Pursuant to Regulatory Guic e 1.33, Procedure ENG-3-006, "River Bend Station Design and Modification Re modification request (PMR) quest.

cannot Control Plan,"

be cancelled requirestothat (i.e. converted a if a prompt modification request or system returned to original configuration) by the date indicated in block 23, a memorandum explaining the need for an extension and the new cancellation date must be prepared, approved and forwarded to document control for permanent retention.

Contrary to the above, on November 17, 1.987, it was found during a review of the PMR status log that extension memoranda had not been approved for 16 PMRs that were not cancelled by the due date. Examples include, PMR 86-98 (due September 15,1987); PMR 86-128 (due October 7,1987) and PMR l 87-35 (due October 23,1987). l This is a Severity Level IV Violation (Supplement 1).

Pursuant to the provisions of 10 CFR 2.201, Gulf States Utilities is hereby required to suhit a written statement or explanation to the U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, Region IV, and a copy to the NRC r Resident Inspector, 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 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 action as may be proper should not be taken. Where good cause is shown, consideration will be given to extending the response time.

FOR THE NUCLEAR REGULATORY COMMISSION

/

/

Ac &

Robert D. Martin Regional Administrator t Arlington, Texas, DatedgdayofMarch1988.

thisy NUREG-0940 I.B-10 l -

,/ UNITED STATES

$ NUCLEAR REGULATORY COMMISSION y j REGION I w

• 476 ALLENDALE RoAo KING oF PRUCSI A. PENNSYLVANIA 1H06 March 28,1988 Docket No. 50-322 License No. NPF-36  !

EA 87-173 Long Island Lighting Company ATTN: Mr. John D. Leonard, Jr.

Vice President - Nuclear P. O. Box 618 Shoreham Nuclear Power Station Wading River, New York 11792 Gentlemen:

Subject:

NOTICE OF VIOLATION (NRC Inspection Report No. 50-322/86-03; and NRC 01 Investigation Reports Nos. 1-86-003 and 1-86-008)

This refers to the NRC inspection conducted on January 27 - February 14, 1986, and two subsequent investigations conducted by the NRC Office of Investigation (01) in response to an allegation received by the NRC concerning deficiencies in the radiochemistry department at Shoreham. During the inspection and investigations, five violations of NRC requirements were identified. The inspection report was sent to you on March 14, 1986. The synopsis for each 01 Report is enclosed.

Three of the violations were identified during the inspection and included two significant deficiencies in the training and qualification of radio-chemistry personnel, as well as the failure to maintain control charts for results of control standards for chloride analysis. These violations were discussed with you and members of your staff at an enforcement conference conducted in the Region I office on March 20, 1986. At that conference, you also discussed the underlying causes of the violations as well as your correc-tive actions. Two other violations, which were not discussed at the enforce-ment conference but were subsequently identified during the two O! investiga-tions, involved two examples of falsification of records, in one instance by a former radiochemistry foreman, and in another instance by a former nuclear ,

chemistry technician at the direction of another former radiochemistry foreman, i The violations, which are described in the encidsed Notice of Violation, apparently were caused by a lack of management involvement in monitoring imple-mentation of the radiochemistry program. Although the program for training and  ;

qualifying personnel in the radiochemistry department appeared adequate, it was I not properly implemented. Furthermore, even though your Quality Assurance Department identified such deficiencies in the program curing an audit conduc-ted in May/ June 1985, management was not responsive to these findings and little, if any, action was taken to correct these deficiencies until af ter the NRC inspection was initiated. This failure to respond to internally identified  ;

audit findings is of significant concern to the NRC.

i NUREG-0940 I.B-11

long Island Lighting Company 2 In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the violations described in the enclosed Notice have been classified in the aggregate at a Severity Level III problem, to focus on the underlying concerns, namely, a breakdown in management control of the radiochemistry department, in partic-ular, the training and qualification of radiochemistry personnel, and a i failure to be responsive to these findings once identified by the Quality Assurance Department. A civil penalty is normally 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 in this case because (1) your prior enforcement history in this area has been good, as evidenced by a Category I rating during the two SALP periods prior to the inspection; and (2) extensive corrective actions were taken once management was informed of these concerns by the NRC.

Nonetheless, we emphasize that any similar deficiencies in training programs at Shoreham, any similar failures to respond to QA findings, or any similar incidents involving falsification of records, may result in more significant enforcement actions, including civil penalties and/or Orders.

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, including actions taken to ensure thrt (1) deficiencies identified at your facility, including those identified by the Quality Assurance Department, are promptly corrected, and (2) your staff, as well as the staf f of any contractors you employ, are aware that falsification of records is a serious offense that cannot and will not be tolerated. 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.

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.

Sincerely, William T. Russell Regional Administrator l

NUREG-0940 1.B-12

1

)

NOTICE OF VIOLATION Long Island Lighting Company Docket No. 50-322 Shoreham Nuclear Power Station License No. NPF-36 j EA 87-173' 1 l

I i During an NRC inspection conducted on January 27 - February 14,-1986, and

subsequent investigations conducted by the NRC Office of Investigations, violations.of NRC requirements were identified. -In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions,"

, 10 CFR 2, Appendix C (Enforcement Policy) (1987), the violations are set forth below:

A. Technical Specification 6.4, "Training", requires, in part, a retraining and replacement program for the station staff be maintained under the Training Supervisor that meets or exceeds the requirements of Section 5 of ANSI N18.1 - 1971. ANSI N18.1 - 1971, Section 5, establishes requirements for training radiochemistry technicians.

Procedure SP No. 71.006.01, written pursuant to the requirements of Technical Specification 6.4, requires that individual technicians demon-strate practical abilities by either following procedure checkout guidelines or through technician task evaluation guides.

Contrary to the above, as of February 1986, the practical abilities of chemistry technicians were demonstrated by open book exams rather than by the use of procedure checkout guidelines or through the use of task

evaluation guidelines.

Technical Specification 6.3.1, "Unit Staff Qualification", requires, in

~

B.

part, that each member of the unit staff shall meet or exceed the minimum qualifications of ANSI N18.1 - 1971 for comparable positions. ANSI-N18.1

- 1971 requires that repairmen in responsible positions shall have a minimum of three years in one or more crafts, i

j Contrary to the above, as of February 1986, radiochemistry technicians, repairmen in responsible positions, routinely performed electrical repair maintenance on electronic equipment of the Radiation Monitoring System, including safety related equipment, without any training or previous f

background in the electronics craft, C. Technical Specification 6.8.1.a "Procedures and Programs", requires that l

, written procedures be established, implemented and maintained covering the activities of Appendix "A" of Regulatory Guide 1.33, Revision 2, February, 1978. Appendix "A" of Regulatory Guide 1.33 requires chemistry and radiochemistry procedures.

i l

i  !

t NUREG-0940 I.B-13 1

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= - . - .

_ . ~ --_. _ . . _ .- . .

2 Chemistry Procedure SP 78.011.38, "Chloride Analysis, Specific lon l

Electrode Method", written pursuant to the requirements of Technical l Specification 6.3.1.a, requires the use of control charts for plotting results of control standards for chloride analysis which is required by the Technical Specifications.

Contrary to the above, between November, 1985 through February, 1986, control charts for plotting results of control standards for chloride analysis which were required by the Technical Specification were not used.

D. Technical Specification 6.8.1.d requires that written procedures be j established, implemented, and maintained covering surveillance and test act,1vities of safety-related equipment.

Station Procedure SP No. 74.631.17, "RBSVS Normal Range Radiation Monitor Functional Test" written pursuant to the requirements of Technical Speci-3 fication 6.8.1.d, requires that procedural steps on the surveillance of certain safety related equipment be initialed off as they are performed.  ;

Contrary to the above, on November 21, 1985,- surveillance testing of Panel 21 of the safety-related Reactor Building Standby Ventilation System was initiated, and

1. the procedure was signed off as complete, by a Nuclear Chemistry Technician, even though he had not completed and initialed all the procedural steps; and

(

j 2. the procedural steps were subsequently initialed by a Radiochemistry

) Foreman using the initials of the Nuclear Chemistry Technician, and ,

i these procedural steps had not been performed.

E. Appendix "B" to License NPF-36 incorporates New York State Discharge Permit No. 0026344 The New York State Discharge Permit No. 0026344 -

, requires that water samples from Outfalls 002 and 003 must be collected during the middle and end of each month for analysis. Section 5.2 of Appendix "B" requires that records and logs relative to environmental aspects of facility operation shall be made and retained in a* manner '

convenient for review and inspection.

Contrary to the above, 1, water samples were not collected for Outfalls No. 002 and 003 in  !

j mid-December, 1985; and 2, when it was discovered in January, 1986 that no mid-December, 1985 '

sample was available for analysis, a sample from a different collection was analyzed and its results were recorded in a discharge .

i log as results of water samples'from mid-December, 1985.

I i

NUREG-0940 1.B-14 ,

i ya-s p - e +-+- tr e +s---- - - --

3 These violations are categorized in the aggregate as a Severity level III problem (Supplements I and IV).

Pursuant to the provisions of 10 CFR 2.201, Long Island Lighting Company 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 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 l l violation: (1) the reason for the violation if admitted, (2) the corrective '

steps that flave been taken and the result 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 issued to show cause why the license should not be modified, suspended, or revoked or why such action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown.

FOR THE NUCLEAR REGULATORY COMMISSION William T. Russell Regional Administrator Dated + King of Prussia, Pennsylvania this day of March 1988 NUREG-0940 I.B-15

II. A. PATERIALS LICENSEES, CIVIL PENALTIES AFD ORDERS NUREG-0940

j 3'

7"%$ UNITED STATES l j

l NUCLEAR REGULATORY COMMISSION I E

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REGION ll 101 W ARIETT A ST N.W.

j ATLANTA, GioRGIA 30323 00T 271987 Docket No. 030-29017 License No. 47-17725-02 l EA 87-157 Beckley Appalachian Regional Hospital ATTN: Mr. Roger Wolz Administrator 306 Stanaford Road I Beckley, WV 25601 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 47-17725-02/87-01 AND 47-17725-02/87-02)

This refers to the Nuclear Regulatory Comission (NRC) inspections conducted by S. L. Waldron on July 27, 1987, and R. A. Brown on August 15, 1987, at Beckley Appalachian Regional Hospital. The first inspection included a review of activities conducted under your license with respect to radiation safety and compliance with NRC regulations and the conditions of your license. The second inspection included a review of the circumstances surrounding your report of an extremely high (374 rem) film badge reading which, after evaluation, was considered to be a photodosimetry error. The reports documenting these inspections were sent to you by letters dated August 7 and September 14, 1987.

As a result of these inspections, violations of NRC regulatory requirements and i conditions of your license were identified. Accordingly, NRC concerns relati"e to the inspection findings were discussed during Enforcement Conferences held at your facility on August 12, 1987, and by telephone on September 10, 1987.

Letters sumarizing these conferences were sent to you on August 28 and September 17, 1987.

The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty involved failure of the Radiation Safety Comittee to conduct quarterly meetings, of the Radiation Safety Officer to review radiation surveys quarterly, of the licensee to possess a Barium-133 source to perform instrument accuracy and constancy tests, of personnel to perform wipe tests on packages received, of the licensee td use sufficiently sensitive instrumentation for performing area wipe tests, of the licensee to record area wipe survey results in the proper units of measure, of the licensee to ime-diately report a reading of 374 rers on an employee's film badge, of the licensee to maintain records shcwing the results of the evaluation of the circumstances surrounding the extremely high reading on the film badge, and of the licensee to maintain accurate records showing radiction exposures. These violations demonstrate the need for prompt and aggressive action to improve the administration and control o' ycur Radiation Safety Program to assure the safe performance of licensed activities and adherence to NRC requiremer.ts.

CERTIFIED MAIL RETURN RECEIPT RE0 VESTED NUREG-0940 II.A-1

Beckley Appalachian Regional Hospital OCT 2 7 N1 To emphasize the need for adequate management control of your Radiation Safety Program, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to i issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty l in the amount of Five Thousand Dollars ($5,000) 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 (1987)

(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 problem is $2,500. The escalation and mitigation factors in the Enforcement Policy were considered and the base '

civil penalty amount has been increased by 100 percent because of your prior poor performance in the area of concern and the ineffectiveness of previous corrective actions for similar problems. ,

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. Violations A.1, A.3, and A.4 are similar to violations described in the Notice sent to you by our letter dated December 18, 1986, Because "similar violations," as described in the NRC Enforcement Policy, are of significant concern to the NRC, please give particular attention in your response to the identification of the root causes of these problems and your corrective action 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 including license suspension or modification 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.

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.

Should you have any questions concerning this letter, please contact us.

Sincerely.

h J. NeTson Grace

/ Regional Administrator

Enclosure:

Notice of Violation and Proposed Irtposition of Civil Penalty NUREG-0940 II.A-2 l

NOTICE OF VIOLATION AND PROPOSED IMPOSITIDT0F CIVIL PENALTY Beckley Appalachian Regional Hospital Docket No. 030-29017 Beckley, WV License No. 47-17725-02 EA 87-157 During the Nuclear Regulatory Connission (NRC) inspections conducted on July 27

, and August 15, 1987, violations of NRC requirements were identified. In accordance with the "General Statement of Polic ment Actions," 10 CFR Part 2, Appendix C (1987)y and Regulatory

, the Nuclear ProcedureConnis-for NRC Enforce-sion 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:

A. License Conditions 14.A and 14.C require that licensed material be used in accordance with statements, representations, and procedures contained in your application dated September 19, 1985, and contained in infonnation received February 13, 1986, which includes Beckley Appalachian Regional Hospital's ALARA Program signed by Dalton G. Smart, Administrator.

1. Section 7, Appendix B, of the application requires the Radiation Safety Connittee to treet no less than once each calendar quarter.

Contrary to the above, between December 12, 1986 and July 28, 1987, no Radiation Safety Connittee meetings were conducted.

This is similar to a violation issued on December 18, 1986.

2. Item 3.a(3) of the ALARA Program requires the Radiation Safety Officer (RS0) to review records of radiation level surveys quarterly.

Contrary to the above, the RSO did not review radiation level surveys between August 14, 1986 and July 27, 1997.

3. Section 10, Appendir D, Calibration of Dose Calibrator, item B, requires that the licensee use Cobalt-57. Barium-133, and Cesium-137 sources to perform instrument accuracy and constancy tests.

Contrary to the above, as of July 29,1987, the licensee did not possess and therefore could not use a Barium-133 source to perform instrument accuracy and constancy tests.

This is similar to a violation issued on Decerber 18,19EE.

4. Section 14, Appendix F, item 2.f, of the application requires that a wipe of the externa *. surface of the final source container be made when cpening packaces containing radioactive caterial.

Contrary to the abcve, the licensee did not perform wipe tests of the final source containers on packages received between August 14, 1986 and July 28, 1987.

This is similar to a violation issued on December 18, 1986.

i NUREG-0940 II.A-3

Notice of Violation 5. Section 17, Appendix I, item 4.b, of the application requires that the method for performing area wipe test be sufficiently sensitive to detect 200 dpm per 100 cme ,

Contrary to the above, the licensee used a Capintec Model CRC-7 dose calibrator to analyze the area wipe test of approximately 100 cme ,

The Capintec Model CRC-7 dose calibrator has a minimum detectable activity of approximately 22,000 dpm.

B. 10 CFR 20.401(b) requires the licensee to maintain records of surveys in i the same units used in 10 CFR Part 20.

10 CFR 20.5(a) requires that radioactivity be measured in tenns of dis-integrations per unit time or in curies.

Contrary to the above, between December 4,1986 and July 28, 1987, the licensee obtained results of area wipe surveys in units of millicuries i and erroneously recorded them in units of millirem per hour.

l C. 10 CFR 20.403(a) requires, in part, that each licensee immediately report any event involving by-product material possessed by the licensee that may have caused or threatened to cause exposure of the whole body of any '

individual to 25 rems or more of radiation.

Contrary to the above, a reading of 374 rems to a film badge assigned to an employee was reported to the licensee by the supplier on March 12, 1987. This possible exposure was not officially reported to the NRC imediately, and the NRC was not aware of the badge reading until a July 27, 1987 inspection, at which time the exposure was considered by the licensee to be a photodosimetry error.

D. 10 CFR 20.401(b) requires that each licensee maintain records showing the ,

results of surveys required by 10 CFR 20.201(b). "Survey" as defined in 10 CFR 20,201(a) is an evaluation of the radiation hazards incident to the use of radioactive material.

Contrary to the above, in March 1987, the licensee did not record the results of an evaluation of the circumstances surrounding a reading of -

374 rems recorded on the film badge of a radiology technologist.

E. 10 CFR 20.401(a) requires that each licensee maintain records showing the radiation exposures of all individuals for whom personnel monitoring is required under 10 CFR 20.202.

Contrary to the above, a film badge exposure of 2380 millirems, which the licensee concluded was not received by the individual to which the badge was assigned, was not removed from the individual's exposure reco-d.

These violations have been assessed in the aggregate as a Severity Lem ' 'f? l problems (Supplement IV and VI).

Cumulative Civil Penalty - $5,000 (assessed equally among the viola NUREG-0940 II.A-4  ;

1 1

Notice of Violation Pursuant to the provisions of 10 CFR 2.201, Beckley Appalachian Regional Hospital 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 "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 I admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further vic'.ations, 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 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 pen-alties 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 Comission. Should the licensee fail to answer within the time specified, an order ixposing 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 mitigaticn 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 explar.ation in reply pursuant to 10 CFR 2.201 but may inc rporate 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 l

, in accordarce with the applicable provisions of 10 CFR 2.205, this matter may

, be referred to the Attcrney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action purst; ant to Section 234c

. of the Act, 42 U.S.C. 2282c.

The responses to the Directer, Office of Enforcement, noted abeve / Reply to a Notice of Violation, letter with paymer,t of civil penalty, arc Answer to a NUREG-0940 II,A-5

Notice of Violation 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 !!. .

j FOR THE NUCLEAR REGULATORY COMMISSION

/<-- . e son Grace

'/ Regional Administrator Dated a,t Atlanta, Georgia thisa?& day of October 1987 i

f I

i NUREG-0940 II.A-6 l

+p. ...m'o, UNITED STATES

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5

• ht NUCLEAR REGULATORY COMMISSION W ASMING TON, D. C. 20655 NAA 0 81888 Docket No. 030-29017 License No. 47-17725-02 EA 87-157 Beckley Appalachian Regional Hospital ATTN: Mr. Roger Wolz Administrator 306 Stanaford Road Beckley, West Virginia 25601 Gentlemen:

SUBJECT:

ORDER IMPOSING CIVIL MONETARY PENALTY (hRC INSPECTION REPORT NOS. 47-17725-02/87-01 AND 47-17725-02/87-02)

This refers to your letters of November 20 and December 11, 1987, in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you by letter of October 27, 1987. Our letter and Notice described violations identified during the inspections conducted at your facility by Region II persennel on July 27 and August 15, 1987. The violatiers were also discussed during Enforcement Conferences conducted at your facility on August 12, 1987, and by telephone on September 10, 1987. To errphasize the significant nature of the violations and the need for improved management control over your radiation safety program a civil penalty of Five Thousand Dollars ($5,000) was proposed, in your responses, you admitted and provided corrective actions for violations A.1, A.3, A.4, A.S. and B. You also denied violations A.2 C, D, and E; and although violation A.2 was denied, corrective actions for this violation were also provided. Additionally, full mitigation of the proposed civil penalty was requested due to the licensee's financial status and inability to pay.

After careful review cf your responses, we have concluded for the reasons given in the Appendix attached to the enclosed Order Imposing Civil Monetary Penalty that violation A.? occurred as stated and that a sufficient basis dees exist to warrant withdrawal of violations C, D, and E. Our records will be adjusted accordingly. Due to these changes and your apparent finarcial situation, we have also concluded in this case that mitigation of the $5,000 proposed civil penalty to $1,000 is warranted. Accordingly, we hereby serve the enclosed Order on Beckley Appalachian Regional Hospital imposing a civil monetary penalty in the amount of $1,000. We will review the effectiveress of your corrective actions during a future inspection.

While we are mitigating the penalty, we must emphasize the need for you as the licensee to understand and comply with your license. Misunderstanding of your license or actions of your consultants does not excuse noncompliance. Failure to take long term corrective action for these violations may result in escalated enforcement actions in the future.

CERTIFIED MAIL RLIURN RtctIPT REOUESTED NUREG-0940 II.A-7

Beckley Appalachian Regional Hospital Additionally, in your response of November 20, 1987, you made several statements to the effect that you were advised by the NRC inspector to take certair actions. You should be aware that it is not NRC's policy to advise the licensee on operational matters. Responsibility for operations, program management, and compliarce with NRC requirements rests solely with the licensee and not the NRC. From time to titre inspectors may refer to MRC regulatory guides and acceptable industrial prectices or standards which provide programatic ouidance; however, reference to such guides, practices, or standards must not be construed as direction from NRC. This matter is addressed further in the Appendix attached to the enclosed Order to this letter.

The NRC plans to conduct followup inspections to verify that corrective actions have been taken for the problems identified. The NRC believes that you and your managerent team should be taking an active role in ensuring that your radiation safety program requirements are met.

4 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 enclosure will be placed in the NRC's Public Document Room.

No response to this letter is required.

Sincerely, h #[,b J Tay1 , Deputy Executive Director for Regional Operations

Enclosure:

Order Inposing Civil Monetary Penalty and Appendix 1

NUREG-0940 II.A-8

UNITES STATES NUCLEAR REGULATORY COMMISSION In the Matter of )

) Docket No. 030-29017 BECKLEY APPALACHIAN REGIONAL HOSPITAL ) License No. 47-17725-02 Beckley, West Virginia ) EA 87-157 ORDER IMPOSING CIVIL MONETARY PENALTY I

Beckley Appalachian Regional Hospital (licensee) is the holder of Haterial License No. 47-17725-02 issued by the Nuclear Regulatory Commission (NRC/

Connission) on April 7,1986. The license authorizes the licensee to employ the use of radioactive materials for diagnostic purposes in patients in accordance with the conditions specified therein.

II A routine unannounced inspection of the licensee's activities was conducted '

on July 27, 1987. The results of this inspection indicated that the licensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposea Imposition of Civil Penalty was served upon the licensee by letter dated October 27, 1987. 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 of Violation and Proposed Imposition of Civil Penalty by letters dated November 20 and December 11, 1987.

In its response, the licensee denied violations A.2. C, D, and E, admitted the remaining violations, and requested nitigation due to the licensee's financial status and inability to pay.

{

NUREG-0940 II.A-9

III After consideration of the licensee's respenses and the statements of fact, explanation, and argument for mitigation contained therein, the NRC staff has determined as set forth in the Appendix to this Order that violations C, 0, and E should be withdrawn, that the remaining violations occurred as stated, and that a portion of the civil penalty propnsed for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be mitigated.

IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 4? U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT:

The licensee pay a civil penalty in the amount of One Thousand OcIlars

($1,000) within 30 days of the date of this Order, by check, draft, or money order, payable to the Treasurer of the linited States and mailed to the Director, Office of Enfercement, U.S. Nuclear Regulatory Consnission, ATTN: Document Control Desk, Washingten, DC 20555.

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 shall be addressed to the Director, Office of Enforcement, l

i NUREG-0940 II.A-10

U.S. Nuclear Regulatory Comission, 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.

If a hearing is requested, the Comission will issue an Order designating the ,

time and place of the hearing. If the licensee fails to request a hearing withf:110 days of the date of this Order, the provisions of this Order shall be effective without further proceedings. If payment has not been made by that the, the matter may be referred to the Attorney General for collection.

In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be:

j (a) whether the licensee was in violation of the Comission's requirements as set forth in the Notice of Violation and Proposed Impesition of Civil Penalty referenced in Section II above as amended in the Appendix to this Order, and (b) whether, on the basis of such violation, this Order should be sustained.

FOR THE NUCLEAR REGVLATORY COMMISSION k_

iafesM.Tay1 , Deputy Executive Director f for Regional Operation Dated at Bethesda, Maryland h  ;

this 8th day of March 1988  !

NUREG-0940 II.A-11

APPENDIX EVALVATION AND CONCLUSION By a letter dated November 20, 1987, the licensee responded to the Notice cf Violation and Proposed Imposition of Civil Perelty dated October 27, 1987. In a letter dated December 11, 1987, the licensee restated its response to viola-tion A.2. In these responsos, the licensee denied four violations and presented corrective actions for one of the denied violetions. The licensee also provided financial inforration and asserted that the licensee was following a prior inspector's instructions on certain procedures. The licensee requests mitica-tion of the civil penalty based on the inability to pay and the fact that the licensee has spent $5.991 on corrective actions as of December 11, 1987. The NRC s evaluations and conclusions regarding the licensee's arguments are as follows:

Restatement of Violation A.1 License Conditions 14.A and 14.C require that licensed material be used in accordance with statements, representations, and precedures contained in the application dated September 19, 1985, and in information received February 13, 1986, which includes Beckley Appalachian Regional Hospital's ALARA Program signed by Dalton G. Smart, Administrator.

Section 7. Appendix B, of the application requires the Radiation Safety Committee to meet no less than once each calendar quarter.

Contrary to the above, between December 12, 1986 and July 28, 1987, no Radio-tion Safety Cennittee meetings were conducted.

This is similar to a violation issued on December 18, 19E6.

Licensee's Response l The licensee admitted to the violation but stated that the Nuclear Medicine imaging equipment vendor representative informed them that the Radiation Safety Committee was to reet semi-annually.

i NRC Evaluation In a Notice of Violation dated December 18, 1966, violation A referenced the same licensee conditions as the Notice of Violation of October 27, 1987.

l Violation A of the Notice dated December 18, 1986, stated that the Radiation

! Safety Cemnittee is required to meet once each calendar cuarter. The licensee's contention that it was misinformed on the required meeting frequency is rejected ilue to the previcus citation of the sant violation. In addition, the license requirements clearly specify that such meetings will be held no less than cuarterly.

)

i I

! NUREG-0940 II.A-12

Appendix Restatement of Violation A.2 License Conditions 14.A and 14.0 require that licersed material be used in accordance with statements, representations, and procedures contained in the application dated September 19, 1985, and in information received February 13, 1986, which includes Beckley Appalachian Regional Hospital's ALARA Prcgram signed by Dalton G. Smart Administrator, ftem 3.a(3) of the ALARA program requires the Radiatien Safety Officer (RS0) te review records of radiation level surveys quarterly.

Contrary to the above, the RSO did not review radiation level survey records besween August 14, 1986 and July 27, 1987, t.icensee's Response In the response dated November 20, 1987, the licensee denied the violation, stating the RSO reviews and initials the radiation level surveys monthly and that the inspector did not review the documents during the July 1987 inspection.

In the supplemental response dated Decerrber ll,1987, the licensee withdrew the l Jenial; by implication, and stated appropriate corrective action.

l NRC Evaluation Upon review of the licensce's response, it was evident the licensee was mistaken as to what records the violation referenced. Violations A.5 and B refer to the radiation level surveys also, and the licensee admitted te both of those violations. As evidenced by the citations, the inspecter did review the docurents and clarified this with the licensee in a telephone conversation on December 2, 1987. The licensee submitted a supplemental response dated December 11, 1987, and stated an appropriate corrective action. In view of these additional clarifications, the violation remains as stated.

Restatenent of Violation A.3 License Conditions 14.A and 14.C require that licensed traterial be used in acccrdance with statements, representations, and crocedures contained in the application dated September 19, 1985, and contained in information received February 13, 1986, which includes Beckley Appalachian Regierial Hospittl's ALARA Program signed by Dalton G. Sr'. art, Administrator.

Sectico 10, Appendix D. Calibratien of Dose Calibrator, item 8, requires that the 1 k esee use Cobalt-57. Barium-133, and Cesium-137 scurces to perform instrurrent accuracy and constancy tests.

Contrary tc the above, as of July 27, 1987, the licensee did r.ot possess ano therefore could not use a Barium-133 source ce perform instrument accuracy anc constancy '.ests.

This is similar to a violation issued on Decerrber 18,19E6.

NUREG-0940 II.A-13

Appendix Licensee's Response The licensee admitted to the violation but stated the NRC inspector in December 1986 instructed t h to obtain Cc-57, Co-60, and Cs-137 sources for performing constancy chet en the dose calibrator. The licensee contends '. hey were cited'by the inspect in July 1987, for following recomendaticos given by the previous inspector in December 1986.

The licensee also stated that the violation is not similar to a previcus violation, since the constancy checks were being performed, but only lacked the Ba-133 source. The licensee states the Ba-133 source was not used because the previous inspector did not instruct them to use it.

Additionally, the licensee referred to NRC Regulatory Guide 10.8, Revision 2, August 1987, and stated that it does not require the use of a Ba-133 source for the constancy checks.

NRC Evaluation Licensees frequently request information from inspectors concerning NRC regulatory requirements NRC inspectors do not give specific instructions for obtaining compliance but occasionally will cite examples of acceptable practices. The responsibility for compliance lies solely with the licensee. To achieve compliance, the licensee must be thoroughly familiar with the pertinent regulations and commitments submitted in its application and additional letters referenced in the license. The inspector who conducted the December 1986 inspection recalls that he provided a copy of the licensee's application and referenced information since the hospital employees could not locate their documents. He also left a copy of NRC Regulatory Guide 10.8, "Guide for the Preparation of Applications for Medical Use Programs," which contains varicus procedures the licensee comitted.to perform in its application. The inspector recalls that he did review the material with the licensee but did not give specific instructions in achieving compliance. The inspector conducting the inspection of July 1987 states she also left copies of the licensee's appli-cation and backup information, as well as NRC Regulatory Guide 10.8, as the licensee employees were again not able to locate the documents. It is apparent the licensee did not thoroughly review the pertinent material left by the inspector in December 1986 to achieve regulatory compliance.

Appendix D, Page 10.8-30, referenced in the license application lists the sources the licensee commited to use for the constancy checks: Co-57, Ba-133, and Cs-137. The licensee asserted that this violation was mistakenly referred to as similar to a previous violation. Specifically, violation C of the Notice of Violation dated December 18, 1986, stated that the licensee did not possess the three sealed sources required to perform constancy checks on the dose calibrator and therefore eculd not perform the constancy checks. Violation A.3 of the Notice dated October 27, 1987, cited the licensee for .iot possessing the required Ba-133 source for the checks. Phile the licensee did possess three sealed sources, a Ba-133 source was not among them. Therefore, this is similar to the previous violation, in that all of the required sources were not available.

NUREG-0940 II.A-14

. --- . = . - - - - . .- - - . - . . - . - . . - _ . .- - .--

Appendix -

-.4 -

-The licensee response letter also referenced NRC Regulatory Guide 10.8 .Revi-sion 2. August 1987. .The inspection was. conducted-cn July 27, 1987. Revisicn 2 had not been issued then and was not operative. The llcensee coninitted to the procedure found in Revision 1, October 1980. Even though Revision 2 had-been issued, the licensee was still required to follo( Revision 1 unless an amend-ment to change this part of the license was requested and issued. g

' Restatement of Violation A.4 License Conditions 14.A and 14.C require that licensed material be used in

-acccrdance with statements, representations, and procedures contained in the apslication dated September 19, 1985, and contained in information received Fe)ruary 13, 1986, which includes Beckley Appalachian Regional Hospital's ALARA Program signed by Dalton G. Smart, Administrator.

Section 14, Appe'ndix F, item P.f, of the application requires that a wipe of the external surface of the final source centainer be made when opening pack-ages containing radioactive material.

Contrary to the above, the licensee did not perform wipe tests of the final source containers on packages received between August 14, 1986 and July 28, 1987c This is similar to a violation issued on December 18, 1986.

Licensee's Response Tho licensee admitted the violation but listed the following three extenuating circumstances concerning the violation. The licensee (1) asserted that it was folicwing the previous inspector's instructions on performing wipe tests en

. packages centaining radioactive material, (2) denied that this violation was similar to a violation cited on December 18, 1986, because the previous inspec-tor's instructions were being followed, and (3) referred to NRC Regulatory Guide 10.8 stating that it does not require wipe tests of the final source containers unless there is a reason to suspect contamination.

NRC Evaluation The licensee, again, stated that it was following a previous inspector's instruc-tions for performing wipe tests of packages containing radioactive material and elso asserted that because of this, violation A.4 was not similar violation.

The inspector who conducted the December 1986 inspection recalls that he left copies of the procedures the licensee committed to perforn, and briefly reviewed these procedures. He did not offer detailed instructions to the.

licensee in achieving compliance. The license condition cited specifically requires the external surface of the final source container be wipe tested. It is ultimately the licensee's responsibility to be familiar with the commitments made in its application and supporting dccuments. Additionally, violation F of the Notice of Violation dated December 18, 1986, stated, "licensee represent-atives stated that packages containing radioactive material routinely received l

1 NUREG-0940- II.A-15 u

____ _ _ _ _- --- - - - - --- - - - - - - - = - - -- - - - - ' " ' ~ ~ - " " " ' ~ '

Appendix by the Nuclear Medicine Department were not wipe tested as required." Viola-tion A.4 of the Notice dated October 27, 1987, also involves a failure to perform wipe tests of packages received and is therefore considered to be similar.

The licensee's third extenuating circumstance refers to Regulatory Guide Revision 2, August 1987, which was not operative at the time of the July 27, 1987 inspection. In the licensee's application dated September 19, 1985, and in subsequent letters, a commitment was made to follow Appendix F of Regulatory Guide 10.8, Revision 1, Octeber 1980, for opening packages of radioactive material. The licensee must comply with all commitments made in the applica-tion dated September 19, 1985, unless an amendment to follow the revised Regulatory Guide it requested and issued.

Restatement of Violation A.5 License Conditions 14.A and 14.C require that licensed material be used in accordance with sittements, representations, and procedures contained in the application dated September 19, 1985, and contained ir information received February 13, 1986, which includes Beckley Appalachian Regional Hospital's ALARA Program signed by Dalton G. Smart, Administrator.

Section 17, Appendix I, item 4.b, of the application requires that the method for performing area wipe tests be sufficiently sensitive to detect 200 dpm per 100 cm'.

Contrary to the above, the licensee used a Capintec Model CPC-7 dose calibrator to analyze the area wipe test of approximately 100 cm'. The Capintec Model CRC-7 dose calibrator has a mininum detectable activity of approximately 22,000 dpm.

Licensee's Response The licensee admitted the violaticn but stated an extenuating circumstance.

The licensee contended that it was misinformed by the vendor and the )revious NRC inspector and that the appropriate equipment was obtained after t'e July 1987 iaspection.

NRC Evaluation The licensee again asserted that it was misinstructed as to the proper equip-ment to use for analyzing area wipe tests. As has been stated in the evalua-tions above, it is the licensee's responsibility to be familiar with the cennitments made in the license application and supporting documents and to achieve compliance with requirements. Also, the licensee is responsible for knowing how to perform measurements properly before applyirg for a license.

Restatement of Violation B 10 CFR 20.401(b) requires the licensee to maintain records of surveys in the same units used in 10 CFR Part 20.

