ML20248G531

Enforcement Actions: Significant Actions Resolved.Quarterly Progress Report,April-June 1989

ML20248G531
Person / Time
Issue date:	09/30/1989
From:	NRC OFFICE OF ENFORCEMENT (OE)
To:
References
NUREG-0940, NUREG-0940-V08-N02, NUREG-940, NUREG-940-V8-N2, NUDOCS 8910100283
Download: ML20248G531 (388)

Text

{{#Wiki_filter:_ - - - - NUREG-0940 Vol. 8, No. 2 l l En~orcement Actions:  ! Significarr: Ac': ions Resolvec. l I i Quarterly Progress Report April - June 1989 1 U.S. Nuclear Regulatory Commission ( tf Enfbreement l l l,. . ,s

                   %                                    l i
                                                                    . ; -a :           <         :t                                                      ,

c. I' W! s i ,-.

1

                                        >r       ,

l l l 5 l Available from Superintendent of Documents U.S. Government Printing Office Post Office Box 37082 Washington, D.C. 20013-7082 A year's subscription consists of 4 issues for this publication. Single copies of this publication are available from National Technical Information Service, Springfield, VA 22161

NUREG-0940 Vol. 8, No. 2 l Enforcement Actions: Significant Actions Resolved ' Quarterly Progress Report April- June 1989 Manuscript Completed: August 1989 Date Published: September 1989 Omce of Enforcement U.S. Nuclear Regulatory Commission Washington, DC 20555 f - %,,,

i ABSTRACT This compilation summarizes significant enforcement actions that have been resolved during one quarterly period (April - June 1989) and includes copies of letters, Notices, and Orders sent by the Nuclear Regulatory . Commission to licensees with respect to these enforcement actions. It is i anticipated that the information in this publication will be widely disseminated to managers and employees engaged in activities licensed by the  ! NRC, so that actions can be taken to improve safety by avoiding future violations similar to those described in this publication. I I i i i l I l l i l l NUREG-0940 itt

l l J CONTENTS 1 Page ABSTRACT.................................................................. 111 , INTRODUCTION................................................................ 1 l SUMMARIES................................................................... 3 i I. REACTOR LICENSEES A. Civil Penalties and Orders Arkansas Power and Light Company, Little Rock, Arkansas (Arkansas Nuclear One) EA 88-283......................................................I.A-I Arkansas Power and Light Company, Little Rock, Arkansas (Arkansas Nuclear One) EA 88-284......................................................I.A-8 Baltimore Gas and Electric Company, Baltimore, Maryland (Calvert Cliffs Units 1 and 2) E A 8 7- 7 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A - 16 Carolina Power and Light Company, Raleigh, North Carolina (H.B. Robinson Plant) EA 88-88......................................................I.A-32 Carolina Power and Light Company

                       -(Brunswick Steam Electric Plant), Raleigh, North Carolina EA 88-316.....................................................I.A-47 Commonwealth Edison Company, Chicago,_ Illinois (DresdenStation)

EA 87-81......................................................I.A-54 Commonwealth Edison Company, Chicago, Illinois (QuadCitiesNuclearPowerStation) . E A 8 7 -8 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A -7 6 Commonwealth Edison Company, Chicago, Illinois I (Byron Station, Unit 1) I EA 88-266.....................................................I.A-97 Duke Power Company, Charlotte, North Carolina (Oconee Nuclear Plant) - EA 8 9 - 3 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A - 10 3 Houston Lighting and Power Company, Houston, Texas (South Texas Project, Unit 1) EA 89-01.....................................................I.A-107 NUREG-0940 v

i l CONTENTS (Continued) l REACTOR LICENSEES (Continued) Py New York Power Authority, White Plains, New York  ; (FitzPatrick Nuclear Power Plant) EA 88-304....................................................I.A-114 Northeast Nuclear Energy Company, Hartford, Connecticut (Millstone Units 1 and 2) EA 88-254....................................................I.A-121 j Portland General Electric Company, Portland, Oregon (Trojan Nuclear Plant) EA 89-16.....................................................I.A-129 Public Service Electric and Gas Company, Hancocks Bridge, New Jersey q (Salem Nuclear Generating Station) 1 EA 88-238....................................................I.A-135 South Carolina Electric and Gas Company, Jenkinsville, South Carolina (V.C. Summer Nuclear Station) EA 88 - 3 05 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A - 141 Toledo Edison Company, Toledo, Ohio (Davis-Besse Nuclear Power Plant) EA 89-49.....................................................I.A-143 Virginia Electric and Power Compan,y, Glen Allen, Virginia (Surry Power Station Units 1 and 2) EA 88-296....................................................I.A-150 Virginia Electric and Power Company, Glen Allen, Virginia (North Anna Power Station) EA 88-311....................................................I.A-167 B. Severity Level III Violation, No Civil Penalty Carolina Power and Light Company, Raleigh, North Carolina (H.B. Robinson Nuclear Plant) EA 89-02...........................s...........................I.B-1 Nebraska Public Power District, Columbus, Nebraska (CooperNuclearStation) EA 89-56.......................................................I.B-6 l l Tennessee Valley Authority, Chattanooga, Tennessee  ! (WattsBarNuclearPlant) l EA 88-253......................................................I.B-9 ' i l NUREG-0940 vi I

CONTENTS (Continued) REACTOR LICENSEES (Continued) Page Detroit Edison Company, Detroit, Michigan (Fermi 2) EA 89-06......................................................I.B-24 l II. MATERIALS LICENSEES l A. Civil Penalties and Orders Advex Corporation, Hampton, Virginia EA 88-315.....................................................II.A-1 Computerized Medical Imaging, Inc., Eau Claire, Wisconsin EA 89-14......................................................II.A-6

Cornish Wireline Service, Inc., Chanute, Kansas EA 89-15.....................................................II.A-13 Department of the Army, Albuquerque, New Mexico EA 88-172....................................................II.A-20 Michael Dimun, M.D., Carnegie, Pennsylvania EA 89-52.....................................................II.A-31 General Electric Company, Wilmington, North Carolina EA 88-302....................................................II.A-36 Anna Jaques Hospital, Newburyport, Massachusetts EA 89-48.....................................................II.A-41 Niagara of Wisconsin Paper Corporation, Niagara, Wisconsin EA 89-65.....................................................II.A-48 P&L Trucks, Inc., McAlester, Oklahoma EA 89-67.....................................................II.A-53 Pesara Pushpamala Reddy, M.D., Kittanning, Pennsylvania EA 88-291....................................................II.A-61 James River Corporation, Richmond, Virginia EA 89-62........'............ ................................II.A-69 St. Agnes Medical Center, Philadelphia, Pennsylvania l EA 88-298....................................................II.A-84 1

St. Joseph's Hospital, Huntingburg, Indiana EA 89-20....................................................II.A-100 l l NUREG-0940 vii

CONTENTS (Continued) MATERIALLICENSEES(Continued) Page Saturn Services, Inc., Tulsa, Oklahoma EA 89-07....................................................II.A-106 The Hospital Center at Orange, Orange, New Jersey EA 89-51....................................................II.A-112 V.A. Medical Center, toma Linda, California EA 88-39....................................................II.A-120 i { Jeffrey- Weisman, M.D., Philadelphia, Pennsylvania i EA 89-23....................................................II.A-129 B. Severity Level III Violation, No Civil Penalty l 1 Allegheny General Hospital, Pittsburgh, Pennsylvania EA 89-89......................................................II.8-1' Alpena General Hospital, Alpena, Michigan EA 89-97......................................................II.B-5 Zacharia Mikros, D.O., Garden City, Michigan EA 89-24.....................................................II.B-11 Schlumberger Technology Corporation, Houston, Texas EA 89-84.....................................................II.B-20 i i i i 1 i NUREG-0940 viii i i

Li ENFORCEMENT ACTIONS: SIGNIFICANT ACTIONS RESOLVED April - June 1989 INTRODUCTION This issue of NUREG-0940 is being published to inform NRC licensees about significant enforcement actions and their resolution for the second quarter 1 of 1989. Enforcement actions are issued by the Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support and the Regional Administrator. The Director, Office of Enforcement, may act for the DEDS in the absence of the DEDS or as directed. The actions involved in this NUREG involve NRC's civil penalties as well as significant Notices of Violation. An objective of the NRC Enforcement Program is to encourage licensees to improve their performance and, by example, the performance of the licensed indu stry. 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 comon defense and security. A brief sumary of each significant enforcement action that has been resolved in the second entitled quarterEach "Sumaries." of 1989 can be sumary found the provides in the section of this enforcement rep EA) action (ort ' number to identify the case for reference purposes. The supplement number refers to the activity area in which the violations are classified according to guidance furnished in the U.S. Nuclear Regulatory Comission's " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13,1988). Violations are categorized in terms of five levels of severity to show their relative importance within each of the following activity areas: 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 i Severity Level III violation, but for which no civil penalties were assessed. Part II. A contains civil penalty or Order actions involving materials licensees. ) Part II.B includes copies of Notices of Violation that has been issued to material licensees, but for which no civil penalties were assessed. i Actions still pending on June 30, 1989 will be included in future issues of this publication when they have been resolved. NUREG-0940 1

l l l < SUMMARIES I. REACTOR LICENSEES , A. , Civil Penalties and Orders Arkansas Power and Light Company, Little Rock, Arkansas  ! (Arkansas Nuclear One) Supplement IV, EA ES-283 l ' A Notice of Violation and Proposed Imposition of Civil Penalty in i the amount of $25,000 was issued March 2, 1989 to emphasize the importance NRC places on assuring that adequate radiological surveys , l are made to preclude radiation exposure in excess of regulatory limits. l The action was based on the failure to control an individual's occupational exposure to less than 3 rems per calendar quarter and l failure to perform adequate surveys to identify radiation sources I that resulted in an individual exceeding the quarterly whole body radiation exposure limits. The base civil penalty was decreased by 50% based on good past performance. The licensee responded and paid the civil penalty on March 29, 1989. i Arkansas Power and Light Company, Little Rock, Arkansas l' (Arkansas Nuclear One) Supplement I, EA 88-284 { A Notice of Violation and Proposed Imposition of Civil Penalty in i the amount of $175,000 was issued April 7, 1989 to emphasize the  ! importance of the prompt resolution of safety issues and the  ! importance of controlling work activities so as not to result in a reduction of plant safety. The action was based on two problems. The first involved the licensee's failure to take adequate i corrective actions for various identified conditions adverse to quality. The second problem involved various violations in which the licensee failure to properly control safety-related equipr.ent. The first problem was escalated 100% because of prior notice and past performance and the second was escalated 50% because the NRC identified a number of the violations. The licensee responded and paid the civil penalty on May 5,1989. Baltimore Gas and Electric Company, Baltimore, Maryland (Celvert Cliffs Units 1 and 2) Supplement I, EA 87-77 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $300,000 was issued April 28, 1988 to emphasize the importance of (1) lastin the EQ program, andaggressive (2) g management management attention to, and action to ensure thatcontrol of, problems are promptly identified and corrected. The action was based on violations of the equipment qualification requirements of 10 CFR 50.49. The licensee responded in letters dated July 12 and 18, 1988. After considering the licensee's responses, an l Order was issued March 20, 1989 imposing a civil penalty. The I licensee paid the civil penalty on April 18, 1989. NUREG-0940 3