NUREG-0940 II.A-16 1

i

- -v

Appendix 10 CFR 20.5(a) requires that radicactivity be measured in terms of disintegra-tions per unit time or in curies.

Contrary to the above, between December 4, 1986 and July 28, 1987, the licensee obtained results of area wipe surveys in units of millicuries and erroneously recorded them in units of millirem per hour.

Licensee's Response The licensee admitted the violation and stated extenuating circumstances. The licensee contended that it was misinformed by the vendor and stated that the

! previous inspector reviewed the technique and unit of measure and approved of both.

NRC Evaluation The licensee must not depend on an outside consultant or an inspector for basic knowledge of routine instrument use. Each licensee should possess this expertise internally and must take responsibility for achieving regulatory compliance.

The inspection process is a sampling review of various conditions and procedures.

If an item is not always noted or cited by one inspector, it should not be automatically considered as NRC approved. The inspector conducting the July 1987 inspection noted in a discussion with licensee personnel that the various units of measurement for radioactivity were not well understood. It is also possible that at the time of the December 1986 inspection, the records were maintained properly and that the failure to record the results in millicuries occurred after the inspection.

Restatement of Violation C 10 CFR 20.403(a) requires, in part, that each licensee imediately report any event involving byproduct material possessed by the licensee that may have caused or threatened to cause exposure of the whole body of any individual of 25 rems or more of radiation.

Contrary to the above, a reading of 374 rems to a film badge assigned to an employee was reported to the licensee by the supplier on March 12, 1987. This possible exposure was not officially reported to the NRC imediately, and the NRC was not aware of the badge reading until a July 27, 1987 inspection, at which time the exposure was considered by the licensee to be a photodosimetry Orror.

Licensee's Response The licensee contended that the NRC has no regulatory authority over the exposure sirce the badged employee is the Administrative Technologist for Radiology and does not work with NRC licensed radioactive material. The NUREG-0940 II.A-17

Appendix licensee determined the badge reading was an error. When the vendor reported the badge reading, it was stated that the exposure occurred out of the holder.

Based on this fact and on the fact that the Technologist rarely performs diagnostic imaging procedures and never performed Nuclear Medicine Studies during the exposure period, the 374 rem badge reading was determined to be in error and also not reportable under NRC jurisdiction.

NRC Evaluation The e:, :"re was reported to the NRC on August 14, 1987, by D. Glenn, Ph.D., a Medical Physics Consultant for the licensee. He did so to ensure compliance with all NRC regulations after an Enforcement Conference between the licensee and the NRC on August 12, 1987. A letter dated September 17, 1987, stated the licensee's evaluation of the filn badge reading has been reviewed by the NRC.

At first, the NRC was concerned that an immediate evaluation was not made and not enough information was known to make a judgement as to the validity or origin of exposure within the reporting deadline. After further discussions with the licensee, the NRC believes that the licensee did perform a prompt evaluation and was justified in not reporting the film badge reading to the NRC. Therefore, violation C will be withdrawn, and our records will be adjusted accordingly.

Restatenent of Violation D 10 CFR 20.401(b) requires that each licensee maintain records showing the results of surveys required by 10 CFR 20.201(b). "Survey" as defined in 10 CFR 20.201(a) is an evaluation of the radiation hazards incident to the use of radioactive material.

Contrary to the above, in March 1987, the licensee did not record the results of an evaluation of the circumstances surrounding a reading of 374 rems recorded on the film badge of a radiology technologist.

Licensee's Response In responding to this violation, the licensee referred to its response te violation C. The licensee denied violation 0 on both the basis that the badge reading was an error and the basis that the employee did not work with any radioactive material during the film badge exposure period. Therefore, the licensee asserted that the NRC did not have regulatory authority over the incident.

NRC Evaluation After further clarification of the licensee's evaluation of the high badge reading, the NRC accepts the licensee's position that the employee did not work with NRC licensed radioactive material during the film badge exposure period and calendar quarter in question. Therefore, the NRC regulations are not binding, and no record of the evaluation is required. Violation D will be withdrawn, and our records will be revised accordingly.

NUREG-0940 II.A-18

I l

Appendix Restatement of Violation E I 10 CFR 20.401(a) requires that each licensee maintain records showing the radiation exposures of all individuals for whom personnel monitering is required under 10 CFR 20.202.

Contrary to the above, a film badge exposure of 2380 millirems, which the licensee concluded was not received by the individual to which the badge was assigned, was not removed from the individual's exposure record.

Licensee's Response The licensee stated that though the individual did not receive the full reported exposure, it should not be entirely removed from her exposure history due to previous quarterly readings of 560 to 830 mrem. The licensee also stated that the Radiation Safety Committee, during the annual review of employee exposures, till make adjustments as necessary at that time, and that the annual review had not been performed at the tire of the NRC evaluation of the badge reading.

NRC Evaluation The NRC accepts the licensee's contention that the film badge records will be properly adjusted at the annual review. It should be noted that the licensee's actions in this situation are viewed as being conservative in evaluating the employee's exposure history. Violation E will be withdrawn, and our records '

will be revised accordingly.

Licensee's Request for Hitigation of Civil Penalty Zn the response dated November 20, 1987, the licensee referenced page 36220 of the September 28, 1987, Federal Register which discusses the NRC's consideration of a licensee's "ability to pay." The licensee also presented financial information about the hospital. In sumary, it stated that the hospital operates in the economically devastated Appalachian region and provided $508,145 in charity care for fiscal year 1986-87 and $171,551 in charity care for the first quarter of fiscal year 1987-88. The hospital's operating deficit for fiscal year 1986-87 was $291,453 and for the first quarter of 1987-88 was  !

$258,564.

ln the response dated December 11, 1987, the licensee stated that $5,991 had been spent on corrective actions to achieve full regulatory compliance. Base ,

on this information, the licensee has requested mitigation of the proposed l civil penalty, i

NRC Response The Federal Register dated September 28, 1987, referenced by the licensee, contains the revised "General Statement of Policy and Procedure for NRC Enforce-ment Actions" of 10 CFR Part 2, Appendix C.Section V.8 addresses civil penalties, which states, "regarding the secondary factor of ability of various classes of licensees to pay the civil penalties, it is not the NRC's intention NUREG-0940 II.A-19

Appendix that the economic impact of a civil penalty be such that it puts a licensee out of business (orders, rather than civil penalties, 6re used when the intent is to terminate licensed activities) or adversely affects a licensee's ability te safely conduct licensed activities. The deterrent effect of civil penalties is best served when the amounts of such penalties take into account a licensee's "ability to pay." In deternining the amounts of civil penalties for licensees for whom the tables do not reflect the ability to pay, NRC will consider as necessary an increase or decrease on a case-by-case basis."

In view of the stated NRC policy, the financial information provided by the licensee, and the corrective actions given in the licensee's responses, it has been determined that the proposed civil penalty should be partially mitigated.

Conclusions After consideration of the responses for November 20, and December 11, 1987, to the Notice of Violation and Proposed Imposition of Civil Penalty issued October 27, 1987, the NRC staff has concluded that a sufficient basis was prcvided for the withdrawal of violations C, D, and E, and that the remaining violations occurred as stated. Additionally, based on the withdrawal of violations C, D, and E, the civil penalty is reduced to $3,500, each violation having been assessed a penalty of $500. Additionally, because of the current financial situation of the licensee, the proposed $5,000 civil penalty has been mitigated to $1,000.

I f

i l

NUREG-0940 II.A-20

o l movy'o, .,

UNITED STATES  !

! n NUCLEAR REGULATORY COMMISSION l E REGION I l 831 PARK AVENUE 4

KINO oF PRUSSIA. PENN$YLVANIA 194M

% o ..* g October 22, 1987 Docket No. 30-19960 i License No. 37-10059-03 1 EA 87-175 BP Oil, Inc.

ATTN: Mr. E. S. Kulinski Refinery Manager Marcus Hook, Pennsylvania 19061 Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC Inspection No. 87-01)

This letter refers to the special NRC safety inspection of activities authorized by NRC License No. 37-10059-03 conducted on July 20-22, 1987 at your facility in Marcus Hook, Pennsylvania. The report of the inspection was forwarded to you on August 27, 1987. The inspection was conducted to revi~1 the circumstances associated with an event identified and reported to the tiRC by an individual working at the refinery. The event involved (1) work loside of, or near, a tank where radiation levels, in excess of regulatt.iry limits, existed in the vicinity of four gauges containing radioactive sources, and (2) subsequent removal of the nuclear gauges from the tank by inolviduals not authorized to perform this activity. During the inspection, eight violations of NRC requirements were identified. On September 3, 1987, we held an enforcement conference with you and members of your staff during which the violations, their causes, and you corrective actions were discussed.

The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (Notice), include, but are not limited to:

excessive radiation levels (at the time the radiation levels inside the tank exceeded 2 millirems per hour, and were as high as 16 rem per hour) inside an acid storage tank which is an unrestricted area; performance of maintenance by approximately 27 individuals inside or near the tank without the gauge's sources being in the locked and shielded position and without a radiation survey being performed prior to the work; removal by unauthorized individuals of the nuclear gauges from the tank while the gguges were in the unshielded position; and failure to place the gauges, once removed, in a shielded storage container. These violations are of significant concern to the NRC because they collectively demonstrate a very serious breakdown in management oversight and control of your activities.

Although the 27 individuals who had entered, or worked near, the tank while the sources were exposed did not receive radiation exposures in excess of regulatory limits in 10 CFR 20.201, the potential existed for significant radiation exposures at your facility. The NRC is also concerned that a similar violation involving an individual entering another tank where excessive radiation levels existed was identified by your staff in 1983 and was not reported to the NRC, as required.

NUREG-0940 II.A-21

SP Oil, Inc. 2 The failure to report the incident in 1983 is of significant regulatory concern because such reporting enables NRC to assure that adequate corrective actions are taken to prevent recurrence. In the future, increased management attention is needed to ensure: (1) adherence to NRC requirements and safe performance of licensed activities; and (2) prompt and effective correction of deficiencies when they are identified.

To emphasize this ne 1, I have been authorized, after consultation with the  ;

Director, Office of Ei nrcement, and the Deputy Executive Director for Regional Operations, to issue th- nclosed Notice of Violation and Proposed Imposition of Civil Penalties in th an.mnt of Two Thousand Dollars ($2,000) for the ,

violations described in the enclosed Notice. The violations have been categorized in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy). Violatiens A and D have been categorized as two Severity Level III violations. Further, the other six violations have been categorized in the aggregate as two separate Severity Level III problems (Violations B and C).

The base value of a Severity Level III violation or problem is $500. The NRC recognizes that your corrective actions in response to this recent incident were prompt and extensive; however, mitigation was considered inappropriate in view of the significance of this event, and the previous event in 1983.

You are required to respond to the enclosed Notice and should follow the instructions specified in the Notice in preparing your response. In your response, you should document the specific actions taken to correct the violations and any additional actions you plan to prevent recurrence. Your response to this Notice, including your proposed corrective actions and the results of future inspections will be considered in determining whether further enforcement action, including license suspension, 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 the enclosed Notice will be placed in the NRC's 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 of 1980, PL 96-511.

Sincerely, b  !

William T. Russell  !

Regional Administrator

Enclosure:

Notice of Violation and 1 Proposed Imposition of Civil Penalties NUREG 0940 II.A-22

. _ j

l NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES 1

BP Oil, Inc. Docket No. 30-19960 Marcus Hook, Pennsylvania 19061 License No. 37-10059-03 EA 87-175 )

On July 20-22, 1987, a special NRC safety inspection was conducted at the licensee's facility in Marcus Hook, Pennsylvania to review the circumstances surrounding an event reported to the NRC by a worker at the facility. The event involved the relocation of nuclear gauges at the facility by unauthorized personnel, contrary to NRC requirements. During the inspection, other 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 (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of tne Atomic Energy Act of 1984, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and the associated civil penalties are set forth below:

A. Condition 15 of License No. 37-10059-03 requires, in part, that removal from service and relocation of non portable devices containing sealed sources be performed only by persons specifically licensed by the NRC or an Agreement State to perform such service. Condition 16 of License No.

37-10059-03 requires that the licensee conduct its program in accordance with the licensee's application for license dated March 28, 1983, which states, in Item IV, that the licensee will contact the nuclear gauge manufacturer to assist in removing the gauge from service and relocation. ,

Contrary to the above, on July 16, 1987, four Ohmart model SHLM sealed-source non portable gauges, each containing approximately 20 millicuries of cesium-137, were removed from Acid Storage Drum No. PV-2504:

1. by persons not specifically licensed to perform this service, and 2, without the gauge manufacturer being contacted prior to removal of the gauges from service.

This is a Severity Level III violation (Supplement IV).

Civil Penalty - $500.

B. 1, 10 CFR 20.105(b)(1) requires that radiation levels in unrestricted areas be limited so that an individual continuously present in the area could not receive a radiation dose in excess of 2 millirems in any hour. 10 CFR 20.3(a)(17) defines an unrestricted area to include any area to which access is not controlled by the licensee for the purpose of protection of individuals from exposure to radiation and radioactive materials.

NUREG-0940 II.A-23

2 Contrary to the above, on July 14-16, 1987, radiation levels existed in an unrestricted area, namely, the inside of Acid Storage Drum No.

PV-2504, such that an individual present in the area for one hcur could receive a radiation dose of greater than 2 millirems.

2. 10 CFR 20.203(b) requires that each radiation area be conspicuously posted with a sign bearing the radiation caution symbol and the words, "Caution (or 0 anger) - Radiation Area."

Contrary to the above, on July 14-16, 1987, a radiation area existed on the inside of Acid Storage Drum No. PV-2504, and the access points to the radiation area were not posted with the required caution sign.

3. 10 CFR 20,203(f) requires that each container of licensed radioactive material bear a clearly visible label identifying the radioactive contents.

Contrary to the above, on July 20, 1987, four Ghmart nuclear gauges, each containing 20 nillicuries of cesium-137, a licensed radioactive material, did not have a clearly visible label identifying the radioactive contents. The labels had been partially obliterated by paint and/or covered with tape.

Collectively, these violation have been categorized as a Severity Level III problem (Supplement IV).

Civil Penalty - 5500 assessed equally among the violations.

C. Condition 16 of License No. 37-10059-03 requires that licensed material be used in accordance with the statements,-representations and procedures contained in an application dated March 28, 1983 and letters dated April 15, 1983, August 14, 1986 and September 26, 1986.

1. Item 1 of the "Nuclear Radiation Gauging Device" procedure, included with the April 15, 1983 letter, requires-that the nuclear _ gauge be locked-out prior to work being conducted inside a vessel.

Contrary to the above, on July 14-16, 1987, approximately 27 individuals worked inside and on a vessel, Acid Storage Drum No.

PV-2504, and four nuclear gauges, each containing approximately 20 millicuries of cesium-137, had not been locked-out prior to the work being conducted.

2. Item 3 of the "Nuclear Radiation Gauging Device" procedure, included with _the April 15, 1983 letter, requires that a radiation survey be conducted prior to entering a vessel bearing a nuclear gauge.

Contrary to the above, on July 14-16, 1987, approximately 27 individuals entered or worked on a vessel, Acid Storage Drum No.

PV-2504, without a radiation survey first being conducted.

l NUREG-0940 II.A-24

i 3

3. Item 5 of the "Nuclear Radiation Gauging' Device" procedure, included with the April 15, 1983 letter, requires that vSenever nuclear gauges are removed from a vessel where they have been installed, the gauges should be transferred immediately to lead shielded containers.

Contrary to the above, on July 16, 1987, four nuclear gauges, each l

containing approximately 20 millicuries of cesium-137, were removed l

from a vessel Acid Storage Drum No. PV-2504, and as of July 20, 1987, l

these gauges, had not been placed in lead shielded storage containers.

Collectively, these violations have been categorized as a Severity Level III problem (Supplements IV and VI).

Civil Penalty - 5500 assessed equally among tFe violations.

D. 10 CFR 20.405 (a)(1)(v) requires that each licensee make a report within 30 days of its occurrence, of levels of radiation (whether or not involving excessive exposure of an individual) in an unrestricted area in excess of ten times of any applicable limit set forth in 10 CFR Part 20.

10 CFR 20.105(b) requires that radiation levels in unrestricted areas be limited so that an individual continuously present in the area could not receive a radiation dose in excess of 2 millirems in any hour. 10 CFR 20.3(a)(17) defines an unrestricted area to include any area to which i access is not controlled by the licensee for the purpose of protection of individuals from exposure to radiation and radioactive materials.

Contrary to the above, on January 19, 1983, an incident occurred in which an individual, who was not a radiation worker, entered an unrestricted area (the Surge Hopper on the Platformer Unit) for approximately 30 minutes, and the individual received a radiation exposure which was estimated by the licensee to be approximately 84 millirem. The level of radiation that existed in the area was approximately 160 millirem per hour, which is greater than ten times the limit of two millirem in an hour for an unrestricted area, as specified in 10 CFR 20.105 (b)(1), and as of July 22, 1987, the licensee had not filed a written report of the occurrence with the NRC.

This is a Severity Level III violation (Supplement IV).

Civil Penalty - 5500.

Pursuant to the provisions of 10 CFR 2.201, BP Oil, Inc. (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 shou include for each alleged violation: (1) admission or denial of ' al i d violation, (2) the reasons for the violation if admitted, (3) the s :c t s sceps that have been ?.aken 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 NUREG-0940 II.A-25

4 adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why tha license should not be modified, suspended, or revoked or why such other action as may be proper siould 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 penalties 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 penalties 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 penalties will be issued. Should the Licensee elect to the 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 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 penalties should not be imposed. In addition to protesting the civil penalties, such aneter may request remission or mitigation of the penalty.

In requesting mitigation of the proposed penalties, 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 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 penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 P S.C. 2282c.

The responses to the Director, Of fice of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalties, and Answer to a i

l I

NUREG-0940 II.A-26 l

i 1

5 l

1 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 I, 631 Park Avenue, King of Prussia, Pennsylvania 19406.

FOR THE NUCLEAR REGULATORY COMMISSION h -

William T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania, this 44 day of October 1987 l

I 4

i NUREG-0940 II.A-27

[ga ucg$\ UNITED STATES y s-q h NUCLEAR REGULATORY COMMISSION 5 t WASHINGTON, D. C. 20655

'g *...*g M 01906 Docket No. 30-19960 License No. 37-10059-03 EA No.87-175 BP Oil, Inc.

ATTN: Mr. E. S. Kulinski Refinery Manager Marcus Hook, Pennsylvania 19C61 Gentlemen:

Subject:

ORDER IEPOSING CIVIL l10NETARY PENALTIES This letter refers to your two letters, hoth dated December 17, 1987, in response to the Notice of Violation and Proposed Imposition of Civil Penalties-sent to you with our letter dated October 22, 1987. Our letter and Notice described violations toentified during NRC Inspection No. 87-01, conducted on July 20-22, 1987. A civil penalty in the amount of 12,000 was proposed to emphasize the need for increased managerrent attention to the radiation safety program to ensure (1) adherence te regulatory requirements and safe performance of licensed activities, and (2) pren'pt and effective correction of deficiencies when they are identified.

In yepr responses to the Notice, you admit the eccw rence of the cited violations, tro of which were individually classified at Severity Level III, and the remaining of which were classified in the aggregate as two separate Severity Level III problems. However, you request mitigation of the amount of the civil penalties baseo on your unusually prompt and extensive corrective actions. Although we ackncwledge these actions, as we did ir cur October 22 letter, after careful '.onsideration of your response, we have concluded, for the reasons given in the Appendix attached to the enclosed Order Imposirg Civil ifonetary Penalties, that mitigaticn of the amount of the cumulative civil peralties is inappropriate. Accordingly, we hereby serve the enclosed Order on BP 011 Inc. irrposing civil monetary penalties ir the cumulative amount of Two Thousand Dollars. I We note that in the descriptiens of your actions to prevent recurrence of the I incidents described in the Cctober 22 Notice, ycu dic not, in response te Violation D, describe the actions taken to assure that ircidents are promptly and properly reporteo to the NRC, if recuired. Therefore, please describe your actions to assure that ircidents are properly evaluated and reported to the NRC, when recuired. We will examine the implementation of your corrective actions during a subs'equent inspection.

The response directed by this letter is rct subject to the clearance procedures

" n of the Office cf Managerrent arc Budget, as required by the aperwork Reduction Act of 1980, PL 96-511.

NUREG-0940 II.A-28

SP Oil, Inc. Zn accordancre with Section 2.790 of the NRC's "Rules of Practice," Part 2, Title 10, Cotle of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room.

Sincerely, p'

\ gf ,.

< TayJ r, Deputy Executive Director

, 'for Regional Operations

Enclosures:

10 Order Imposing Civil Monetary Penalties 20 Appendix - Evaluation and Conclusion cc w/encis:

Public Document Room (PDR)

Nuclear Safety Information Center (NSIC)

Connonwealth of Pennsylvania i l

l l

HUREG-0940 II.A-29

1 UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket No. 30-19960

) License No. 37-10059-03 BP OIL, INC. ) EA 87-175 Marcus Heck, Pennsylvania .)

ORDER IMPOSING CIVIL MONETARY PENALTIES 8P Oil, !nc., Marcus Hook, Pennsylvania 19061 (the "licensee") is the holder of License No. 37-10059-03 (the "license") issued by the Nuclear Regulatory Comission (the "Commission" or "NRC") which authorizes the licensee to p>ssess and use various fixed nuclear gauges. The license was issued on May 2, 1983, replacing License No. 37-10059-02, and is due to expire on April 30, 1988, i

i II An NRC safety inspection of the licensee's activities under the license was l

conducted on July 20-27, 1987. During the inspection, the hRC staff I determined that the licensee had not conducted its activities in full ccmpliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Peralths was served upcn the licensee by letter dated October 22, 1907. The Notice states the nature of the violations, the provisiens of the Nuclear Regulatory Commission's recuirements thet the licensee had violated, and the civil penalty amount for each cf the violations. Two responses, bcth dated December 17, 1987, to the Notice of Violation and Proposed Irposition of Civil Penalties, were received from the licensee.

NUREG-0940 II.A-30

.g.

fn its responses, the licensee admits that the violations occurred but reauest mitigation of the proposed civil penalty. Upon censideration of the answers roceived, the statements of facts, explanations, and arguments for rerission or mitigation of the prcpesed civil penalties centained therein, ano as set forth in the Appendix to this Order, the Deputy Executive Director for Regional Operations has deterrrined that the peralties proposed for the violations designated in the Notice cf Violation and Proposed Imposition of Civil Penalties should be imposec.

IV

n view of the foregoing and pursuant to Section 2:a of the Atcmic Energy Act of 1954, as amended 42 U.S.C. 2282 and 10 CFR 2.205, IT IS hEREBY ORDERED ThAT:

The licensee pay currulative civil penalties in the amourt of Two Thousand Dollars ($2,000) within thirty days cf the date of this Order, by check, draft, or money order, payable to the Treasurer of the United States and mailed to the U.S. Nuclear Regulatory Ccemission, ATTN: Document Control Desk, Washington, D.C. 70555.

V The licensee may, within thirty days of the date of this Order, request a hearing. A request for a hearing shall be clearly Parked as a request for heGring and shall be addressed te the U.S. Nuclear Regulatory Comissien,  !

NUREG-0940 II.A-31

Occument Control Desk, Washington, D.C., with c copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, 475 Allendale Road, King of Prussia, Pennsylvania.

?f a hearing is requested, the Commission will issue an Order designating the tire and place of the hearing. If the licensee fails to request a hearing within thirty days cf this Order, the provisions of this Order shall be effective without further proceedings. If pa> tent has not been made by that tine, the matter may be referred to the Attorney General for collection.

In the event the licensee reouests a hearing as provided above, the issue to be considered at such hearing shall be whether, the proposed civil penalty should be imposed, in whole or in part.

FOR THE FUCLEAR FiGULATORY COMMISSION

1. ,) /

James M. Taf or, Deputy Eyecutive Director for Regional Operations Dated at Bethesda, Maryland thisist day of Ma rch 1988.

NURF.G-0940 II.A-32

Appendix Evaluation and Conclusion On October 22, 1987, a Notice of Violation and Proposed Imposition of Civil Penalties was issued for violations of a license issued to BP Oil, Inc. The licensee responded to the Notice by two letters, dated December 17, 1987, and admits the violations, but requests mitigation of the cumulative amount of the civil penalties. The hRC's evaluation and conclusion regarding the licensee's responses are as follows:

I. Restatement of Vin 1ations A. Condition 15 of License No. 37-10059-03 requires, in part, that I removal from service and relocatics of non-portable devices I containing sealed sources be performed only by persons specifically licensed by the NRC or and Agreement State to perform such service.

Condition 16 of License No. 37-10039-03 requires that the licensee conduct its program in accordance with the licensee's application for license dated March 28, 1983, which states, in Item IV, that the licensee will centact the nuclear gauge manufacturer to assist in removing the gauge from service ano relocation.

Contrary to the at' eve, on July 16, 1987, fcur Ohmart model SHLM sealed-source non-portable gauges, each containing approximately 20 millicuries of cesium-137, were removed from Acid Storage Drum No.

PV-2504:

1. by persons not specifically licensec '.o perform this service, and.

2. without the gauge manufacturer being contacted prior to removal of the gauges from service.

This is a Severity Level III violation (Supplement IV).

Civil Penalty - $500 B. 1. 10 CFR 20.105(b)(1) recuires that radiation levels in unrestrie-ted areas be limited so that an individual centinuously present in the area could not receive a radiation dose in excess of 2 nillirems in any hour. 10 CFR 20.3(a)(17) defires an unrestric-ted area to include any area to which access is not controlled by the licensee for the p'urposh of protection of individuals from execsure to radiatien and radioactive materials.

Contrary to the above, en July 14-16, 1987, radiation levels existed in an unrestricted area, namely, the inside of Acid Storagt' Drum Nc. PV-2504, such that an ir.dividual present in the area for one hour could receive a radiaticn dose of greater than 2 millirems.

2. 10 CFR 20,203(b) requires that each radiation area be con-spicuously rested with a sign bearing the radiation cautien symbol and the words, "Caution (or Darger) - Radiation Area."

NUREG-0940 II.A-33

Appendix Contrary to the above, on July 14-16, 1987, a radiation area existed on the inside of Acid Storage Drum No. PY-2504, and the access points to the radiation area were not posted with the recuired caution sign.

3. 10 CFR 20.203(f) reovires that each container of licensed radioactive material bear a clearly visible label identif>ing the radioactive contents.

Contrary to the above, on July 20, 1987, four Ohmart nuclear gauges, each containing 20 millicuries of cesium-137, a licensed radioactive material cid not'have a clearly visible label l identifying the radioactivicontents. The labels had been  ;

partially cbliterated by patnt and/or covered with tape. I Collectively, these violatien have been categorized as a Severity Level III problem (Supplerent IV).

Civil Penalty - $500 assessed ecually among the violations.

C. Condition 16 cf License No. 37-10059-03 requires that licensed material be used in acccrdance with the statements, representations and procedures contaired in an application dated March 28, 1983 and letters dated April 15, 1983, August 14, 1986 and September 26, 1986.

1. Iter 1 of the "Nuclear Radiation Gauging Device" precedure, included with the April 15, 1983 letter, recuires that the nucl'ar e gauge be locked-out prior te rcrk being conducted inside a vessel.

Contrary to the above, er July 14-16, 1987, approximately 27 individuals workec inside and en a vessel, Acid Storage Drum No.

PV-2504, and four nuclear gauges, each centaining approximately 20 millicuries of cesium-137, had not been locked-out prior to thc work being conducted.

2. Item 3 of the "Nuclear Radiation Gauging Device" procedure, ircluded with the April 15, 1983 letter, requires that a radia-tion survey be conducted prior to entering a vessel bearing a nuclear gauge.

Contrary to the above, on' July 14-16, 1987, approximately 27 individuals worked inside and on a vessel, Acio Storage Drum Nc.

FV-2504, without a radiation survey first being conducted.

3. Item 5 of the "Nuclear Radiation Gaugirg Cevice" procedure, included with the April 15, M83 letter, requires that whenever nuclear gauges are removed from a vessel where they have been installed, the gauges should be transferrod imediately to lead shielded contairers.

Contrary to the above, on July 16, 1987, four nuclear gauges, each containing approxicately 20 millicuries of cesium-137, were removed f rom a vessel Acid Storage Drum No. PV-2504, and as of July 20, 1907, these gauges, had ret been placed in lead shielded storage contairers.

NUREG-0940 II.A-34 l

t

Appendix Collectively, these violations have been categorized as a Severity Level III prcblem (Supplements IV and VI).

Civil Penalty - $500 assessed equally among the violaticts.

D. 10 CFR 20.405(a)(1)(v) requires that each licensee make a report within 30 days of its occurrence, of levels of radiation (whether or not involving excessive exposure of an individual) in on unrestricted area in excess of ten times of any applicable limit set forth in 10 CFR Part 20.

10 CFR 20.105(b) requires that radiotion levels in unrestricted areas be limited so that an individua k' continuously present in the area could not receive a radiation dose in excess of 2 millirems in any l hour. 10 CFR 20.3(a)(17) defines pr1 unrestricted area to include any area to which access is not controlled by the licensee for the purpose of protection of individuals from expo:ure to radiation ar.d radioactive materials.

Contrary to the above, on January 19, 1983, an incident occurred in which an individual, who was not a radiation worker, entered an unrestricted area (the Surge Hopper on the Platformer Unit) for approximately 30 minutes, and the individual received a radiation .

exposure which was estimated by the licensee to be approximately 84 l millirem. The level of radiation that existed in the area was i apprcximately 160 millirerr. per hour, which is greater than ten tves the limit of two millirem in an hcur for an unrestricted area, as  !

specifie,d',in 10 CFR 20.105(b)(1), and as ct July 22, 1987, the l licensee had not filed a written report c' the occurrence with the  !

NRC. j This is a Severity Level III violation (Supplement IV).

l Civil Penalty - $500 II. S_ummary of License Response i

The licensee, in its two responses, admits the occurrence of the viola-  !

tions, one of which involved an incident similar to an incident whien )

occurred in 1983. Further, the licensee does rot contest classification i of the Severity Level of the violations. However, the licensee takes  !

issue with the NRC statement, in it's October 27. 1987 letter, that "nitigation (of the civil penalties] was considered inappropriate in view cf the significance cf this event, and the previous event in 1983" since itt corrective actions were unusually prcrpt and extensive. Further, the licensee indicated that the 1983 event occurred, in part, because they relied on the acvice of an errployee of the Ohmart Corporation (the gauge manufacturer and'distributcr) and that incident shoulo not be used to deny nitigatien in the present case. In addition, the licensee indicated that a written report of the 1983 incident was not filed with the NRC because c advice given by an Ohrcrt employee.

NUREG-0940 II.A-35

Appendix III. NRC Evaluation of Licensee Response It is not clear, from the licensee responses, whether the aovice provided by Ohmert Corporation actually contributed to the 1983 incident (involving excessive radiation levels in an unrestricted area), or contributed to the licensee's failure to report the incident to the NRC.

In any case, the advice provided by Ohmart Corporation is not relevant to whether mitigation is appropriate since it is the responsibility of the licensee to ensure that all NRC requirements, including the conditions cf the license, are met.

Furthermore, even if the responsibility for the 1983 incident, and/or the failure to report it to the NRC, rested solely with Ohnart, it wculd not form the basis for mitigation in this case since that incident provided the licensee prior notice of a problem, yet effective corrective actions were not taken to prevent recurrence, as evidenced by the 1987 incident.

Accordingly, the NRC actually corsidered escolating the cumulative amcunt of the civil penalties in accordance blth Sections V.B.3 and V.B.4 of the Enforcernert Policy. However, in light of the prev.pt and corrprehensive actions taken by licensee managerent in response to this recent incident in July 1987, the NRC determined that, en balance, neither escaletion nor mitigation of the amount of the civil penalties was considered appro-priate.

fV. NRC Conclusion The licensee did not provide a sufficient basis for mitigation of the curnulative amo0nt of the civil per.alties. Therefore, the NRC concludes that cumulative civil penalties of $2,000 shou;c be imposed.

1 1

NUREG-0940 II.A-36

U9dTEo STATES

[ja aso

• o NUCLEAR REGULATORY COMMIS$ TON O " ,$ REGION H h j 101 MARIETTA STREET.N.W.

58

• ATL ANTA.0EoRol A 30323 JUL 171987 Occket No. 030-12965 License No. 47-17564-01 EA 87-96 Kermit Butcher ATTN: Mr. Kermit Butcher i P. O. Box 213 Elkins, WV 26241 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 47-17564-01/87-01)

This refers to the Nuclear Regulatory Commission (NRC) insnection conducted by L. Franklin at the kermit Butcher facility in Elkins, West Virginia, on May 27, 1987. The inspection included a review of licensed activities as they relate to radiation safety. As a result of this inspection, significant failures to comply with NRC regulatory requirements were identified, and accordingly, NRC concerns relative to the inspection findings were discussed by W. Cline, Chief, Nuclear Materials Safety and Safeguards Branch, NRC, Region II, with you and a member of your staf f during an Enforcement Conference held by telephone on June 4, 1987.

The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Panalty included the improper storage of licensed material.

As a result of the improper storage, licensed material was stolen. The failure to secure the material from unauthorized removal when unattended has apparently persisted for several years. The other violations involved a failure to make the proper notifications to the NRC upon the loss of licensed material, multiple examples of the failure to carry shipping papers during transport, the use of licensed material by unauthorized persons, a failure to maintain leak test records, several examples of the failure to perform a physical inventory, and a failurt to post required documents. While these other viclations are not as serious as the improper storage violation, they contributed significantly to the conclusion that a breakdown of management gontrol over your radiation safety program occurred.

To emphasize the need to improve management oversight and control of your radiation safety program, I have b :n authorized, af ter 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 Five Hundred Dollars (5500) for the violations described in the enclosed Notice, in accordance with the "General Statement ef Policy and Procedure for NRC Enforcement Action," 10 CFR Part 2, Appendix C (19??) (Enfo. cement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity level Ill problem. The base s alue of a civil penalty for a Severity level III violation or problem is

$500. The escalation and mitigation factors in the Enforcement Policy were NUREG-0940 II.A-37

Kermit Butcher - considered and no adjustment hac been deemed appropriate. Any mitigation that may have been warranted for your prior good performance is offset by the multiple examples of several of the violations.

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 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 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 enclosures will be placed in the NRC Public Document Room.

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 by the Paperwork Reduction Act of 1980, PL 96-511.

Should you have any questinns concerning this letter, please contact us.

Sincerely,

. a %W J. Nelson Grace Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. NRC Inspection Report NUREG-0940 II.A-38

NOTICE OF VIOLATION AND PROPOSED IMPOSITIOR~0F CIVIL PENALTY Kermit Butcher Docket No. 030-12965 Elkins, WV License No. 47-17564-01 EA 87-96 During the Nuclear Regulatory Commission (NRC) inspection conducted on May 27, 1987, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions,"

l 10 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Commission proposes to i impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of l 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. License Condition 17 requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in application dated June 15, 1982 and letter dated February 4, 1983.