Carolina Power and Light Company, Raleigh, North Carolina (H. B. Robinson Plant) Supplement I, EA 88-88 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued June 15, 1988 to emphasize the importance of proper evaluation of the ECCS system. The action was based on failure of the 10 CFR Part 50, Appendix K required ECCS evaluation model used to reficct the most damaging single failure relative to the ECCS safety fajection subsystem. The evaluation results erroneously assumed that two of the three SI pumps would be operable during design basis accidents. There were several scenarios where only on SI pump would be operable and not meet the single failure criteria. The licensee responded in a letter dated July 15, 1988. After considering the licensee's response, an Order Imposing Civil Penalty was issued March 17, 1989. The licensee paid the civil penalty on April 14, 1989. Carolina Power and Light Company, Raleigh, North Carolina (Brunswick Steam Electric Plant) Supplement I, EA 88-316 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $150,000 was issued March 16, 1989 to emphasize the significance of safety systems being unable to perform their intended function, lhe action was based on two individuci events that individually resulted in a loss of secondary containment integrity during fuel sipping operations. The first involved an inoperable standby gas treatment system, and was escalated 100% because the NRC identified the problem and poor past performance due to operator attention to detail. The second violation involved inoperable secondary containment isolation dampers. The licensee responded and paid the civil penalty on April 17, 1989. Commonwealth Edison Company, Chicago, Illinois (Dresden Station, Unit 3) Supplement I, EA 87-81 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $150,000 was issued April 29, 1988 to emphasize the importance of environmental qualification. The action was based on violations of equipment qualification requirements of 10 CFR 50.49. The licensee responded in letters dated June 28 and July 1,1988. After considering the licensee's responses, an Order Imposing Civil Monetary Penalty in the amount of $150,000 was issued May 3, 1989. The licensee paid the civil penalty on June 2, 1989. Commonwealth Edison Company, Chicago, Illinois (Quad Cities Station, Units 1 and 2) Supplement I, EA 87-82 A Hotice of Violation and Proposed Imposition of Civil Penalty in the amount of $150,000 was issued October 20, 1988 to emphasize the importance of environmental qualification and meeting regulatory i deadlines. The action was based on a violation of the equipment ' qualification requirements of 10 CFR 50.49. The licensee responded in letters dated November 21 and December 19, 1988. After considering NUREG-0940 4

the licensee responses, the civil penalty was mitigated by 50%. An Order Imposing Civil Monetary Penalty in the amount of $75,000 was issued May 3, 1989. The licensee paid the civil penalty on June 2, 1989. Commonwealth Edison Company, Chicago, Illinois (Byron Station, Unit 1) Supplement I, EA 88-266 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued May 24, 1989 to emphasize the importance of ensuring that critical plant parameters and systems are controlled in accordance with appropriate station procedures and that necessary corrective actions are taken in response to generic communications. The action was based on a loss of one train of the residual heat removal system while the reactor coolant system water level was being lowered on September 19, 1988. The licensee responded and paid the civil penalty on June 26, 1989. i Duke Power Company, Charlotte, North Carolina (0conee Nuclear Plant) Supplement I, EA 89-32 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued April 11, 1989 to emphasize the need for testing and maintenance to assure the availability of safety systems if called upon. The action was based on the failure to have two independent reactor building cooling trains operable as required. The civil penalty was mitigated by 50% because of the licensee's prompt and extensive corrective actions. The licensee responded and paid the civil penalty on May 8,1989. Houston Lighting and Power Company, Houston, Texas (South Texas Project) Supplement I, EA 89-01 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued March 17, 1989 to emphasize the importance of verifying that equipment that is relied upon in the design of the plant is in fact installed and available. The action was based on the licensec's failure to install, prior to plant licensing in 1988, the vortex suppressors in the emergency sumps which supply the suction for the safety injection and containment spray pumps in the recirculation mode. The licensee responded on April 12, 1989. After considering the licensee's response, the proposed civil penalty was withdrawn on June 30, 1989. New York Power Authority, White Plains, New York (Fitzpatrick Nuclear Power Plant) Suppiement I, EA 88-304 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $75,000 was issued March 13, 1989 to emphasize the need to improve performance. The action was based on the licensee's failure to properly analyze two potential safety issues. The first, despite information available from a contractor's report that i I questioned whether certain reactor building room coolers were receiving adequate service water flow, the licensee failed to evaluate system operability. In the second, the licensee failed NUREG-0940 5

l 1 to recognize and evaluate the rise in ultimate sink temperature to a value 2.5*F above that assumed in the plant accident analysis. The civil penalty was escalated by 50% for multiple examples. The licensee responded and paid the civil penalty on April 7, 1989. Northeast Nuclear (Millstone Units Energy) 1 and Company, 2 Supplement Hartford, I, EA 88-254 Connecticut A Notice of Violation and Proposed Imposition of Civil Penalty in ' the amount of $50,000 was issued on April 21, 1989 based on a violation of the equipment qualification requirements of 10 CFR 50.49. The licensee responded and paid the civil penalty on May 19, 1989. Portland General Electric Company, Portland, Oregon (Trojan Nuclear Plant) Supplement I, EA 89-16 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $75,000 was issued on April 4,1989 to emphasize the need to maintain a strong independent Quality Assurance organization, and to properly evaluate and procure materials and equipment to be used in safety-related structures, systems, and components. The action was based on the failure to adequately assure the quality of equipment and components purchased commercial grade for use in safety-related systems. The base civil penalty we.. increased by 50% based on the multiple examples of the violations. The licensee responded and paid the civil penalty on April 28, 1989. Public Service Electric and Gas Company, fiancocks Bridge, New Jersey (Salem Nuclear Generating Station Units I cod 2) Supplement I, EA 88-238 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued on April 21, 1989 based on a violation of the equipment qualification requirements of 10 CFR 50.49. The licensee responded and paid the civil penalty on May 22,1989. South Carolina Electric and Gas Company, Jenkinsville, South Carolina (V.C. Summer Nuclear Station) Supplement III, EA 88-305 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $62,500 was issued on March 2, 1989 to emphasize the need for adequate management and implementation of security requirements. The action was based on multiple significant failures to control access to the protected area of the plant.  ! Section I concerned general access control violations and ' Section II concerned an event in which a terminated employee was i allowed access to the site without fulfilling the authorization,  ; badging, or search requirements. The base civil penalty was mitigated by 75% in the first violation due to the licensee's identification of the violation nd the corrective action taken once it was identified. The licensee responded and paid the civil penalty on March 27, 1989. NUREG-0940 6

Toledo Edison Company, Toledo, Ohio (Davis-Besse Nuclear Power Station) Supplement I, EA 89-49

           / Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued April 21, 1989 tu emphasize the importance of operator attention and maintaining control of licensed activities in the Control Room. The action was based on a number of violations identified as the result of an               '

inspection following an improper reactor startup that occurred on December 18, 1988. The licensee responded and paid the civil penalty on May 22, 1989. Virginia Electric and Power Company, Glen Allen, Virginia (Surry Power Station) Supplement I, EA 88-296 A hotice of Violation and Proposed Imposition of Civil Penalties in the amount of $500,000 was issued May 18, 1989 to emphasize the significance the NRC places on the ability of this and other licensees to self-identify deficiencies, conduct appropriate evaluations, and institute prompt and adequate corrective action. The action was based the failure of the Unit I refueling cavity seal, design issues, and the failure to meet technical specification operability requirements for emergency service water pumps. The licensee responded and paid the civil penalties on June 14, 1989. Virginia Electric and Power Company, Glen Allen, Virginia (North Anna Power Station) Supplement I, EA 88-311 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued Apiil 21, 1989 to emphasize the need to take lasting, effective action to assure prompt identification and resolution of equipment deficiencies. The action was based on the licensee's failure to take corrective actions for identified deficiencies in the control room ventilation and it.strument air system. The base civil penalty was mitigated by 50% because of the extensive corrective actions taken by the licensee. The licensee responded and paid the civil penalty on May 22, 1989. B. Severity Level III Violation, No Civil Penalty Carclina Power and Light Company, Raleigh, North Carolina (H. B. Robinson Nuclear Plant) Supplement I, EA 89-02 A Notice of Violation was issued on April 6, 1989 based on the failure to perform an adequate analysis for electrical overcurrent on motor control centers which involved an initial plant design error and provide procedures appropriate for pressure testing the turbine generator which resulted in the introduction of hydrogen gas into portions of the station and instru m t air systems. A civil penalty was not proposed because it was identified by the licensee as a result of their Design Basis Reconstitution Program and immediate corrective action was taken. NUREG-0940 7

Nebraska Public Power District, Columbus, Nebraska (CooperNuclearStation) Supplements,EA89-56 A Notice of Violation was issued April 20, 1989 based on the failure to take adequate corrective action following a loss of control air 3 pressure for EDG No. 1 on January 17, 1989 due to a crack in a tube ' fitting. A civil penalty was'not proposed because of the licensee's prompt reporting of the diesel's failure and the immediate and extensive corrective actions. Tennessee Valley Authority, Chattanooga, Tennessee ' (Watts Bar Nuclear Plant) Supplement VII, EA 88-253 A Notice of Violation was issued October 21, 1988 based on statements by the licensee concerning internal reviews to support a position on compliance with Appendix B at Watts Bar. A civil penalty was not proposed. The licensee responded in a letter dated November 21, 1988 and a restatement of the NOV was issued June 5, 1989. Detroit Edison Company, Detroit, Michigan (Fermi 2) Supplements,EA89-06 A Notice of Violation was issued May 23, 1989 based on violations involving a failure to properly initiate and complete timely corrective action in response to concerns from the manufacturer's regarding recommendations for lubrication, maintenance, and main-tenance intervals for all AK type circuit breakers. A civil penalty was not proposed because an earlier penalty had been proposed for failure to implement timely corrective actions and as a result of that civil penalty the licensee had proposed broad corrective actions that should eliminate future problems of this type. II. MATERIALS LICENSEES A. Civil Penalties and Orders Advex Corporation, Hampton, Virginia Supplement IV, EA 88-315 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $2,000 was issued March 16, 1989 to emphasize the importance of the need to ensure implementation of effective controls of your licensed program. The action was based on the failure to control an individual's. occupational exposure 4 to less than 1.25 rems and failure to perform adequate surveys > which would have prevented the exposure. The licensee responded and paid the civil penalty on April 7,1989. 1 i Computerized Medical Imaging, Inc., Eau Claire, Wisconsin Supplements IV and VI, EA 89-14 A Notice of Violation and Proposed Imposition of Civil Penalty in I the amount of $2,500 was issued March 8, 1989 to emphasize the HUREG-0940 8 j

importance of ensuring that ir, the future the licensee will exercise greater control over all NRC licensed activities. The action was based on the failure to secure or maintain constant surveillance and immediate control of radioactive materials in an unrestricted area resulting in the theft of the material, failure to secure used generators stored in an unrestricted area, failure to properly evaluate personnel radiation doses, and failure to use lab coats or other protective clothing when handling radioactive material. The licensee responded and paid the civil penalty on April 4, 1989. Cornish Wireline Service, Inc., Chanute, Kansas Supplement VI, EA 89-15 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $500 was issued on May 5, 1989 to emphasize the importance of meeting all requirements associated with the safe use of radioactive materials and the importance of discontinuing the use of licensed materials when those requirements cannot be met. The action was based on the finding that the licensee willfully failed to provide personnel dosimetry to well-logging operators for a 19 month period. The licensee responded and paid the civil penalty on June 9, 1989. Department of the Arnty, Albuquerque, New Mexico Supplement VI, EA 88-172 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $1,000 was issued August 24, 1988 to emphasize the importance of ensuring that requirements essential to radiation safety are met and the importance of improving the oversight of licensed pr grams. The action was based on violations involving failure to 1) adequately secure one gauge against unauthorized removal,(2 utilize a Radiation Safety Officer not listed on the license and who had not received the requisite training, (3) conduct physical inventories of licensed material, (4) maintain records pertaining to the receipt of licensed material, (5) conduct leak tests of sealed sources of radioactive material, and (6) post copies of several necessary documents. The licensee responded on September 28 and November 10, 1988. After considering the licensee's responses, Violation I was withdrawn and the civil penalty associated with that violation was withdrawn in a letter dated April 7, 1989. Michael F. Dimun, M.D., Carnegie, Pennsylvania EA 89-52 An Order to Cease and Desist Use of Licensed Material, Effective Immediately was issued March 17, 1989. The action was based on the fact that Dr. Dimun's license expired without a request for timely renewal on February 28, 1987 and the licensee continued ' to possess a radioactive source containing strontium-90. Subsequently, t NUREG-0940 9

the source was transferred to an authorized recipient in accordance with the terms of the Order. General Electric Company, Wilmington, North Carolina Supplement VII. EA 88-302 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $20,000 was issued March 13, 1989 to emphasize that acts of discrimination against an employee who raises safety concerns or who communicates with the NRC will not be tolerated. The action was based on the improper transfer of an employee and subsequent termination due to the employee's participation in protected activities. The evidentiary basis for the improper conduct was a Recommended Decision and Order issued by an Administrative Law Judge from the Department of Labor. The licensee responded and paid the civil penalty on May 26, 1989. Anna Jaques Hospital, Newburyport, Massachusetts Supplements IV and VI, EA 89-48 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $1,250 was issued March 28, 1989 to emphasize the importance  ; of management, and in particular the RS0, continually maintaining ' adequate control over the radiation safety program. The action was based on failures to notify the NRC of a diagnostic misadministration, label certain syringes containing radiopharmaceuticals, perform required constancy, linearity and geometrical variation tests of the dose calibrator perform certain required surveys and maintain certain records of some of these activities. The base civil penalty was mitigated by 50% because of good past performance. The licensee responded and paid the civil penalty on April 27, 1989. Niagara of Wisconsin Paper Corporation, Niagara, Wisconsin  ! Supplement VI, EA 89-6b A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $750 was issued on May 31, 1989 to emphasize the importance of maintaining adequate control over gauges containing radioactive material. The action was based on two violations which involved failure to have licensed individuals perform the removal of a generally-licensed radioactive gauge from its installed location and transfer of a radioactive gauge to an unlicensed metal salvage yard. The base civil penalty was increased by 50% because the licensee's corrective actions were not timely. Thb licensee responded and paid the civil penalty on Jur.a 16, 1989. P&L Trucks, Inc., McAlester, Oklahoma EA 89-67 3 An Order to Show Cause why License Should not be Suspended and Revoked (Effective Immediately) was issued May 11, 1989 based on numerous violations which indicate that the licensee has made little or no effort to develop and maintain a program for l Nt! REG-0940 l 10 1 - - - - - - 1

I l ensuring compliance with the NRC license and regulations. The Order required the licensee to transfer all licensed material ( to an authorized recipient, and, thereafter, revoked the license. Pesara Pushpamala Reddy, M.D., Kittanning, Pennsylvania Supplement VI, EA 88-291 A hotice of Violation and Proposed Imposition of Civil Penalty in the amount of $1,500 was issued May 12, 1989 to emphasize the need for increasing and maintaining adequate management oversight of licensed activities to enstre that activities are conducted safely and in accordance with the terms of the license. The action was based on violations involving failure to: provide training, perform required package receipt surveys, perform dose calibrator constancy and linearity testing, perform sufficiently sensitive analysis on survey wipe samples, and provide notification of change in mailing address. The , base civil penalty was escalated by 200%: 50% due to NRC identification, 50% for corrective actions which were neither prompt nor comprehensive, and 100% for poor prior performance. The licensee responded and paid the civil penalty on May 31, 1989. James River Corporation, Richmond, Virginia , i Supplement IV, EA 89-62 A Notice of Violation and Proposed Imposition of Civil Penalty , in the amount of $1,250 and an Order Modifying License was I issued June 2,1989 to emphasize the need to ensure that adequate oversight and control of generally licensed material is maintained at all of the licensee's facilities throughout the country. The action was based on an incident in which a generally-licensed device containing 22.5 millicuries of americium-241 was inadvertently disposed of in a sanitary landfill. The Order requirec the licensee to conduct an audit and develop a corporate plan to ensure compliance with the terms of the general license. The licensee responded and paid the civil penalty on June 23, 1989. St. Agnes Medical Center, Philadelphia, Pennsylvania Supplement VI, EA 88-298 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $2,500 was issued February 2,1989 to emphasize the importance of increased and improved management attention to activities authorized by the license. The action was based on failure to perform required constancy tests prior to use of dose calibrator on two occasions, failure to perform three different types of required surveys, and use of the dose calibrator to assay patient doses for numerous days after a linearity test of the instrument indicated erroneous responses. The licensee responded on February 23, 1989, and after considering the response an Order Imposing a Civil Monetary Penalty was issued April 10, 1989. The licensee paid the civil penalty on May 5,1989. I NUREG-0940 11

St. Joseph's Hospital, Huntingburg, Indiana Supplements IV and VI, EA 89-20 A Notice of Violation and Proposed Imposition of Civil Penalty in the amoun+ of $2,500 was issued March 16, 1989 to emphasize the importance of en;; ring that in the future the licensee will exercise greater control over all NRC licensed activities. The action was based on numerous violations including use of licensed material by individuals not authorized, failure of the Radiation Safety Committee to meet and review the radiation safety program, failure to check and test the dose calibrator, failure to measure the ventilation rates in areas where radioactive gases are used, failure to perform surveys, failure to control licensed material in an unrestricted area, and failure to calibrate radiation survey instruments as required. The licensee responded and paid the civil penalty on April 12, 1989. Saturn Services, Inc., Tulsa, Oklahoma EA 89-07 An Order to Confirm Transfer of Regulated Material (Effective Immediately) was issued February 8,1989. The action was based on the findings of an inspection which determined that the licensee had been using, contrary to the licensee's commitments to NRC, its radioactive sources regularly in the conduct of gas and oil well logging without a valid NRC license. The Hospital Center at Orange, Orange, New Jersey Supplements IV and VI, EA 89-51 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $3,750 was issued April 5, 1989 to emphasize the need for increased management attention to the radiation safety program to assure that licensed activities are conducted safely and in accordance with the terms of the license. The action was based on a number of violations including: (1) failure to perform certain required surveys, (2) failure to maintain proper control and surveillance of certain unsecured materials, (3) failure to perform the required constancy, linearity and geometrical variation tests on a dose calibrator, and (4) failure by a technologist to wear appropriate protective clothing and devices while handling radioactive material. The i base civil penalty was increased by 50% because NRC identified the violations. The licensee responded and paid the civil penalty on April 28, 1989. i V.A. Medical Center, Loma Linda, California Supplements IV and VI, EA 88-39 A Notice of Violation hand Proposed Imposition of Civil Penalties in the amount of $6,500 was issued May 10, 1989 to emphasize the importance of complying with license and regulatory requirements. The action was based on violations involving failure to (1) evaluate radiation exposures, (2) perform annual refresher training, (3) perform various surveys, (4) evaluate dose calibrator results, NUREG-0940 12

i l and (5) review and renew research projects using licensed materials ) on an annual basis. The base civil penalty was increased by 100%  !' because of the licensee's poor prior performance. The licensee responded and paid the civil penalty on June 13, 1989. Jeffrey Weisman, M.D., Philadelphia, Pennsylvania Supplements IV and VI, EA 89-23 A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $1,250 was issued March 13, 1989 to emphasize the i need for maintaining continued management attention and oversight  ! of the radiation safety program to ensure that activities are conducted safely and in accordance with the terms of the license. The action was based on the failure of the Radiation Safety Officer to implement the radiation safety program, to provide training to individuals and to perform several instrument calibration checks. The base civil penalty was increased by 150%.because NRC identified the violations and prior notice. The licensee responded and paid the civil penalty on April 21, 1989. B. Severity Level III Violation, No Civil Penalty Allegheny General Hospital, Pittsburgh, Pennsylvania Supplements IV and VI, EA 89-89 A Notice of Violation was issued May 25, 1989 based on violations involving: (1) failure to properly label radiopharmaceuticals on two occasions, resulting in three diagnostic misadministration, (2) failure to properly secure licensed material stored in an J unrestricted area, (3) use of licensed material by a physician on a number of occasions without wearing the required ring dosimeter, and (4) use of material by an individual prior to being authorized for such use by the RSC. A civil penalty was not proposed because the violations which caused the misadmini-strations were identified by the licensee's staff and were reported to the NRC and the corrective actions were prompt and extensive. Alpena General Hospital, Alpena, Michigan Supplement VI, EA 89-97 A Notice of Violation was issued June 28, 1989 based on violations involving (1) ordering a therapy dosage of iodine-131 without a-written request from the physician who was going to perform the procedure, (2) failure of the Radiation Safety Committee to consistently meet at required intervals from 1984-1987,(3) failure ! to include a representative of the nursing service on the RSC, (4) failure to consistently test a Capintec CRC-12 dose calibrator for instrument linearity at required intervals during 1984 and 1987, and (5) failure to measure the thyroid burden of an individual who helped prepare and administer a therapy dosage of iodine-131. A civil penalty was not proposed because of prior good performance. NUREG-0940 13