Application dated June 15, 1982, in the part entitled "Handling Procedures,"

requires that when licensed material is stored it must be maintained in a locked area.

Contrary to the above, between November 30, 1986 and April 20, 1987, a Troxler gauge model 3411B containing two sealed sources was stored in an unlocked storage building. This violation resulted in the theft of the gauge.

B. 10 CFR 20.402 requires, in part, that each licensee shall report to the NRC by telephone immediately af ter it determines that a loss or thef t of licensed material has occurred, under circumstances indicating that a substantial hazard may result to persons in unrestricted areas, and shall, within 30 days af ter learning of the loss or thef t, make a report in writing to the NRC.

Contrary to the above, the licensee failed to make the required immediate report af ter learning of the thef t of licensed material. The theft was identified on April 20, 1987, and was not reported to the NRC until May i, 1987. In addition, no written report was filed by the licensee within 30 days after learning of the theft.

C. 10 CFR 71.5(a) requires that each licensee who transports licensed material outside of the confines of its plant or other place of use 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.

49 CFR 172.200(a) requires that each person who effers a hazardous material for transportation shall describe the hazardous material on a shipping paper.

Contrary to the above, the licensee has transported licensed hazardous material outside the confines of its office approximately 100 times per year since June 1983 without shipping papers.

NUREG-0940 II.A-39

Notice of Violation D. License Condition 12 requires that licensed material shall be used by, or under the supervision and in the physical presence of, Kathy Tenney.

Cont-ary to the above, Kathy Tenney has not been in the employ of the licensee since approximately May 1985, and since that time licensed material has been used without proper supervision approximately 100 times per year.

E. License Condition 13(b) requires that records of leak tests be maintained for inspection by the NRC.

Contrary to the above, on May 27, 1987, the licensee did not have records of leak tests that were performed on a Troxler gauge serial no. 4935 during March 1985 and October 1985, and on Trox er gauge serial no. 9741 during March 1985, April 1986, and October 19S6.

F. License Condition 14 requires that the licentee conduct a physical inventory of all sealed sources possessed under the license at six-month intervals.

Contrary to the above, no inventory was conducted between October 1985 and February 1987, an interval that exceeds six months.

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, referenced documents, and operating procedures. If posting is not practicable, the licensee may post a notice that describes the documents and where tney may be examined. The licensee is also required to post Form NRC-3, "Notice to Employees," to permit individuals who frequent any portion of a "restricted area" to observe the form.

Contrary to the above, on May 27, 1987, the licensee had not posted the documents or the notice of where the documents might be examined, nor had the licensee posted Form NRC-3 in or near a restricted area.

These violations have been evaluated in the aggregate as a Severity Level Ill problem (Supplement VI).

Cumulative civil penalty - $500 - assessed equally among the violations.

Pursuant to the provisions of 10 CFR 2.201, Kepit Butcher (Licensee) is hereby required to submit a written statement or explanation to the Director, Of fice 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 violation, (2) the reasons for the violation if admitted, (3) the '

corrective steps that have been taken and the results achieved, (4) the correct-ive steps which will be taken to avoid furtbar 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.

NUREG-0940 II.A-40

Notice of Violation Within the same time as provided for the response required above under 10 CFR 2.201, Kermit Butcher may pay the civil penalty by letter addiessed to the Of rector, Office of Enforcement, U. S. Nu: lear 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 the cumulative amount of the civil penalties if more than one 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. Nu: lear Regulatory Commission. Should Kermit Butcher 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 Violatien" l 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 in whole or in part, such answer may regtr$t remission or mitigation of the penalty.

In requesting mitigation of the proposed penalty, the five. factors addressed in Section V.8 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 l incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing i 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 i impusing a civil penalty. l l

Upon failure to pay the penalty due, which has been subsequently determined ir.

accordance with the aoplicable provisions of IU 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.

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, ATT4: Documant Control Cesk, Washington, DC 20555 with o copy to the Regional Administrator, U.S. Nuclear Regulatory l Commission, for the appropriate Region. 1 FOR THE NUCLEAR REGULATORY COMMISSION

\ ,jk1

'J. Nelson Grace Regional Administratcr Dated at Atlanta, Georgia this /1 day of July 1987 NUREG-0940 II.A-41

u

[p na ,Ig UNITED STATES NUCLEAR REGULATORY COMMISSION g g

. j WASHINOTON, D. C. 20555

(*****,/ FEB c n pgen Docket No. 030-12p65 License No. 47-17564 01 EA 87-96 Kermit Butcher ATTN: Mr. Kermit Butcher Post Office Box 213 Elkins, West Virginia 26E41 Gentlemen:

SUBJECT:

ORDER IMF0 SING A CIVIL MONETARY PENALTY This refers to your letters of August 7 and November 10, 1987, in response to the Notice of Violation and Proposed Imposition of Civil Penalty forwarded by our letter of July 17, 1987, and in response to our request for additional information dated September 23, 1987. Our letter and Notice described seven violations icentified during the NRC inspection conducted on May 27, 1987. To emphasize the need to improve management oversight and control of your Radiation Safety Program, a civil penalty of Five Hundred Dollars ($500) was proposed.

In your initial response, you described your investigation to determine how a Troxler gauge was lost and eventually found. You also stated that you should not be liable for a fine because the gauge was recovered, no injury resulted, and all violations had been addresseo.

In your second response, you denied the occurrence of a portion of violation E and admitted the occurrence of the remaining six violations. You also submitted records to substantiate ycur partial denial.

After consideration of your responses including the evaluation of the records submitted in your second response, we have concluded for the reasons given in the Appendix to the enclosed Order Imposing Civil Monetary Penalty that the March 1985 example of violation E is withdrawn, that the remaining portion of violation E occurred as stated in the Notice of Violation and Proposed Inposition of Civil Penalty dated July 17, 1987, and that an adequate basis for mitigation of the proposed civil penalty amount was not provided. Accordingly, we hereby serve the enclosed Order on Kermit Butcher imposing a civil penalty in the amount of Five Hundred Dollars ($500). We will review the effectiveness of your corrective actions during a subsequent inspection.

CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-U34U ll.A-42

Kermit Butcher 2 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's Public Document Room.

Sincerely,

/

7 ~.

J es M. Taylo , Deputy Executive Director for Regional Operations

Enclosure:

Order Imposing Civil Monetary Penalty with Attachment NUREG-0940 II.A-43

UNITED STATES NUCLEAR REGULATORY CO MISSION In the Matter.of Docket No. 030-12965 KERMIT BUTCHER License No. 47-17564-01 Elkins, WV EA 87-96 ORDER IMPOSING CIVIL MONETARY PENALTY I

Kennit, Butcher (licensee) is the holder of Materials' License No. 47-17564-01 issued by the Nuclear Regulatory Comission (NRC/Comissicr.) on July 18, 1977, and renewed April 20, 1983. The license authorizes the use of moisture censity gauges in accordance with the conditions specified therein.

II A routine inspection of the licensee's activities was conducted on May 27, 1987. The results of this inspection indicated that the licensee had not conaucted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Peralty was served upon the licensee by letter dated July 17, 1987. The Notice states the nature of

%he violations, the provisions of the NRC's reouirements that the licensee had violated, and the amount of the civil penalty proposed for the violations. The licensee respondea to the Notice of Violation and Proposed Imposition of Civil Penalty by letters dated August 7 and November 10, 1987.

NUREG-0940 II.A-44

2 Ill 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 in the Appendix to this Order that one example of violation E is withdrawn, that the other examples of violation E and the remaining violations occurred as stated, and that the penalty proposed for the violations designated in the Notice of Violation and Proposed Irrposition of Civil Penalty should be imposed.

IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act 09 1954, as amended ( ACT), 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED ThAT:

The licensee pay a civil penalty in the amount of Five Hundred Dollars

($500) within 30 days of the date of this Order, by check, draf t, or money order, payable to the Treasurer of the thiited States ard mailed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission.

ATTN: Cccument Control Desk, Washington, D.C. 20555.

The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing should b>e clearly marked as a "Request for an Enforcement Hearing" and shall be addressed to the Director, Otfice of Enforcement U.S NUREG-0940 II.A-45

3 Nuclear Regulatory Commission, ATTN: Document Control Desk, Washingten, D.C.

20555, with a copy to the Regional Administrator, Region II.

If a hearing is requested, the Comission will issue es a der 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 by that time, the matter may be referred to the Attorney General for collection.

In the event the licensee requests a hearing as provided above, the issues to se considered at such hearing shall be:

(a) whether the licensee was in violation of the NRC requirements as set forth in Violation E of the Notice of Violction and Proposed Imposition of Civil Penalty in Section 11 above as amended by Section III of this Order, and (b) whether, on the basis of such violation and the other admitted violations set forth in the Notice of Violation, this Order should be sustained.

FOR THE NUCLEAR REGULATORY COMMISSION Q

/

,4a. s M. Taylck Deputy Executive Director or Regional Operations Dated at Bethesda, Maryland this 2nd day of February 1988 f

i NUREG-0940 II.A-46 l

i APPENDIX EVALUATIONS AND CONCLUSIONS On July 17, 1987, a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for violations identifieo during a routine NRC inspection. Kermit Butcher (licensee) partially responded to the Notice on August 7,1987, and a request for a supplemental response was issued an September 23, 1987. Kermit Butcher completed its response by letter dated November 10, 1987. In these responses, the licensee requested that the entire civil penalty be mitigated, denied the occurrence of a portion of violation E, i submitted records to verify this denial, and admitted the occurrence of the l remaining six violations. The NRC's evaluations and conclusions regarding the licensee's arguments are as fallows:

Restatement of Violation E License Condition 13(b) requires that records of leak tests be maintained for inspection by the NRC.

Contrary to the above, on May 27, 1987, the licensee did not have records of leak tests that were performed on a Troxler gauge serial no. 4935 during March 1985 and October 1985, and on Troxler gauge serial no. 9741 during March 1985, April 1985, and October 1986.

Sumary of Licensee Response The licensee denied that no records existed for leak tests performed on Troxler gauge nos. 4935 and 9741 during March 1985 and provided copies of these records in its November 10, 1987, response. Although the licensee admitted that records did not exist for leak tests October 1985 and on Troxler gauge no.9741 performed during on Troxler April gauge 1986 and no. 4935 October during 1986, the licensee assumed that these leak tests were being performed in an appropriate manner.

NRC Evaluation Based on information provided in the licensee's November 10, 1987, response, the NRC staff agrees that leak test records did in fact exist for leak tests performed on Troxler gauge nos. 4935 and 9741 during March 1985. Records did not exist for leak tests performed on Troxler gauge no. 4935 during October 1985 and on Troxler gauge no. 9741 during April 1986 and October 1986.

Sumary of Licensee Request for Mitigation in its initial response, the licensee addressed the violation involving the failure to store a Troxler gauge containing two sealed sources in a locked area which resulted in the theft of the gauge and described its investigation to determine how the gauge was lost and eventually found. The licensee also stated that it should nct be liable for a fine because the gauge was recovered, no injury resulted, and all said violations had been addressed.

NUREG-0940 II A-47

Appendix 2 NRC Evaluation 'of Licensee Request for Mitigation The licensee's explanation for Vioation A fails to establish that the loss of the gauge was not caused by inadequate security. Although the storage building was often unlocked, there are insufficient grounds for concluding that the gauge was not stolen by an outsider. In this regard, even thcugh the gauge did not appear to be stolen following forcible entry, it was not nossible to conclude, as the licensee believes, that a trusted employee took it.

Moreove', the proposed civil penalty was assessed for several violaticns, not just the failure to secure licensed material from unauthorized removal, khile the other violations were not as serious as the improper storage violation, they contributed significantly to the conclusion that a breakdown of management control over your' Radiation Safety Program occurred. Although the gauge was successfuliy recovered and no injury occurred, the evidence continues to support a management breakdown, and there were multiple occurrences of several of the violations. Therefore, based on review of the information submitted in the licensee's responses, the NRC staff believes that the licensee did not provide an adequate basis for mitigation of the proposed civil penalty.

NRC Conclusion After careful consideration of your responses, the NRC staff has concluded that the March 1985 example of violation E is withdrawn, that the other examples of viulation E and the remaining violations cccurred as stated, and that an adequate basis for mitigation of the civil pe ralty was not provided by the 11cer.see. Consequently, the proposed civil penal +.y in the amount of $500 should be imposed.

HUREG-0940 II.A-48

p2 Hop UNITED STATES

,7f *g NUCLEAR REGULATORY COMMISSION y 7, REGloN m t vn acestvett mono e -l etcN couw. immois som

..... FEB ? 61980 Docket Nos. 030-00902, 030-07040, 030-29480, and 070-00145 Licenses No. 34-00738-04, 34-00738-07, 34-00738-09, and SNM-159 EA 87-226 Case Western Reserve University ATTN: Agnar Pytte, President 10900 Euclid Avenue Cleveland, Ohio 44106 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS NO. 030-00902/87001(ORSS);

NO. 030-29480/87001(DRSS); NO. 030-07040/87001(ORSS); AND NO. 070-00145/87001(DRSS))

This refers to the inspection conducted during the period November 17-24, and December 10-11, 1987, at your facility in Cleveland, Ohio. As a result of the inspection, numerous violations of NRC requirements were identified by NRC inspectors. An enforcement con',erence to discuss the violations, causes, and corrective actions was held between Mr. J. Henderson and other members of your staff and me and others of my staff on November 30,1987, in the NRC Region III office.

The NRC inspection effort was initiated af ter %e news media in the Cleveland, Ohio area contacted the NRC on November 8, i k , about technicians' concerns that a laboratory may have been contaminated. Initial contact with the Radiation Safety Officer (RS0) on November 9,1987, indicated' that the contamination was low level and would be decontaminated the next day. After additional surveys were performed, NRC was informed by the licensee, on November 13, 1987, that the contamination was more wide spread than originally reported and decontamination could take up to one month. Based on this information, an onsite inspection of the licensee's facility was conducted i which identified multiple violations of radiation safety requirements indicating a loss of control over your broadscope program. As a result of the inspection findings, licensed activities were suspended on November 25, 1987 and confirmed by a Confirmatory Action Letter. In a letter dated December 8, 1987, the suspension of licensed activities was rescinded by the NRC after extensive programmatic changes were made to the radiation safety program, h

NUREG 0940 II.A-49 l l

l

2 Case Western Reserve University FEB 2 61988 To emphasize the importance that licensees must place on radiation safety and control of 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 Fenalty in the amount of Ten Thousand Dollars

($10,000) for the violations described in the enclosed Notice. The violations have been categorized at a Severity level II in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy).

The violations described in the enclosed Notice represent a significant breakdown in the implementation of your radiation safety program. During the previous NRC inspection conducted May 7-9, 1986, four violations were identified, and NRC expressed concern over a lack of management attention to certain radiation safety provisions in that no active program existed for tritium smear surveys or radiation survey instrument calibration. At that time, escalated enforcement action was discussed if future inspections revealed lack of management attention to these matters. NRC is particularly concerned that although you apparently took some corrective actions for the l four violations identified during this 1986 inspection, these violations were identified as repeat violations during this most recent inspection.

The failure to adequately correct these past violations, as well as the numerous other violations identified, demonstrates a serious breakdown in management control'of'your radiation safety program. While such a breakdown in a 1.icensee program is often classified at Severity Level III, your employees' extremely poor performance in carrying out their responsibilities of adhering to NRC requirements reflects a careless disregard for these NRC requirements and is the basis for categorizing these violations at Severity Level II. Interviews of your employees, including members of management, showed that they were aware of NRC requirements and previous NRC identified violations, yet failed to adequately correct violations or implement an effective audit program to assure that the requirements of the license w being followed.

The base value of a civil penalty for a Severity Level II violation is $4,000.

The escalation and mitigation factors in the Enforcement Policy were considered.

The base civil penalty amount has been increased by 150 percent because of your prior poor performance in this area and the failure to take adequate corrective actions subsequent to the identification of violations during the most recent events. Because of your failure to take adequate corrective actions for known violations of NRC requirements, NRC issued two Confirmatory Action Letters (CALs) on November 20 and 25, 1987, to insure that an adequate radiation safety program was in place while licensed activities were conducted.

NUREG-0940 II.A-50

1 l

l Case Western Reserve University FEB 2 61988 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 including license suspension is necessary to ensure compliance with NRC regulatory requirements.

1 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 of 1980, Pub. L. No.96-511.

Sincerely, y

eqavisP A. Bert Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Inspection Reports No. 030-00902/87001(DRSS);

No. 030-29480/87001(DRSS);

No. 030-07040/87001(DRSS);

No. 070-00145/87001(DRSS) l 1

l l

4 I

, NUREG-0940 II.A-51

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Case Western Reserve University ) Docket Nos. 030-00902, Cleveland, OH ) 030-07040, 030-29480,

) and 070-00145

) Licenses No. 34-00738-04,

) 34-00738-07, 34-00738-09,

) and SNM-159

) EA 87-226 During an NRC inspection conducted during the period November 17-24, and December 10-11, 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 (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:

License No. 34-00738-04 A. License Condition No. 19 requires that licensed material be possessed and used in accorda'n'ce with the statements, representations, and procedures contained in certain referenced documents.

Contrary to the above, licensed material was not possessed and used in accordance with statements, representations and procedures contained in referenced applications and letters, as evidenced by the following violations:

1. The referenced letter dated August 27, 1982, states in Item 6 that Table I of Regulatory Guide 8.23 would be followed for frequency determination of laboratory surveys. Table I requires laboratory areas where less than 200 microcuries of radioactive material are Jsed be surveyed at least monthly.

However, during the November 1987 inspection it was determined that laboratories using less than 200 microcuries of radioactive material have not been surveyed monthly as required. For example, Laboratory No. 471 in Rainbow Babies and Children Hospital was not surveyed between June 1986 and November 17, 1987. Also, a number of other laboratories have not been surveyed monthly. Laboratories No.

411, 415, and 419 were not surveyed between August 10, 1987 and November 17, 1987.

NUREG-0940 II.A-52

l 1

Notice of Violation FEB 2 61989'

2. Item No. 3 in the referenced letter dated August 27, 1982, states training will be provided to radiation workers initially and annually thereafter. The initial training would be provided by or under the direction of the Radiation Safety Of ficer (RS0). The annual refresher training would be provided by and be the responsibility of each Principle Investigator (PI).

However, radiation workers did not receive training as required.

Specifically, one technician working in the Neonatal Metabolism Laboratory Room No. 471 did not receive initial training in September 1985 and annual refresher training thereafter, and two technicians working in the same laboratory did not receive initial tr.ining in July 1986. Also, as of the last annual refresher

, training for radiation workers held in September 1986, of I

approximately 500 film badged radiation workers, only 90 attended the training session.

3. The referenced letter dated April 18, 1980, states in Item 1 under the title, University Radiation Safety Committee, that the Committee '

will review the institution's entire radiation safety program on an annual basis.

However, the Committee did not review the entire radiation safety orogram annually as required. Specifically, a licensee representative stated the' Committee did not review the entire radiation safety program in 1985, 1986, or 1987.

P

4. The referenced application dated June 11, 1979, states in Section G.,

Personal Contamination, that the storing, preparation, or eating of food, as well as smoking, is forbidden in laboratories where radioactive materials are handled.

However, during the November - December 1987 inspection of selected labs, coffee pots, coffee cups, food, trays, plates and other eating utensils were observed in laboratories involving work with unsealed licensed materials. Rainbow Babies and Children Hospital Laboratory Room No. 471 and the School of Medicine Laboratory Rooms E717, 276, 267, and W-247 are specific examples. In addition, a licensee I representative in the Wearn Building stated the PI in Laboratory No. 416 routinely smokes in areas where unsealed licensed material is used.

)

i This is a repeat violation.

l I

NUREG-0940 II.A-53 I i

j

f Notice oY Violation FEB 2 61988

5. The referenced application dated June 11, 1979, states in Item M.3, I that all personnel who may be exposed to radioactive materials do so under the direction and supervision of the Pl.

l However, on October 30, 1987, between-10 to 17 children were allowed to enter Laboratory No. 471 in Rainbow Babies and Children Hospital where they may have been exposed to radioactive material and were given candy by laboratory personnel while not-under the recognized l direction and supervision of the Pl.

l 6. Item I.2. of the referenced' application dated June 11, 1979,. states that all minor spills of radioactive materials shall be cleaned up immediately by the persons working 4 the area and it should then be monitored to check the contamination level.

However, on November 23, 1987, a minor spill of phosphorJs-32 occurred in a W-200 series laboratory and had not been cleaned up or monitored by laboratory personnel as required.

This is a repeat violation.

7. Item No. E2, in the referenced application dated June 11, 1979, states snat, when necessary, film badges are to be worn by all

. appropriate laboratory personnel and by other persons designated by the RPD.' These badges are to be worn on the outside of the outermost garments.

However, film badges were not always worn as required by laboratory l

personnel. Specifically, on November 18, 1987, a technician performing todine-125 iodinations in Laboratory No. 416 in the Wearn Building was observed not wearing the required whole body film badge, j i

This individual stated her film badge and laboratory coat were left l at home.

8. Item 14.g. in the referenced letter dated April 18, 1980, states for ,

l those usages which could result in significant extremity dosage, a ,

finger badge is required, j However, personnel working with millicurie quantities of phosphorus-32 l in Laboratory No. 267 in the school of medicine and interviewed by the inspectors during the November-December 1987 inspection, who routinely use radioactive material which could result in a significant extremity dose, were not wearing the required finger badge.

I NUREG-0940 II.A-54 1

Notice of Violation FEB 2 61988 9 The referenced application dated June 11, 1979, states in Item E.(3)(b), Radiation Monitoring (Surveys), that "Each PI and the RPO will be responsible for insuring that their respective survey instruments are calibrated once per year by the manufacturer or commercial vendor."

However, the licensee failed to have survey instruments calibrated annually. Soecifically, a Victoreen Serial No. 191 located in Laboratory Room No. E-709 of the School of Medicine was last calibrated on December 28, 1985, a Mini-Monitor Serial No. 21921 located in Laboratory No. 267 has no calibration history according to laboratory personnel and the Thyac II survey meter located in Laboratory Room No. 471 of Rainbow Babies and Children Hospital was found on November 4, 1987, had no calibration history. These survey instruments had not been used by the licensee for a long period of time, at least several years.

This is a repeat violation.

10. The referenced appli:ation dated June 11, 1979, states in Item F.

that all personnel shall be required to wear laboratory coats whenever clothing contamination is possible. This type of protective clothing shall be worn only in the laboratory or in other vicinities where radioactive materials are teing used, and shall at no tihie be worn in ' cafeterias or dining halls.

However, during a walk-through of selected laboratories in November 1987, individuals were observed in areas of possible contamination without wearing the required lab coats. The School of Medicine Laboratory No. W-277 and Laboratory No. 416 of the Wearn Building are examples. In addition, on November 19, 1987, three film badged individuals were observed in the cafeteria wearing laboratory coats.

11. The referenced letter dated April 18, 1980, states in Item D. under the title University Radiation Safety Committee, that the Committee will meet at least quarterly.

However, the University Radiation Safety Committee has not met quarterly as required. Specifically, the Committee failed to meet between September 25, 1986 and April 6, 1987.

I l

NUREG-0940 II.A-55 i

Notice of Violation FEB 2 61988

12. . Item No. 8 in the referenced letter dated April 18, 1980, s t a t'e s ,

"each PI is furnished with a copy of our Rules and Procedures for Handling Nonhuman Use Radioactive Materials. He in turn reviews these rules and procedures with all personnel assigned to his laboratory or area of responsibility. The Rules and Procedures pamphlet is kept in a central location ar.d is available to all of the personnel in the area. All of this information constitutes the instructions each laboratory worker must follow."

However, during the Novemhr 1987 inspection, a copy of the Rules and Procedures were not available in certain laboratories and certain individuals interviewed were not aware of the requirements contained in the Rules and Procedures. Specific individuals interviewed who work in Laboratory Room los. 471, 416, and E8056 could not find copies of the Rules and Procedures and were not aware of the requirements contained therein.

13. Item 10 of the referenced letter dated April 18, 1980, states in the section titled Housing of Animals in Cages, Animals Used for ladi_oisotope Experiments, that it is the responsibility of the PI to insure that the room, hallway, door and the individual cages or pens are labeled "Radioactive" and that this label also indicate the isotope involved and the activity.

However,d0 ring the November 1987 inspection, the inspectors found that doors and cages of animals used for radioisotope experiments were not labeled as required. For example, the PI in Laboratory Room No. 471 etated that it was common practice not to label cages housing animals used for radioisotope research. In addition, a door in the animal housfng facility where animals are kept for radioisotope research, as well as the refrigerator in Laboratory Room No. EB09A where these animals are stored after sacrifice, were not labeled as required.

14. The referenced application dated June 11, 1979, states in Item (E)(3)(a), Radiation Survey, that the Radiation Protection Officer (RPO) or his representative will conduct surveys of laboratories using radioactive material at least two times per year, in addition, to any emergency evaluations.

However, a review of records and interviews with licensee personnel showed that approximately 250 of the 330 laboratories using licensed material were not surveyed by the Radiation Protection Officer or his designee at the required frequency of at least two times per year in 1987. For example, during 1986 and 1987 laboratory room 253 was surveyed only on June 18, 1986 and October 26, 1987.

i NUREG-0940 II.A-56

FEB 2 61988 Notice of Violation -6 B. License Condition No.12 states licensed material shall be used by, or under the supervision of, individuals designated by the University Radiation Safety Committee.

Contrary to this requirement, interviews with personnel during the November 1987 inspection showed that licensed material is not used by or under the supervision of individuals designated by the University Radiation Safety Committee. Specifically, it was learned that the Radiation Safety Officer reviews applications for licensed material use and forwards the applications to the currerit Chairman of the University Radiation Safety Committee for final approval without input by other committee members.

C. License Condition No.12 lists a specifically named individual as Chairman of the University Radiation Safety Committee.

Contrary to the above, the listed individual is not currently Chairman of the Radiation Safety Committee. Specifically, in 1982, a now individual was named as Chairman of the Committee and no amendment to the license was made to authorize this change.

D. License Condition No. 13(c) requires each sealed source containing licensed material to be tested for leakage and/or contamination at intervals not to exceed six months except that each source designed for the purpose of Dmitting alpha particles shall be tested at intervals not to exceed three months.

Contrary to this requirement, sealed sources have not been tested for leakage every six months or three months as required. Specifically ten sealed sources were not tested for leakage between December 1986 and October 1987, an interval of more than six months. In addition, two americium-241 plated sources designed for emitting alpha particles were l not tested for leakage between December 1986 and October 1987, an l interval of more than three months.

This is a repeat violation.

E. 10 CFR 19.11(a) requires each licensee to post current copies of the following documents: (1) 10 CFR Parts 19 and 20; (2) the license, license conditions or documents incorporated into a license by reference, and amenoments thereto; and (3) the operating procedures applicable to licensed activities.

l I

l l NUREG-0940 II.A-57

Notice of Violation FEB 2 61988 Contrary to the above, during a November 1987 walk-through inspection of selected buildings, hallways, and laboratories, it was observed that required documents were not adequately posted in areas where individuals engage in licensed activities would be aware of such documents. For example, 10 CFR Parts 19 and 20 and copies of the University license and operating procedures _were not posted in hallways or laboratory rooms located in the Wearn Building, School of Medicine and the animal housing facility and in Laboratory Room No. 471 of the Rainbow Babies and Children Hospital.

License No. 34-00738-07 F. License Condition No. 13(A) requires the cobalt-60 sealed source contained in the U.S. Nuclear Corporation irradiator to be tested for leakage and/or contamination at intervals not to exceed six months.

Contrary to this requirement, this nominal 4200 curie cobalt-60 sealed source has not been tested for leakage and/or contamination every six months as required. Specifically, this source was not tested between December 1986 and October 1987, an interval of more than six months.

License No. 34-00738-09 G. License Condition No. 12(A) requires the cobalt-60 sealed source contained in an AECL Model Gammacell 220 irradiator to be tested for leakage and/or contamination at intervals not to exceed six months.

Contrary to this requirement, this nominal 7000 curie cobalt-60 sealed scurce has not been tested for leakage and/or contamination every six months as required. Specifically, this source was not tested between December 1986 and October 1987, an interval of more than six months.

H. License Condition No. 14 states that before initiation of irradiator operations or after reloading of sources in the irradiator and before restart of the irradiator, a radiation survey shall be conducted to determine radiation levels around, above, and below the irradiator with the sources in the shielded position and in the exposed position. The results of the survey shall be 'sent to the U.S. Nuclear Regulatory Commission, Regior III Of fice not more than 30 days af ter the survey is conducted.

Contrary to this requirement, the results of this survey performed when irradiation operations resumed on December 16, 1986, were not submitted to the NRC Region.III office as required.

l NUREG-0940 II.A-58

Notice of Violation FEB 2 61988 License No. SNM-159

1. License Condition No. 12(A) requires the sealed Pu-Be neutron sources to be tested for leakage and/or contamination at intervals not to exceed six months.

Contrary to this requirement, a 1 curie Pu-Be neutron source has not been tested for leakage or contamination every six months as required.

Specifically, a 1 curie Pu-Be neutron source used in'the Rockefeller Builotng was not tested between December 1986 and October 1987, an interval of more than six months.

Collectively, these violations have been classified in the aggregate as a Severity Level 11 problem (Supplement IV and VI).

Cumulative Civil Penalty - 510,000 (assessed equally among the violations).

Pursuant to the provisions of 10 CFR 2.201, Case Western Reserve University (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:

(1) admission or denial of the alleged violation; (2) the reasons for the violation if admittqd; (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 e.n 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.

l tdithin 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 l the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payab.le to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of j the civil penalties if more than one civl' penalty is proposed, or may protest I imposition of the civil penalty in whole or in part by a written answer l addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory I Commission. Should the Licensee fail to answer within the time specified, an I order impot,ing the civil penalth 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, ln addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty, i

NUREG-0940 II.A-59

Notice of Violation FEB 2 61988 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

.tritten 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.

The responses to the Director, Office of Enforcement, noted above (Reply .

to a Notice of Violation, letter with payment of civil penalty, and Answer l to Notice of violation) should be addressed to: Director, Office of i Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control i Desk, Washington, DC 20555 with a copy to the Regional Administrator, U.S. j Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Eilyn, Illinois, 60137. ,

FOR THE NUCLEAR REGULATORY COMMISSION r'

A. Bert Bavis ,

Regional Administrator  ;

Dated at Glen Ellyn, Illinois this 24, day of February 1988, i

i l

l I

l l

4 NUREG-0940 II.A-60

.*# ho UNITED STATES NUCLEAR REGULATORY COMMIS$10N REGION I 631 PAnK AVENUE MIN 3 oP PRusslA. PENNSYLVANIA te4ot

% . . . /,

January 25, 198d Docket No. 70-1100 License No. SNM-1067 EA 87-195 Combustion Engineering, Inc.

ATTN: Dr. Paul McGill Vice President - Nuclear Fuel Nuclear Power Systems - Manufacturing P. O. Box S00 Windsor, Connecticut 06095 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY

, (NRC INSPECTION REPORT NO. 70-1100/87-05)

This refers to the NRC inspection conducted on October 5 - 9 and 19 - 23, 1987 at your facility in Windsor, Connecticut, of activities authorized by Special Nuclear Materials License No. SNM-1067. The report of the inspection was forwarded to you on November 17, 1987. During the inspection, several violations of NRC requirements were identified. On December 1,1987, an enforcement conference was conducted with you and members of your staf f to discuss the violations, their causes, and your corrective actions.

The violations, which are described in the enclosed Notice include: (1) failure

- to promptly clean up excessive contamination levels identified in the pellet ,

shop; (2) failure to perform adequate surveys prior to work being conducted in l certain parts of the shop; (3) failure to make measurements and bioassays of '

individuals working in the area to determine any intake of contamination; and j (4) failure to maintain certain records as required. These conditions, which )

created a substantial potential for an exp2sure in excess of the regulatory i limit, were caused by inadequate management attention to the maintenance of the aging equipment at your facility, inadequate training of personnel working with or near that equipment, and a lack of written procedures required by the license for personnel performing activities in that area.

These violations are symptomatic of a lack of management attention to che Radiation Safety Program at the Windsor facility. The NRC recognizes that I these iaficiencies existed prior to your designation as the new Vice President  !

- Nuclear Fuel, in September, 1987. Nonetheless, given the extent of management's inattention, a rigorous and thorough assessment nf all aspects of

your manuf acturing operation is needed to determine the adequacy of this j J

program; including the responsibilities and authorities of organizational l personnel with respect to the radiation protection program, and the adequacy of i staffing levels with respect to qualified health physics oversight, to ensure

' that all activities are conducted safely and in accordance with the terms of  ;

, the license.

t CERTIFIED Mall 1

REYURN RECETPT REQUESTED NUREG-0940 ll.A-61 2

Combustion Engineering, Inc. 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 "General Statement of Policy and Procedure for NRC Enforcement Actions,"

10 CFR Part 2, Appendix C (1987) (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 escalation and mitigation factors in the Enforcement Policy were considered and no adjustment of the base penalty was deemed appropriate.

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. Further, you should describe in detail your plans for (1) performing an assessment of your radiation protection program, particularly, with regard to staffing, procedures, training and improvements in supervisory oversight of radiological control activities; and (2) instituting appropriate corrective measures to upgrade the program based on the assessment findings.

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 enclo-sure 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 of 1980, Pub. L. No.96-511.

Sincerely,

& J.A O T.

William T. Russell Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc:

Public Document Room (POR) local Public Document Room (LPOR)

Nuclear Safety Information Center (NSIC)

State of Connecticut NUREG-0940 II.A-62

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Combustion Engineering, Inc. Docket No. 70-1100 C-E Power Systems Nuclear Fuel Manufacturing License No. SNM-1067 EA 87-195 During an NRC inspection conducted on October 5-9 and 19-23,1987, 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 (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 l U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil l penalty are set forth below:

A. Special Nuclear Material License No.1067 (SNM-1067), Part 1, License Condition, Section 3.2.8.1, "Contamination Surveys" requires that for Pellet Shop Building #17 removable alpha contamination of 10,000 dpm per 100 square centimeters be immediately cleaned up.

Contrary to the above, from September 15, 1987 to October 23, 1987, plan-alpha contamination levels were identified in certain locations of the

, pellet shop to be as high as 160,000 dpm per 100 square centimeters, and the contamination was not cleaned up.

B. 10 CFR 20.103(b)(1) requires that the licensee, as a precautionary procedure, use process or other engineering controls, to the extent practicable, to limit concentrations of radioactivr materials in air to levels below those which delimit an airborne radioactivity area as defined in 20.203(d)(1)(ii).

Contrary to the above, from August 12, 1987 to October 23, 1987, process i or other engineering controls were not used to the extent practicable to limit concentrations of radioactive materials in air in the pellet shop.

These controls were deficient in that certain equipment associated with the manufacturing of pellets (such as hoses), which are designed to confine the uranium oxide to the ventilated enclosures that contain the pellet presses, were not adequately maintained, resulting in leakage of uranium in the pellet shop.

C. 10 CFR 20.103(a)(3) requires, in part, that the licensee, for purposes of determining compliance with 10 CFR 20.103, use suitable measurements of concentrations of radioactive materials in .s.tr for detecting and evaluating airborne radioactivity in restricted areas. .

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3 NUREG-0940 II.A-63

Notice of Violation Contrary to the above, from August 12, 1987 to October 23, 1987, suitable measurements were not made of th, concentrations of radioactive materials in the air for detecting and evaluating airborne radioactivity in the pellet-shop, a restricted area, in order to determine compliance with 10 CFR 20.103, in that the samples taken were not representative of the air breathed by the employees.

D. 10 CFR 20.103(a)(3) requires, in part, that the licensee, as appropriate, use measurements of radioactivity in the body, measurements of radioactiv(ty excreted from the body, or any combination of such measurements as may be necessary for timely detection and assessment of individual intakes of radioactivity by exposed individuals.

Contrary to the above, on August 12 and September 26, 1987, air samples taken indicated that a potential existed for intake of radioactive materials by workers, and appropriate measurements of radioactivity in the body, measurements of radioactivity excreted from the body, or any combination of such measurements were not made as necessary in each case to ensure timely detection and assessment of individual intakes or radioactivity.

Specifically,

1. On August 12, 1987, the licensee determined, based on the air sample measurements in the pellet shop, that eleven individuals received between 21 and 68 maximum permissible concentrations (MpC) hours, and only urinalysis for insoluble uranium oxide was performed on these individuals rather than a whole body count and/or fecal analysis which would have been necessary in these circumstances to assess the individuals' intakes; and

2. On September 26, 1987, the licensee determined, based on air sample measurements, that an individual received about 38 MpC hours, and only urinalysis for insoluble uranium oxide was performed on this individual rather than a whole body count and/or fecal analysis which would have been necessary in these circumstances to assess the individual's intake.

E. 10 CFR 20.103(c) specifies, in part, that when respiratory protective equipment is used to limit the inhalation of airborne radioactive material, the licensee may make allowance for this use of respiratory protective equipment in estimating exposures of individuals to this material, provided that the licensee satisfies certain conditions, including maintaining and implementing a respiratory protection program which includes certain elements set forth is 10 CFR 10.103(c)(2) and (3) including: surveys and bioassays as appropriate to evaluate actual exposures; written n'ocedures regarding supervision and training of personnel; and written procedures regarding selection, fittin;, and maintenance of respirators, and issuance of a written policy statement on respirator usage.

Contrary to the above, as of October 21, 1987 and for an indeterminate period of tin'e prior to that date, respiratory protective equipment was

used to limit the inhalation of airborne radioactive material and an e allowance was made for this use in estimating exposures, but the respiratory protection program did not include the following elements required by 10 CFR 20.103(c)(2), and (3)

c NUREG-0940 II.A-64 i

6 Notice of 'liolation a. adequate bioassays and other surveys, as appropriate, to evaluate individual exposures and to assess protection;

b. written procedures for training of personnel in the proper use of respiratory protective equipment;

c. written procedures .for properly fitting respiratory protection '

devices to individuals; and i d. issuance of a written policy statement on respirator usage.

F. 10 CFR 20.201(b) requires that each licensee make such surveys as may be necessary to comply with the regulations in Part 20, and are reasonable ,

, under the circumstances to evaluate the extent of radiation hazards that I 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 presence of radioactive materials or other sources of radiation under i,

a specific set of conditions.

Contrary to the above,

1. surveys were not made to assure compliance with 10 CFR 20.103(a),

which limits the exposure of individuals to concentrations of radioactive materials in air in restricted areas, in that:

a. On September 26, 1987, an evaluation was not made of the radio-logical hazards existing at the Pellet Press No. 1 enrichment ,

hood to ensure that a worker assigned to perform an enrichment clean-up on the highly contaminated equipment was provided with. L 1 appropriate protective equipment,

b. As of October 23, 1987, evaluations of the radiological hazard to workers drinking water in the Pellet Shop from two water 1 fountains contaminated with radioactive material had not been made until af ter decontamination of the fountains,

2. On October 23, 1987, an adequate survey was not made to assure compliance with 10 CFR 20.103(a) to evaluate the extent of hazards

present when individuals and equipment exited the Pellet Shop, in that the frisker used to detect the presence of contamination on i individuals and equipment exiting the Pellet Shop was malfunctioning. I G. SNM-1067, Part 1, License Condition, Section 2.7.2, "Operating Procedures for Nuclear Fuel Manufacturing" states, in part, that all operations involving radioactive materials shall have written procedures which shall include the appropriate safety requirements and which shall be followed.

1 Section 3.1.1, "Radiation Work Permit Procedures" states, in part, that written operating procedures for the Health and Safety group are provided j and followed.

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, l NUREG-0940 II.A-65 J l

Notice of Violation Contrary to the above, as of October 23, 1987, the Health and Safety group was not orovided with certain procedures that were necessary to implement the rad'ation protection program. Specifically, no written procedures were provided for several radiological safety activities including the requirements for writing Radiation Work Permits as required by SNM-1067, section 3.1.1; for implementing the respiratory protection program as required by 10 CFR 20.103(c); for implementing a bioassay program as required by 10 CFR 20.103(a)(3); or for sampling liquid waste tanks as required by 10 CFR 20.106(c)(7).

H. 10 CFR 19.12 requires that all individuals working in a restricted area be instructed in the precautions and procedures to minimize exposure to radiation and radioactive materials, and in the applicable provisions of the Commission's regulations and licenses.

Contrary to the above,

1. On September 26, 1987, a individual working in a restricted area I was not instructed in the procedures and precautions necessary to I perform the enrichment hood clean-up, and to minimize an intake of '

concentrations of radioactive material.

2. As of October 23, 1987, individuals working in the Pellet Shop, a restricted area, had not been instructed in the purposes and functions of protective devices (i.e., respiratory protective equipment), or in proper frisking techniques to minimize their exposure to radioactive materials.

I. 10 CFR 19.11 (a) requires in part that each licensee post any notice of violation involving radiological working conditions, and any licensee response to the Notice.

Contrary to the above, as of October 23, 1987, neither the Notice of Violation sent to the licensee on May 26, 1987 with NRC Inspection Report No. 70-1100/87-01, nor the licensee's response, dated June 17, 1987, to the Notice, had ever been posted.

J. 10 CFR 20.401(b) requires in part that each licensee maintain records showing the results of surveys required by 10 CFR 20.201(b).

Contrary to the above, as of October 23, 1987, records of surveys for an incoming damaged fuel assembly on April 6,1987 and of surveys to support the RWP which controlled the work on the fuel assembly on April 7,1987 i were not maintained in accordance with 10 CFR 20.401(b). i Collectively, these violations have been categorized as a Severity Level III problem (Supplement IV).

Cumulative Civil Penalty - $12,500 assessed equally among the violations, i i

l NUREG-0940 II.A-66

Notice of Violation Pursuant to the provisions of 10 CFR 2.201, Combustion Engineering, Inc. 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) adniission 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.

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 Direc-tor, Of fice 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 accord-ance 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. ,

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 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 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.

i

]

NUREG-0940 II.A-67

i Notice of Violation The responses to the Director, Office of Enforcement, noted above (Reply to l a Notice of Violation, letter with payment of civil penalty, and Answer to a .

Notice of Violation) shculd be addressed to: Director, Office of Enforcement,

! U.S. Nuclear Regulatory Commission, ATTN: Docu:nent Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, for the appropriate Region, and, if applicable, a copy to the NRC Resident Inspector, at the facility which is the subject of this Notict!. '

FOR THE NUCLEAR REGULATORY COMMISSION 1

/(A]LLG_-Tu William T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania this g,f day of January 1988 l

l l

NUREG-0940 II.A-68 1

I.__ ._ . _ . . . - - -- . . . , _ . _ _

d l

n ais UNitt0 sf Af ts

/ga *. NUCLEAR REGULATORY COMMISSION 8 e , I mtcloN s,i 1

e,

, "( ' f tesmoostvtttmono cot , w~. w~ois sein WAR i 71987 Occket No. 030-19025 License No. 04-19044-01 EA 87-28 Radiation Sterilizers, Inc.

ATTN: Mr. Allan Chin 3000 Sand Hill Circle Menlo Park, CA 94025 i Gentlemen:

SUELJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 030-19025/87001(ORSS))

This refers to the NRC inspection of activities authorized by NRC License No. 04-19644-01 conducted on January 14 and 27, 1987, at Sciiaumburg, Illinois and Westerville, Ohio. The report of the inspection was forwarded to you by letter dated Febrcary 12, 1987, During the inspection, violations of NRC requirements were identified. The results of the inspection were discussed on February 17, 1987 during an enforcement conference held in the NRC Region !!!

of fice between you and members of your staf f, and Mr. C. J. Paperiallc< and members of the NRC staff.

The violations that are described in the enclosed Notice include: (1) failure '

to test smoke and temperature alarms at required intervals; (2) f ailure to maintain an operable warning beacon in the ms2e entrance to the gamma cell; g (3) f ailure to maintain an operable access barrier to the gamma cell, a l situation which could lead to accidental 96rsonnel entry; (4) failure to ,

maintain operatle control panel water level indication and an operaole system to detect and shutdown the irradiator in the event of source storage pool excessive water loss; (5) failure to make a thorouch visual check of the entire gamma cell before exposing the source; (6) failure to use personal i initial tags for access control as required; (7) failure to maintain a seismic r detector in an operable condition, and (8) failure to post an emergency -

telephone call list in the control room. I Collectively, these violations demonstrate a significant breakdown in management

] oversight and control of your radiation safety program. The NRC is particularly concerned about your f ailure to p omptly repair safety-related systems af ter you became aware that the systems were not functioning properly and that contrary

to your commitm it in response to the March 28, 1985 Notice of Violation (NOV),

, the resul ts of the monthly safety-system tests were not provided to the corporate ,

)

office, in addition, two of the violations at your Schaumburg, Illinois facility, {

failure to test gamma cell smoke and temperature alarms and failure to maintain  !

an operable warning beacon in the maze entrance, were cited in the March 28, 1985 l NOV, and are therefore repeat violations. I 1

CERTIFIED XAIL i

! RTfi3tN RECEIPT REQUESTED i

{

)

NUREG-0940 II,A-69 I i

l

Radiation Sterilizers, Inc. 2 MAR 171987. 1 To emphasize the importance of maintaining safety-related systems in a fully operable state and promptly correcting identified problems, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed imposition of Civil Penalty in the amount of Ten Thousand Dollars ($10,000) for the violations set forth in the Notice.

In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (198f' (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 problem is $5,000.

The escalation and mitigation factors in the Enforcement Policy were considered, and in this case the base civil penalty has been increated by 100 percent because of: (1) your prior knowledge of the problems, (2) your failure to take prompt and ef fective corrective measures for previously identified violations, and (3) the duration of some of the violations.

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, l you should document the specific actions taken and any additional actions you plan to prevent recurrence. In particular, you should describe what actions l will be taken to ensure that facility management as well as corporate management are made aware of the operability status of the safety-related systems at your i licensed facilities and what steps will be taken to ensure prompt repair of malfunctioning components or systems. 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 ccmpliance with NRC regulatory requirements. Your response j will also be considered during the process of evaluating your license renewal ,

application.

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 Occument Room.

The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Marlagement and Budget as required by the Paperwork Reduct. ion Act of 1980, PL 96-511.

Sincerely, CN h$ o0 ^ ~ &

A. Bert Davis Acting Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Inspection Report No. 030-19025/87001(0RSS)

NUREG-0940 II.A-70

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Radiation Sterilizers, Inc. Docket No. 030-19025 3000 Sand Hill Circle License No. 04-19644-01 Menlo Park, CA 94025 EA 87-28 During an NRC inspection conducted or. January 14 and 27,1987, violations of NRC requirements were identiftad. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatcry Commission proposes tc 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:

1. License Condition No. 20 requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in the documents, including any enclosures, listed below:

(1) Applications dated January 21, 1981 and August 30, 1983.

(2) Letters dated February 4, 1983, April 18, 1983, November 28, 1983 and September 6, 1985.

A. The referenced applications dated January 21, 1981 and Augus. 30, 1983 require that a safety system test be performed on o "anthly basis to assure proper operation of the gamma cell smokc and temperature alarms.

Contrary to the above, the gamma cell smoke and temperature alarms were not tested between October 1986 and January 14, 1987 at the Schaumburg, Illinois facility and were not tested between May 1985 and January 27, 1987 at the Westerville, Ohio facility.

This is a repeat violation.

B. The referenced application dated January 21, 1981 requires that a red beacon in the maze will start flashing whenever a source is "not down" or when radiation is presant. Also, a lighted sign at the entrance to the maze will show the source status by indicating whether or not entry is permitted.

Contrary to the above, during the period October 1986 to January 14, 1987, the beacon in the maze and the lighted sign at the entrance to the maze at the Schaumburg, Illinois facility were inoperable,. l This is a repeat violation.

NUREG-0940 II.A-71

Notice of Violation 2 MAR 171987 C. The referenced letter dated November 28, 1983 requires that within the maze there will be two doors that are positioned to prevent accidental personnel access and cannot be pushed open to gain access to the maze.

Contrary to the above, on January 27, 1987, an NRC inspector observed that one of the two doors to the maze malfunctioned and opened thereby making it possible for an individual to accidentally gain access to the maze.

D. The referenced application dated January 21, 1981 and the referenced letter dated February 4, 1983, require that status lamps for water level in the storage pool be provided on the console indicating "ok" or "water being added." The referenced letter dated April 18, 1983 requires that if a situation develops where gross water loss occurs the entire source control system shuts down.

Contrary to the above, during the period October 1986 to January 14, 1987, the water level status lamps and the gross water loss syst.:ns were inoperable at the Schaumburg, Illinois facility.

E. The referenced applications dated January 21, 1981 and August 30, 1983, require that prior to leaving the radiation cell, operators conduct a visual and audible che.:k of the cell to assure that everyone else is out of the cel .

Contrary to the above, on January 14, 1987, an NRC inspector observed an operator leaving the gamma cell at the Schaumburg, Illinois facility without visually' checking the entire cell prior to raising the radioactive sources. Also, on January 28, 1987, an operator at the Westerville, Ohio facility stated that he does not routinely visually check the entire cell perimeter to assure that everyone is out of the cell prior to raising the radioactive sources.

F. The referenced letter, dated September 6, 1985, requires that when an individual at the Schaumburg, Illinois facility enters the gamma cell the personal initial tag be placed on the proper board and when the individual exits the cell the initial tag be removed from the board and the individual verify that no tags remain on tne board.

Contrary to the above, on January 14, 1987, an NRC inspector observed an individual entering the gamma cell at the Schaumburg, Illinois facility without placing his personal initial tag on the proper board.

The facility General Manager discontinued the use of the tags in December 1986.

G. The referenced application dated August 30, 1983, requires that a seismic detector, which will shut the system down if preset shock values are exceeded, be included in the safety system at the Westerville, Ohio facility.

NUREG-0940 II.A-72

Notice of Violation 3 MAR 171997 Contrary to the above, during the period December 2,1986 to January 27, 1987, the seismic detector at the Westerville, Ohio facility was inoperable and would not shut down the system.

H. The . referenced letter dated February 4,1983, requires that an emergency telephone call list be posted at all' times in the control room at the Schaumburg, Illinois facility.

Contrary to the above, during the period January 1986 to January 14, 1987, the emergency telephone call list was not posted in the control at the Schaumburg, Illinois facility.

Collectively, these violations have been categorized as a Severity 1.evel III problem (Supplements IV and VI).

Cumulative Civil Penalty - $10,000 - assessed equally among the violations.

Pursuant to provisions of 10 CFR 2.201, Radiation Sterilizers, Inc. is hereby required to submit a written statement or explanation to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Mashington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, IL 60137 within 30 days of the date of this Notice. This reply 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 which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an sdequate reply is not received within the time specified in this Notice, the Director, Office o Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper shculd 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 affirma. ion.

Within the same time as provided for the response required above under 10 CFR 2.201, Radiation Sterilizers, Inc. may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Ten Thousand Dollars ($10,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Of fice of Inspection and Enforcement. Should Radiation Sterilizers, Inc. fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Radiation Sterilizers, Inc. elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may:

(1) deny the vio1ations 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 sheuld 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.

NUREG-0940 II.A-73

E 17 S #e Notice cf Violation 4 In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C 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., cite page and paragraph numbers) to avoid repetition. The attention of Radiation Sterilizers, Inc. is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing civil penalties.

Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicabl. provisions of 10 CFR 2.205, this matter may be referred to the Attorr aneral, and the penalty, unless compromised, remitted, or mitigat cay be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282.

Sincerely, A. Bert Davis )

Acting Regional Administrator Dated at Glen Ellyn, Illinois, this / day of March 1987.

l l

l NUREG-0940 II.A-74

8

.!  % UNITED STATES NUCLEAR REGULATORY COMMISSION s  :

wAsenwoTow. o.c. rosas

• • • • • AUG 181987 Docket No. 030-19025 License No. 04-19644-01 EA 87-28 Radiation Sterilizers, Inc.

ATTN: Mr. Allan Chin 3000 Sand Hill Road Building No. 4-245 Henlo Park, CA 94025 l

l Gentlemen:

SUBJECT:

ORDER IMPOSING A CIVIL HONETARY PENALTY This refers to your letters dated April 29 and 30, 1987, in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you by our letter dated March 17, 1987. Our letter and Notice described eight violations categorized collectively as a Severity Level III problem which were identified during an HRC inspection conducted on January 14 and 27, 1987, at Schaumburg, Illinois and Westerville, Ohio.

To emphasize the importance of raintaining safety-related systects in a fully operable state and promptly correcting identified problems, a civil penalty of Ten Thousand Dollars ($10,000) was proposed. The proposed civil penalty had been escalated by 100 percent because of* (1) your prior knowledge of the problems; (2) your failure to take prompt and effective corrective measures for previously identified violations; and (3) the duration of some of the violations.

In your responses you admitted that four of the violations occurred as described in the Notice, you denied fa r violations and you offered several reasons for full mitigation of the civil penalty.

After consideration of your responses, we have concluded for the reasons given in the Appendix attached to the enclosed Order Irnposing Civil Penalty that six of the eight violations, including two repeat violations, did occur as originally stated in the Notice. Violations C and G have been withdrawn.

While a sufficient basis was not provided by you for mitigation of the proposed penalty, because two violations have been withdrawn, the proposed penalty has been reduced by twenty-five percent. Accordingly, we hereby serve the enclosed Order on Rediation Ster 1112ers, Incorporated imposing a civil monetary penalty in the arnount of Seven Thousand Five Hundred Dollars ($7,500).

We will review the effectiveness of your corrective actions during a subsequent inspection.

CERTIFIED HAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-75

Radiation Sterilizers. Inc. 2 In accordance with Section 2.790 of the tiRC.'s "Rules of Practice" Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room.

Sincerely.

[

W M. Taylor, uty Executive rector for Regional Operations

Enclosures:

As stated NUREG-0940 II.A-76

UNITED STATES NUCLEAR REGULATORY C0 MISSION In the Matter of )

) Docket No. 030-19025 Radiation Sterilizers, Incorporated ) License No. 04-19644-01 Schaumburg, Illinois ) EA 87-28 Westerville, Ohio )

ORDER IMPOSING CIVIL MONETARY PENALTY I

Radiation Sterilizers, Incorporated (Licensee) is the holder of Byproduct Materials License No. 04-19644-01 (License) issued by the Nuclear Regulatory Comission (Comission or NRC) on July 2,1981. The License is currently under timely renewal. The License authorizes the Licensee to irradiate materials other than explosives or highly flammable products in accordance with the conJitions specified therein.

I l

II Inspections of the Licensee's activities at its faci ies in Schaumburg, Illinois, and Westerville, Ohio, were conducted on January 14 and 27, 1987, respectively. The results of those 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 March 17, 1987. 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 of Violation and Proposed Imposition of Civil Penalty by letters dated April 29 ar.d "O,1987.

NUREG-0940 II.A-77

2 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 six of the eight violations occurred as stated in the Notice and that the penalty proposed for the violations designated in the Notice should be reduced by 25 percent and imposed.

IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy /.ct of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT:

The Licensee pay a civil penalty in the araount of Stven Thousand Five Hundred Dollars ($7,500) 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 Comission, ATTN: Document Control Desk, Washington, DC 20555.

The Licensee may request a hearing within 30 days of the date of this Order.

A request for hearing should be clearly marked as a "Request for an Enforcement Hearing" and shall be addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Pashington, DC 20555, with a copy to the Assistcr.t General Counsel for Enforcement at the same address and to the Regional Administrator, Region 111.

NUREG-0940 II.A-78

l If a hearing is requested, the Comission 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 paynent has not been made by that time, the matter may be referred to the Attorney General for collection.

fn the event the Licensee requests a hearing as provided above, the issues to be considered at such hearing shall be:

(a) whether the Licensee was in violation of the Comission's requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalty referenced in Section II above and modified by this Order, and

! (b) whether, on the basis of such violations, this Order should be sustained.

FOR THE NUCLEAR REGULATORY COMMISSION C

a es M. Taylor Deputy Executive irector for Regional Operations Dated at Bethesda, Maryland this 18

• day of August 1987 NUREG-0940 II.A-79

APPENDIX EVA M TIONS AND CONCLUSIONS On March 17, 1987, a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for violations identified during NRC inspections.

By letters dated April 29 and 30, 1987, Radiation Sterilizers, Incorporated (licensee) responded to the Notice. In its response, the licensee admits certain violations occurred as described in tile Notice, denies other violations, and provides reasons why it believes that mitigation of the proposed civi*, penalty is appropriate. Provided below are: fl) a restatement of each violation; (2) a sumary of the licensee's response regarding each violation; 53) NRC's evaluation of the licensee's response; (4) tb licensee's arguments in support of mitigation of the proposed civil penalty, and (5) HRC's conclusicas regarding the violations and the proposed civil penalty.

I. Licensee's Arguments Regarding Violations A. Violation A Restatement of the Violation The referenced applications dated January 21, 1981 and August 30, 1983, require that a safety system test be performed on a monthly  !

I basis to assure proper operation of the gama cell smoke and temperature alarms.

Contrary to the above, the gama cell smoke and temperature alarms were not tested between October 1986 and January 14, 1987, at the Schaumburg, Illinois facility and were not tested between May 1985 and January 27, 1987 at the Westerville, Ohio facility.

This is a repeat violation.

Sumary of Licensee's Response The licensee does not contest the violation, but does deny the repetitive nature of the violation.

The licensee stated that the violation cited from the previous inspection in March .985 was for the failure to test all safety systems, not just the smoke and temperature alarms. .y properly documenting that tests were not perforned, the licensee felt that it was in compliance with the requirement. The licensee also contends that the NRC inspector, during an August 1985 audit, verbally stated that test schedule adherence at the Westerville facility was adequate, even though tests had not been performed for the two previous months. Furthermore, the licensee believed that the visual checks which were made of the smoke and fire detectors constituted a reasonable inspection of these devices.

NUREG-0940 II.A-80

Appendix NRC Evaluation of Licensee's Rasponse Periodic safety system testing islintended to ensure that safety systems remain functional. The smoke and temperature alarms were included in the list of safety systems that were not tested as of March 1985 at the Schaumburg. Illinois facility. Although the 1985 and 1987 violations'are not identical in scope, the 1987 violation constitutes a repetitive failure.on the part of licensee management to ensure that safety systems are successfully tested. Maintaining a record of the failure to perform the tests does not satisfy the requirement to perform the tests.

Contrary to the licensee's assertion, an audit was not performed by the NRC in August 1985. The inspector was at the Westerville, Ohio, facility to observe a source loading. The safety system testing schedule was reviewed by the inspector, but no records of test activities were reviewed. The inspector did not approve or assess the compliance of any licensee testing schedule or activities. No inspections were performed at the facility until the January 1987 inspection.

A visual inspection of an active safety system device does not constitute a test of the device. The National Fire Protection Association as well as device manufacturers provide testing gu' dance for heat and smoke detection systems.

No basis has been provided for withdrawal of this violation.

I B. Violation 8 Restatement of the Violation The referenced application dated January 21,~1981 requires that a red beacon in the maze will start flashing whenever a source is "not down" or when radiation is present. Also, a lighted sign at the entrance to the maze will show the source status by indicating whether or not entry is permitted.

Contrary to the above, during the period October 1986 to January 14, 1987, the beacon in the maze and the lighted sign at the entrance to the maze at the Schaumburg, Illinois facility were inoperable.

This is a repeat violation.

Sumary of Licensee's Respense The licensee does not contest the violation, but does deny the repetitive nature of the violation. The licensee contendt in the response letter that the warning beacon and warning sign are "not part of the safety s"stem and irdicate stetus only" and that no coripromise in plant safety rctulted from their inoperable status. l NUREG-0940 II.A-81

Appendix ,

The licensee further states that personnel at the Schaumburg facility were aware that the warning beacon and sign were not ,

functioning and that the photo ce11s and pressure mats were operative and would protect personnel by alarming and shutting the The basis for denial of system the repeatdown if entry were violation attemp(ted.

is that: 1) only the warning beacon was found '

inoperable in March 1985, due to a burned out lamp (the warning sign was functioning properly); and (2) since the prior violation was caused by a burned out bulb and the present violation was caused by a disconnected wire, the proposed corrective action resulting from the March 1985 inspection would not have prevented the later failure of the warning beacon.

NRC Evaluacion of Licensee's Response The NRC considers these devices to be part of the facility safety systems. The licensee had also previously defined "all function and  :

status lights and signs" to be safety systems in the January 21, 1981 application for a license. Although plant safety was not seriously jeopardized with the loss of the warning devices, as other i entry control devices remained intact, one portion of the redundant '

safety system was clearly not functional and had not been functional I for a period of about three months. Regarding the licensee's argument 1 that the violation is not repetitive, a letter in response to the I similar violation in March 1985 stated that, in order to correct the circumstances which resulted in the violation, the monthly safety system report would be reviewed by the facility General Manager and ,

forwarded to the Corporate Office. During the 1987 inspection, the '

warning beacon was found to be nonfunctional as was found in 1985, a I viciation of License Condition No. 20. The General Manager was only vaguely aware and the Corporate Office was totally unaware of the system failures. Therefore, had the corrective action for the previous violation been fully implemented, the later failure of the warning beacon would have been identified.

No basis has been provided for withdrawal of this repeat violatier..

C. Violation C Restatement of the Violation The referenced letter dated November 28, 1983 requires that within the maze there will be two doors that are positioned to prevent accidental personnel access and cannot be pushed open to gair, access to the maze.

Contrary to the above, on January 27, 1987, an NRC inspector observed that one of the two doors to the maze malfunctioned and opened thereby making it possible for an individual to accidentally gain access to the maze.

NUREG-0940 II.A-82

Appendix Sumary (f Licensee's Response The licensee denies the violation.

The licensee contends that the maze doors are not part of the casic safety system required by 10 CFR 20.203, but were installed voluntarily.

The licensee also asserts that there was never a chance that a person could have entered the maze and be exposed to radiation, as, first, the area where the doors are located is contained within another area which is maintained locked and, secondly, the other safety devices would have shut down the system if such an attempt were made. The licensee also pointed out that the door malfunctioned wtiile it was closing, not opening. The licensee also asserts that a single mechanical equipment failure should not be considered to be a license violation.

NRC Evaluation of Licensee's Response The NRC agrees that the wording of the citation was incorrect. The violation should have been worded "remained open" rather than "opened."

The NRC further agrees that licensees are not ordir erily cited for violations resulting from matters not within their control, such as equipment failures that were not avoidable by reasonable licensee quality assurance measures or management controls. The failure of the maze door appears to be an isolated incident, with no evidence that reasonable licensee actions would have prevented the failure, in addition, the licensee recognized the failure and took appropriate action to fix the door.

This violation is withdrawn.

D. Violation D Restatement of the Violation The referenced application dated January 21, 1981 and the referenced letter dated February 4,1983, require that status lamps for water level in the storage pool be provided og the console indicating "ok' or "water being added." The referenced letter dated April 18, 1983 requires that if a situation develops where gross water loss occurs the entire source control system shuts down.

Contrary to the above, during the period October 1986 to January 14, i 1987, the water level status lamps and the gross water loss system were inoperable at the Schaumburg, Illinois facility.

Sumary of Licensee's Response The licensee does not contest the violation.

E. Vic,lation E Restatement of the Violation The referenced applications dated January 21, 1981 and August 30, 1983, require that prior to leaving the radiation cell, coerators NUREG-0940 II.A-83

Appendix conduct a visual and audible check of the cell to assure that everyone else is out of the cell.

Contrary to the above, on January 14, 1987, an NRC inspector observed an operator leaving the gamma cell at the Schaumburg, Illinois facility without visually checking the entire cell prior to raising the radioactive sources. Also, on January 28, 1987, an operator at the Westerville, Ohio facility stated that he does not routinely visually check the entire cell perimeter to assure that everyone is out of the cell prior to raising the radioactive sources.

Summary of Licensee's Response The licensee states that it believes that the inspector placed a different interpretation on the requirement to conduct a check of the cell by adding the word "entire". In the licensee's view, if the operator visually observes everyone else precede him from the cell, this constitutes an acceptable visual check. The licensee asserts that, with regard to the Schaumburg situation, the inspector preceded the operator from the cell, and the operator, knowing that the inspector was the only other person present, did not make a cc@lete walk around the cell perimeter, and that all portions of the cell were observed except for the far wal,1. With regard to the Westerville situation, the operator stated that he always made sure people who went into the cell with him were accounted for before he started the system. The licensee states that the actions and statements of these operators were in compliance with its license.

NRC Evaluation of Licensee's Response The requirement states that operators are required to conduct a visual check of the cell to assure that everyone else is out of the cell prior to each start-up. A prudent and complete search of the cell requires more than observing those persens in the cell with the operator to have exited. Because there are parts of the cell that are obscured from sight when looking from the entryway, it is recessary to make a thorough visual inspection of all areas within the cell.

Further, there may be situations where an individual entered the cell without the operator's knowledge.

The inspector observed an incomplete visual check of the cell at the Schaurrburg f acility. Operators at both facilities inforned the inspectors that this type of search method was routinely used as they were trained to do cell searches in that manner. An entire cell search is necessary to ensure that no individuals had, unknown to the operator, entered the cell.

No basis has been provided for withdrawal of this violation.

F. Violation F Restatement of the Violation The referenced letter, dated September 6,1985, requires that when an individual at the Schaunburg, Illinois facility enters the garna cell, the personal initial tag be placed on the proper board and NUREG-0940 II.A-84

Appendix- when the individual exits the cell the initial tag be removed from the board and the individual verify that no tags remain on the board.

Contra y to the above, on January 14, 1987 an NRC inspector otiserved an individual entering the ganna cell at the Schaumburg, Illinois facility without placing his personal initial tag on the prop 3r board. The facility General Manager discontinued the use of the tags in December 1986.

Sunnary of Licensee's Response The licensee denies the violation.

The licensee contends that the personal tag system is an internal I control and therefore should not be considered part of the license.

The licensee further contends that the system was discontinued according to the licensee, because a better personnel accounting system was going to be installed.

NRC Evaluation of Licensee's Response The personal tag system procedure was specifically submitted to the NRC in a September 6, 1985, letter which is referenced in License Condition No. 20. As such, the NRC used this information as part of its evaluation of the licensee's safety program in this area. The new personnel accounting system had not been installed by the date of the inspection even though the tag system had been discontinued in December 1986. Further, the NRC has not reviewed or approved another personnel accountability system to replace the tag system.

No basis has been provided for withdrawal of this violation.

G. Violation G Restatement of the Violation The referenced application dated Augusta 30, 1983, requires that a seismic detector, which will shut the system down if preset shock values are exceeded, be included in the safety system at the Westerville, Ohio facility.

Contrary to the above, during the period December 2,1986 to January 27, 1987, the seismic detector at the Westerville, Ohio facility was inoperable and would not shut down the system.

Sunnary of Licentee's Response The licensee denies the violation. The licensee refers to the license, which states that e seismic detector will be in place when required, and argues that the detector is not required because Westerville is in an area of minimal seismic activity by ANSI and NRC standards.

NUREG-0940 II.A-85

l l

l Appendix 7_ ,

l NRC's Evaluation of Licensee's Response The carthquake probability for the Westerville, OH, area is.very low, less than 0.1g horizontal acceleration at 90% confidence over a 50 year period.according to the U.S. Geological Survey.

ANSI N42.10-1984, "Safe Design and Use of Panoramic Wet Source Storage Gama Irradiators (Category IV)," Section 8.25, requires interlocked seismic detectors for facilities in areas where greater than 0.39 horizontal acceleration would be expected at 90%

confidence over a 50 year period. This is the applicable standard utilized during NRC licensing review for determining seismic event protection requirements at pool irradiators. Consequently, the NRC agrees that the interlocked seismic detector was not a required safety system at the Westerville, OH, facility.

This violation is withdrawn.

H. Violation H l Restatement of the Violation The referenced letter dated February 4,1983, requires that an emergency telephone call list be posted at all times in the control room at the Schaumburg, Illinois facility.

Contrary to the above, during the period January 1986 to January 14, 1987, the emergency telephone call list was not posted in the control room at the Schaumburg, Illinois facility.

Surrr.ary of Licensee's Response The licensee does not contest the violation.

II. Sumary of Licensee's Arguments for Mitigation of the Civil Penalty The licensee raises numerous argunents for nitigation of the proposed civil penalty in its April 30, 1987, letter. Briefly sumarized, these are: (1) there was no prior warning of potential civil penalty, (2) there was insufficient time to prepare for the enforcement meeting, (3) there was never any threat to the safety of the public or workers.

(4) RSI has been sensitized to the new level of compliance enforcement (5) RS! has already been damaged in the medical market, (6) RSI will be severely damaged in the food market if any penalty is levied, (7) a majority of the alleged violations are the result of misconceptions, misunderstandings and misinterpretations, (8) several of the violations were a result of the licensee's attempt to improve its safety system, and (9) RS!'s prior inspection responses were tailored to meet existing enforcement sensitivity levels.

NRC's Evaluation of Licensee's Recuest for Mitigation The NRC Enforcement Policy is contained in 10 CFR Part 2, Appendix C, a public document. That policy does not require a warning prict to NUREG-0940 II.A-86

Appendix issuance of any enforcement action. It is the licensee's responsibility to be aware of enforcement options therein. With regard to the licensee's argument that it had insufficient time-to prepare for the enforcement meeting, the NRC rotes that the licensee was notified by telephone on January 27, 1987, of the upcoming enforcement meeting. The enforcement meeting was held on February 17, 1987, three weeks later. The proposed violations were discussed with licensee representatives during the inspection exit interviews and during that telephone call on January 27, 1987. The licensee thus had sufficient time in which to prepare for the enforcement meeting.