Zacharia Mikroe, D. 0., Garden City, Michigan i Supplement VI, EA 89-24 A Notice of Violation and Termination of License was issued May 24, 1989 based on numerous violations indicative of a significant breakdown in control of licensed activities. The licensee requested termination of the license before NRC undertook further escalated ' enforcement action. Schlumberger Technology Corporation, Houston, Texas Supplements IV and VI, EA 89-84 A Notice of Violation was issued June 14, 1989 based on violations involving material inventory and control of licensed material. A civil penalty was not proposed because of the licensee's identification of the problem, prompt reporting, and prompt and extensive corrective actions. I NUREG-0940 14 l

1 I.A. REACTOR LICENSEES, CIVIL PENALTIES AND ORDERS 1 tlUREG-0940

jv#"% UNITED STATES jr , NUCLEAR REGULATORY COMMISSION , r, j REGION IV af 811 RYAN PLAZA DRIVE, SUITE 1000 l

          ,                               ARLINGTON, YEXAS 70011                                                                                                         !

MAR 2 129 Docket Nos. 50-313 and 50-368 License Nos. DPR-51 and NPF-6 EA 88-283

                                                                                                                                                                        ))

Arkansas Power & Light Company ATTN: Mr. Gene Campbell Vice President Nuclear Operations Post Office Box 551 Little Rock, Arkansas 72203 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY  ! (NRC INSPECTION REPORT'N05, 50-313 & 50-368/88-41 and 88-48) This is in reference to NRC inspections conducted on November 3-4 and November 29-30, 1988, at Arkansas Nuclear One (ANO) near Re.scilville, Arkansas, and to our discussions of these inspections with you and other Arkansas Power & Light Company (AP&L) officials during an enforcement conference in our Arlington, Texas offices en December 21, 1988. This correspondence also reflects NRC's review of your consultant's report on the magnitude of a radiation exposure to the skin of an individual. This report was received in our Arlington offices on January 17, 1989 and has been reviewed by Region IV and by staff of the Radiation Protection Branch of the Office of Nuclear Reactor Regulation. Both inspections followed reports from AP&L of apparent radiation exposures to individuals in excess of NRC limits. The results of these inspections, in which a number of apparent violations of NRC requirements were identified, were provided to you in NRC inspection reports dateo November 23 and December 14, 1988. An apparent violation identified in the December 14, 1988, report concerning exceeding liquid radioactive effluent release rate limits was discussed at a subsequent enforcement conference and will be dealt with in separate correspondence. These overexposure and the circumstances surrounding them were discussed in detail in the referenced inspection reports. Both of the events involved radiation exposures apparently resulting from " hot particles," extremely small CERTIFIED MAIL RETURN fiECEIPT REOUESTED NUREG-0940 I.A-1 ( __

Arkansas Power & Light Company MAR 2 ;ggg but highly radioactive particles which can impart a significant radiation dose to humans. The first event, which may have resulted from hot particles on the floor and a contaminated inspection cover gasket, occurred on November 2, 1988 1 and involved a maintenance worker in ANO Unit I who received a 3.2-rem exposure, i When added to the individual's previous exposure, this resulted in a 4.5-rem quarterly whole body exposure, a violation of NRC's 3-rem quarterly limit. The second event occurred on November 23, 1988 and involved a painter's helper picking up a hot particle on his clothing which resulted in an exposure to a small area of the skin calculated at 61 rems, significantly in excess of NRC's limit of 7.5 rems per quarter to the skin of the whole body. The violations in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) include: (1) an overexposure to an individual in excess of NRC's quarterly limits for radiation exposures to the whole body, (2) a failure to have conducted adequate surveys which could have prevented the whole body overexposure, (3) an overexposure to an individual in excess of HRC's quarterly limits for the skin, and (4) in relation to the skin exposure, a failure to have provided individuals adequate instructions. Although our inspection report dated November 23, 1988, identified inadequate instructions as being applicable to the whole body overexposure, we have withdrawn its applicability to that exposure based on our conclusion that the failure to have conducted adequate surveys was the roct cause of that overexposure, and, had adequate surveys been done, it is likely that workers would have been properly instructed. We have concluded, however, that a failure to provide adequate instruction is applicable to the violation involving the skin overexposure. The overexposure that occurred on November 2 and the failure to have conducted surveys adequate to detect the actual radiological conditions, which are the subject of Violations A.I. and A.2. in the Notice, are significant violations of NRC requirements. We recognize your efforts to equip workers with radiation detection dosimetry resulted in the detection of the overexposure. Nevertheless, we believe that AP&L's experience with hot particles, as well as AP&L's knowledge of the industry's experience, should have resulted in a radiation protection program that placed a far greater emphasis on the need to conduct thorough radiation and contamination surveys prior to and during work involving primary system components. We note also that this work followed efforts to loosen and remove by filtration radioactive corrosion products in the primary coolant system, an evolution that enhanced the possibility of activated corrosion products being trapped at the location where the work was being done. We find it significant that, based on all of the information available to you, you did not anticipate or expect to encounter hot particles in this type of work. In addition, this incident demonstrated a need for ensuring that potentially significant changes in radiological conditions are communicated to appropriate supervisory personnel. In this instance, the health physics technician who surveyed the area prior to the work beginning found what he thought to be markedly higher radiation levels than he expected. Although he took appropriate action in reducing the allowable stay times for the maintenance workers, he did not alert supervisory personnel to the changing l conditions. l NUREG-0940 I.A-2

Arkansas Power & Light Company g Although the second overexposure, Violation B.I. in the Notice, is considered less significant from a radiological perspective in that it resulted in an exposure to a small area of the skin as opposed to a whole body exposure, it too illustrated some weaknesses in your radiation protection practices in that had the instructions to these worhers been clear in regard to personnel monitoring requirements, it is likely that the hot particle would have been detected long before it was and would have resulted in an exposure of less magnitude. Thus, we have included Violation B.2. for failing to have provided clear instructions to these workers. Although we continue to view AP&L's radiation protection program as an aggressive and comprehensive program that is properly oriented toward maintaining radiation exposures as low as possible, we consider the occurrence of these events an indication of weaknesses that offer important lessons to be applied to your program for dealing with hot particles and your efforts to train radiation protection technicians to be sensitive to the need to involve supervisory personnel in crucial radiation protection matters. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), Violations A.I. and A.2. in the enclosed Notice have been classified collec-tively at Severity Level III. To emphasize the importance NRC places on assuring that adecuate radiological surveys are made to preclude radiation exposures in excess of regulatory limits, I have been authorized, after consultation with the Director, Office of Enforcement, end the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, to issue the enclosed in the amount Notice of of Twenty-Five Violation Thousand and Prop Dollars (osed

                                                    $25,000)      Imposition for the violationsof Civil Fenalty described in the enclosed Notice.

The base value of a civil penalty for a Severity Level III violation is $50,000. We evaluated the factors in the Enforcement Policy that may be considered in adjusting this amount and determined that an overall reduction of the base civil penalty of 50 percent is warranted. In arriving at this amount, your good past performance in the area of radiation protection, your identification, and your corrective action were balanced against your prior knowledge of hot particle problems both at AN0 and the industry in general. We believe the corrective actions you described during the enforcement conference will result in considerable improvement in your program for considering the possibility of and detecting hot particles so as to preclude a recurrence of these events. We encourage AP&L to thoroughly analyze these events and apply all of the lessons that may come from them, including those involving the adequacy of surveys and the actions of radiation protection technicians. You are required to respond to this letter and shou d follow the instructions specified in the enclosed Motice when preparing your response. In your response, you should document the specific actions taken and any additional NUREG-0940 I.A-3

Arkensas Power & Light Company 4- 9 3; ' 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 accordarte 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 Idanagement and Budget as required by the Paperwork Reduction Action of 1980, Pub. L. No. 96-511. Sincerely, A w fk Robert D. Martin di Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc: Arkansas Radiation Control Program Director NUREG-0940 I.A-4 1

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY

                                                                                                                                                                                                                                       }

Arkansas Power & Light Company Docket Nos.: 50-313 Arkansas Nuclear One (ANO) 50-368 License Nos: DPK-51 NPF-6 EA No.: 88-283 During NRC inspections conducted on November 3-4 and November 28-29, 1988, l violations of NRC requirements were identified. In accordance with the

         " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Consnission proposes to impose-a civil penalty pursuant to Section 234c 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. Violations Assessed A Civil Penalty _

1. 10 CFR 20.101(a) limits the whole body exposure of an individual in a restricted area to 1.25 rems per calendar quarter, except as provided by 10 CFR 20.101(b). 10 CFR 20.101(b) allows a whole body exposure of 3 rems per calendar quarter provided specified conditions  !

l are met. Ccntrary to the above, on November 2,1988, an individual working under the "B" steam generator at ANO, Unit 1, in a restricted area, received a whole body dose of 3.216 rems, resulting in a cumulative whole body dose for the cuarter of 4.546 rems.

2. 10 CFR 20.201(b) requires that each licensee make such surveys as (1) may be necessary to comply with the requirements of Part 20 and (2) are reasonable under the circumstances. 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 a specific set of conditions.

Contrary to the above, on November 2,1988, surveys performed by health physics technicians evaluating radiation hazards incident to the work being performed beneath the "B" steam generator at ANO, Unit 1, were not adequate in that they failed to identify radiation sources that resulted in en individual exceedino the quarterly whole bodyradiationexposurelimitsof10CFR20.101[b). These violations are considered collectively as a Severity Level III violation (SupplementIV). Cumulative Civil Penalty - $25,000 (assessed equally between the viola ticr.s) NUREG-0940 1.A-5

                                                                                     )

N2 g , Notice of Violation 1 B. Violations Not Assessed A Civil Penalty

1. 10 CFR 20.101(a) limits the exposure to the skin of the whole body. 4 of an individual in a restricted area to 71 rems per calendar, quarter.

Contrary to the above, on November 23, 1988, an individual wcrking around the main steam isolation valves, a restricted area, in ANO,. < Unit 1, received an exposure of 61 rems to the skin due to the . presence of a hot particle. J This is a Severity Level IV violation (Supplement IV).  !

2. 10 CFR 19.12 requires in part that all individuals working in or frequenting any portion of a restricted area be instructed in the' health protection problems associated with exposure to such ,

radioactive materials or radiation and in precautions or procedures to minimize exposure. Contrary to the above, an individual working near the main steam isolation valves, a restricted area (and receiving an overexposure to the skin), on November 23, 1988, was not properly instructed in the precautions to minimize exposure included on Radiation Work Permit 882154 and, therefore, did not exercise the proper measures of monitoring for possible contamination when exiting the area in < which he was working. This is a Severity Level IV violation (Supplement IV). Pursuant to the provisions of 10 CFR 2.201, Arkansas Power & Light 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 alleoed 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)thedatewhenfullcompliancewillbeachieved. If an j adequate reply is not received within the time specified in this Notice, an I order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the 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 may protest imposition of NUREG-0940 1.A-6

Notice of Violation D" T _3 the civil penalty in whole or in part by a writtee ammrer 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 i (2) demonstrate extenuating circumstances, (3) show error in this Notice, or i (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. l In requesting mitigation of the proposed penalt l Section V.B of 10 CFR Part 2, Appendix C (1988)y, thebesix factors addressed in should addressed. Any j 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 riay be referred to the Attorney General, and the penalty, unless l 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 , l Notice o. 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 Gb Dr Robert D. Martin Regional Administrator Dated at Arlington, Texas, this 2nd day of March 1989. NUREG-0940 I.A-7

• UNITED STATES

[# NUCtEAR REGULATORY COMMISSION

                                                  $            U                            REGION IV 011 RYAN PLAZA DRIVE SUITE 1000 ARUNGTON, TEXA8 78011
                                                      ,g APR -71989 Docket Nos. 50-313 & 50-368 License Nos. DPR-51 & NPF-6 EA No. 88-284 Arkansas Power & Light Company ATTN: Mr. Gene Campbell                                                          ;

Vice President, Nuclear Operations l Post Office Box 551 i Little Rock, Arkansas 72203  ! l i Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC ANO INSPECTION REPORT NOS. 88-35, 88-38, 88-42 AND 88-48) l This is in reference to several NRC inspections conducted at Arkansas Nuclear One (AN0) between October 24 and December 31, 1988, and to NRC's discussions with Arkansas Power and Light Company (AP&L) personnel at an enforcement conference in NRC Region IV's offices in Arlington, Texas on January 23, 1989. The reports of these inspections were issued on November 18, December 14, and December 22, 1988, and on January 18, 1989. The purpose of the enforcement conference was to address several apparent violations of NRC requirements discussed in these inspection reports and to address NRC's resultant concerns about the conduct of activities at ANO in three general areas: the promptness of AP&L's corrective actions once problems are identified; the adequary of AP&L's controls of safety-related equipment; and the adequacy of AP&L's measures to ensure safety systems meet design requirements. l NRC has reviewed all of the information in these inspection reports and the information provided by AP&L during and after the enforcement conference and is issuing the enclosed Notice of Violation and Proposed Imposition of Civil Pecalties(Notice). The violations in the enclosed Notice fall into two general problem areas: 1) violations which illustrate AP&L's failure to CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.A-8

APR -7191B Arkansas Power & Light Company -2 ' i initiate prompt corrective actions to resolve potential safety concerns; and j

2) violations which illustrate AP&L's failure to maintain adequate control of '

safety-related equipment. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions " 10 CFR Part 2, Appendix C, 53 Federal Register 40019 (October 13, 1988),(Enforcement Policy), these have been J aggregated into two Severity. Level III problems. In regard to the timeliness of AP&L's resolution of identified safety concerns, we have concluded that the number and significance of issues which were not promptly resolved are indicative of a programmatic breakdown. As discussed in detail in the referenced inspection reports, AP&L failed to resolve promptly issues involving: mechanical stresses on safety-related equipment, the operability of the containment penetration room ventilation system, the lack of stress analysis for a section of pipe in the penetration room ventilation l I system and the response times of various safety-related components. These were all matters that should have been resolved more promptly because each raised questions about whether components and systems would perform as intended to assure nuclear safety. The fact that AP&L ultimately determined these issues to have minimal impact on nuclear safety does not alter our view of the regulatory significance of failing to address these matters more promptly. In regard to AP&L's control of safety-related equipment, NRC considers AP&L's failure to ensure the operability of an emergency feedwater pump during a plant heatup, which is a violation of plant technical specifications, and AP&L's failure to assure the proper reassembly of valves associated with the ANO Unit 1 reactor coolant system to be significant issues. The event involving the feedwater pump occurred when ANO Unit 1 was heated up I to 515' F in late November 1988 with the steam-driven emergency feedwater pump l not coupled to its steam turbine, a violation of AN0's technical specifications requiring two emergency feedwater pumps to be operable when the plant is heated l above 280 F. AP&L's failure to properly reassemble valves led in one instance I to a reactor coolant system leak on December 16, 1988, when the packing material was blown out of a valve by reactor coolant system pressure and resulted in a leak rate of approximately 25 gallons per minute. Although AP&L took immediate and appropriate actions to correct these problems and minimize the impact on plant safety, they remain significant in that they appear to be symptomatic of a general decline in attention to safety-related activities at ANO. As you indicated at the enforcement conference, the sum of the ANO events discussed at this meeting may in part be attributed to an erosion of the degree to which administrative controls are strictly observed and an erosion of the degree to which individuals accept personal responsibility for their work. Clearly, AP&L must take steps to ensure that matters that may affect the safe ! operation of the plant are promptly resolved and must reinforce in its employees a sense of the importance of attention to procedures and details whtn plant safety is involved. We wish to emphasize, however, our interest in AP&L's commitment to thoroughly evaluate these events to understand their significance both individually and collectively and to firmly establish and correct the root causes. NRC considered whether enforcement measures in NUREG-0940 I.A-9

APR -7 1989 Arkansas Power & Light Company -3 ' addition to those being ttken were necessary to address the root cause or causes of these problems, but has elected to defer other actions pending the outcome of AP&L's evaluation and your commitment to have a review conducted by individuals associated with the Middle South system but outside the AP&L 1 organization. Nonetheless, to emphasize the importance of the prompt resolution of safety issues and the importance of controlling work activities so as not to result in a reduction of plant safety, I have been authorized after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of

 $175,000 for the violations described in the enclosed Notice.

The base value for each of the Severity Level III problems is $50,000. However, the civil penalty adjustment factors in the enforcement policy were considered and resulted in the following adjustments in the penalties. The j civil penalty for the corrective action violation in Section I of the Notice  ! was increased by 100 percent based on our consideration of the prior notice and past performance factors. Specifically, this problem was identified during NRC inspections in late 1987, and led to a management meeting with AP&L. In addition, AP&L's failure to take prompt corrective actions to resolve the issue of high temperatures in the containment building resulted in a previous violation and in a proposed $100,000 civil penalty which was issued in March , 1988. The civil penalty for the violations in Section II of the Notice was ' increased by 50 percent because two of these violations were discovered by an NRC inspector and reasonably should have been identified earlier by the plant staff. No other adjustments were deemed appropriate. NRC appreciates the candor displayed by AP&L during the January 23 enforcement conference. We also anticipate that the corrective actions you outlined then, in addition to those you may undertake as a result of your continuing review of these issues, will result in both improved attention to detail by your staff and in enhancing the safe operation of the ANO plants. As a result of the information presented at the enforcement conference, we are not issuing a citation for the issue involving the loss of decay heat removal as it meets the criteria for a non cited violation. We also are not issuing citations for the two design control issues discussed because both--one involving the penetration room ventilation system and one involving the decay heat removal system--are encompassed by Violations I.A through I.D in the Notice. The remaining issues discussed at the enforcement conference involving the misaligned valve during integrated leak rate testing of the containment and a liquid discharge in excess of your technical specification limits will be addressed in separate correspondence. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice wnen 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 l NUREG-0940 I.A-10

                                                                        & - i 1989 Arkansas Power & Light Company         -4 '

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 i to the clearance procedures of the Office of Management and Budget as required l by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Sincerely, j / c5ert D Aw u -

                                     ,      - Regional Adnjinirdrator              ,

1

Enclosure:

l Notice of Violation and Proposed Imposition of Civil Penalties ( cc: Arkansas Radiation Control Program Director j I I I r NUREG-0940 1.A-11

APR -7195 NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES Arkansas Power & Light Com Dockets: 50-313; 50-368 Arkansas Nuclear One (ANO)pany Licenses: DPR-51; NPF-6 EA 88-284 During NRC inspections conducted October 24 through November 30, October 30 through November 4, November 28-29, and December 1-31, 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 53 Federal Register 40019 (October 13,1988), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2282, and 10 CFR Part 2.205. The particular violations and associated civil penalties are set forth below: I. Violation Involving Failure to Take Prompt Corrective Action Criterion XVI of Appendix B to 10 CFR Part 50 requires in part that conditions adverse to quality, such as failures, malfunctions, deficien-cies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. Contrary to the above, AP&L failed to promptly correct identified conditions adverse to quality as evidenced by the following: A. Licensee Memorandum NDC-10313 dated January 8, 1982, identified that certain calculated equipment nozzle loads exceeded design and/or vendor-allowable loads. For example, the calculated load on the decay heat removal pu:np suction nozzle was 14,870 f t-lbs versus an allowable of 3,800 ft-lbs. A report for a nozzle-load study performed by Bechtel was issued to AP&L on December 31, 1985. This report again identified equipment nozzle loads which exceeded vendor-allowable loads in 22 cases and Bechtel Power Corporation-allowable loads in seven cases. Corrective action for this matter was not prompt in that the identified deviations from allowable equipment nozzle loads were not resolved until November 1988.