The NRC disagrees that there was no threat posed to public health and safety by the violations. The licensee's failure to promptly address safety concerns reflects a lack of management attention to the radiation safety program. The level of safety to workers was decreased when certain safety systems were not functional. Had workers or members of the public been actually harmed, the enforcement action which was proposed would have been more severe, including possible license suspensien.

The NRC expects that its licensees will exhibit increased sensitivity to safety matters as the logical result of enforcement action. However, such sensitivity is not considered to warrant mitigation of the civil penalty under the Enforcement Policy.

While it is not the NRC's intention that the economic impact of a civil penalty be such that it puts a licensee out of business or adversely affects a licensee's ability to safely conduct licensed activities, the fact that enforcement action may be counterproductive to the licensee's ccmpetitive position ir. the marketplace is not a basis for mitigating the prepcsed civil penalty.

With regard to the licensee's argument that some of the violations are the result of misunderstandings, the NRC emphasizes that the violations were cited against license conditions and against information submitted l to the NRC by the licensee. The NRC expects its licensees to be aware of commitments made to the NRC, and the conditions of their licenses.

4 Although the licensee has initiated efforts to upgrade its safety prcgrams, in so doing, it unnecessarily rendered safety equipment nonfunctional for extended time periods pending implementation of these improvements. Additionally, the NRC had not approved the system mdifications or incorporated the new designs into the licensee's license.

Finally, due to regulatory concerns at irradiation facilities over the past several years, the NRC has developed more detailed guidance for licensing and inspecting irradiators and has increased the frequency for irradiation facility irspections. However, the NRC notes that it has net changed its thresh:lds fer assessing various erforcement sanctions. The Enfcrcement Policy clearly states that the purpose of the enforcenent program is to prenote and protect the radiological health and safety of the public and that, consister.t with the purpose of this program, prompt NUREG-0940 II.A-87

Appendix and vigorous enforcement action will be taken when dealing with licensees who do not achieve the necessary metic.ulous attention to detail and the high standard of compliance which the NRC expects of its licensees.

III. NRC Conclusion The NRC staff has concluded that six of the eight violations did occur as originally stated in the March 17, 1987, Notice of Violation and Proposed Imposition of Civil Penalty. These six violations, including two repeat violations, collectively represent a significant breakdown in management oversight and control of the radiation safety program. A sufficient basis for mitigation was not provided as detailed in Section !! above; however, the'NRC staff h'as concluded that a 25 percent reduction in the base civil penalty is appropriate as two of the eight violations have been withdrawn. Therefore, the NRC staff has concluded that a $7,500 civil penalty should be imposed.

NUREG-0940 II.A-88

ga asaw

,e o g UNITED STATES y g NUCLEAR REGULATORY COMMISSION WASHING TON, D. C. 20555 3 l

• • ' FEB 8 1988 Docket No. 030-19025 License No. 04-19644-01 EA 87-28 Radiation Sterilizers, Inc.

ATTN: Dr. Allan Chin 3000 Sand Hill Road Building No. 4-245 Menlo Park, California 94025 Gentlemen:

SUBJECT:

ORDER AMENDING AUGUST 18, 1987 ORDER IMPOSING CIVIL MONETARY PENALTY Enclosed is an Order amending the August 18, 1987 Order Imposing Civil Monetary Penalty. As a result of your December 23, 1987 letter and a reevaluation by the NRC Staff, violations F and H of the Notice of Violation have been recategorized as separate Severity level IV violations with no civil penalty.

Accordingly, an adjusted civil penalty of $5,000 is imposed.

In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," Part 2, Title i 10, Code of Federal Regulations, a copy of this letter and the enclosed Order  !

! will be placed in the NRC's Public Document Room.

The response directed by 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.

Sincerely, s

n :_-

J .es M. Tay1 , Deputy Executive Director l for Regional Operations

Enclosure:

As Stated CERTIFIED MAIL RETURN RECEIPT REOUESTED NUREG-0940 II.A-89

UNITED STATES NUCLEAR REGULATORY COMMISSION In Matter of )

) Docket No. 030-19025 Radiation Sterilizers. Incorporated ) License No. 04-19644-01 Schaumburg, Illinois ) EA 87-28 Westerville, Ohio )

ORDER AMENDING AUGUST 18, 1987 CRDER IMPOSING CIVIL PCNETARY PENALTY I

On August 18, 1987 an Order Imposing Civil Monetary Penalty (Order) was issued to Radiation Sterilizers, Inc. (Licensee). The Order imposed a civil monetary penalty in the amount of $7,500 upon the Licensee for the viciations set forth in a Notice of Violation issued to the Licensee on March 17, 1987, as amended by the Order.

l II By letter dated September 8, 1987 the Licensee requested a hearing on the Order.

At the Licensee's reouest, a meeting was held en October 1,1987 to discuss the civil penalty action. Thereafter, discussions were held with the Licensee concerning settlement of this civil penalty case. By letter dated December 23, 1987 the Licensee offered to pay a civil penalty of $5,000 and to withdraw its request for a hearing.

III The NRC has reevaluated this civil penalty action in light of information provided by the Licensee. As a result of its review, the NRC has determined that Violations F and H of toe Notice of Violation in comparison with the NUREG-0940 II.A-90

2 other violations comprising the Severity Level III problem for which the civil penalty was imposed are clearly of minor significance and should be categorized as separate Severity Level IV violations with no civil penalty.

Accordingly, the Staff is remitting the civil penalty for these two violatiens.

This results in an adjusted civil penalty of $5,000.

IV fn view of the above and pursuant to 10 CFR 2.205(g) of the Commission's regulations, I am hereby amending the August 18, 1987 Order by remitting the civil penalty for violations F and F. The Licensee is hereby ordered to pay a civil monetary penalty in the amount of $5,000 within 30 days of the date of l

this Order.

FOR THE NUCLEAR FEGULATORY COMMISSION

/

Aames M. Taylor [', Deputy Executive Director

/ / for Regional Operations Le DG2cd at Bethesda, Maryland this f U f tay of February 1988.

l I

l 1

NUREG-0940 II.A-91 l

• Me 8 k UNITED STATES NUCLEAR REGULATORY COMMISSION i

b W ASHINGTON, D, C. 20555

(*****,/ SEP 011987 Docket No. 40-08027 License No. SUB-1010 EA 87-108 Sequoyah Fuels Corporation ATTN: J. G. Randolph President Kerr-McGee Center P.O. Box 25801 Oklahoma City, OK 73125

SUBJECT:

ORDER TO SHOW CAUSE AND NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY at the Sequoyah This Fuelsrefers to the Facility, inspections Gore, Oklahomaand investigations during the period ofconducted.4, January 1986 through September 16, 1986. These efforts were undertaken as a followup to the January 4, 1986 accident in which a cylinder filled with uranium hexafluoride ruptured while it_was being heated in a steam chest. Investigations were conducted by an Augmented Investigation Team (AIT) and by the NRC Office of Investigations (01). A copy of the 01 Report 4-86-005 synopsis is enclosed.

The 01 investigation was conducted to determine, among other matters, whether Sequoyah Fuels Facility management and supervisory personnel made willful false statements to the NRC regarding their knowledge of heating of overfilled uranium hexafluoride cylinders and whether a letter from Kerr-McGee to the NRC dated January 29, 1986 included material false statements.

Following the January 4, 1986 accident, Kerr-McGee agreed not to restart the Sequoyah Fuels Facility until NRC authorization had been obtained. Additional comitments were made and confirmed in a Confirmation of Action Letter issued by NRC Region IV to the licensee on January 17, 1986. In an Order Modifying License issued October 2, 1986, the NRC identified certain actions that would be required before restart of the Facility wotrid be authorized. A condition in this Order was the presence of an approved Independent Oversight Team (IOT) on a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per day basis while the plant is operating. The IOT was required ,

because of the NRC's concerns about the conduct of individuals with supervisory responsibilities. The 10T has been continued pending completion of the NRC investigctions and review of the results of those investigations. Close monitoring was also necessary to ensure full compliance with all procedures and to ensure that managemant and supervisory personnel demonstrate, in attitude and implementation, a proper comitment to safe operating practices.

The IOT has been in place at the Facility since November 5, 1986. The Facility resumed operations December 11, 1986. In letters dated February 24, 1987, April 6, 1987, and May 7, 1987, Sequoyah Fuels Corporation requested phased reduction of the IOT. These requests were supported by reports from the 10T concerning the HUREG-0940 II.A-92

Sequoyah Fuels Corporation areas monitored by the team. These reports indicate a satisfactory level of operational performance and that the objectives for the IOT have been achieved.

I have reviewed these reports and reports of NRC inspections and concluded that the operation of the Facility now justifies reduction of the 10T coverage and that reduced coverage will still ensure fulfillment of remaining objectives.

Therefore, the I0T coverage requirement may now be reduced to one shift per day, seven days per week, with shift coverage to be conducted randomly during the 24-hour period.

After careful review of the 01 investigation report and consultation with the Comission, we have concluded that the following enforcement actions should be taken for certain findings made by the investigation.

The NRC staff has concluded that several Sequoyah Fuels Corporation employees were aware of improper practices at the Facility and did not fully disclose their knowledge of these practices to NRC investigators. In particular, it appears that certain supervisors were aware of the weight limitations and the prohibitions on heating overfilled cylinders. These supervisors acquiesced in, if not condoned, heating of uranium hexafluoride cylinders with more than the maximum net weight and then failed to reveal the full extent of their knowledge.

They signed cylinder status sheets reflecting excessive cylinder weights.

Their actions demonstrated a lack of candor with the NRC that cannot be accepted.

Thus, I cannot completely remove the IOT without further assurance that the NRC can rely on the performance and integrity of supervisory personnel at the Facility.

Accordingly, I am issuing the enclosed Order to Show Cause why Kerr McGee should l be allowed to continue to operate while certain supervisors are permitted to perform licensed activity. The Order lists various management actions that should be considered and addressed to provide the NRC with the necessary confi-dence as to those supervisors. The Order also requires information as to replacement personnel if the company should decide to remove the named supervisors from licensed activity. Following receipt of your response to the Order, the NRC intends to schedule a meeting concerning these issues. Thereafter, I will consider complete removal of the 10T requirement.

The NRC is also concerned about the actions and lack of candor of some of the operators at Sequoyah Fuels Facility, especially Patrick Sanders. However, no enforcement action is being taken as to these operators; as we believe that by directing enforcement action to the supervisors, they will ensure proper per-formance by the operators and create an atmosphere that will lead to candor with the NRC in the future.

The NRC issued a Notice of Violation and Proposed Imposition of Civil Penalties on October 14, 1986 for violations of procedures, some of which were associated with the January 4, 1986 accident. The total proposed civil monetary penalty was $310,000. Sequoyah Fuels Corporation responded to the Notice of Violation and an Order Imposing Civil Monetary Penalties in the amount of $310,000 was issued February 5, 1987. The penalties were paid by Sequoyah Fuels Corporation on March 2, 1987. In view of these penalties and the changes in managerrent at l the Facility, additional penalties are not being proposed for violations that occurred prior to th accident.

NUREG-0940 II.A-93

Sequoyah Fuels Corporation However, in January 1986 the NRC requested assistance from Kerr-McGee/Sequoyah Fuels Corporation in answering certain questions asked by members of the Congress.

One question sought information as to supervisory or management knowledge of heating of overfilled cylinders. The licensee's response, dated January 29, 1986, indicated that management did not have that knowledge but was silent as to supervisory personne;, when in fact management, including the Assistant General Counsel-Litigation, knew that at least one supervisor was aware of the inproper practice. Thus, the response was false by omission. The response was prepared by corporate attorneys, but without adequate supervision by corporate management and technical personnel. The response was signed by Dr. John C. Stauter, Director, Nuclear Licensing and Regulation, Kerr-ficGee Corporation, who did not read the report of the company's Internal Investigation Team, but instead relied entirely on the work of the attorneys. In fact, he still had not read the report as of the date he was interviewed by OI in April 1986. Because of our concern over the apparent failure to meet the responsibility to provide accurate information to the NRC, the Order Modifying License of October 2, 1986 required that all information provided to the NRC be submitted under oath or affirmation of the President, Sequoyah Fuels Corporation, who is responsible for the manage-ment of the activities under the license. On June 19, 1987 the licensee requested that this requirement be lifted.

The response contained in the January 29, 1986 letter is a false statement that was material to the actions taken by the NRC and could have resulted in the NRC submitting incorrect information to the Congress. While this submission may not have been a deliberate effort to provide false information, the submission was clearly misleading. The submission constitutes a careless disregard for the need to provide complete and accurate infornation to the Connission. The NRC must be confident that it can rely on the information furnished by a licensee.

Misleading the Ccamission by omission of facts that are known to a licensee cannot be tolerated. These deficiencies were apprently caused by management's delegation of its responsibility for preparing the responses to its attorneys, who did so without adequate oversight or input by licensee personnel who had knowledge of the requested information. Therefore, the decision to remove the requirement for the President of Sequoyah Fuels Corporation to sign all submissions under oath or affirmation will be deferred until the NRC has evaluated the licensee's response to the Show-Cause Order and the Notice of Violation described below.

In addition, I am issuing the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $8,000 for the violation described in the enclosed Nctice to emphasize the importance of complete candor in dealing with the NRC. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFF. Part 2, Appendix C (1987) (Enforcement Policy),

the violation described in the enclosed Notice has been categorized at a Severity Level II. The escalation and nitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. Since this civil penalty is intended to focus attention on the need for management involvement in preparing responses, a separate action is not being taken for Dr. Stauter's failure to assure that the response was complete and accurate.

NUREG-0940 II.A-94

Sequoyah Fuels Corporation You are required to respond to this letter and should follow the instructions specified in the enclosed Notice and Order when preparing your respense. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence of the violations for which you have been cited. After reviewing your responses to this Notice and Order, 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.

En 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 Public Document Room.

The responses directed by this letter and the enclosed Notice and 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.

Sincerely, M .

J nes M. Tay1 eputy Executive Director for Regional Operations l

l

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty Order to Show Cause 01 Report 4-86-005 Synopsis i

1 NUREG-0940 II.A-95

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Sequoyah Fuels Corporation Docket No. 40-08027 Sequoyah Fuels Facility License No. 508-1010 Gore, Oklahoma EA 87-108 As a result of NRC investigations conducted January 4, 1986 through September 16, 1986, violations of NRC requirements have been identified. In accordance with the "General Statement of Policy and Procedure or NRC Enforcement Actions,"

10 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Comission proposes to irepose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("ACT"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below.

In January 1986 the NRC requested the Xerr-McGee Corporation, owner of Sequoyah Fuels Corporation, to provide information to enable the NRC to respond to members of Congress. Question 11 asked:

"Did company supervisory or management personnel approve of the practice of reheating overfilled cylinders at the Sequoyah plant, or have any knowledge of this procedure? Had other overfilled cylinders ever been ,

reheated before at this facility, and if so was it with or without the i knowledge of management? List all instances where overfilled cylinders  !

were reheated."

In a letter dated January 29, 1986 and signed by the Director, Nuclear Licensing and Regulation, the Xerr-McGee Corporation responded to the question propounded by the NRC as follows:

Management personnel had no knowledge that any such practice was ever followed at the Sequoyah Facility and had specifically prohibited it. The written procedure for "Uranium Hexafluoride Product Handling and Shipping", a copy of which is attached, prominently states in two places:

"Note: Do not heat a cylinder which has been overfilled.

Evacuate the overfilled cylinder without heating until the maximum net weight is attained. This is necessary to prevent rupture of the cylinder due to hydfostatic pressure."

Interviewing of employees and reviewing of records are continuing in order to determine whether there have been any instances of cylinder overfilling in the past, and if overfilling has occurred, the nature and degree of overfilling and what steps were taken by the company.

(Enphasis added)

Contrary to Section 186 of the Atomic Energy Act of 1954, as amended, the statement made in the January 29, 1986 letter that "management personnel had no knowledge that any such practice was ever followed" constitutes a material false statement. The statement is false in that, although the cuestion sought information regarding the approval or knowledge of supervisory or management personnel regarding reheating overfilled cylinders, the response omitted mention of supervisory personnel although the licensee had knowiedge that some supervisors knew of this practice. This statement had the ability to mislead the NRC in that it omitted information regarding the licensee's knowledge that NUREG-0940 II.A-96

Notice of Violatioa supervisors knew of the practice and, to the contrary, gave the impression that supervisory personnel did not know of or approve of the heating of overfilled cylinders. In fact, the licensee had information that some supervisors did know of the practice, and the response to the question as it was first drafted was modified as a result of the licensee's knowledge that supervisors knew of this practice. The statement was material in that it addressed an issue that was important for the NRC to resolve in ensuring that the plant would be operated safely before authorizing restart of operations and had the capability of influencing the NRC with regard to its resolution of this issue and in preparing and submitting the NRC's response to Question 11 to Congress.

This statement constitutes a material false statement and is a Severity mevel 11 violation (Supplement V11).

Civil Penalty - $8,000.

Pursuant to the provisions cf 10 CFR 2.201, Sequoyah Fuels Corporation is hereby l

required to submit a written statement or explanation to the Director, Office of Enforcement, U. S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D. C. 20555 with copies to (1) the Assistant General Counsel for Enforcement, Office of the General Counsel, and (2) the Regional Administrator U. S. Nuclear Regulatory Comission, Region IV, 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 the 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, and (4) the corrective steps that will be taken to avoid further violations.

If an adequate reply is not received within the time specified in this Notice, the Deputy Executive Director for Regional Operations may issue an order to show cause why the license should not be modified, suspended, or revoked or thy 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, Sequojah Fuels Corporation may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U. S. Nuclear Regulatory Comission, Washington, D. C. 20555 with a check, draf t, or money order payable to the Treasurer of the United States in the amount of Eight Thousand Dollars ,

($8,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the U. S. Nuclear Regulatory Comission, Washington, D. C. 20555. Should Sequoyah Fuels Corporation fail to answer within the time specified, the Deputy Executive Director for Regional Operations will issue an order imposing the civil penalty in the amount proposed above.

Should Sequoyah Fuels Co:poration elect to file an answer in accordance with 10 CFR 2.205 protesting the civil peralty, 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.

NUREG-0940 I1.A-97 I l

Notice of Violation 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 the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of Sequoyah Fuels Corporation is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing civil penalties.

Upon failure to pay any civil penalty due which subsequently have been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.

FOR THE NUCLEAR REGULATORY COMMISSION

/

m J s M. Tay , Deputy Executive Director fo. Regional Operations Dated at Bethesda, Maryland this /JP day of September 1987 NUREG-0940 II.A-98

l l

UNITED STATES OF AMERICA NUCLEAR REGULATORY COMISSION In the Matter of ) l

)

SEQUOYAH FUELS CORPORATION ) Docket No. 40-08027 P. O. Box 5801 ) License No. SUB-1010 Oklahoma City, OK 73125 ) EA 87-108 ORDER TO SHOW CAUSE I.

Sequoyah Fuels Corporation (the licensee) (SFC) is the holder of Source Material License No. SUB-1010 which authorizes the licensee to possess and use source material for the purpose of refining uranium from uranium ore concentrates and converting this uranium to urar.ium hexafluoride (UF 6 ) f r use by enrichment facilities. The li e was most recently renewed on September 20, 1985 and will expire on September 30, 1990.

II.

On January 4, 1986 a cylinder containing in excess of 30,000 pounds of UF6 ruptured while being heated in a steam chest at the Sequoyah Fuels facility in Gore, Oklahoma. The cylinder had been overfilled to the point that its contents exceeded the cylinder's maximum allowable shipping weight of 27,560 pounds.

A process operator, with the consent of his supervisor, had placed the cylinder in a steam chest to heat the cylinder to facilitate removal of the excess UF6 '

While the cylinder was being heated, the cylinder wall ruptured because of the expansion of UF6 as it changed from the solid to the liquid phasc. Heating of the overfilled cylinder was contrary to the requirements of the license and the licensee's operating procedures. The high pressure in the cylinder and the large size of the rupture resulted in the rapid release of much of the NUREG-0940 II.A-99

UF6 into the atmosphere. One individual employed by the licensee died because of exposure to hydrogen fluoride (a hydrolysis product of UF6 ). Other employees received exposures to uranium and hydrogen fluoride.

By letter dated January 9,1986, the licensee comitted not to restart the VF6 conversion process at the Sequoyah facility without the concurrence of the NRC. In addition, the licensee made a number of comitments in meetings with the NRC Region IV staff. These comitments were confirmed in a Confirmation of Action Letter issued by Region IV to the licensee dated January 17, 1986.

1 Kerr-McGee Corporation promptly instituted an internal investigation of the '

event. (A letter from Sequoyah Fuels Corporation to the Director, Office of Inspection and Enforcement, dated September 24, 1986, sumarizes the results of this investigat'.on.) The NRC initiated a number of inspections, investigations, and reviews after the January 4 accident with the assistance of other State and Federal agencies to determine the cause and effects of the event and the efficiency and adequacy of the response of the licensee to the event. The NRC also has inspected and reviewed all of the requirements of the license.

As a result of these efforts, several violations of NRC requirements were identified. These violations were addressed in a Notice of Violation dated October 14, 1986 and an Order Imposing Civil Monetary Penalties issued February 5, 1987. These actions addressed procedural deficiencies in the management and operation of the Sequoyah facility, which were associated with the January 4, 1986 accident.

NUREG-0940 II.A-100

In an Order Modifying License issued October 2, 19C6, the NRC specified certain actions required before restart of Sequoyah Fuels Facility would be authorized.

These conditions included imposition of an independent ovarsight team (IOT) to maintain a 24-hour surveillance while the facility is in operation. The IOT was required to ensure full conpliance with required procedures because of NRC concerns with th> cnnduct of certain supervisors. The Director, Office of Inspection and Enforcement, was authorized to relax or rescind all or part of those requirements. On October 16, 1986 the Conunission authorized restart and the facility har resumed operations. Reports of the 10T and NRC inspections have been revir.wed by the staff. Based on NRC consideration of these reports and submittals from the licensee, in a letter accompanying this Order, the Deputy Executive Director for Regional Operations has reduced the required IOT coverage from 24-hours to 8-hours per day.

l III The NRC investigations of the accident and the management and operation of the facility sought information concerning possible overfilling and heating V 'JF6 cylinders, including supervisory knowledge of and acquiescence in those practices which violated authorized procedures. An NRC Augmented Investigation Team (AIT) conducted its inquiry ininediately following the accident. In addition, subse-quent to the accident, Sequoyah Fuels Corporation formed an Internal Investi-9dion Team (IIT) to investigate the cause of the accident. The IIT report concluded that the Januar) 4, 1986 rupture was "most likely caused by heating of the nyerfilled cylinder" and also noted that overfilling regularly occurred.

i NUREG-0940 II.A-101

Zn March 1986, the Office of Investigations (01) commenced an investigation weich, in addition to the above areas of inquiry, also examined whether willful material false statements were made in the January 29, 1986 letter.

The NRC investigations revealed that several Sequoyah Fuels Corporation employees in supervisory positions apparently were aware that UF6 cylinders were being filled beyond the authorized limit and were subsequently heated while in an overfilled condition. The licensee's September 24, 1986 response to a question from the Comis;1on stated that: "some supervisory perscnnel either acquiesced in or condoned this practice" (i.e., heating with more than the maximum net ,

i weight). In the course of responding to questions from the various investigators, ]

Messrs. J. Brewer, L. McCoy, L. Reid, and J. Swimmer did not appeer to fully dist. jose their knowledge of the overfilling and heating of the UF6 cylinders, information provided by other SFC employees, including the operators and the l Facility Manager, indicated that these supervisors were more aware of the subject practices th3n they revealed. These supervisors were aware of the weight limitations for cylinders and the provisions of Operating Procedure N-280-1, Revision 6, which prohibited the heating of overfilled cylinders. They all signed cylinder status sneets reflecting excessive weights. Further, some of the statements of these individuals to the investig; tors were inconsistent.

IV.

The holder of a license from the NRC has a clear obligation to be candid and forthcoming in dealing with the NRC and its staff. The effectiveness of the regulatory program is dependent on the ability of NRC investigators to obtain NOREG-0940 II.A-102

i complete and accurate information in determining the causes of accidents in order to protect the pu'lic health and safety as well as workers in licensed facilities. The OI investigation revealed a lack of candor among supervisory personnel, specifically with regard to Messrs. Brewer, McCoy, Reid, and Swimmer.

2t appears that these supervisors knew about and acquiesced in practices that tere contrary to authorized procedures. The NRC needs assurance that these supervisors will properly run plant operations, ensure that these operations will be conducted in accordance with authorized procedures, and in the future provide complete and accurate information to the NRC.

l v.

In view of the foregoing, pursuant to sectiont 63,161 b, i, ano o,182, and

'86 of the Atomic Energy Act of 1954, as amended, and the Commission's regula-tions in 10 CFR 2.202 and Part 40, IT IS HEREBY ORDERED THAT THE LICENSEE:

Show cause why e Order should not be issued suspending licensed activities while the following individuals are involved in licensed activities:

1. J. Brewer, Shift Supervisor

2. L. McCoy, Area Supervisor

3. L. Reid, Shift Supervisor

4. J. Swimer, Shif t Supervisor The response should at a minimum &ddress actions such as disciplinary action taken or to be taken, training conducted or scheduled to be conducted and management controls, including disciplinary policies, instituted which will NUREG-0940 II A-103

provide assurance if these employees are allowed to perform licensed activities, that the licensee will have, and the NRC should have, confidence that each of these individuals will be candid with the NRC in the future. If the licensee should decide to remove these supervisors from licersed activities, the response should include information concerning their replacements, to provide assurance that the replacements are qualified and will be candid with the NRC so that they can be relied on to provide complete and accurate information.

VI.

The licensee may show cause why this Order should not have been issued and should 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. If the licensee fails to file an answer within the specified time the Deputy 'xecutive Director for Regional Operations may issue without further notice an Order described above.

The licensee or any other person who has an iriterest adversely affected by this Order may request a hearing on this Order within 30 days of the date c,f its issuance. Any answer to this Order or request for hearing shall be submitted l

to the Director, Office of Enforcement, U.S. Nuclear Regulatory Conunission, ATTN: Docunent Control Desk, Washington, D. C. 20555, with copies to (1) the i

I NUREG-0940 II.A-104

Assistant General Counsel for Enforcement, Office of the General Counsel, and (2) the Regional Administrator, Nuclear Regulatory Commission, Region IV, 611 Ryan Plaza Drive, Suite 1000, Arlington, TX 76011. 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 affected by this Order and should address the criteria set forth in 10 CFR 2.714(d).

Xf 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 shall be whether this Order shall be sustained.

FOR THE NUCLEAR REGULATORY COMMISSION

/ 1

Et'3' mes M. Tay , Deputy Executive for Regional Operations Dated at Bethesda, Maryland this /3fday of September 1987 NUREG-0940 II.A-105

,,(pa nom [o, UNITED STATES f eq g NUCLEAR REGULATORY COMMISSION

'T.

I W A$HINGTON, D. C. 20555 e /

E....* fE81( 7968 Docket No. 40-08027 License No. SUB-1010 EA 87-108 Sequoyah Fuels Corporation ATTN: J. G. Randolph President Xerr-McGee Center Post Office Box 25801 Oklahoma City, Oklahoma 73125 Gentlemen:

SUBJECT:

ORDERS IMPOSING CIVIL MONETARY PENALTY, l MODIFYING LICENSE AND TO SHOW CAUSE This refers to your letter dated September 25, 1987, in response to the September 1, 1987 Notice of Violation and Proposed Imposition of Civil Penalty and your letter dated October 1, 1987, in response to the September 1, 1987 Order to Show Cause. We also refer to your supplemental response of November 13, 1987 to our letter dated October 19, 1987 requesting a further response to the Notice of Violation. Our letter and Notice described a violation identified during NRC inspections and investigations conducted at the Secuoyah Fuels Facility, Gore, Oklahoma, during the period of January 4, 1986 through September 16, 1986. These inspections and investigations were undertaken fo11cwing the January 4, 1986, accident in which a cylinder filled with uranium hexafluoride ruptured while being heated in a steam chest.

An Order Modifying License was issued October C, 1986 (EA 86-91) identifying certain actions required before restart of the facility would be authorized by the NRC. Due to NRC concern over cbtaining accurate information frem the licensee, this Order required that all information thereafter provided to the NRC be submitted under oath or affirmation of the President, Sequoyah Fuels Corporation.

A further recuirement of the October 1986 Order was the presence of an approved Independent Oversight Team (IOT) on a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per day basis while the plant is operating. This requirement was imposed while concerns about certain supervisors were being investigated and resolved. The IOT has been in place at the Facility since November 5, 1986, and operations were resumed on December 11, 1986. The September 1, 1987 NRC letter authorized reduction of the IOT coverage rer,.irement to one shift per day, seven days per week, with shift coverage to be conducted randomly during the 24-hour period. This letter also stated that following review of your response to the September 1, 1987 Crder to Show Cause, a meeting would be scheduled concerning the issues addressed in the Order and the staff would consider complete removal of the IOT requirement. The NRC held that meeting with you on January 12, 1988.

NUREG-0940 II.A-106

I i

Sequoyah Fuels Corporation As stated above, an investigation of the January 4, 1986 event was conducted by i the Office of Investigations (01). The O! investigation raised doubts as to  !

whether certain Sequoyah Fuels Corporation supervisors were aware of improper l practices at the Facility and fully disclosed their knowledge of these practices  !

to NRC investigators. Accordingly, the NRC issued the September 1, 1987 Orcer to Show Cause why Kerr-McGee should be allowed to continue operation while four named supervisors are permitted to perform licensed activities.

In response to the October 2, 1986 and September 1, 1987 orders, you have sub-mitted revised corporate proceduru and protecols for ensuring the ccepleteness and accuracy of information in written submittals to the NRC. In additien, you have reviewed and revised operating procedures for the Facility. You have developed an extensive training program for these operating procedures ano established a specific training program on interactions with the NRC. You have required employees to sign statements committing themselves to following corporate policies and procedures. Further, the four supervisors named in the Order to Show Cause have affirmed that they have received extensive training concerning procedures to follow and that they appreciate the importance of full, l complete, and accurate corinunications with the NRC.

The NRC has conducted numerous inspections since the accident, reviewed your procedures and operations, and interviewed workers. The performance of the IOT has been carefully monitored, including review of its reports and discussion with the head of the ICT concerning the progress that has been made in areas of concern. Through these activities and the reetings on January 12, 1988, it is evident that there is a clearly improved attitude in the management and operation of Sequoyan Fuels Facility. This attitude emphasizes safe operation, following of procedures, and attentien to detail. This attitude, the expanded training program, and charges in organizational structure all reflect strcng management control and improved interaction with ccrporate management. The ICT has expressed positive views in regard to operating croceceres, management controls and oversight. I'. is noteworthy that the :0T has expressed positive views as to the competency, attitude, and candor of the #our supervisors subject to the Septerber 1, 1987 Crder to Shcw Cause.

Since we are now satisfieo that there is reasonable assurance that act cities will be cerducted properly, pursuant to paragraph IV A.3 of the October 2, 1986 Order Modifying License, the recuirement for the IOT specified in paragraph IV A.1 is eliminated. Inspections will ensure that strong managerent oversight will centinue. Also, in light of the actions discussed above, the requirement for all written submissions to the NRC to be under the oath of the President, SFC, specified in paragraph IV A.2 of the October 2, 1986 Order Medifying License, is removed. As I am satisfied that there is reasonable assurance that the superviscrs named in the Order to Show Cause will be fcrthright and candid with the NRC in the future, the Order to Show Cause is rescirded, io emphasize the importance of providing complete and accurato informatien to the Conr11ssion, a Civil Penalty of Eight Thousand Dollars ($8,000) wcs proposed in the referenced Notice of Violation and Propcsed Imposition of Civil Penalty.

In your response, while you recognize the importance of candor with the NRC, you deny the violation stated in the Notice of Violation. After consideration of your response, we have concluded, for the reasons given in the Appendix NUREG-0940 II.A-107

Sequoyah Fuels Corporation attached to the enclosed Order Imposing Civil Penalt), that the violation did occur as described in the Notice of Violation and Proposed Imposition of Civil Penalty. Accordingly, we hereby serve the enclosed Order on SeQuoyah Fuels Corporation imposing a civil monetary penalty in the amount of Ei@ t Thousand Dollars ($8,000).

ln 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 enclosures cill be placed in the NRC's Public Document Room.

Sincerely,

,./

s l

' Jeres M. Tay1 Deputy Executive Director for Regional Operations

Enclosures:

As stated cc: w/ enclosures Oklahoma Radiation Control Program Director 1

J NUREG-0940 II.A-108

UNITED STATES NUCLEAR REGULATORY COMMISSION in the Matter of )

)

Sequoyah Fuels Corporation ) Doc:Mt No. 40-08027 Sequoyah Fuels Facility ) License No. 50B-1010 Gore, Oklahoma ) EA 87-108 ORDEP !!! POSING CIV!L MONETARY PENALTY Sequoyah Fuels Corporation (the licensee) is the holder of Scurce Material License No. 5U8-1010 issued by the Nuclear Regulatory Comission (NRC/Connis s ion) . The license authorizes the licensee te possess and use source material for the purpose of refining uranium from uranium ore concentrates and converting this uranium to uranium hexafleuride (UF 6

) for use by enrichM nt facilities. The license was most recentij renewed on September 20, 1985, and I

aill expire on September 30, 1990.

I

! II Following an accicent on January 4, 1986 in which a cylinder overfilled with uranium hexa *1curide ruptured while being heated in a steam chest, the NRC conductec a series of special inspections and investigatiens at the licensee's Seouoyah Fuels Facility, Gore Oklahoma.

9he NRC f rivestigations of the accicent and the management and cperatien of the Facility scught information concerning possible overfilling and heating of UF 6

cylinders, and whether supervisory personnel had kncwledge of and accuiesced in these practices to the extent they violated authcrized precedures. Aisc, in  !

January 1986 the NRC requested Kerr-McGee Corporation, owrer of Sequoyah Fuels NUREG-0940 II,A-109

)

l

2-Corporation, to provide information to enable the NRC to respond to cuestions from members of Congress concerning the accident. As a result of the NRC investigations, the SRC staff concluded that the licensee had not concucted its activities in full compliance with NPC requirefrents in that a material f alse staterrent was submitted in resporse to the NRC request for information. A written Notice of Violatice and Proposed Imposition of Civil Penalty was served on the licensee by letter dated September 1, 1987. The Notice stated the nature of the violation, the provision of the NRC's requirements that the licensee had violated, and the amount of the civil penalty propcsed for the violation. The licensee responded to the Notice of Violation and Proposed impositien of Civil Penalty by letter dated September 25, 1987.

i After consideration of the licensee's response cen.vg the violation and the statements of fact and explanation contained therein, the Deputy Executive Director for Regional Cperations has determined, as set forth in the Appendix to this Order, that the violation occurred as statec anc that the penalty preposed for the violation designated in the Notice of Violation ano Proposed Mposition of Civil Penalty should be imposed.