8. Report of Abnormal Condition (RAC) 2-88017 issued by the licensee on February 3, 1988, documented a problem with Unit 2 engineered safety features (ESF) response time testing methodology. Procedure 2305.03,

                                          " Engineered Safety Features System Response Time Test," did not measure or account for the time required for ESF actuated pumps or fans to accelerate and develop required discharge pressure or air flow. The discrepancy in the test method applied to the previous ESF response time tests for high pressure safety injection pumps, low pressure safety injection pumps, containment spray pumps, emergency feedwater pumps, and containment cooling fans. Corrective action for this identified condition was not prompt in that testing of components and comparison with Technical Specification (TS) requirements was not completed until October 27, 1988.                                        i NUREG-0940                               I.A-12                                      ;

APR -71989 Notice of Violation -2 , C. Concerns with performance of the Unit 1 penetration room ventilation system were identified by an NRC inspector and documented as an unresolved item in NRC Inspection Report 50-313/87-18; 50-368/87-18 issued on July 16, 1987. These concerns related to the ability of the system to produce a vacuum in and draw air from each of the six penetration rooms in accordance with the system design. Licensee test data indicated that vacuum in the penetration rooms was significantly less than the low vacuum alarm setpoint during system operation. Corrective action to verify that this system would perform as designed was not prompt in that system performance was not verified until November 1988. D. Condition Report (CR) 1-88-0122 initiated by the licensee on August 5, 1 1988, identified a deficiency in that there were no existing stress calculations for certain piping containing Valves CV-2123, CV-2126, CV-2133, and CV-2136 in the Unit 1 penetration room ventilation system. The CR stated that operability of the system during a seismic event could not be shown by the existing qualifying calculations since the weights of the valves were not included in the analyses. Corrective action for this issue was not prompt in that the deficiency was not scheduled to be resolved prior to the plant entering an operational condition where this system was required to be operable. The assigned action had a due date of December 1, 1988, but the plant was scheduled to restart from a refueling outage in November 1988. This is a Severity Level III violation. Civil Penalty - $100,000 II. Violations Involving Inadeouate Control of Safety-related Equipment Status A. Violation of Technical Specifications TS Section 3.4.1 states that the reactor shall not be heated above 280 F unless both emergency feedwater (EFW) pumps and their flow paths are operable. Contrary to the above, on November 24, 1988, Unit I was heated above 280*F with the P7A turbine driven emergency feedwater pump inoperable because it was not coupled to its turbine driver.

8. Violation of 10 CFR Part 50, Appendix B, Criterion XIV Criterion XIV of Appendix B to 10 CFR Part 50 requires that measures shall be established for indicating the operating status of systems of the nuclear power plant, such as by tagging valves and switches, to prevent inadvertent operation.

I NUREG-0940 I.A-13

l APR -7 m Notice of Violation -3, i Contrary to the above, on November 28, 1988, it was found that messeres were not established to prevent inadvertent operation of the uncoupled P7A turbine driven emergency feedwater pump. The system was aligned for automatic initiation and inadvertent operation was I possible for a period of up to 4 days, creating the potential for equipment damage or personnel injury. C. Violations of 10 CFR Part 50, Appendix B, Criterion V Criterion V of Appendix B to 10 CFR Part 50 requfres that activities  ! affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, " i procedures, or drawings.

1. Contrary to the above, on December 16, 1988, with Unit 1 in hot standby, appropriate work instructions were not implemented for a seal weld repair of Valve MU-45C. After repairing thic manual high pressure safety injection valve, the valve was reopened before the packing glard studs were reinstalled, resulting in an approximate 25 gpm high pressure reactor coolant system leak.

2. Contrary to the above, on December 16, 1988, the licensee )

discovered that previous maintenance work on high pressure safety injection manual isolation valve MU-45D had been { performed without implementation of appropriate work instructions. This led to the improper reassembly of the valve in that the yoke was only partially threaded (three threads) into the valve body, creating the potential for a failure of i this yoke and an unisolable reactor coolant system leak. The above violations are considered collectively as a Severity Level III 1 I problem (Supplement 1). Civil Penalty - $75,000. (Assessed equally among the violations) Pursuant to the provisions of 10 CFR 2.201, Arkansas Power & Light Company l (Licensee) is hereby required to submit a written statement or explanation to ] { the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, within 1 30 days of the date of this Notice. This reply should be clearly marked as a l

 " Reply to a Notice of Violation" and should include for each alleged violation:                      1 (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved (4) the corrective steps that will be taken to avoid further violations,and(5)thedatewhenfullcompliancewillbeachieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be l

ta ken. Consideration may be given to extending the response time for good i 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-14

APR -7 ;989 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 i 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 4 the cumulative amount of the civil penalties proposed above or may protest imposition of the civil penalties in whole or in part by a written answer  : addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory l l 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 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 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., 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. 1 Upon failure to pay any civil penalty due which subsequently has been determined l in accordance with the applicable provisions of 10 CFR 2.205, this matter may I be referred to the Attorney General, and the penalty, unless compromised, l remitted, or mitigated, may be collected by civil action pursuant to Section l 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, 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 Arkansas Nuclear One. FOR THE NUCLEAR REGULATORY COMMISSION

hklD. M p&

j obert j Regional Admin 1str or Dated at Arlington, Texas, This 7th day of April 1989. NUREG-0940 I.A-15

e UNITED STATES j

                                             /                                NUCLEAR REGULATORY COMMISSION                                                     4 j*             j                                     REGION i r                               475 ALLENDALE ROAD KING OF PRUS$tA, PENNSYLVANIA 19406
                                                 *"**                                     April 28, 1988 Docket Nos. 50-317; 50-318 License Nos. OPR-53; DPR-69 EA 87-77 Baltimore Gas and Electric Compary ATTN: Mr. J. A. Tiernan Vice President                                                                                       i Nuclear Energy                                                                                       1 Post Office Box 1475                                                                                          l Baltimore, Maryland 21203                                                                                      I Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS N05. 50-317/87-07; 50-318/87-08) This refers to the NRC inspection conducted on March 23-27, 1987 to review the l program for the environmental qualification (EQ) of equipment at Calvert Cliffs, ! Units 1 and 2. The inspection report was sent to you on April 28, 1987. During l the inspection, violations of NRC requirements were identified involving the lack of qualification of certain items of electric equipment used in both units. i On May 13, 1987, an enforcement conference was conducted with you and members of

your staff to discuss the extent of the violations known at that time (as your review was continuing), the causes of the violation, and the corrective actions taken or planned.

The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), included the failure to include, on the list of electric equipment important to safety, certain equipment whose failure under postulated environmental conditions could prevent satisfactory I accomplishment of safety functions; and the failure to maintain, for certain i items of electric equipment, a complete file of documentation to demonstrate that the items were qualified to perform their intended function (s) during the postulated environmental conditions. One of these items identified by the NRC included the use of unqualified tape splices on the electrical leads of the l Auxiliary Feedwater System solenoid operated blocking valves at both units. j After you performed an additional evaluation subsequent to the NRC inspection and found additional unqualified items, you shut down Unit 1 on April 1,1987 (Unit 2 was shut down at the time) to conduct an extensive review of the EQ program. During this review, your staff determined that these unqualified tape splices were used in several other areas at Calvert Cliffs, and also determir.ed that other unqualified electrical components were used extensively in many systems and affected many components, including heat shrink splices, terminal blocks, relays, T-drains, a coil, and handswitches. CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 1.A-16

l Baltimore Gas and Electric Company 2 These deficiencies clearly should have been known to you, particularly in the case of tape splices, since it was reasonable to expect that a licensee would (1) assure that these connections would be included on the master EQ list, and (2) perform field verification for electrical equipment which should have included these connections. Tape splices are able to be qualified only under specific installation procedures and for specific tape materials, whereas the tape splices utilized at Calvert Cliffs consisted of several wraps of standard electrical tape. With respect to other unqualified components, you clearly should have known that qualification was incomplete in light of the nature of the items, the systems involved, previous guidance provided by the NRC (i.e., IE Bulletins, Circulars, and Information Notices), and problems identified during NRC inspections in 1984 and 1985. Although these prior problems included findings related to the lack of adequate documentation to support qualification of certain electrical equipment, effective corrective actions were not taken at that time. If adequate field verifications and qualification file reviews had been performed, these EQ deficiencies would have been identified earlier. The violations described in this Notice demonstrate that Baltimore Gas and Electric Company's management did not provide adequate attention to the EQ program at Calvert Cliffs in that the engineering department responsible for establishing and implementing the EQ program did not clea.rly communicate to craft personnel in the field the guidelines for installing and maintaining electrical equipment to ensure that they were environmentally qualified. In addition, the lines of responsibility for personnel involved in establishing, implementing, and monitoring these EQ activities were not clearly defined, and the Quality Assurance Department oversight of EQ program implementation was not adequate. Furthermore, a deficiency concerning the use of unqualified tape splices was identified by your staff in December 1986 during a review of slow stroke times for certain solenoid valves; however, an extensive evaluation was not performed at that time and the extent of the problem was not recognized. The failure to identify unqualified tape splices, at that time, represented another example of the NRC concern expressed during previous SALP evaluations that your staff was, at times, slow to recognize the existence of potential safety issues and was not always effective in reviewing, evaluating, and resolving potential safety problems, including their underlying deficiencies. This concern was also conveyed in a Notice of Violation and Proposed Imposition of Civil Penalties issued to Baltimore Gas and Electric Company on September 26, 1985 for failure to aggressively iden-tify and correct deficiencies that existed in the Post Accident Sampling System at Calvert Cliffs. While progress has been made to improve your process for identifying, evalua-ting, and resolving safety issues, to emphasize the icgrtance of (1) lasting management attention to, and control of, the EQ program, and (2) aggressive management action to ensure that problems are promptly identified and corrected, I have been authorized, after consultation with the Commission and the Deputy Executive Director for Regional Operations, to issue the Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) in the amount NUREG-0940 1.A-17