IV

n view of the foregoing and pursuant to Secticr. 234 of the Atenic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205, 'T lS HEREBY

';iOERED TF/,T:

NUREG-0940 II.A-110

The licensee pay a civil penalty in the amount of Eight Thousand Dollars

($8,000) within 30 days of the date of this Order, by check, draft, or noney order, payable to the Treasurer of the United States ard mailed to the Director, Office of Enforcement U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk Washington, D.C. 20555.

The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing shoulo be clearly marked as a "Recuest for an Enforcement Hearing" and shall be addressed to the Director, Office of Enforcement, U.S.

l Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C.

20555, with a copy to the Assistant General Counsel for Enforcement at the same address, and to the Regional Administrator, U.S. Nuclear Regulatory Comission, Region IV.

If a hearing is requested, the Commission will issuc an Order designating the timo and place of the hearir.g. 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 parent has not been made by that time, the matter may be referred to the Attorney Gereral for collection.

l In the event the licensee requests a hearing as provided above, the issues to be consicered at the hearing shall be:

l l

I NUREG-0940 II.A-111  !

(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 referred to in Section II above, and (b) whether, on the basis of that violation, this Order should be sustained.

FOR THE NUCLEAR REGULATORY COMMISSION s'

\ g

/ . Tay r

-Oeputy Executive Director u- for Regional Operations Dated at Bethesda,, Maryland, this/o f k ayd of M w m1988.

a NUREG-0940 II.A-112

APPENDIX EVALUATION AND CCNCLUSICNS On Septeiter 1, 1987, a Notice of Violation and Proposed Imposition of Civil Penalty (NOV) was issued to Sequoyah Fuels Corporation (SFC) for the violation identified during investigations following a January 4, 1986, accident. SFC responded to the Notice on September 25, 1987. In its response, SFC denied the violation.

The NRC's evaluation and conclusion regarding the licensee's arguments are as follows:

I. Restatement of Violation In January 1986 the NRC recuested the Kerr-McGee Corporation, owner of Sequoyah Fuels Corporation, to provide information to enable the NRC to respond to members of Congress. Question 11 asked:

"Did company supervisory or management personnel approve of the l

practice of reheating overfilled cylinders at the Sequoyah plant, or have any knowledge of this vocedure? Had other overfilled cylinders ever been reheated before at this facility, and if so was it with or withcut the knowledge of maragement? List all instances where overfilled cylinders were reneated."

In a letter dated January 29, 1986, and signed by the Director, Nuclear Licensing and Regulation, the Kerr-McGee Corporation responded to the questien propeunced by the NRC as folicws:

Management personnel had no knowiedge that any such practice was ever followed at the Sequoyah Facility and hac specifically prohibited it.

The written procedure for "Uranium Hexaf'w ride Product Hardling and Shipcing", a copy of which is attached, prcminently states in two places: ,

"Note: Do not heat a cylinder which has been overfillec.

Evacuate the everfilled cylinder without heating until the maximum net weight is attainea. This is necessary to prevent rupture of the cylinder due to hydrostatic pressurc."

Interviewing of employees and reviewiro of records are continuing in order to determine whether there have been any instances of cylinder overfilling in the past, and if overfillirg has occurred, the nature and degree of overfilling and what steps were taken by the ccmpany.

(Emphasis addec) l i

NUREG-0940 II.A-113

Appencix Contrary to Section 180 of the Atomic Energy Act of 1954, as amended, the statement made in the January 29, 1986, letter that "management personnel had no knowledge that any such practice was ever followed" constitutes a material false staterrent. The statement is false in that, althougt, the question sought information regarding the approval or knowledge of supervisory or management personnel regarding reheating overfilled cylinders, the response omitted mention of supervisory personrel although the licensee had knowledge that sorre supervisors knew of this practice.

This statement had the ability to mislead the NRC in that it critted information regarding the licensee's knowiecge that supervisors knew of the practice and, to the contrary, gave the impression that superviscry personnel did not know of or approve of the heating of overfillec cylinders. In fact, the licensee had inferreation that some supervisors did know of the practice, and the response to the Questien as it was first drafted was modified as a result of the licensee's knowledge that supervisors knew of this practice. The statement was material in that it addressed an issue that was important for the NRC to resolve in ensuring that the plant would be operated safely before authorizing restart of operations and had the capability of influencing the NRC with regarc to its resolution of this issue and in preparing and submitting the NRC's response to Question 11 to Congress.

This statement constitutes a material false statement and is a Severity Level !I violation (Supplerent VII).

Sumary of Licensee's Resconse The licensee denies the violaticr stating ten its failure to mentien "supervisory perscnnel" in the answer te NRC as due to not having reached a conclusion on the entire group of "superviser/ personnel" and there was no intent to mislead the Comission by omissica of this information in the January 29, 1986, letter. The licensee states that dC believed its answer to Questien 11 was accurate in that "management personnel" had stated in interviews with licensee investigators that they did not knew of any practice of heating overfilled cylinders and were not aware of such instances in the period prior to the January 4, 1986, incident. The licensee notes that no statement as to "supervisory personnel" was made because of conflicting statements as to what censtituted an "overfill" by supervisory and operating personnel during interviews conducted by SFC, and that its answer stated: "Interviewing of erployees and reviewing cf records are continuing ...." The licersee also noted that interviews anc document reviews were comenced the next weekenc after the January 29, 1986 letter was transmitted tc NRC. The results of this centinuing investigation were reported to NRC on September 18, 1986, in response to the NRC's recuest dated September 10, 1986, and contained detailec inferration on this issue not possible te be reportec on January 29, 1986.

Further, tFe licensee states that the indivicuals who were involvec in preparation cf the Kerr-McGee answer did not intenc to mislead the NRC by omitting the trention of "supervisory personnel" and that SFC was aware that the NRC had conductec a more extersive incuiry than SFC had at the NUREG-0940 II.A-114

Appendix time of the January 29 letter. In addition, the licensee states that the NRC was not in fact misled by the SFC response in that the NRC response to Congress stated that first-line supervisors had apparently approved reheating of overfilled cylinders.

In addition, the licensee argues that it has operated the facility safely and responsibly since restart of operations and tseen completely candid in responding to all Comission inquiries, and for this reason, the civil penalty should be remitted.

NRC Evaluation of Licensee's Response Licensee management is responsible for ensuring that correct anc complete information is provided to the NRC in regard to evaluation of the safety of licensed activities. The licensee's response admits knowledge of conflicting statements regarding overfilling of cylinders and the nature of past practices from interviews conducted by SFC prior to the January 29 l letter to NRC, and that this infermation was omitted frem the letter. The licensee's contention that the NRC had cenducted a more extensive inouiry and already had sufficient knowledge of "supervisory personnel" involvement in these practices to preclude being misled is imaterial in that this does not abrogate the licensee's rescensibility to respond to the NRC in a correct and complete manner. In addition, whether or not the licensee intended to mislead the Commissien is irrelevant. The fact remains that the licensee's submission was false and material. It was clear from the NRC's request for information that the NRC intended to rely on the licensee's answer in evaluating this matter and responding to Congress. Therefere, the licensee has not provided a sufficient basis for withdrawal of this violation and the NRC staff concludes that tnis violation occurred as stated in the Notice. Furthermora, the fact tN t the licensee believes it has operated its facility safely since restart'of operations anc been candid in responding to Comissien inquiries cces not previde a sufficient basis for mitigation of this civil penalty which is based en the particular material false statement described above.

. NRC Conclusion The NRC concludes that the alleged violation occurred as stated in the Notice of Violation and that no mitigation of the civil penalty is warranted.

Therefore, the proposed Civil Penalty in the arount of Eight Thousand Dollars

($8,000) should be imposed.

NUREG-0940 II.A-115

UNITto STATES

!s** *f 4, 'g NUCLE AR REGULATORY COMMIS$10N d e i S Rf CloN lli 3 f 199 noostvtLT mo AD

( *...*

. j o c c ~ .u.v ~. n.u ~ ois .. n ,

DEC 18 tW7 General Licensee (10 CFR 31.5)

EA 87-215 The Mead Corporation World Headquarters ATTN: Mr. Russell E. Kross, Director Human and Environmental Protection Department Courthouse Plaza Northeast Dayton, OH 45463 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 999-90003/87006) ,

i This refers to the inspection conducted during the period August 18 through i October 26, 1987, at your Kalamazoo, Michigan facility. The inspection was in response to a licensee reported event regarding loss of static eliminator bars. Subsequently, other static eliminator bars were discovered lost by the licensee at other facilities within the Mead Corporation and reported to the NRC. An enforcement conference, to discuss the events, causes, and corrective actions, was held in the NRC Region III office on November 24, 1987.

It appears that during the 1979-1987 time frame, you removed and discarded 21 static eliminators to either scrapyards or landfills in both NRC Agreement and Non-Agreement states. Nine of the static eliminators were discarded from facilities in Agreement states and are not the subject of this enforcement action. The twelve static eliminators discarded within NRC jurisdiction were also not leak tested as required since 1979. It appears that the root cause of the events stemmed from programmatic weaknesses in the ability of Mead Corporation to maintain control over and leak test those devices.

To emphasize the need to develop and implement a program that ensures proper control over generally licensed devices, as well as the need to leak test such devices at required frequencies, 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 Penalties in the amount of One Thousand Five Hundred Dollars (51,500) 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 (1987) (Enforcement Policy),

the violations described in the enclosed Notice have each been categorized at Severity level III.

CERTIFIED MAIL liETURN RECElPT REQUE5TED NUREG-0940 II.A-116

The Mead Corporation The base civil penalty for a Severity Level III violation is $500. The NRC Enforcement Policy allows for escalation or mitigation of a civil penalty under certain circumstances. In this case, escalation of the base civil penalty was considered for the multiple examples of v_iolation of 10 CFR 31.5(c)(8) at each facility; however, this was offset by the unusually prompt and extensive corrective actions taken once you identified the problem.

For these reasens, no adjustment to the base civil penalty is warranted for the violations.

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.

ln 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 of 1980, Pub. L. No.95-511.

Sincerely, I

3

/

A. Bert Day s

. Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalties NUREG-0940 II.A-117

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES The Mead Corporation General License Dayton, Ohio (10 CFR 31.5)

EA 87-215 Duriag an NRC inspection conducted during the period August 18 through Octeber 26, 1987, violations of NRC requirenents 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 penalties are set forth below:

1. Violations Assessed Civil Penalties 10 CFR 31.5(c)(8) requires that, except as provided in 10 CFR 31.5(c)(9),

a general licensee shall dispose of a device containing byproduct material only by transfer to persons holding a specific license pursuant to 10 CFR Parts 30 and 32 or from an Agreement State to receive the device.

A. Contrary to the above, between 1979 and 1987, at the Mead Corporation's Kalamazoo, Michigan facility, four generally licensed static eliminator bars containing americium-241 were disposed of but not transferred to a person holding a specific license pursuant to 10 CFR Parts 30 and 32 or from an Agreement State to receive the device or as excepted by 10 CFR 31.5(c)(9). -

This is a Severity Level III violation (Supplement VI).

Civil Penalty - $500 B. Contrary to the above, between 1979 and 1987, at Mead Corporation's Alexandria, Pennsylvania facility, three generally licensed static eliminator bars containing americium-241 were disposed of but not transferred to a person holding a specific license pursuant to 10 CFR Parts 30 ind 32 or from an Agreement State to receive the device or as excepted by 10 CFR 31.5(c)(9).

This is a Severity Level III violation (Supplement VI).

Civil Penalty - $500 j C. Contrary to the above, between 1982 and 1987, at the Mead Corporation's Lynchburg, Virginia facility, five generally licensed static eliminator bars containing polonium-210 were disposed of but not transferred to a person holding a specific license pursuant to 10 CFR Parts 30 and 32 or from an Agreement State to receive the device or as excepted by 10 CFR 31.5(c)(9).

This is a Severity Level III violation (Supplement VI).

Civil Penalty - $500 NUREG-0940 II.A-118

Notice of Violation DEC 1 8 1997

2. Violations Not Assessed Civil penalties 10 CFR 31.5(c)(2) requires that the general licensee test the device for leakage of radioactive material at no longer than six-month intervals or as described on the label.

A. Contrary to the above, between 1979 and 1987, the licensee failed to leak test static eliminator bars containing americium-241 at its Kalamazoo, Michigan facility every six months.

This is a Severity Level IV violation (Supplement VI).

l B. Contrary to the above, between 1979 and 1987, the licensee failed to leak test static eliminator bars containing americium-241 at its Alexandria, Pennsylvania facility every six months.

This is a Severity Level IV violation (Supplement VI). I C. Contrary to the above, subsequent to 1982, the licensee failed to leak test static eliminator bars containing polonium-210 at its Lynchburg, Virginia facility every 13 months as described on the label.

This is a Severity Level IV violation (Supplement VI).

Pursuant to the provisions of 10 CFR 2.201, the Mead Corporatien (Licensee) is I hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days 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 the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.

Uithin 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 NUREG-0940 II.A-119

Notice of Violation -3 18 W97 civil penalty will.be issued. Should the' Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the citil 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) shpw 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 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 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.-

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, l

U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, OC 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III.

FOR THE NUCLEAR REGULATORY COMMISSION h

i /

J m A. B t Da is Regional Administrator i Dated at Glen Ellyn, Illinois 4 this /f day of December 1987 4

4 NUREG-0940 II.A-120

('%

f, . .,g UNITED STATES y g NUCLEAR REGULATORY COMMISSION W ASHING TON, D. C. 20555

%.....)l GEC 1 F W Docket No. 030-15183 '

License No. 45-18488-01 EA 87-127 Tidewater Memorial Hospital ATTN: Ms. Louise Osborn President Tappahannock, Virginia 22560 Gentlemen:

SUBJECT:

ORDER IMPOSING A CIVIL MONETARY PENALTY This refers to your letter dated October 7,1087, in response to the Notice of Violation and Proposed Imposition of Civil Penalty (NRC Inspection Report No. 45-18488-01/87-01) sent to you by our letter dated September 11, 1987. Our letter and Notice described several violations identified as a result of an NRC inspection. To errphasize the need for adequate management control of the Radiation Safety Program, a Civil Penalty of Two Thousand Five Hundred Dollars

($2,500) was proposed.

In your response dated October 7,1987, you denied the occurrence of violations A.1, A.2, A.3, A 4, A.7, and A.8, and you affirmed the occurrence of the remaining violations. You also requested remission or mitigation of the proposed civil penalty.

After consideration of your response, including the evaltsation of new information submitted after the NRC inspection on June 17, 1987, we have con-cluded for the reasons given in the Appendix attached to the enclosed Order Imposing Civil Monetary Penalty that violations A.I. A.2, A.3, A.7, and A.8 occurred as stated in the Notice, that violation A.4 should be withdrawn, and that remission or mitigation of the proposed civil penalty is not warranted.

Because the proposed civil penalty was assessed equally among the two violations and violation A.4 was withdrawn and is one of fifteen examples, the proposed civil penalty amount has been reduced by 1/15th of 1/2 of the total ($83.33).

Accordingly, we hereby serve the enclosed Order on Tidewater Memorial Hospital imposing a civil monetary penalty in the amount of Two Thousand Four Hundred Sixteen Dollars and Sixty-Seven Cents ($2,416.67). We will review the 4

effectiveness of your corrective action during a subsequent inspection.

CERTIFIED MAIL RETURN RECFIPT RE0 VESTED l

NUREG-0940 II.A-121 l

Tidewater Memorial Hospital 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 enclosure will be placed in the NRC's Public Document Room.

Sincerely,

' *% $ M ,

ames Lieberman, Director Office of Enforcement

Enclosure:

Order Imposing Civil Monetary Penalty with Attachment

.i l

s I

i l

(

1 NVREG-0940 II,A-122-

]; .

4

m 4 1 UNITED STATES ,

NUCLEAR REGULATORY COMMISSION

]

In the Matter of ) Docket No. 030-15183 ,

) License No. 45-18488 01 TIDEWATER MLM0 RIAL HOSPITAL ) ' EA 87-127 Tappahannock, Virginia )

ORDER IMPOSING CIVIL MONETARY PENALTY I

Tidewater Memorial Hospital (licensee) is the holder of Material License No. 45-18488-01 issued by the Nuclear Regulatory Commission (NRC/ Commission) on July 26, 1979. The license authorizes the licensee to empicy the use of radioactive materials for diagnostic and therapeutic purposes in patients in accordance with the conditions specified therein.

l 11 A routine unannounced inspection of the licensee's activities was conducted on t'

Jure 17, 1987. The results of this inspection indicated that the licensee had not conducted its activities in full complidoce with NPC requirements. A i written Notice of Violation and Proposed Imposition of Civil Penalty was served upon the licensee by letter dated September 11, 1987. The Notice stated the !

l nature of the violations, the provisions o' the NRC's requirements that the licensee had violated, and the amount of t.n civil penalty propcsed for the violations. The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalty by letter dated October 7, 1987.

l I

NUREG-0940 II.A-123 f "

Ill After ccnsideration of the licensee's response and the statements of fact, explanation, and argurnent for mitigation contained therein, the hRC staff has detennined as set forth in the Appendix to this Order that violation A.4 should be withdrawn, that the remaining examples of violation A and violation B occurred as stated, that the Severity level III categorization is warrdnted, and that the majority of the penalty proposed for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be imposed.

i IV fn view of the forecoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as an: ended (Act), 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED TPAT:

The licensee pay a civil penalty in the amount of Two Thousand Four Hundred Sixteen Dollars and Sixty-Seven Cents ($2,416.67) within 30 days of the date of this Order, by check, draf t, or money oroer, payable to the Treasurer of the United States and nailed to the Director, Office of Enforcerr.ent, U.S. Nuclear Regulatory Connission, ATTN: Docunent Control Desk, Washington, DC 20555.

1 4 NUREG-0940 II.A-124 i

_ , ,,- p-,v-

i The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing should be clearly rarked as a % quest for en Enforcerera Hearing" and shall be addressed to the Director, Office of Enforcement, U.S.

Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Adm.inistrator, Region !!,101 Marietta St.,

b.W., Suite 2900 Atlanta, GA 30323.

If a hearing is requested, the Cocynission will issue an Order designating the i time and place of the hearing, if the licensee fails to request i hearing ,

i within 30 days of the date of this Order, the provisiens of this Order shall be j ef f ective without further proceediligs. If payment has not been made by that_ ,

tine, the ratter may be referred to the Attorney General for collection. .

t In the event the licensee reqv*sts a hearing as provided above, the issues o ,

t

] be considered at such hearing shall be:

l (a) whether the licersee was in violation of the Comission's requirements as set forth in the Notice of Violation and Proposed imposition of Civil j i Penalty referenced in Section !! above as amended in the Appendix to this i

, Order and i 4 t

i e

(b) whether, on the basis of such violaticn, this Order should be si, sained.  ;

FOR THE NUCLEAR REGULATORY COMMISSIGN 1 .

, y .b =/ -

J) m Lieberman, Director  !

' Office of Enforcenent  !

Dated at Bethesda, Maryland

this /6% day of December 1987  ;

1 NUREG-0940 II.A-125  !

, _ - , , _ , . . , _ _ . . , ~ .,,

APMiNDIX EVALVATIONS AND CONCLUSICh5 On 5e, 11, 1987, a Notice of Violation and Prepnsed Imposition of Civil Penalty . "'a ' was issued for violations iaentified during a routine NRC inspection. T . water Memorial Hospital responded to the Notice on October 7, 1987. .The .see denied the occt.rrences of violations A.1, A.2, A.3, A.a, A.7, and A .d af fimed the occurrence of the remaining violations. The licensee also requested remission er mitigation of the proposed civil penalty amoun t. The NRC's evaluation and conclusien for the violations which were contested and denied by Tidewater Memorial Hospital are as follows:

Restatement of Violation A.1 License Condition 17 requires the licer.see to posses; and use licensed material in accordance with statements, representations, and procedures contained in its license application dated January 23, 1979, letter dated July 24, 1984, and Model As low As Reasonably Achievable IALARA) Program dated July 27, 1984, inc afing any enclosures.

Item 7(1) of the license application, Medical Isotopes Comittee (Comittee Administrative Duties and Frecuency), requires the Medical Isotopes Comittee to review the entire Radiation Safety Program at least annuclly to detersnine that all activities are being conducted safely and in accordance with the Nuclear Regulatory Commissien/ State Regulations and the conditiotis of the respective radioactive material licenses.

Contrary to the above, between July 27, 1984 an9 June 17, 1987, the Medical Isotopes Comittee did not review the Radiation Safety Program.

,Sumary of Licensee's Response The licersee contends that their consultant, Dr. Dean Broga, visits the hospital on a semiannual basis and that Dr. Broga's visits include a review of exposure levels in restricted and unrestricted areas, personnel exposures, postings, quality assurance programs, handling procedures, usage and storage, and all protocols followed by the Nuclear Medicine Department. The licensee also states that Dr. Broga's findings are discussed at the Radiation Safety Comittee meetings and also sent to the Radiation Safety Officer in written form. The licensee asserts that Dr. Broga's semiannual review nore than meets the requirements of License Condition 17. Item 7(1). 3 NRC Evaluation of Licensee's Response License Condition 17, Item 7(1), requires the Medical _ Isotopes Comittee (also known as the Radiation Safety Comittee (RSC)) to review the entire Radiation Safety Program at least annually. Dr. Broga's semiannual survey report is the product of an individual outside consultant and does not constitute an annual review of the Radiation Safety Program by the Medical isotopes Comittee. Medical isotopes Comittee minutes reviewed betweqn July 27, 1984 and June 17, 1987 did not record any annual review of the Radi,tica Safety Procram. Also, no formal review of the program, independent of the Medical Isotope Comittee quarterly meetings, was perfomed by members of the Medical isotopes Comittee, acting as a majority of a quorum. In addition, if the RSC had actuhlly performed an adequate formal annual review of the Radiation Safety Program, in lieu of relying NUREG-0940 II.A-126

hppendix -2 solely en a consultant's semiannual review, many of the sixteen examples of violations prcpesed in the Seprember 11, 1987 Notice could have been avoided er would have been licensee-identified. The licensee's affirmation of ten of these examples also indicates minimal involvement by the RSC in managing the Radiation Safety Program. Because no formal annual review of the entire Radiation Safety Program was performed by the Medical Isotopes Cwnittee members, violation A.1 remains as stoted.

Restatement of Violation A.2 License Condition 17 requires the licensee to possess and use licensed material in accordance with statements, representations, and procedures contained in its license application dated January 23, 1979, letter dated July 27, 1984, and Fodel As low As Peasonably Achievable IALARA) Program dated July 27, 1984, including any enclosures.

Item 3(a)(3) of the Model ALARA Program requires the Padiation Safety Officer (RS0) to perform a quarterly review of records of radiation levels in urrestricted and restricted areas to determine that they were at ALARA levels during the previous quarter.

Contrary to the above, between July 27, 1984 and February 8, 1985, between July 2e,1985 and Jantiary 31, 1986, between January 31, 1986 and July 24, 1986, betwer n July 24, 1986 and March 16, 1987, the RSO did not perfonn a quarterly review of records of radio; ion levels in restricted areas.

Aoditionally, between July 27, 1984 and June 17, 1987, the RSO did not perform a quarterly review of records of radiation levels in unrestricted areas.

Surtrrary of Licensee's Response lhe licensee contends that th( exact implication of the three ALARA violations as referenced in violations A.E, A.3. ano A.4 is unclear. The licensee states that they review quarterly exposure records at all RSC meetings to ensure compliance with ALARA levels. With the exception of the Radiclogist (who serves es the R50), the licensee rarely has any monitored individual who approaches the ALARA Level I limits. The licensee states that Dr. Broga's (outside consultant) survey includes levels in restricted and unrestricted areas. The nuclear medicine technologist who performs the weekly exposure surveys is als^ a merrber of the RSC and is responsible for reporting any unusual situations to the Conynittee. The licensde contends that Dr. Broga's review includes ways to limit exposure, and that Tidewater Memorial Hospital does not have individuals receiving significant exposur.s as a function of their routine job responsibilities. The licensee eyplains that, if anything, its only mistake was its failure to document its efforts in a manner consistent with the inspector's expectations. The licensee further explains that it plans to amend its license application to more accurately reflect its program. Also, the licensee lists the dates of all RSC meetings held between July 27, 1984 and April 28, 1987.

NRC Evaluation of Licensee's Response Dr. Broga's review of radiation levels in restricted areas was perfonned approxi-mately semiannually, Dr. Broga s review was comprised of a contamination and exposure survey of restricted areas. The results were compiled into a "Nuclear HUREG-0940 II.A-127

Appendix Medicine Survey Report" and mailed to Dr. Lagundino, the licensee's Radiologist and RSO. The results of the report were also discussed, but not documented at the Radiation Safety Corrvnittee Meeting that coincided with Dr. Broga's visit.

As stated in violation A.P the R50 was required to perform a quarterly review of records of radiation levels in ut, restricted areas. The dates when Dr. Broga performed his contamination and exposure surveys (July 27, 1984; February 18, 1985; July 24, 1985; January 31,1986; July 24,1986; and March 16,1987) did not ccnstitute a ruarterly frequency.

Dr. Broga's review of radiation levels did not include contarnination or exposure survey results of unrestricted areas (hallways, adjacent rooms, etc.).

All of Dr. Broga's swipes and exposure survey treasurements were collected from points within the restricted areas (hot lab and injection / imaging areas).

The weekly surveys of unrestricted areas conoucted by the nuclear inedicine technologist did not ccostitute a quarterly review of raoiation levels in unrestricted and restricted areas by the RSO, Dr. Lagundinu. Under these circumstances, violation A.2 was correct as stated.

Restatement of Violation A.3 License Condition 17 requires the licensee to possess and use licensed rnaterial ,

in accorcance with sta'tements, representations, ano procedures contained in its I license application dated January 23, 1979, letter dated July 27, 1984, and Model As Low As Reasonably Achievable ( ALARA) Program dated July 27, 1984, including any enclosures.

Item 3(a)(1) of the Model ALARA Program states that the Radiation Safety Officer (RS0) will perform an atinual review of the Radiation Safety Program for adherence to ALARA concepts.

Contrary to the above, between July 27, 1984 and June 17, 1987, the R$0 did not perform an annual review of the Padiation Safety Program.

S_ummary of Licensee's Response The licensee addresses violation A.3 in the "Summary of Licensee's Response" for violation A.2. The licensee states that quarterly exposure recordt are reviewed at all RSC mer.tinos in order to ensure compliance to ALARA levtIs and that rarely does anyone approach ALARA Level i limits except fer their Radiologist (R50). The licer.see also contends that Dr. Broga's review includes ways to limit exposure, and that the license does not have individuals receiving significant exposures as a function of their rcutine je5 responsibilities.

NRC Evaluation of Licensee's Response The NRC staff rnaintains that the i;censee's R50 did not perform any annual evaluation or review of the Radiation Safety Prcgram for acherence to ALARA concepts. Such a review would have involved an annual evaluation of all individual occupational external exposure records for the four preceding quarters. The review also wculo have involved a review of specific procedures for reducing exposures (individual and collective) to as low as is reasonably achievable. Particular attention would have been directed towards any individuals who exceeded the licensee's investigational levels I and II.

NUREG-0940 II.A-128

Appendix -4 I

Item 6(b) of the July 27, 1984 Podel ALARA Prcgram states that each ouarterly l expcsure that equals or exceeds Investigational Level I shall be reviewed by the RSO. This program also states that the RSO shall report the results of the review at the first RSC meeting following the quarter when the exposure was recorded and that the RSC shall consider cach such exposure in comparison with those of others perfonning similar tasks ana shall reccrd the review in the RSC minutes. The RSC meeting conducted on February 18, 1985 may have reviewed Level I, but contrary to the Model ALARA Program, no explanation, cortparison, or review was recorded in the RSC minutes regarding Dr. Lagundino's exposure level.

Dr. Lagundino's exposure should have been discussed and documented during the R50's annual review of the Radiation Safety Progt in.

The licensee's docurrents show that Dr. Broga designates his review cf the ALARA program t,y only a check mark placed under the category "yes" of the "Nuclear Medicine Survey Report" and associated "Radiation Protection Survey-Nuclear Medicine." The NRC staf f contends that a check mark does not constitute an acequate record of a program review of the Radiation Safety Program for adherence to ALARA ccocepts.

Item 1.a of the Model ALARA Procram requires the monacement of Tidewater Memorial Hospital to establish an organization for development of an ALARA program, to include the RSC and RSO. The NRC. .staf f views the lack of tirnely and complete ALARA reviews as a joint responsibility of the RSO and the RSC. In addition, if tne RS0 had actually performed an adequate formal annual review of the Radiation  !

Safety Program, in lieu of relying solely on a consultant's semianrual review, i many of the sixteen exarrples cf violations proposed in the Septernber 11, 1987 ,

hotice could have been avoided or would have been licensee-identified. The l

licensee's affinnation of ten of these examples also indicates adrnission of minimal involvement by the RSO in tronaging the Radiation Safety Progrern. Therefore, violation A.3 remains as stated. i Pestatement of Violation A.4 License Condition 17 recuires the licensee to possess and use licensed material in accordance with statements, representaticns, and procedures contained in its license application dated January 23, 1979, letter dated July 27, 1984, and Model As low As Reasonably Achievable (ALAPA) Prograrn dated July 27, 1984, including any enclosures.

Items 2(c)(2) and 3(a)(E) of the Model Al APA Program requircs that the Radiation Safety Officer (RS0) and Radiation Safety Corinittee (RSC) review at i least quarterly the occapatioral radiatien exposures of authorized users and workers to determine that their exposures are ALARA in accordance with the provisions of Section 6 (Establishment of Investigational Levels In Order to Monitor Individual Occupational External Fadiat'on Exposures) of the Model l ALARA program.

Contrary to the above, between July E4, 1985 and November 11, 1986, the RSO and PSC' failed to perform ovarterly reviews of occupational radiation exposures.

Surnmary of Licensee's Respase The licensee adOessed violation 3.4 in the "Surnmary of Licensee's Response" NUREG-0940 II.A-129 )

l

Appendix for violation A.2. The licensee statu that it reviewed the quarterly exposure records at all RSC rreetings in order t; ensure compliance with ALARA levels.

The licensee lists the dates of all RX rrectings held between July 24, 1985 ar,d November 11, 1986.

NRC Evaluation of Licensee's Respr,'se Based on subsequent information submitted to cur office in letters dated June 18, July 15, and October 7,1987, we have determined that the RSO and F.SC had performec quarterly reviews of cccupational rac'iation expnsures during the ciuarterly RSC meetings. Therefore, based on this new informt 'on we agree that the provisions of items 2(c)(2) and 3(a)(2) of the license api ication werE nct violateo. Accordingly, violation A.4 has been withdrawn and our records wili be adjusted acccrdingly.

Restatement of Violation A.7 License Condition 17 requires the licensee to possess and use licensed mater 7al in accordance with statements, representations, and procedures contained in its license application dated January 23, 1979, letter dated July 27, 1984, and Model As low As Reason 1bly Achievable (ALARA) Program dated July 27, 1984, including any enclosures.

Item 11 of the license application, facilities and Eouipment, requires the radioisotope laboratory to be lecked when the physician or technician is not in attenaance.

Contrary to the above, between approximately May 1,1987 and June 17, 1987, the radioisotope laboratory was not locked cr secured when the physician or technician was not in attendance.

Summary of Licensee's Response The licensee states that violations A.7, A.11, A.12, and A.14 stem from the

, relocation of their nuclear ocpartment. The licensee contends that it was unable to get irrediate key centrol from the contractor when its nuclear medicine laboratory was moved, and this resulted in the violation. The licensee also claims that since it presently uses a radiopharracy, it does not routinely possess coses in the radioisotope laboratory for af ter-hour use. The licensee further explains that the area was under the supetvision of the nuclear medicine technologist during daytir:e hours and thet af ter-hours the area is not cpen to the public and is u. 'er the scrutiny of security and the emergency room staff.

The licensee concludes by stating that although it may not have been in strict compliance with this requirement, the steps taken were sufficient to guard against problems which the re ulation is designed to prevent. The posting violations

( A. ll, A.12, and A.14 were af firmed.

NRC Evaluation of Licensee's Response On June 17, 1987, at approximately 11:00 a.m. , the NRC inspector arrived at lidewater Memorial Hospital to perform a routine, unannounced inspection. Upon entry into the nuclear medicine department (hot lab and injection / imaging areas), the inspector was unable to locate the nuclear medicine technologist or any department individual for approxinately 30 minutes. During this time, no NUREG-0940 II.A-130 B

Appendix physician or technichn was in attendance in the nuclear medicine department.

Also, the two access dcors leading into the nuclear medicine department (injection / imaging area) and the hot lab dcor loca*2d within the department were not locked. Consecuently, access into the nuclear medicine department was not controlled or restricted. Although the licensee claims that it does not routinely possess radiopharmaceutical single dose units for after-hours use, it does routinely possess radioactive materials (to include radiopharmaceuticals, I contaminated single dose syringes collected for storage, and a cesium #350982A-07 j sealed source used for dcse calibrator tests) which must be secured at all tirnes l trom unauthorized removal . Therefore, violation A.7 should remain as stated j Restaterr it of violation A.8 License Conditien 17 requires the licersee to possess and use licensed material in accordance with statements, representations, and procedures contained in its license application dated January 23, 1979, letter dated July 24, 1984, and Model As low As Reasonably Achievable (ALARA) Program dated July 27, 1984, including any enclosures.

Item 12(3) of the license application, Radiation Safety Training for Radiation Workers, recuires all individuals who work with radiation sources (including security, nursing, and housekeeping personnel) to receive periodic trainin at least annually in radiation safetv..

s Contrary to the above, between August 9, 1984 and January 31, 1986, the licensee did not instruct security, nursing, ano housekeeping personnel in radiation safety.

Sumary of Licensee's Response

]

l The licensee states that Dr. Broga has routinely presented an overview of the license operation and short training programs during th( n;eetings which he has attended and that many of these overviews and training programs were not documented.

The licensee con >nds that, since they are a very small hospital, the members of the RSC are in daily contact with most of the hospital employees, especially any of 'thnse who have reason to be in and arcund the areas where radioactive material is used. Most training is done on a one-on-one basis when an egloyee begins employment. The licensee states that the violation is not one for .hich the licensee had been previously cited, and concludes by indicating that they have recently reviewed their training efforts in accortance with ALARA and are in the process of instituting a new system.