Baltimore Gas and Electric Company 3 of Three Hundred Thousand Dollars ($300,000) for the violations described in the enclosed Notice. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49," contained in Generic Letter 88-07 (Enclosure 2), the violations described in the enclosed Notice have been determined to be extensive and to have affected many systems and components, and therefore are considered to be an EQ Category A problem. The. base value of a civil penalty for an EQ Category A problem is $300,000. In determining the civil penalty amount, the NRC considered the foer factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49", for escalation and mitigation of the base civil penalty amount. These factors consist of (1) identification and prompt reporting of the EQ deficiencies (150%); (2) best efforts to complete EQ within the deadline ( 50%); (3) corrective actions to result in full compliance ( 50%); and (4) duration of a violation which is significantly below 100 days (-50%). With respect to the first factor, even though the majority of items were identified by your staff, only 25% mitigation is warranted since you had an opportunity in December J986 to identify these deficiencies, but they were not identified until after the NRC inspection in March 1987. With respect to the second factor, 50% escalation is warranted since best efforts were not applied to complete EQ within the deadline, and the NRC had previously identified problems in this area. With respect to the th,ird factor, only 25% mitigation is warranted, even though extensive corrective actions were taken after NRC identification of the tape splice violation in March 1987, since those actions should have been taken in December 1986. With respect to the fourth factor, mitigation is inappropriate since these EQ violations existed in excess of 100 days. Therefore, on balance, no adjustment to the base civil penalty amount is 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. 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. NUREG-0940 I.A-18

I l Baltimore Gas and Electric Company 4 The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget, otherwise required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Sincerely, William T. Russell ( Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Generic Letter 88-07 cc w/encis: See Next Page l

l l NUREG-0940 1.A-19

Enclosure 1 NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Baltimore Gas and Electric Company Docket Nos. 50-317; 50-318 Calvert Cliffs, Units 1 and 2 y cense Nos. DPR-53; DPR-69 EA 87-77 During an NRC inspection conducted on March 23-27, 1987 of the licensee's program for environmental qualification (EQ) of equipment, violations of NRC requirements were identified. In accordance with the " Modified Enforcement Policy Relating to 10 CTR 50.49, Environmental Qualification of Electrical Equioment Important to Safety of Nuclear Power Plants," contained in Generic Lettu 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursua-nt 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 50.49(d), (f), and (j), respectively, require, that (1) a list of electric equipment important to safety be prepared, and information concerning performance specifications, electrical characteristics and postulated environmental conditions for this equipment be maintained in a qualification file; (2) each item of electric equipment important to safety shall be qualified by testing and/or atalysis of identical or similar equipment, and the qualification based on similarity shall include a supporting analysis to show that the equipment to be qualified is acceptable; and (3) a record of the qualification shall be maintained in an auditable form to permit verification that each item of electrical equipment important to safety is qualified and that the equipment meets the specified performance requirements under postulated environmental conditions. i l Contrary to the above, as of March 27, 1987, certain environmental qualification files did not include the required documentation to demonstrate environmental qualification, or the listing of electrical  ; equipment important to safety was found not to be complete. Examples of each violation include:

1. Tape splices, an item of electric equipment important to safety, were installed on Unit I and 2 components in various safety i systems, including solenoid blocking valves, 4 KV motor terminations, 480 V motor splices, and 120 V control and instrument splices.

These tape splices were made using standard electrical tape and neither test data nor analysis existed in a qualification file to demonstrate qualification of these splices. This condition existed since at least November 30, 1985. NUREG-0940 I.A-20

2 i

2. Numercus other items of electric equipment important to safety were installed at both units but were not included on the list of electric equipment important to safety, and did not have a record file to '

demonstrate qualification. This condition existed since at least " l November 30,19fs5 and the items included: (1) unqualified heat l shrink assemblies (Raychem and Ideal); (2) unqualified terminal blocks (Buchanan 100, GE CR151, and unidentified phenolic-type); (3) unqualified relays (Square D, Struthers Dunn, and Telemechanique); i (4) weepholes in electrical junction boxes absent or not in the proper l l orientation; (5) T-drains in motor operated valves not installed; I (6) an unqualified coil; and (7) unqualified handswitches. These violations constitute an EQ category A problem. Civil Penalty - 5300,000 (These EQ violations existed in excess of 100 days of-plant operation). Pursuant to the provisions of 10 CFR 2.201, Baltimore Gas and Electric Company (Licensee) is hereby required to submit a written statement of explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a

                  " Reply to a Notice of Violation" and should include for each alleged violation:                                                                                                    l (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance was or will be achieved. If an adequate reply is not received within the time specified in this Not'.ce, 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 Direcur, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil pena'lty 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. NUREG-0940 I.A-21

l l 3 In requesting mitigation of the proposed penalty, the mitigation factors in the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power i Plants," contained in Generic Letter 88-07, should be addressed. Any written ' answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure 1 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 h the Attorney General, and the penalty, unless I 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 4 Notice of Violation) should be. addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, a copy to the Regional Administrator, U. S. Nuclear Regulatory Commission, 475 Allendale Road, King of Prussia, PA, 19406 and a copy to the NRC Resident inspector, Calvert Cliffs. FOR THE NUCLEAR REGULATORY COMMISSION

                                        *&         == J William T. Russell Regional Administrator                     i Dated aj King of Prussia, Pennsylvania this 25 day of April 1988.

1 i NUREG-0940 I.A-22

uq [ p na jo 'g UNITED STATES g 'f y, g NUCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20555 E

 $           q
   .....*                               NAR 201939 Docket Nos. 50-317 and 50-318 License Nos. DPR-53 and DPR-69 EA 87-77 Baltimore Gas and Electric Company ATTN: Mr. G. C. Creel                                                               i Vice President Nuclear Energy Post Office Box 1475 Baltimore, Marylend 21203 Gentlemen:

SUBJECT:

ORDER IMPOSING A CIVIL MONETARY PENALTY i l This letter refers to your two letters, dated July 12 and 18,1988, in response l to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you with our letter dated April 28, 1988. Our letter and Notice described violations of equipment qualification (EQ) requirements identified during i en NRC inspection conducted on March 23 -27, 1987. In accordance with the  ;

        " Modified Enforcement Policy Relation to 10 CFR 50.49" contained in NRC Generic Letter 88-07, the violations were classified as an EQ Category A problem and a civil penalty in the amount of $300,000 was proposed to emphasize the importance of (1) lasting management attention to, and control of, the EQ program, and (2) aggressive management action to ensure that problems dre promptly ioentified and correctec.

In your responses to the Notice, you admit the occurrence of the cited violations. However, you state that the violations were not significant, and the severity of this EQ problem was not appropriately classified by the NRC. Further, you request full or partial mitigation of the civil penalty for reasons described in your responses. Af ter careful consideration of your responses, we have concluded, for the reasons given in the Appendix attached to the enclosed Order Imposing a Civil Monetary Penalty, that the violations occurred as stated in the Notice and were appropriately categorized as an EQ Category A problem, and a'ny mitigation of the civil penalty amount is inappro-priate. Accordingly, we hereby serve the enclosed Order on Baltimore Gas and Electric Company imposing a civil monetary penalty in the amount of Three Hundred Thousand Dollars. You are required to respond to the enclosed Order, end you should follow the instructions specified therein when preparing your response. The responses directed by this letter and the enclosed 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. NUREG-0940 1.A-23

Baltimore Gas and Electric Company 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 Document Room. Sincerely, Hu MA L. Thompso , J y Executive Director for D Nuclear Materials Safety, Safeguards and Support Operations

Enclosures:

1. Order Imposing A Civil Monetary Penalty

2. Appendix - Evaluation and Conclusion cc w/encls:

M. Bowman, General Supervisor, Technical Services Engineering T. Magette, Administrator, Nuclear Evaluations Public Document Room (PDR) local Public Document Room.(LPDR) Nuclear Safety Information Center (NSIC) hRC Resident Inspector State of Maryland (2) I NUREG-0940 I.A-24

UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket Nos. 50-317 and 50-318 License Nos. DPR-53 and DPR-69 Baltimore Gas and Electric Company l EA 87-77 Calvert Cliffs, Units 1 and 2 ) ORDER IMPOSING CIVIL MONETARY PENALTY l 5 l Baltimore Gas and Electric Company, Baltimore, Maryland (the " licensee") is the holder of License Nos. DPR-53 and DPR-69 (the " licenses") issued by the Nuclear Regulatory Comission (the "Comission" or "NRC") which authorizes the opera-tion of the Calvert Cliff's nuclear reactors in Lusby, Maryland. , II An NRC safety inspection of the licensee's activities under the license was conducted on March 23-27, 1987. During the inspection, the NRC staff determined 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 dateo April 28, 1988. The Notice states the nature of the violations, the provisions of the Nuclear Regulatory Comission's requirements that the licensee had violated, and the civil penalty amount for the violations. Two responses, dateo July 12 and July 18, 1988, to the Notice of Violation and Proposed Imposition of Civil Penalty, were received from the licensee. In its response, the licensee admits the violations, but requested reduction of the severity level of the violations and full or partial mitigation of the civil penalty. NUREG-0940 I.A-25

III Upon consideration of the responses received, the statements of fact, explanations, and arguments for remission or mitigation of the proposed civil penalty contained therein, and as set forth in the Appendix to this Order, the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Support Operations has determined that the penalty proposed for the violations 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 1954, as amended (42 U.S.C. 2282, PL 96-295), and 10 CFR 2.205, IT IS HEREBY ORDERED THAT: The licensee pay a ctvil penalty in the amount of Three Hundred Thousand Dollars ($300,000) within thirty days of the date or this Order, by check, draft, or money order, payable to the Treasurer of the United States and mailed to the U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. 20555. V The licensee may, within thirty days of the date of this order, request a hearing. A request for a hearing shall be clearly marked ds a request for hearing and shall be addressed to the U.S. Nuclear Regulatory Comission, Document Control Desk, Washington, D.C., with a copy to the Regional Administrator, Region I. NUREG-0940 1.A-26

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 thirty days of this Order, the provisions of this Order shallbeeffectivewithoutfurtherproceedings. 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, on the basis of the violations confirmed by the licensee in its July 12 and July 18, 1988 responses, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION l / / H

                                       /        . av L. Thompson Jr.        ,

puty Executive Director for Nuclear Materials Safety, Safeguards and Support Operations Dated at Rockville, Maryland this & % day of March 1989 i NUREG-0940 I.A-27

                                                                                   )

APPENDIX l EVALUATION AND CONCLUSION i On April 28, 1988, a Notice of Violation and Proposed Imposition of Civil 1 1 Perialty (Notice) was issued to Baltimore Gas and Electric Company (licensee) for violations that occurred at Calvert Cliffs. The licensee responded to the Notice by two letters, dated July 12 and July 18, 1988, and admits the violations, but requested reduction of the severity level of the violations and full or partial mitigation of the civil penalty. The NRC's evaluation and conclusion regarding the licensee's responses are as follows: , i u i I. Restatement of Violations 10 CFR 50.49(d), (f), and (j), respectively, require, that (1) a list of electric equipment important to safety be prepared, and information concerning performance specifications, electrical characteristics and postulated environmental conditions for this equipment be maintained in a qualification file; (2) each item of electric equipment important to safety shall be qualified by testing and/or analysis of identical or

                                                                             ~

similar equipment, and the qualification based on similarity shall include a supporting analysis to show that the equipment to be qualified is acceptable; and (3) a record of the qualification shall be maintained in an auditable form to permit verification that the electrical equipment important to safety is qualified and that the equipment meets the j specified performance requirements under postulated environmental I conditions. Contrary to the above, as of March 27, 1987, certain environmental qualification files did not include the required documentation to demonstrate environmental qualification, or the listing of electrical equipment important to safety was found not to be complete. Examples of each violation include:

1. {

Tape splices, an item of electric equipment important to safety, were installed on Unit I and 2 components in various safety systems, including solenoid blocking valves, 4 KV motor terminations, 480 V motor splices, and 120 V control and instrument splices. These tape splices were made using standard electrical tape and neither test data nor analysis existed in a qualification file to demonstrate  ; qualification of these splices. This condition existed since at  ! least Novenber 30, 1985.