NRC Evaluation of Licensee's Response At the tirr.e of the inspection, the Chief Radiologic Technologist stated that he had been responsible for cocrdinating nest RSC meetings and training program schecules. The Chief Radiclogic Technologist also stated that be had scheduled an in-service presentation on iadiation safety to be conducted by Dr. Broga at the RSC meeting on February 18, 1985. This presentation was scheduled for maintenance, housekteping, and nursing personnel, but only one nurse, who was an RSC member representative attended the presentation. During the RSC rreeting held on January 31, 1986, maintenance, housekeeping, and nursing personnel attended an in-service presentation by Dr. Broga. However, no annual radiation safety training was provided for housekeeping and nursing personnel between at NUREG-0940 II.A-131

Appendix -7 least August 9, 1984 and January 31, 1986. Also, no annual scheduling was proposed nor was training perforrned for any security personnel between August 9, 1984 ano June 17, 1987. Items 3(b)(1) and (?) of the ALARA program, l dated July 27, 1984, state that the RSO will schedule briefings and educatiorial  !

sessioris to inform users, workers, and ancillary personnel of ALARA program )

efforts. Based on this information, violation A.8 remains as stated. )

NRC Conclusion l

After consideration of the October 7,1987 response to the Notice of Violation  !

and Proposed Irrposition of Civil Penalty issued September 11, 1987, the NRC  !

staff has concluded that sufficient basis was provided for the withdrawal of violation A.4, but that the tcmaining violations occurred as stated. The NPC staff agrees that the licensee has not had sionificant overexposures, contamination incidents, or other radiation mishaps. However, the evidence continues to support a r:ianagernent breakdown due to the totcl number of violations. Based on these violatio;. and in view of the magnitude of the noncompliances, the Severity Level III categorization and the rnajority of the proposed $2,500 civil penalty are warranted. Because the proposed civil penalty was assessed i equally arnong the :wo vinlations and violation A.4 was one example of 15 in I violation A and has been withdrawn, the prcposed civil penalty amount has been reduced by 1/15th cf 1/2 of the total ($83.33). Therefore, a civil penalty ir. I the arrount of $2,416.67 should be.imposeo.

l l

NUREG-0940 II.A-132

uNITEo STATES

[pa af og%' ' NUCLE AR REGULATORY COMMISSION J #

REGION 11 j Io1 MARIETTA STREET,N W.

• e ATLANTA, GEORGI A 30323

\ . . . . . '# SEP 111987 Docket No. 030-15183 License No. 45-18488-01

'EA 87-127 Tidewater Memorial Hospital ATTN: Ms. Louise Osborn President Tappahannock, Virginia 22560 Ger.tlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (URC INSPECTION REPORT NO. 45-18488-01/87-01)

This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by Ed Kline at Tidewater Memorial Hospital (, licensee) in Tappahannock, Virginia, on June 17, 1987. The inspection included a review of activities conducted with respect to radiation safety. As a result of this inspection, significant failures to comply with NRC regulatory requirements and conditions of your license were identified, and these concerns were discussed with you in an Enforcement Conference held at your facility on June 14, 1987. The report documenting this inspection and the Enforcement Conference was sent to you by l

letter dated August 12, 1987.

The violations described in the enclosed Notice of Violation and Proposed Imposi-tion of Civil Penalty involved failures: (1) of the Medical Isotopes Committee (MIC) to annually review their program, (2) of the Radiation Safety Officer (RS0) to perform quanarly reviews of records of radiation levels in restricted and unrestricted areas to determine that they were at as low as reassnably achievable (ALARA) levels during the previous quarter, (3) of the RSO to perform annual reviews of the Radiation Safety Program for adherence to ALARA concepts,

((1 of the RSO and the MIC to perform quarterly reviews of occupational radia-t1Jn exposures to authorized users and workers to determine that their exposures are ALARA, (5) of personnel to test the dose calibrator for accuracy on a quarterly basis, (6) of personnel to test the dose calibrator for linearity on a quarterly basis, (7) of personnel tn lock or secure the radioisotope laboratory when the physician ar technician is not in attegdance, (8) of personnel to annually train all individuals who work with radiation sources, (9) of personnel tc monitor with a survey meter and wipe test unopened radioactive ptekages upon receipt, (10) of personnel to wipe test the external surfaces of final source containers upon receipt, (11) of personnel to post areas where radioactive materials are used or stored with prcper radiation caution signs and labels, (12) of personnel to post a copy of radiation safety procedures in the Nuclear Medical Department, (13) of personnel to advise management of survey findings and recommendations on a monthly basis, (14) of personnel to post required documents in the laboratory, (15) of personnel to calibrate survey meters every six months, and (16) of personnel to leak test a cesium-137 sealed source every six months. These multiple violations demonstrate the need for prcmpt and aggressive action to improve the administration and control of your Radiation Safety Program to ensure the safe performance of licensed activities and adherence to NRC requirements.

NUREG-0940 II.A-133

Tidewater Memorial Hospital SEP 111987 To emphasize the need for adequate management control of your Radiation 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 Two Thousand Five Hundred Dollars ($2,500) for the violations described in the enclosed Notice. In accordance with the "General Statement of Policy and Precedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987)

(Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment of the base civil penalty am',unt has been deemed appropriate.

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.

En 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. l 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,

' J. alson Grace

[

Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty NUREG-0940 II.A-134

NOTICE OF VIOLATION AND PROPOSED IMPOSITIOR OF CIVIL PENALTY Tidewater Memorial Hospital Docket No. 030-15183 Tappahannock, Virginia License No. 45-18488-01 EA 87-127 During the Nuclear Regulatory Commission (NRC) inspection conducted on June 17, 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 (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), 12 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:

A. License Condition 17 requires the licensee to possess and use licensed material in accordance with statements, representations, and procedures contained in its license application dated January 23, 1979, letter dated July 27, 1984, and Model As Low As Reasonably Achievable (ALARA) Program dated July 27, 1984, including any enclosures.

1. Item 7(1) of the' license application, Medical Isotopes Committee (Committee Administrative Outies and Frequency), requires the Medical Isotopes Committee to review the entire Radiation Safety Program at least annually to determine that all activities are being conducted safely and in accordance with the Nuclear Regulatory Commission / State

[ Regulations and the conditions of the respective radioactive material l licenses.

l Contrary to the above, between July 27, 1984 and June 17, 1987, the Medical isotopes Committee did not review the Radiation Safety Program.

2. Item 3(a)(3) of the Model ALARA Program requires the Radiation Safety Officer (RS0) to perform a quarterly review of records-of radiation levels in unrestricted and restricted areas to determine that they were a:-ALARA levels during the previous quarter.

Contrary to the above, between July 27, 1984 and February 8, 1935, between July 24, 1985 and January 31, 1986, between January 31, 1986 and July 24, 1986, and between July 24, 1986 and March 16, 1987, the RSO did not perform a quarterly review of records of radiation levels in restricted areas. Addition 41 1y, between July 27, 1984 and June 17, 1987, the RSO did not perform a quarterly review of records of radiation levels in unrestricted areas.

3. Item 3(a)(1) of the Model ALARA Program states that the Radiation Safety Officer (RS0) will perform an annual review of the Radiation Safety Program for adherence to ALARA concepts.

Contrary to the above, between July 27, 1984 and June 17, 1987, the i RSO did not perform an annual review of the Radiation Safety Program. l

4. Items 2(c)(2) and 3(a)(2) of the Model ALARA Program requires ths' the Radiation Safety Of ficer (RS0) and Radiation Safety Committee (RaC) I review at least quarterly the occupational radiation exposures of NUREG-0040 II.A-135

Notice of Violation authorized users and workers to determine that their exposures are ALARA in accordance with the provisions of Section 6 (Establishment of Investigational Levels In Order to Monitor Individual Occupational External Radiation Exposures) of the Model ALARA program.

Contrary to the above, between July 24, 1985 and November 11, 1986, the RSO and RSC failed to perform quarterly reviews of occupational radiation exposures.

5. Item 10(2)(8) of the license applicstion, Calibration of Instruments, specifies that the dose calibrator will be tested for accuracy oa a quarterly basis.

Contrary to the above, the licensee did not test the dose calibrator for accuracy between January 25, 1984 and July 27, 1984, between July 27, 1984 and February 8,1985, between February 8,1985 and July 24, 1985, between July 24, 1985 and January 31, 1986, between January 31, 1986 and July 28, 1986, and between July 28, 1986 and June 17, 1987.

6. Item 10(2)(B) of the license applicatinn, Calibration of Instruments, specifies that the dose calibrator will be tested for linearity on a quarterly basis.  :

l Contrary to the above, the licensee did not test the dose calibrator '

for linearity between July 27, 1984 and January 16, 1985, between June 19, 1985 and November 1,1985, and between June 20, 1986 and October 30, 1986.

7. Item 11 of the license application, Facilities and Equipment, requires the radiosotope laboratory to be locked when the ohysician or technician is not in attendance.

Contrary to the above, between approximately May 1, 1987 and June 17, 1987 the radioisotope laboratory was not locked or secured when the physician or technician was not in attendance.

8. Item 12(3) of the license application, Radiation Safety Training for Radiation Workers, requires all individuals who work with radiation sources (including security, nursing, and housekeeping personnel) to receive periodic training at least angually in radiation safety.

Contrary to the above, between August 9, 1984 and January 31, 1986 the licensee did not instruct security, nursing, and housekeeping personnel in radiation safety.

9. Items 14(B)(3) and (B)(4) of the license application, Procedures for Examining Incoming Rtdioisotope Packages (Procedures for Package Inspec-tion), require that incoming, unopened, radioactive packages be monitored with a survey meter and wipe tested.

Contrary to the above, on July 25, 1985, February 3, 1986, February 4, 1986, and July 26, 1986, radioactive packages received by the licensee containing Syncor Corporation technetium-99m agents were neither monitored with a survey meter nor wipe tested.

NUREG-0940 II.A-136

Notice of Violation 10. Item 14(B)(7) of the license application, procedures for Examining Incoming Radioisotope Packages (Procedures for Package Inspection),

requires that the external surface of the incoming final source container, which is transported in a radioactive materials package, be wipe tested.

Contrary to the above, on July 25, 1985, February 3, 1986, February 4, 1986, and July 26, 1986, the external surfaces of final source containers, which contained Syncor Corporation technetium-99m agents, were not wipe tested upon receipt.

11. Item 15(A)(3) of the license application, Standards for Radioisotope Controls, requires that all areas where radioactive materials are used or stored be conspicuously posted with radiation caution signs and labels in accordance with the provisions of pertinent federal and state radiation control regulations.

10 CFR 20.203(b) requires that each radiation area be conspicuously posted with a sign or signs bea-ing the radiation caution symbol and the words: "Caution Radiation Area."

Contrary to the above, on June 17, 1987, the licensee did not post with radiation signs and/or labels two access doors into the imaging room of the Nuclear Medicine Department and'ono access door into the radioisotope laboratory (Hot Lab).

12. Item 15(A)(8)(d) of the license application, Standards for Radioisotope Controls, requires that a copy of radiation safety procedures be conspicuously posted at locations where radioactive materials are used.

Contrary to the above, on June 17, 1987 the licensee did not post a copy of radiation safety procedures in the Nuclear Medicine Department.

13. Item 17(B)(9) of the license application, Safety Procedures, requires that the licensee conduct health physics surveys and advise management of the findings and recommendations on a monthly basis for routine matters, or immediately when necessary.

Contrary to the above, between July 24, 1984 and June 17, 1987, the management was not advised of survey findings and recommendations on I a monthly bas s.

14. Item 17(B)(9) of the license application, Safety Drocedures, requires that NRC Form 3, the NRC license for radioactive materials and all supporting documents, emergency orocedures, and Parts 19, 20, Title 10, Code of Federal Regulations, be properly posted in the laboratory.

Contrary to the above, on June 17, 1987, the licensee did not have NRC Form 3, the NRC license for radioactive materials and all supporting documents, emtegency procedures, and Parts 19, 20, Title 10, Code of Federal Regulations, posted in the laboratory.

NUREG-0940 II.A-137

Notice of Violation 15. The licens'ee's letter dated July 27, 1984, requires the licensee to abide by the terms of the March 14, 1980, letter which states that the licensee will calibrate survey meters every six (6) months.

Contrary tio the above, between July 25, 1986 and June 16, 1987, the licensee did not calibrate a Victoreen Cutie Pie Model 740-F (Serial No. 2649) survey meter and a Eberline Model E-120 (Serial No. 6153) survey meter.

• B. 10 CFR 35.14(e)(1)(1), in ef fect between July 1,1984 and through March 31, 1987, required that any licensee who possesses sealed sources as celibration or reference sources pursuant to 10 CFR 35.14(d) shall cause each sealed source containing byproduct' material, other than-hydrogen 3, with a half-life greater than thirty days in any form other than gas to be tested for leakage and/or contamination at intervals not to exceed six months.

Contrary to the above, between July 2, 1984 and February 8, 1085, and between July 24, 1986 and March 16,.1987, the licensee did not leak test a cesium-137 sealed source (No. 35609828-07, E-Vial).

These violations have been assessed in the aggregate as a Severity Level III problem (Supplement VI).

Cumulative civil penalty - $2,500 (assessed equally among the violations)

Pursuant to the provisions of 10 CFR 2.201, the 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 correctiva. 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 witnin 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 affirgation.

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 w' thin 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 NUREG-0940 II.A-138

1 Notice of Violation should be clearly marked as an "Answer to a Notice of uiolation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate exten-

,uatino circumstances, (3)'show error in this Notice, or (4) show other reasons why th; 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 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 the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensea is directed to the other provisions of 10 CFR 2.205, regarding the procedure fo-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.

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.

FOR THE NUCLEAR REGULATORY COMMISSION l

J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia thisl/dayofSeptember1987 NUREG-0940 II.A-139

UNITED STATES

[Se afogb NUCLEAR REGULATORY COMMISSION

'O" #'

REGION ll h .

101 MARIETTA STRE ET, N.W.

a ATL ANT A. GEORGI A 3o323

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J A N 2 71988 Docket No. 0303-03375 License No. 47-01458-01 EA-87-214 United Hespital Center ATTN: Mr. Bruce Carter Administrator P. O. Box 1680 Clarksburg, WV 26301 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PEN'.LTY (NRC 1NSPECTION REPORT NO. 47-01458-01/87-01)

This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by L. Franklin at your Clarksburg, West Virginia, f acility on October 22, 1987. l The inspection included a review of licensed activities as they relate to I radiation safety and compliance with NRC regulations. As a result of this inspection, significant failures to comply with NRC regulatory requirements were identified, and NRC concerns relative to the inspection findings were discussed at an Enforcement Conference held it. Clarksburg, West Virginia, :n November 10, 1987. A summary of that conference was provided to you by letter dated November 20, 1987.

The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) include the failure to: conduct a meeting of the Radiation Safety Com.atttee, conduct daily and weekly radiation surveys, perform a geometric variation test of the dose calibrator, properly post a radiation area, conduct training of ancillary personnel, conduct an annual review of the Radiation Safety Program, and properly store radioactive material which resulted in allowing a dose rate of three millirems per hour in an unrestricted area.

Collectively, these violations are considered significant when taken in the aggregate and reflect both a management breakdown in the Radiation Safety Program at your facility and a complacent attitude regarding radiation safety.

Furthermore, the number of violations indicate a serious lack of appreciation for the safety significance of a viable Radiation Safety Program. However, s'nce the NRC inspection, we have noted a significant improvement in your Radiation Safety Program as a result of extensive corrective actions directed by you and the Radiation Safety Of ficer.

To emphasize the need to improve management control over your Radiation Safety Program, I have been authorized, after consultation with the Director, Of fice of Enforcement, and the Deputy Executive Director for Regional Operations, to issue de enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Thousand Two Hundred Fif ty Dollars ($1,250) for the violations described in the enclosed Notice, in a:cordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions,"

NUREG-0940 II.A-140

United Hospital Center #N27 2 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem because they collectively indicate a management breakdown in i control of your Radiation Safety Program. The base value of a civil penalty i

for a Severity Level III violation or problem is $2,500. The NRC Enforcement Policy allows for reduction of a civil penalty under certain circumstances.

In this case, the base civil peralty is reduced by 50 percent because of your unusually prompt and extensive corrective actions, which included a detailed plan for the carrection of these violations and prevention of future similar l violations.

You should also be advised that the issue that was discussed during the ent'orce-ment conference relative to an incident where a member of your staff removed licensed material from the facility and subsequently administered it at a location other than the faility is under review by the staff, and you will be advised of the results of that review when it is completed.

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 inspec-tions, 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.

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 l by the Paperwork Reduction Act of 1980, PL No.96-511.

Should you have any questions concerning this letter, please contact us.

Sincerely, 2-

/O J. Nels,on Grace Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty NUREG-0940 II.A-141

NOTICE OF VIOLATION AND PROPOSED IMPOSITICR OF CIVIL PENALTY United Hospital Center Docket No. 030-033375 Clarksburg, West Virginia License No. 47-01458-01 EA 87-214 Ouring an NRC inspection conducted on October 22, 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 (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:

A. License Condition 19 requires that the licensee shall conduct its program in accordance with the statements, representations, and procedures contained in the application dated April 17, 1983, and in letters dated January 20, 1984; February 28, September 4, September 16, December 29, 1986; and May 8, June 10, and August 25, 1987.

1. Item 7 of the application states, in part, that the Medical Isotopes Committee shall meet not less than once in each calendar quarter.

Contrary to the above, the Medical Isotopes Committee did not meet during the period between January 16, 1986, and August 6, 1986. l This is a repeat violation.

2. Item 7 of the application states, in part, that the Medical Isotopes Committee shall review the entire Radiation Safety Program at least annually.

Contrary to the above, the Medical Isotopes Committee did not perform an annual review of the Radiation Safety Program in 1985 and 1986.

3. Item 12 of the application states, in part, that the personnel training program will be given to all personnel who work with or in the vicinity of radioactive' materials and that the training program will be of sufficient scope to ensure that all personnel, including clerical, housekeeping, aqd security personnel, receive proper instruction in the items specified in 10 CFR 19.12 before assuming duties with or in the vicinity of radioactive materials, and during annual refresher training.

Contrary to the above, as of October 22, 1987- and for an indeterminate period of time prior to that date, the licensee did not conduct a training program for clerical, housekeeping, and security personnel.

D. Item 10 of the application states, in part, that survey meters will be calibrated on a quarterly basis.

Contrary to the above, the licensee failed to calibrate survey meters '

consisting of the Eberline Model E-520 (S/N 685) and the Texas Nuclear Model 9122 (S/N 44) during the fourth quarter of 1986 (October 1 -

December 31, 1986).

NUREG-0940 II.A-142

Notice of Violation 5. Item 10 of the application states, in part, that tests for geometrical variation on dose calibrator will be conducted upon installation and after maintenance and/or repair.

Contrary to the above, as of October 22, 1987, the licensee failed to perform geometrical variation tests on the dose calibrator upon installation and after maintenance and/or repair.

6. Item 17 of the application states in part that all elution, preparation, j and injection areas will be surveyed daily, j

)

Contrary to the above, the licensee failed to perform daily surveys. f of the elution, preparation, or injection areas on November 22, 1986; December 6 and 20, 1986; January 10 and 17, 1987; March 26, 1987; and May 16, 1987.

7. Item 17 of the application states that all other laboratory areas will be surveyed weekly.

Contrary to the above, the licensee f ailed to perform weekly surveys of various laboratory areat during the weeks of January 7 and 14,1987; February 4, 1987; and March 4, 1987.

{

B. 10 CFR 20.203(b) states that each radiation area shall be conspicuously '

posted with a sign or signs bearing the radiation caution symbol and the words: CAUTION RADIATION AREA. 10 CFR 20.202(b)(2) states that a radiation area means any area, accessible to personnel in which there exists radiation at such levels that a major portion of the body could receive in any one hour a dose in excess of 5 millirems or in any 5 consecutive days a dose in excess of 100 millirems.

Contrary to the above, as of October 22, 1987, the licensee failed to properly post the "hot lab", a radiation area,-with a sign as described above.

C. 10 CFR 20.105(b)(1) states, in part, that no licensee shall possess, use or transfer licensed material in such a manner as to create in any unrestricted trea radiation levels which, if an individual were continuously present in the area, could result in his receiving a dose in excess of two millirems-in any one hour.

, Contrary to the above, as of October 22, 1937, the licensae failed to properly use licensed material in the hot lab in that radiation levels in the adjacent unrestricted area (a waiting room) were measured at three millirems per Sour.

D. 10 CFR 20.402(a)(1) requires, in part, that each licensee shall report to the Commissien, by telephone, immediately after it determines that a loss or theft of licensed material has occurred in such quantities and under such circumstances that it appears to the licensee that a substantial hazard may result to persons in unrestricted areas.

NUREG-0940 II.A-143

Notice of Violation 10 CFR 20.402(b) requires, in part, that each licensee who makes a report under 10 CFR 20.402(a) shall, within 30 days after learning of the loss or theft, make a report in writing to the U.S. Nuclear Regulatory Commission, Document Control Desk, Washington, DC 20555, with a copy to the appro-priate NRC Regional Office.

Contrary to the above, on July 21, 1982, 14 Iridium-192 seeds used during a brachytherapy treatment and containing approximately 1.1 millicuries each were lost by the licensee. In addition, nine additional Iridium-192 seeds, containing approximately 0.9 millicuries each, were lost in January 1983. No immediate report was made by the licensee nor was the required 30 day written report filed in either case.

These violations have been categorized in the aggregate as a Severity Level III problem (Supplements IV and VI).

Cumulative Civil Penalty - $1,250 (assessed equally among the violations)

Pursuant to the provisions of 10 CFR 2.201, United Hospital Center is hereby required to submit a written statement or explanation to the Director, Office l of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date 'I 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 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 af firma-tion.

f 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 eth a check, draft, or money order payable to the Treasurer of the Uniteo - "e< in the amount of the civil penalty proposed above, or the cumulative amount s' t ie 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.

En addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty.

NUREG-0940 II.A-144

Notice of Violation Zn 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 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, l or mitigated, may be collected by civil action pursuant to Iection 234c of the Act, 42 U.S.C. 2282.

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.

FOR THE NUCLEAR REGULATORY COMMISSION l

9-s J. Nelson Grace Regional Administrator Dated at Atlanta, Geo.gia this Qy//< fay of January 1988 l

l l

NUREG-0940 II.A-145

1. 1. 4 UNITED STATES y ,,q NUCLEAR REGULATORY COMMISSION l REGloN IV

$11 RYAN PLAZA oRIVE. SUITE 1000

'\ , . ,

• ARLINGTON, TEXAS 70011 I E 1 6 196T Docket No. 030-20511 License No. 35-12400-02 EA 87-140 Wego Perforators,_inc.

ATTN: Mr. Marshall Bracken 1315 N. Broadway Post Office Box 594 Ada, Oklahoma 74820 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. E0-20511/87-01)

This refers to the inspection conducted on June 22, 1937, at the Wego Perforators, Inc. facility at Ada, Ok aboma. A routine unannounced radiation safety inspection by Mr. Ronald Xeato of the activities authorized by NRC i Materials License 35-12400-02 disccveied violations which collectively l demonstrate a significant breakdown it management oversight and a loss of control over the radiation safety prog am.

As a result of our inspection, violations of NRC requirements have been identified. The violations include (1) use of licensed material at an unauthorized location, (2) unauthorized users of licensed material, (3) failure to properly mark containers used to transport radioactive material, (4) failure to properly label containers used to transport radioactive material, (5) failure to maintain documentation showing the results of special form materials testing, and (6) failure to maintain documentation showing the results of Department of Transportation specification 7A package analyses.

During an enforcement conference conducted in the Region IV offices on July 30, 1987, the findings of the NRC inspection were discussed with you.

At that time, you submitted for consideration corrective actions taken and planned to preclude future recurrence. In addition, you committed to retaining a consultant to review procedures, reegamine license requirements, audit your operations, develop management controls, and provide on-the-job training for those individuals using licensed material. A Confirmation of Action Letter documenting the above commitments was forwarded to you on August 7, 1987. You also comitted to maintain sealed sources in locked storage until your license was amended to reflect new personnel involved in licensed operations.

To emphasize the need to improve management oversight and control over the licensed program, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-146

Wego Perforators, Inc. Operations, to issue the enclosed Notice of Violation and Proposed Imposition cf Civil Penalty in the amount of Five Hundred Dollars ($500) for the >

violations described in the enclosed No+1ce. In accordance with the "General Statement of Polic and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) y(Enforcement Policy), the violations described in the enclosed Notice have been classified in the aggregate at a Severity Level III. The l escalation and mitigation factors in the Enforcement Policy were considered l and no adjustment-has been deemed appropriate.  ;

l 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 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.

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, i k 6l Robert D. Martin Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition Of Civil Penalty cc:

Oklahoma Radiation Control Program Director NUREG-0940 II.A-147

l l

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Wego Perforators, Inc. Docket No. 030-20511 Ada, Oklahoma License No. 35-12400-02 EA 87-140 During an NRC inspection conducted on June 22, 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 (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:

A. License Condition 10 requires that licensed material be used at Wego Perforators, Inc., i miles south on Interstate 35, Norman, Oklahoma, and at temporary job sites of the licensee anywhere in the United States where NRC maintains jurisdiction.

Contrary to the above, as of June 22, 1987, the licensee's permanent use/ storage f acility had been relocated to 1315 N. Broadway, Ada, Oklahoma.

B. License Condition 12 requires that licensed material shall be used by, or under the supervision of and in the physical presence of, one of three specifically named individuals.

Contrary to the above, on approximately six occasions during the period of 1985 through June 1987, two individuals not named on the license had used licensed material without being under the supervision of and in the physical presence of any of the individuals named on the license.

C. License Condition 17 requires the licensee to transport licensed material or deliver with licensedofmaterial the provisions 10 CFRtoPart a carrier

71. 10 forCFR transp(ort 71.5 a)inrequires, accordance in part, that each licensee who transports licensed material outside of the confines of its plant, or delivers licensed material to a carrier for transport, comply with the applicable requirements of the Department of Transpor.tation (00T) in 49 CFR Parts 170-189.

1. 49 CFR 172.310 requires, in part, that each package containing radioactive material be marked to idertify gross weight and Type A or Type B packaging, as appropriate.

Contrary to the above, as of June 22, 1987, transportation containers used to transport radicactive well logging sources had not been marked to identify gross weight or Type A or Type B packaging.

2. 49 CFR 172.403 requires, in part, that each package of radioactive material, unless excepted from labeling by Sections 173.421 through 173.425, be labeled, as appropriate, with a RADI0 ACTIVE WHITE-1, a RADI0 ACTIVE YELLOW-II, or a RADIOACTIVE YELLOW-III label.

NUREG-0940 II.A-148

l Notice of Violation l Contrary to the above, as of June 22, 1987, transportation containers which were not excepted from labeling by Sections 173.421 through 173.425 and which were used to transport radioactive well logging sources were not labeled with an appropriate RADI0 ACTIVE WHITE-1, a RADI0 ACTIVE YELLOW-II, or a RADI0 ACTIVE YELLOW-III label.

I

3. 49 CFR 173.476(a) requires, in part, that each shipper of special- j form radioactive materials shall maintain on file for a period of at I least one year after the latest shipment a complete safety analysis that demonstrates that the special form material meets the requirements of 49 CFR 173.469 Contrary to the above, as of June 22, 1987, the licensee had no documentation verifying that special form materials which had been shipped within the last year met the requirement of 49 CFR 173.469.

4 49 CFR 173.415(a) requires, in part, that each shipper of a U.S. D0T Specification 7A Type A package maintain on file for at least one

, year after the latest shipment a complete documentation of tests and an engineering evaluation or comparative data showing that the construction methods, package design, and materials of' construction comply with the specification.

Contrary to the above, as of June 22, 1987, the licensee had not maintained documentation of tests and an engineering evaluation or comparative data for shipments made during the preceding year showing that the construction methods, package design, and materials of construction of radioactive materials transportation containers met the Specification 7A package requirements.

Collectively, the above violations have been categorized as a Severity Level 111 problem (Supplements IV and V).

Cumulative Civil Penalty - $500 (assessed equally among the violations).

Pursuant to the provisions of 10 CFR 2.201, Wego Perforators, Inc. (Licensee) ir hereby required to submit a written statement or explanation to the Di ~ 'or, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 da) af 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 ta ken . Consideration aay 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.

NUREG-0940 II.A-149

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, 0.' 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 (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 the 10 CFR 2.201 reply oy 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 i', posing 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, re.mitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.

1 The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of c'vil 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.

FOR THE NUCLEAR REGULATORY COMMISSION ddd/ kad Robert D. Martin Regional Administrator Dated at Arlington, Texas, this[dayofDecember1987.

NUREG-0940 II.A-150

UNITED STATES fja asog%,

NUCLE AR REGULATORY COMMISSION

? '. #

REGION 11 0 ,, 101 MARIE TTA STRE E T. N W.

• ~ t A T L ANT A. GEORGI A 30323

. J.'. . AUG 0 31987 Docket No. 030-12811 and 030-12570 License No. 47-05322-03 and 47-05322-02 g EA 87-74 i

Wheeling Hospital, Inc.

ATTN: Mr. J. Thomas Jones Assistant Administrator Medical Park Wheeling, WV 26003 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N05. 47-05322-03/87-01 AND 47-05322-02/87-01)

This refers to the Nuclear Regulatory Comission (NRC) inspection conducted by E. B. Kline at Wheeling Hospital, Inc. on April 29, 1987 of ynur teletherapy and nuclear medicine licenses. The inspection included a review of procedures and selective examination of records, interviews with personnel, and direct observations by the inspector. As a result of this inspection, significant failures to conply with NRC regulatory requirements were identified, and accordingly, NRC concerns relative to the inspection findings were discussed by W. E. Cline, Chief, Nuclear Materials Safety and Safeguards Branch, NRC, Region II, with you and members of your staff in an Enforcement Conference held on May 22, 1987. A Confirmation of Action letter concerning actions to be taken regarding the replacement of a defective teletherapy treatment timer was sent to you on June 12, 1987.

The violations described in the enclosed Notice of Violation and Proposed imposition of Civil Penalty involved a failure to: (1) review visiting physician credentials, (2) possess a copy of a license or permit identifying the visiting authorized user, (3) review the credentials of the Teletherapy Physicist, (4) conduct educational sessions for the ALARA program, (5) conduct emergency training exercises fcr the event of a teletherapy unit failure at intervals not to exceed six months, (6) calibrate survey instruments at intervals not to exceed twelve months, (7) calibrate primary beam calibration instrument at intervals not to ex ?ed twenty-four months. (8)sissue personnel monitoring devices at intervals not to exceed two weeks, (9) perform an annual review of the Radiation Safety Program, (10) record the operation of a radiation monitoring device on a daily basis, (11) perfom timer constancy and linearity measurements during the monthly output spot-checks of the teletherapy unit, (12) survey patients treated with temporary implants upon removing the last temporary implant source, (13) count the number of brachytherapy sources returned to the storage area, and (14) conduct a Radiation Safety Comittee meeting at least quarterly. These violations demonstrate the need for improvement in the administration and control of your Radiation Safety Program to ensure the safe performance of licensed activities and adherence to NRC requirements.

NUREG-0940 II.A-151

4 Wheeling Hospital, Inc. AUG 0 31987 To emphasize the need for adequate management control over the Radiation Safety Program, I have been authorized, af ter 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 e 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 /.ctions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), the violations described in the encloseo 1 Notice have been categorized in the aggregate as a Severity Lev.'1 Ill problem.  ;

The base value of a civil penalty for a Severity Level Ill violation or problem is $2,500. In considering the escalation i.nd mitigation f actors set forth in ,.

the Enforcement Policy, the NRC recognizes that your prior performance has been -

good. However, mitigation of the civil penalty based on this f actor was not deemed appropriate because of (1) the number of violations identified during this inspection, and (2) most of the violations should have been detected and corrected by management during the routine performance of program supervision and audits.

You are required to respond to this letter and should follos the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken an1 any additional -

actions you plan to prevent recurrence, in addition to the need for corrective action regarding the spec'.fic matters identified in the enclosed Notice, we are concerned about the implementation of your management contral systems that permitted this situation to develoo. Consequently, your response should s -

describe those p6rticular actions taken or planned to improve the effectiveness of your program. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NPC 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 enclosures will be placed in the NRC Public Document Room.

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 by the Paperwork Reduction Act of 1980, PL 96-511.

Should you have any questions concerning this letter, please contact us.

Sincerely, r  %

(,w

^&k

. J. Nelscn Grace .

Regional Administrator

Enclosures:

1. Notice of Violation and Proposh Imposition of Civil Penalty

2. Inspection Report NUREG-0940 11.A-152

+

NOTICE OF VIGLATION AND PROPOSED IMPOSITIOTOF civil PENALTY Wheeling Hospital, Inc. Docket Nos. 030-12811 and 030-12570 Wheeling, West Virginia License Nos.47-05322-03 (Teletherapy) and 47-05322-02 (Nuclear Medicine)

EA 87-74 During the Nuclear Regulatory Comission (NRC) inspection conducted on April 29, 1987, violations of NRC requirements were identified. In accordance eith the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR . art 2, Appendix C (1987), the Nuclear Regulatory Comission-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:

A. License Condition 22(a) of License No. 47-05322-03 requires a visiting physician to receive prior written permission from the hospital's Administrator and its Medical isotopes Committee before the physician is authorized to use licensed material for human use under the tenns of this license.

Contrary to the above, the licensee did not issue written permission from the hospital's Administrator and its Medical isotopes Comittee prior tc authorizing Dr. Sameer Rafia, a visiting physician from Brooklyn Methodist Hospital, to use licensed material for radiation therapy of patients from April 29, 1984 to April 29, 1987. This violation applies to License No. 47-05322-03 only.

B. 10 CFR 35,27(a)(2) and (3) authorizes a licensee to permit any visiting medical authorized user to use licensed material for medical use under the terms of the licensee's license for sixty days each year if, among other things, the licensee possesses a copy of a medical use license issued by the Commission or an Agreement State or a permit issued by the Comission or Agreement State broad licensee either of which identifies the visiting medical user by name and specifies the procedures which the visiting user is authorized to perfonn.

Contrary to the above, on April 29, 1987, the licensee did not possess a copy of a license issued by the Comission nr an Agreement State, or a permit issued by the Comission or Agreement State broad licensee that authorizes medical use by Dr. Sameer Rafia even though over the past three years Dr. Rafia worked at the licensee's facility two or three t'mes per year while another physician was on vacation. This violation applies to License No. 47-05322-03 only.

C. 10 CFR 35.22(a)(4)(iv) requires a licensee's Radiation Safety Comittee to maintain minutes of their meetings including a sumary of deliberations and discussions.

10 CFR 35.22(b)(2) requires a licensee's Radiation Safety Comittee to '

review, on the basis e,f safety and with regard to training and expernnce, and approve or disapprove any individual who is to be listed as a NUREG-0940 II.A-153

Notice of Violation Teletherapy Pnysicist before submitting a license application or request for such amendmer.t or renewal.

Contrary to the above, the licensee's Radiation Safety Consnittee did not review and document the training and experience of the Teletherapy Physicist, Mr. Virgil Yoder (Consultant), before submitting-their license application for Amendment No. 8 on February 10, 1983. This violation applies tu License No. 47-05322-03 only.

I D. License Condition 23 af License No. 47-05322-03, requires the licensee to possess and use licensed material described in items 6, 7, and 8 of this license in accordance with statements, representations, and procedures contained in the license application dated June 10, 1982.

License Condition 19 of License No. 47-05322-02 requires the licensee to conduct its program in accordance with the statements, representations, and procedures contained in the licensee's letter with updated application and attachtrents received March 25, 1982, (including ALARA program dated August 15, 1980, as an attachment).

1. Item 15, Enclosure No. Ill(b)(1) and (2) of the license application dated June 10, 1982, requires the Radiation Safety Officer (RS0) to schedule briefings and educational sessions to inform workers of ALARA program efforts end assure that authorized users, workers, and ancillary personnel who may be exposed to radiation will be l instructed in the ALARA philosophy and informed that management, the Radiation Safety Comittee and the RSO are committed to implementing the ALARA concept.

Contrary to the above, the RS0 has not scheduled briefings and educational sessions to inform workers of ALARA program efforts nor initructed all authorized users, workers, and ancillary personnel who may be exposed to radiation in the ALARA philosophy since 1986. This violation applies to License No. 47-05322-03 only.

2. Item 13(b) of the license application dated June 10, 1982, requires the licensee to conduct "dry runs" at least every six (6) months of the emergency prncedures for the teletherapy unit in the event the shutter fails to close.

Contrary to the above, the licensee did ilot conduct "dry runs" of the emergency procedures betweer Stober 29, 1985 and April 29, 1987, an

! intei,? in exce .., cf six (6, months. This violation applies to l Licer.s No. 47-05322-03 only.

3. Item 9(b)(1) of the license ipplication dated June 10, 1982, requires the licent.ee to calibrate survey instruments every twelve (12) months.

l Contrary tc the above, the licensee did not calibrate a Eberline R0-i survey treter between November 15, 1984, ann June 4, 1986, an inteval ,

in excess of twelve (12) months. This violation applies to License No. " -05322-03 only.

NUREG-0940 II.A-154 m -

Notice of Violation 4. Item 9(b)(2) of the licerte application dated June 10, 1982, requires I the licensee to calibrate the primary beam calibration instruments every twenty-four (24) months.

Contrary to the above, the licensee did not calibrate the Victoreen R Meter Model 570 (Serial #2126) and Capintec Model 172-2 (Serial

1. 607023) primary beam calibration instruments between February 20, 1969 and May 31, 1972, and between May 31, 1972 and June 5, 1985, intervals in excess of twenty-four (24) months. These violations apply to License No. 47-05322-03 only.

5. Item 8(a)(b) of license application dated June 10, 1982, requires the licensee to issue personnel monitoring devices comprised of body fiim bddges and ring TLD badges on a biweekly basis.

Contrary to the above, the licensee issued personnel monitoring devices on a monthly rather than a biweekly basis between January 14, 1985 and April 14, 1987. This violation applies to License No. 47-05322-03 only.

6. Item 15, raciosure No. Ill(a)(1) of license application dated June 10, iM2 (License No. 47-05322-03), and Attachment E of the ALARA Program dated August 15, 1980, included with the updateo application and attachments received March 23, 1982 (License No. 47-05322-02), requires the licensee's RSO to perform an annual review of the Radiation Safety Program for adherence to ALARA concepts.

Contrary to the above, the licensee's RS0 did not perfonn an annual review of the Radiation Safety Program between June 13, 1984 and February 11, 1987, an interval in excess of one (1) year. This vio'ation applies to both license Nos. 47-05322-03 and 47-05322-02,

7. Item 20, Cesium Procedures - Removal of Cesium No.5 of updated application and attachments received March 25, 1982, requires the attending gynecological nurse to monitor the cesium implant patient and the accumulated linen, pads, and solid waste with an ion chambec meter epon removal of the cesium by the Cesium Curator.

Cortrary to the above, the attending gynecological nurse ild not monitor twenty-four (24) cesium implant patients and the accumulated linen, nads, and solid waste with an ion chamber meter upon removal of the cesiua1 by the Cesium Curator between 1983 and 1987. This violation applies to License No. 47-05322-02 only.

8. Item 7, Appendix B, of undated application and attachments received March 25, 1982, requires the Medical ?sotopes Comittee to meet not less than once in each calendar quarter.

Contrary to the above, the Medical isotopes ^omittee did not meet between June 13, 1984, and May 22, 1985, and between May 22, 1985, and December 11, 1985, and between December 11, 1985 and November 13, 19CS, all three intervah i' excess of a calendar quarter. This violation applies to License No. 47-05322-02 only.

NUREG-0940 II.A-155

Notice of Violation E. License Condition 23 of License No. 47-05322-03 requires the licensee to possess and use licensed material described in Items 6, 7, and 8 of this license in accordance with statements, representations, and procedures contained in t% letter dated October 20, 1982, signed by J. Thomas Jones, Associate Administrator, which requires the licensee to monitor and record the operation of the radiation monitoring devices (Primalert 10, Area Alarm Monitor, Model 05-433) on a daily check procedure.

Contrary to the above, the licensee did not record the operation of the Primalert 10 on April 17, 1986, March 3, 1986, December 17, 1985, November 18, 1985, and May 15, 1985. This violation applies to License No. 47-05322-03 only.

F. 10 CFR 35.634(a)(1) requires the licensee to perform output spot-chrcks on

- each teletherapy unit once in each calendar month, which includes determination of timer constancy and timer linearity over the range of use.

Contrary to the above, the licensee did not determine the timer constancy j and timer linearity over the range of use in the montnly output spot-check '

dated April 23. 1987. This violation applies to License No. 47-05322-03 only.

G. 10 CFR 35.406(a) requires the licensee to count the number of brachytherapy sources returned to the storage area to ensure all sources taken from the storage area have been returned.

Contrary to the above, the licensee did not count the number of brachy-therapy sources returned to the storage area on April 13, 1987, after removal of the sources from a temporary implant patient located in room 201. This violation applies to License No. 47-05322-02 only.

The violations have been evaluated in the aggregate as a Severity Level 111 problem (Supplements IV and VI).

(Cumulative civil penalty - $2,500 - assessed equally among the violations.)

Pursuant to the provisions of 10 CFR 2.201, Wheeling Hospital. Inc., 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 denia' of the violation, (2) the reasons for the violation if admitted, (3) the correc-tive 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 nut 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 cai hown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or a f firma tion.

NUREG-0940 II.A-156

Notice of Violation Within the same time as provided for the response required above under 10 CFR 2.201, Wheeling Hospital, Inc., may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, 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 the cumulative amount of the civil penalties if more than one is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer cdiressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should Wheeling Hospital, Inc., fail to answer within the time specified, an order imposing the civil penalty will be issued. Should Wheeling Hospital, Inc., elect to file an answer in accordance with 10 CFR 2.205 protest-ing the civil penalty, in whole or in part, such answer should clearly be 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 circum-stances, (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 l 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 (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 the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Wheeling Hospital, Inc.'s attention is directed to %e ot'ler 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 dCCordance 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.

The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation) should be addressed to: Director, Office of Enforecment, U.S. Nucler.r Regulatory Commission, ATTN: Document Control Des'(, Washington, DC d555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region 11, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323.

FOR THE NUCLEAR REGalATORY COMMISSION A fan ~

.// J. ' Nelson Grace Rt.gional Administrator Dated at Atlanta, Georgia i this 3 day of Aegust 1987 i NUREG-0940 II.A-157

[ge *% ,

, UNITED $TATES 2 a NUCLEAR REGULATORY COMMISSION e, e l wAsem.cTon. o. c. rosss

%' . . . . /

DEC 161987 Docket Nos. 030-12570 and 030-12811 License Nos. 47-05322-02 and 47-05322-03 EA 87-74 Wheeling Hospital, Inc.

ATTN: Mr. J. Thomas Jones Assistant Administrator Medical Park Wheeling, WV 26003 Gentlemen:

SUBJECT:

ORDER IMPOSING A CIVIL MONETARY PENALTY This refers to your letters dated August 5, 26, 27, and 28, and September 28, 1987, in response to the Notice of Violation and Proposed Imposition o.* Civil Penalty sent to you by our letter dated August 3,1987. Our letter and Notit:e described numerous apparent violations identified as a result of an NRC inspection. To emphasize the ne+d for adequate management control of the Radiation Safety Program a civil penalty of Two Thousand Five Hundred Dollars

($2,500) was proposad.

In responses dated August 5, 26, c.7d 27, 1987, you denied the occurrence of violations A, 8, C, 0.4, 0.6, 0.8, and G and did not contest violations 0.1, 0.2, 0.3, 0.5, 0.7, E, and F. You also requested reclassificatica of the overall Severity Level and proposed civil penalty amount.

Af ter consideration of your responses, including the evaluation of new informa-tion submitted to the HRC af ter the NRC inspection on April 29, 1987, we have concluded for the reasons giveh in the Appendix to the enclosed Order imposing Civil Monetary Penalty that violations A, R. C, and 0.4 should be withdrawn, violations 0.6, 0.8, and G occurred as st< :.ed in the Notice of Violation and Proposed Imposition of Civil Penalty dated August 3,1987, and the Severity level and a portion of the proposed civil penalty Since violations A, 8, and C have been withdrawn, the c!are warranted.

vil penalty amount has been reduced by $1071 (5357 per violatfor). Violation 0.4 was one example of many and its withdrawal does not affect the civil penalty amount. Accordingly, we hereby serve the enclosed Order on Wheeling Hospital, Inc. imposing a civil monetary penalty in the amount of One Thousand Four Hundred Twenty-Nine Dollars

($1,429). We will review the effectiveness of your corrective actions during a subsequent inspection.

' A number of unresolved items were noted in eference to new information submitted in your responses. These appear to be in violation of NRC requirements and will be addressed by future NRC correspondence and inspect,as. These unresolved items are further discussed in Enclosure II.

CERTIFIED MAIL WTURN RECElpT REQUESTED NUREG-0940 II.A-158

Wheeling Hospital, Inc. 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.

Sincerely, fA1tk. - A  %

ames Lieberman, Director Office of Enforcement

Enclosures:

1. Order Imposing Civil Monetary Penalty with Appendix

2. Unresolved Items i

l l

NUREG-0940 II,A-159

UNITED STATES NUCLEAR REGULATORY COMMISSION In the matter of )

) Docket Hos. 030-12570 and 030-12811 WHEELING HOSPITAL, INC. ) License Nos. 47-05322-02 and 47-05322-03 Wheeling, WV ) EA 87-74 GROER IMPOSING CIVIL MONETARY PENALTY I

Wheeling Hospital, Inc. (licensee) is the holder of Materials License Nos. 47-05322-02 and 47-05322-03 issued by the Nuclear Regulatory Commission (NRC/ Commission) on April 27, 1977 and July 22, 1977, respectively. The licenses authorize the licensee to employ the use of radioactive materials for j i

diagnostic and therapeutic purposes for patients in accordance with the conditions specified therein.

II A routine unannounced inspection of the licensee's activities was conducted on April 29, 1987. The results c' this inspection indicated that the licensee had not conducted its activities in full compliance with NRC requirements. A l written Notice of Violation and Proposed Imposition of Civil Penalty was served upon the licensee by letter dated August 3,1987. The Notice stated the nature of the violations, the provisions of the NRC requirements that the licensee had violated, and the amount of the civil penalty proposed for the violations. The licensee responded to the Notice of Vinlation and Proposed Imposition of Civil ,

NUREG-0940 II.A-160

i Penalty by letters dated August 5, 26, 27, and 28, and September 28, 1987.

111 Af ter consideration of the licensee's responses and the statements of fact, explanation, and argument for mitigatior, the NRC staff has determined, as set forth in the Appendix to this Order, that violations A, B, C, and D.4 should be withdrawn and violations D.6, D.8, and G occurred as stated. Also, a portion of the proposed civil penalty for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalty as amended by the Appendix to this Order should be imposed.

IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of Is54, as amended (Act), 42 U.S.C, 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT:

The Licensee pay a civil penalty in the amount of One Thousand Four Hundred Twenty-Ninc Dollars ($1,429) 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.

NUREG-0940 II.A-161

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 shall be addressed to the Director, Office of Enforcement, U.S.

Nuclear Regulatory Coannission, ATTH: Document Control Oesk, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, GA 30323.

If a hearing is requested, the Commission will issue an Order designating the time and place of the tearing. 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 by that time, the matter may be referred to the Attorney General for collection.

In the event the licensee requests a hearing as provided above, the issues to De considered at such hearing shall be:

(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 referenced in Section 11 above as amended in the Appendix to this Order, and (b) whether, on the basis of such violations this Order should be sustained.

FOR THE NUCLEAR REGULATORY C0tH15510N lleA bbw J nes Lieberman, Director fice of Enforcement i

Dated at Bethesda, Maryland this itM day of December 1987.

NUREG-0940 II.A-162

APPENDIX EVALUATION AND CONCLUSION By letters dated August 5 and 26, 1987, the licensee responded, in part and in full, ra rectively, to the Notice of Violation and Proposed Imposition of Civil Penalty dated August 3, 1987. In a letter dated August 27, 1987, the licensee restated its response in part. In a letter dated August 28, 1987, the licensee submitted copies of records requested by the NRC on August 14, 1987; and in a letter dated September 28, 1987, the licensee submitted copies of records requested by the NRC on April 29 and September 24, 1987. In these responses, the licensee denied four violations and parts of a fifth, did not contest two violations and parts of a third, and requested reclassifi-cation of the overall Severity Level and civil penalty amount based on new information and apparent prior condonation by the NRC. Provided below are restatements of the violations, licensee responses, staff evaluations, and conclusions.

Restatement of Violation A 3 License Condition 22(a) of License No. 47-05322-03 requires a visiting physician to receive prior written permission from the hospital's Administrator i and its Medical Isotopes Committee before the physician is autherized to use licensed material for human use,under the terms of this license.

Contrary to the above, the licensee did not issue written permission from the j hospital's Administrator and its Medical Isotopes Committee prior to I authorizing Dr. Sameer Rafla, a visiting physician.from 8rooklyn Methodist Hospital, to use licensed material for radiation therapy of patients from April 29, 1984 to April 29, 1987. This violation applies to License No. 47-05322-03 only.

Licensee's Response The licensee contends that the physician was merely a part-time physician assisting an authorized user under 10 CFR 35.25 and was therefore not a visiting physician requiring written pernission per License Condition 22(a). The licensee of fers three exhibits as evidence of Courtesy Staf f appointments for 1980-1981.

NRC Evaluation At the time of the inspection on April 29, 1987 and through the Enforcement Conference on May 27, 1987, the licensee did not clearly dispute the violation; however, the licensee response dated August 5, 1987 indicates that Dr. Rafia should have been considered as working under the supervision of Dr. Bonnesen in accordance with 10 CFR 35.25. Therefore, based on this new information we agree that the provisions of License Condition 22(a) would not have applied. Accordingly, violation A has been withdrawn. Our records will be revised accordingly.

Restatement of Violation 8 10 CFR 35.27(a)(2) and (3) authorizes a licensee to permit any visiting medical authorized user to use licensed material for medical use under the terms of the NUREG-0940 II.A-163

9ppendix licensee's license for sixty days each year if, among other things, the licensee possesses a copy of a medical use license issued by the Comission or an Agreement State or a permit issued by the Commission or Agreement State broad licensee either of which identifies the visiting medical user by name and specifies the procedures which the visiting user is authorized to perform.

Contrary to the above, on April 29, 1987, the licensee did not possess a copy of a license issued by the Commission or an Agreement State, or a permit issued by the Comission or Agreement State broad licensee that authorizes medical use by Dr. Sameer Rafla even though over the past three years Dr. Rafia worked at the licensee's facility two or three times per year while another physician was on vacation. This violation applies to License No. 47-05322-03 only.

Licensee's Response The licensee responded that Dr. Rafla was supervised and therefore was not a visit,ing physician in the context of 10 CFR 35.27. ilso, an authorized user on the licensee's staff reviewed Dr. Rafla's credentials prior to Dr. Rafia commencing work.

NRC Evaluation i

The licensee is not required to possess a copy of Dr. fafia's medical use license i l

or permit if he was working under the supervision of ai authorized user such as Dr. Bonnesen in accordance with 10 CFR 35.25. T here f oi re, based on our with-drawal of violation A, we withdraw violation B. Our re:ords will be revised accordingly.

Restatement of Violation C 10 CFR 35.22(a)(4)(iv) requires a licensee's Radiation Safety Committee to maintain minutes of their meetings including a summary of deliberations and discussions.

10 CFR 35.22(t)(2) requires a licensee's Radiation Safety Committee to review, on the basis of safety and with regard to training and experience, and approve or disapprove any individual who is to be listed as a Teletherapy Physicist before submitting a licease application or request for such amendmer,c or renewal.

Contrary to the above, the licensee's Radiation Safety Committee did not review and document the training anc experience of the Teletherapy Physicist, Mr. Virgil Yoder (Consuliant), before submitting their license application for Amendment No. 8 on February 10, 1983. This violaticn applies to License No.

47-05322-03 only.

Licensee's Response i

The licensee contends that the present 10 CfR 35.22(b)(2) requirement was not operative during the time period cited in violation C, nor was 10 CFR 35.27 (superseded text) operative prior to the hiring of their consulting Teletherapy Physicist. Additicnally, the licensee states that Mr. Yoder's qualifications

< were reviewed in 1977.

NUREG-0940 II.A-164

Appendix NRC Evaluation Violation C, issued on August 3, 1987, related to activities in February 1983. i Dua to an error, it cited 10 CFR 35.22 which did not go into effect until April 1, l 1987. The NRC agrees that the violation was in error and we withdraw violation C. j Our records will be revised accordingly. _j 1

Rastates,ent of Violation D.4 License Condition 23 of License No. 47-05322-03, requires the licensee to possess and use licensed material described in items 6, 7, and 8 of this license in accordance with statements, representations, and procedures contained in the license application dated June 10, 1982.

Item S(b)(2) of the license application dated June 10, 1982, requires the licensee to calibrate the primary beam calibration instruments every twsnty-four (24) months.

Contrary to the above, the licensee did not calibrate the Victoreen R Meter Model 570 (Serial #2126) and Capintec Model 172-2 (Serial #607023) primary beam calibration instruments between F.ebruary 20, 1969 and May 31, 1972, and between May 31, 1972 and Jun 5,1985, intervals in excess of twenty-four (24) months.

These violations apply to License No. 47-05322-03 only.

Licensee's Response The licensee contends the following:

The primary beam calibrations are performed by an outside consultant who uses his own instrument.

The teletherapy license was issued on July 23, 1977. Therefore, there is no reason te calibrate the primary beam calibration instrument prior to that date.

The Victoreen R Meter Model 570 primary beam calibration instrument was used prior to 1977 for the calibration of x-ray therapy equipment

- only. This instrument was not utilized for the annual calibration or monthly spot-check of the Co-60 teletherapy unit at anytime.

The Capintec Model 172-2 was used for annual calibrations and monthly spot-checks between July 22, 1977 and July 1984. Since July 1984, a Capintec Model 192 has been utilized. Both instruments were controlled and maintained by Mr. Yoder when he performed these calibrations. These instruments have been calibrated every 24 months as required and the calibration reports are maintained by Mr. Yoder.

Wayne Butler, Ph.0, performs no monthly spot-checks. He does confer with Mr. Yoder bi-weekly regarding patient treatments and chart e. hecks.

NUREG-0940 II.A-165

l Appendix

• The Capintec Model 192 (Serial No. 46101442) was used foi annual calibrations and monthly spot-checks in 1986 and 1987. The Capintec Model 192 ($erial No. 94C747) was used in 1984 and 1985. The Capintec Model 172-2 was used between 1977 and 1983.

NRC Evaluation Although many of the licensee's arguments do not directly address this violation as stated, the staf f agrees that the primary beam calibration instruments were not required to be calibrated prior to the 1977 teletherapy license issuance.

Based upon the new informati3n provided in the licensee responses, we are with-drawing violation 0.4 since an outside party calibrated the instruments at intervals not in excess of twenty four months. Our records will be revised accordingly.

Restatement of Violation 0.6 License Condition 23 of License No. 47-05322-03, requires the licensee to possess and use licensed material described in items 6, 7, and 8 of this license in accordance with statements, representations, and procedures contained in the lic4nse application dated June 10, 1982.

License Condition 19 of License *ho. 47-05322-02 requires the licensee to conduct its program in accordance with the statements, representations, and procedures contained in the liunsee's letter with updated application and attachments received March 25, 1982 (including ALARA program dated August 15, 1980, as an attachmentT.

Item 15, Enclosure No. lil(a)(1) of the license application dated June 10, 1982 (License No. 47-05322-03), and Attachment E of the ALARA Program dated August 15, 1980, included with the updated application and attachments received March 23, 1982 (License No. 47-05322-02), require the licensee's Radiation Safety Officer (R50) to perform ~an annual review of the Radiation Safety Program for adherence

, to ALARA concepts.

Contrary to the above, the licensee's RSO did not perform an annual review of the Radiation Safety Program between June 13, 1984 and February 11, 1987, an interval in excess of one year. This violation applies to both License Nos. 47-05322-03 and 47-05322-02.

Licensee's Response The licensee contends that the violation was licensee-identified and corrected on February 11, 1987, prior to the NRr inspection.

NRC Evaluation NMA Medical Physics Services documented and reviewed with the licensee, in four separate consulting reports, the licensee's failure to perform an annual review of the Radiation Safety Program. In a NMA Medical Physics Services consulting report dated February 6,1985, the consultant notified the licensee 4

of the annual review due on March 14, 1985. Again in a consulting report dated NUREG-0940 II.A-166

1 Appendix May 1986, the consultant alerted the licensee of the required annual review.

Then on September 17, 1986, NMA Medical Physics Services notified the licensee of their deficiency in conducting an annual review. The final notification by ,

NMA Medical Physics Services of Wheeling Hospital's annual review deficiencies l was documented in a consulting report dated February 4,1987. Tine licensee responded by performing an annual r(view on February 11, 1987. Violation 0.6 was correct as stated.

Restatement of Violation D.8 License Condition 19 of License No. 47-05322-02 requires the licensee to conduct its program in accordance with the statements, representations, and procedures contained in the licensee's letter with updated application and attachments received March 25, 1982 (including ALARA program dated August 15, 1980, as an attachment).

Item 7, Appendix B, of undated application and attachments received March 25, 1982, requires the Medical isotopes Committee to meet not less than once in each calendar quarter.

Contrary to the above, the Medical Isotopes Committee did not meet between June 13, 1984 and May 22, 1985, and between May 22, 1985 and December 11, 1985 and between December 11, 1985 and November 13, 1986, all three intervals in excess of a calendar quarter. This violation applies to License No. 47-05322-02 only.

Licensee's Response The licensee contends that these failures were licensee-identified and corrected in November 1986, prior to the NRC inspection.

NRC Evaluation Dr. Moren, Ph.D. , an outside Consulting Physic'st for Wheeling Hospital, noted in an earlier consulting report which evaluateo Wheeling Hospital's Nuclear Medicine Department that the Radiation Safety Committee (RSC) had not met since June 13, 1984. NKA Medical Physics Services documented tt.e infrequency of RSC cretings in two separate consulting reports date8 November 1984 and February 1985. The November 1984 consulting report alerted the licensee of a missed RSC meeting during the third calendar quarter of 1984 The February 1985 consulting report also alerted the licensee of a missed RSC meeting during the second calendar quarter of 1985. Also hMA Medical Physics Services indicated in a consulting report dated February 6,1985 that the RSC had not performed an annual ALARA review of the hospital's Radiation Safety Program. Consequently, based on Dr. Moren's consulting report and NMA Medical Physics Services' consulting reports, Wheeling Hospital was aware of their f requency of missed PSC meetings since at least June 13, 1984. Violation 0.8 was correct as stated.

Restatement of Violation G 10 CFR 35.406(a) requires the licensee to count the number of brachytherapy sources returned to the storage area to ensure all sources takeri f rom the storage area have been returned.

NUREG-0940 II.A-167

l l

Appendix Contrary to the above, the licensee did not count the number of brachytherapy sources returned to the storage area on April 13, 1987, after removal of the sources from a temporary implant patient located in room 2C1. This violation applies to License No. 47-05322-02 only.

Licensee's Response The licensee contends that their "retur. -.1" entry or "the time and date of return" entry for April 13, 1987, on Enclosure 4 of their letter of_ August 5, 1987, conforms'to7he"data elements re'qdired'b'~y 10 CFR 35.406(a).

NRC Evaluation The NRC evaluation is based on 10 CFR 35.406(a) requiring the licensee to return the brachytherapy sources to the storage area and count the number returned to ensure that all sources taken from the storage area havt. been returned. The Gntry "returned" or the "time and date of return" entry does not constitute a count of the brachytherapy sources. Therefore, violation G remains as stated.

Conclusions Based on the review o,'f the partia1 response (August 5, 1987), the full response (August 26, 1987), and the partial response (August 27, 4987) by the licensee to the Notice of Violation and Proposed Civil Penalty issued on August 3,1987, violations A, B, C, and 0.4 have been withdrawn and violations 0.6, 0.8, and G have been reaf firmed. The unresolved items described in Enclosure 11 to the letter, which appear to be in violation of NRC requirements, will bc eviewed during future NRC inspections. The evidence continues to support a onagement breakdown due to the remaining violations and subsequent information revealing additional program deficiencies. Mitigation for violations 0.6 and 0.8 is inappropriate, notwithstanding the licensee's self-identification, in view of the opportunities available for self-identification and the knowledge the licensee had of the recurring conduct. We do note, as observed by the licensee,.that some of the violations were not identified by the NRC in a previous inspection.

NRC inspections are an audit. The inspector does not cover every aspect of a licensee's operation. The licensee has responsibility for full compliance not the NRC inspector. Based on these violations, and in view of the magnitude of the noncompliances, no mitigation of the Severity Level (III) is warranted.

Based upon the withdrawal of violations A, B, and C, reouction in the civil penalty amount by $1071 is warranted. Therefore, a civil penalty in the amount of $1,429 should be imposed.

NUREG-0940 II.A-168

ENCLOSURE II UNRESOLVED ITEMS A number of unresolved items are noted.in reference to new information submitted in the licensee's responses. An unresolved item is defined as a matter for which NRC needs more information in order to determine compliance.

Please be aware that these unresolved items will be reviewed during future NRC inspections. These unresolved items, along with the requirements which must be satisfied, are specified below:

10 CFR 35.406(h)(1) requires recording the names of individuals permitted to handle sources, i

10 CFR 35.406(b)(2) requires the licensee to make a record of brachytherapy source use to include the number and activity of the sources in storage, after the removal, and the initials of the individual who removed the sources from storage.

10 CFR 35.406(b)(3) requires the licensee to make a record of the following:

Patient.'s name and room number Number and activity of sources in storage af ter the return of the sources to storage The documents submitted of the five cesium implants performed between April 10 and June 16, 1987 did not appear to contain the required information listed above.

On August 14, 1987 ccpies of Wheeling Hospital's records pertaining to Cesium-137 brachytherapy treatments subsequent to April 1, 1987 were requested.

This information was requested in reference to the licensee's implementation of requirements as defined in 10 CFR 35.406(c) and 35.415(a)(4). '.n your letter dated August 28, 1987, no records of a brachytherapy implant survey were submitted to this Office regarding a Cesium-137 implant performed on April 10, 1987 (patient name: Penn, room 201). Since your letter of August 28, 1987 indicates that the "Cesium Room and Patient Survey Heter Readings" form had been created imediately following the April 29, 1987 NRC inspection in order to satisfy the requirenents of 10 CFR 35.406(c) and 35.415(a)(4), it cannot be established whether the required surveys were conducted and whether records of the surveys had been kept. Your letter of August 28, 1987 indicates that all Cesium-137 brachytherapy treatments since April 29, 1987 have used the new form and all future treatments will continue to use this form.

10 CFR 35.415(a)(4) requires that records of surveys performed in contiguous restricted and unrestricted areas include the time of the survey. According to records submitted, the four implants performed between May 15 and Jt.ne 16, 1987 do not indicate the tima of the surveys. In order to assure cocpliance to 10 CFR 35.415, future brachytherapy surveys must include the time of the survey.

These unresolved items will be reviewed during a future NRC inspection at your facility.

NUREG-0940 II A-169

II.B. MATERIAL LICENSEES, SEVERITY LEVEL III VIOL ATION, i NO CIVIL PENALTY

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UNITED STATES NUCLEAR REGULATORY COMMISSION l

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t 479 ALLENOALE ROAD KING oF PRUS$1 A, PENNSYLVANIA 18400 l

February 1,1988 l Docket No. 030-06102 Licer se No. 37-03426-02 l EA 87 230

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Keystone portland Cement Company ATTN: James L. Longenbach Vice President of Operations Bath, Pennsylvania 18014 Gentlemen:

Subject:

NOTICE OF VIOLATION (N7C Inspection No. 030-06102/87-01)

This letter refers to the NRC inscection conducted on November 24, 1937, at your facility in Bath, Pennsylvania of activities authorized by License No.

37-CM 2f-02. The report of the inspection was forwarded to you on December 29, 1987. During the inspection, violations of NRC requirements were identified.

On January 6,1987. we held an enforcement conference with you and members of your staff during which the violutions, their causes and your corrective actions were discussed.

The violations are described in the enclosed Notice of Violation, and include a citation for the removal of three gauges containing radioactive material from a process line by individuals who did not possess a specific license to do so, and the failure to lock the radioactive sources in the closed position while the gauges were removed. Although the health and safety of individuals was not af fected by this violation, or the ot: 3r violations identified during the inspection, the NRC is concerned because the violations could have resulted in the unnecessary exposure of individuals to radiation. The violations demon-strate the importance of (1) appropriate attention to this program to prevent recurrence of these violations, and (2) appropriate training of personnel so that they are aware of the location of, and hazards associated with, these gauges.

The violation pertaining to the unauthorized handling of the gauges is classified  ;

at Severity Level III in accordance with the "Geeral Statement of Policy and j Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, (Enforcement i Policy) (1987). Although a civil penalty is normally proposed for a Severit-/ }

Level III violation, af ter consultation with the Director, Of fice 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 (1) the violation, when di; covered by your contractor, was promptly reported to the NRC; and (2) your corrective actions were unusually prompt and extensive. Nonetheless, we emphasize that any similar violations in the future may result in additional enforcement action, such as a civil penalty or Order. The other violations in I the enclosed Notice are classified at Severi'y Level IV.

CERi!FIED MAIL IfETURN TtECE!Pt REQUESTED

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NUREG-0940 II B-1 1

._______________________u

l Keystone Portland Cement Co. You are required to respond to the enclosed Notice and, in preparing your response, you should follow the instructions specified in the Notice. In your response, your sho;)d 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 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, Yitle 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room.

The response 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.

Sincerely, M.

l liam T. Russell Regional Administrator

Enclosure:

Notice of Violation cc w/ enc 1:

Frank Silfies, Plant Manager l Public Document Room (PDR) l Nuclear Safety Information Center (NSIC)

Commonwealth of Pennsylvania NUREG-0940 II.B-2

NOTICE OF VIOLATION Keystone Portland Cement Company Docket No. 030-06102 Bath, Pennsylvania License No. 37-03426-02 l EA-87-230  ;

1 During an NRC inspection conducted on November 24, 1987, at the licensee's facility in Bath, Pennsylvania, violations of NEC requirements were identified.

Zn accordance with'the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the particular violations are set forth below:

A. License Condition 15 of License No. 37-03426-02 requires that installation, relocation, removal from service, maintenance, repair, and initial radiation surveys of devices containing licensed material, and installation, replacement, and disposal of sealed sources containing licensed material used in devices, be performed only by the device manufacturer or by persons specifically authorized by the Commission or an Agreement State to perform such services.

License Condition 17 of License P . 37-03426-02 requires that licensed material be possessed and used in accordance with statements, representations and procedures contained in the application dated January 4, 1984. Item 15 of the application dated January 4, 1984, states that all work pertaining to sealed sources will be performed by Ohmart (a device manufacturer) personnel, and indicates that when it is necessary to work on the pipe on which a device is attached, the source wou?d be turned off and locked in the off position until the rork is completed.

Contrary to the above,

1. In March and September 1987, three nuclear gauges containing the licensed material (cesium-137) were removed from slurry lines by pipefitters who were not employed by the device manufacturer and were not specifically authorized by the Commission to remove the gauges.

Further, at the time of removal, the sources were not locked in the off position; and

2. In 1985, licensee employees installed several nuclear gauges on various tanks at the facility, and these individuals were not employed by the device manufacturer and were not specifically authorized by the Commission to install these gauges.

This is a Severity Level III violation (Supplement VI).

B. 10 CFR 20.203(f)(1) and (2) requires that each container of licensed material bear a durable, clearly visible label identifying the radioactive contents and bearing the radiation caution sycbol and the words "Caution (or ' Danger') Radioactive Material" xcept as specifically exempted in 10 CFR 20.203(f)(3).

NUREG-0940 11.8-3

I l

Notice of Violation Contrary to the above, as of November 23, 1987, three crates located in the Carpenter Shop contained Ohmart nuclear gauges (containing cesium-137), one of which was removed from service in March 1987 and the other two which were removed from service in September 1987, and the crates were not properly labeled nor did-the gauges themselves have clearly visible labels. The labels that were on the gauges were obscured by dirt and were unreadable. (Nothing in 10 CFR 20.203(f)(3) exempted these containers from these labelling requirements.)

This is a Severity Level IV Violation (Supplement IV).

C. Condition 12 of License No. 37-03426-02 requires that licensed material shall be used by, or under the supervision of, Michael Kapustic.

Contrary to the above, between October 25, 1985 (when Michael Kapustic left the company) and November 24, 1987, licensed material was used by individuals other than Michael Kapustic and these individuals were not under his supervision.

This is a Severity Level IV violation (Supplement VI).

D. Condition 16 of License No. 37-03426-02 requires that the licensee conduct physical inventories every six months to account for all sealed sources received and possessed under the license. The records of the inventories shall be maintained for two years from the date of the inventory for inspection by the Commission, and shall include the quantitias and kinds of licensed material, location of sealed sources and the date of the inventory.

Contrary to the above, as of November 24, 1987, the prior two inventories of sealed sources were performed on August 17, 1984, and August 21, 1987, an interval in excess of six months.

This is a Severity Level IV violation (Supplement VI).

Pursuant to the provisions of 10 CFR 2.201, Keystone Portland Cement Company (Licensee) is hereby required to submit a written statement of explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region I, 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) the reason for the violation if admitted (2) the corrective steps that have been taken Tnd 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 i

NUREG-0940 II.B-4

Notice of Violation '

action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown.

FOR THE NUCLEAR REGULATORY COMMISSION W M1. k p Regional liam T. Ru> sell Administrator Dated at JK ng of Prussia, Pennsylvania this / Si day of February 1988 ,

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