2. Numerous other items of electric equipment important to safety were installed at both units but were not included on the list of electric equipment important to safety, and did not have a record file to demonstrate qualification. This condition existed since at least November 30, 1985 and the items included: (1) unqualified heat shrink assemblies (Raychem and Ideal); (2) unqualified terminal blocks (Buchanan 100, GE CR151, and unidentified phenolic-type);

(3) unqualified relays (Square D, Struthers Dunn, and Telemechanique); (4) weepholes in electrical junction boxes absent or not in the proper orientation; (5) T-drains in notor operated valves not installed; (6) an unqualified coil; and (7) unqualified hand switches. NUREG-0940 1.A-28

Appendix These violations constitute an EQ category A problem. Civil Penalty - $300,,000 (These EQ violations existed in excess of 100 days of plant opuation). II. Sumary of Licensee Response The licensee, in its responses, admits the occurrence of the violations. l However, the licensee contends that the NRC must first find, under the Modified Enforcement Policy Relating to 10 CFR 50.49 (Modified' EQ Enforce- , ment Policy) which was attached to Generic Letter 88-07, that a violation l 1s safety significant before issuing a civil penalty. The licensee states that the NRC did not, in the April 28, 1988 letter and Notice, address this issue and submits that none of the violations were safety significant. In support of its argument, the licensee indicates that (1) both units were i shutdown for two months, and before restarted, all EQ items were found to I be operable, qualified or qualifiable; (2) it is inappropriate for the NRC not to consider the operability of equipment in determining safety signi-ficance and civil penalty assessment, i.e., it is inappropriate to assume ' that the unqualified equipment is inoperable; and (3) these violations were simply documentation violations, most of which were identified by the licensee after the NRC inspection and corrected prior to startup, and therefore, should be classified at Severity Level IV as would any NRC-identified EQ finding that is corrected by the licensee prior to completion ) of the inspection, or shortly thereafter.  ; The licensee also claims that any NRC enforcement action must conform to 10 CFR Part 2, Appendix C, and that, should application of the Modified EQ Enforcement Policy result in civil penalties that would be inappropriate under 10 CFR Part 2, Appendix C, the penalties cannot stand. The licensee indicates that the importance of safety significance for purposes of NRC enforcement is one of the key elements of 10 CFR Part 2, Appendix C, and, i since the proposed civil penalties have not, in the licensee's judgment, considered the safety significance of the violation, the civil penalties are inappropriate. , The licensee also requests that, if the NRC makes the determination that irrposition of a civil penalty is appropriate, in accordance with the Podified EQ Enforcement Policy, the penalty should be substantially mitigated since (1) the licensee contends that the deficiencies at Calvert Cliffs constitute at most a Category C EQ problem, (2) if fairness and equity among licensee's is to be achieved, there should be comparability between the civil penalties assessed under 10 CFR Part 2, Appendix C and the Modified EQ Enforcement Policy, and (3) the NRC should have allowed the full 50% mitigation for the licensee's corrective actions rather than the 25% allowed. III. NRC Evaluation of Licensee Response I With regard to the licensee's arguments concerning the safety significance of the violations and the categorization of the violations as a Category A . problem, the NRC, under the Modified EQ enforcement Policy, considers ' violations of EQ requirements to be safety significant because the electrical equipment required to be qualified are those which are important to safety. , This is a case in which it appears that components were properly categorized l NUREG-0940 1.A-29 I

i i Appendix as important to safety. If a licensee cannot demonstrate that such a component is qualified, for enforcement purposes, a significant violation has occurred. The only exceptions include those cases in which a docu-mentation deficiency is essentially one of a minor nature which is readily correctable based on existing knowledge, tests, or analyses. These would then be considered at a Severity Level IV or V. In this case, the licensee failed to have sufficient documentation, including adequate analyses, in qualification files prior to November 30, 1985, to support the environ-mental qualification of equipment important to safety affecting many systems and components. The NRC recognizes that most of the items were qualified or found to be qualifiable and corrected prior to startup. However, as set out in the Modified EQ Enforcement Policy, the NRC will assume, for enforcement purposes, that equipment whose qualification cannot be demonstrated could affect . operability of the associated system. Furthermore, the items did not constitute simple documentation problems. Some of these components were replaced prior to startup. In addition, substantive engineering analyses were performed by the licensee during the shutdown, or would have l been required to be performed to support qualification for those items which were replaced, and these reanalyses could not have been done within  ; the period of an NRC inspection. Minor documentation deficiencies which can be corrected within a short period of time are considered by the NRC staff to be of lesser significance (Severity Level IV or Y violations) whether or not identified during an inspection. Because substantive i analyses were needed or would have been necessary had equipment not been ' replaced, the violations here are not appropriate for Severity Level IV or V classification. Furthermore, since these deficiencies affected many systems and components, the deficiencies constituted a Category A problem and the imposition of a civil penalty is clearly proper under the Modified EQ Enforcement Policy. With respect to the licensee's arguments concerning the legality of I issuance of civil penalties in accordance with the Modified EQ Enforce-l ment Policy, the NRC rejects the licensee's claim that this action must conform with 10 CFR Part 2, Appendix C. 10 CFR Part 2, Appendix C, is a Statement of Policy and not a regulation. It was not promulgated in accordance with rule making procedures. As a Statement of Policy, it is the Commission's statement as to how it generally intends to approach enforcement of its requirements. In accordance with 10 CFR Part 2, Appendix C, the Comission may deviate from this guidance in circumstances when it is considered warranted. The Commission established a special EQ enforcement policy (initially in August 1985 and modified in April 1988) because a departure from this guidance is warranted in the context of EQ to emphasize that, when the deadline for equipment qualification was esta-blished, the Commission expected it to be met. The April 1988 Modified l EQ Enforcement Policy describes how the NRC will exercise its enforcement l authority for licensees who did not comply with the EQ rule as of November 30, 1985. NUREG-0940 I.A-30

{ Appendix With respect to the licensee's argument that the civil penalties under l 10 CFR Part 2, Appendix C, and the Modified EQ Enforcement Policy should be ' comparable, the staff notes that the Commission established a special EQ enforcement policy because of the delays by licensees in achieving compliance with the requirements of 50.49. The purpose of this special policy was to send a message to all licensees that the Commission would issue significant civil penalties for licensees who had a clear opportunity but who failed to meet EQ requirements as of November 30, 1985. The Commission determined that these special circumstances requiced a different approach to enforce-ment than that specified by 10 CFR Part 2, Appendix C, and it exercised its discretion in accordance with 10 CFR Part 2, Appendix C, and Section 234 of the Atomic Energy Act of 1954, as amended, to create and implement a special enforcement policy for violations of EQ requirements in such circumstances. With respect to the licensee's request for mitigation of the civil penalty, the NRC's escalation and mitigation factors set forth in the Modified EQ Enforcement Policy include (1) identification and reporting (Factor 1); (2) best efforts to complete the requirements within the deadline (Factor 2); (3) corrective actions (Factor 3); and (4) duration of the violation (Factor 4). In this case, the base civil penalty for the Category A problem at Calvert Cliffs was mitigated by 25% based on Factor 1 and 25% based on Factor 3, but was escalated FCi based on Factor 2. The NRC maintains that it has appropriately evaluated the application of the factors when considering the licensee's actions taken after its initial identification of the tape splice deficiencies in December 1986. While the NRC recognizes that extensive corrective actions were taken after the NRC's follow-up inspection in March 1987, the corrective actions taken when the tape deficiencies were first identified in December 1986 were unacceptable and reflected a narrow review of the deficiencies. Thus, mitigation by not more than 25% based on this factor was appropriate. To give full mitigation for corrective actions under these circumstances would inappropriately reward the licensee's poor initial corrective actions. The NRC also recognizes that most of the violations were identified by the licensee and, therefore a 25% reduction based on this factor was appro-priate. However, full 50% mitigation based on this factor was deemed inappropriate because it was the NRC inspection in March 1987 which identified additional EQ deficiencies and which caused the licensee to perform additional reviews and evaluations. Therefore, in summary, the licensee's arguments do not provide an adequate basis for mitigation of the civil penalty. IV. NRC Conclusion The licensee did not provide a sufficient basis for reclassification of the severity of the problem or for mitigation of the amount of the civil penalt:y. Therefore, the NRC concludes that the deficiencies constitute an EQ Category A problem and a civil penalty of $300,000 should be imposed. NUREG-0940 I.A-31

m Afcg UNITED STATES [m Do NUCLEAR REGULATORY COMMisslON l' REGION ll g j 101 MARIETTA STREET N.W.

• e ATLANTA, GEORGI A 30323

  %,""'m /

JUN 151988 Docket No. 50-261 License No. DPR-23 EA 88-88 Carolina Power & Light Company ATTN: Mr. E. E. Utley Senior Executive Vice President Power Supply and Engineering and Construction Post Office Box 1551 Raleigh, North Carolina 27602 Gentlemen: 1

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N05, 50-261/88-03 AND 50-261/88-04) This refers to the NRC inspections conducted on January 11 - February 10 March 7, 1988, and February 11 - March 10, 1988, at the H. 8. Robinson Plant. I The inspections included a review of the circumstances surrounding your identi-fication of several accident scenarios during which the minimum number of safety injection (SI) pumps necessary to meet design basis requirements would not be maintained. Those potential scenarios were identified by your staff in January and February 1988, during a review conducted in response to a letter from the NRC dated January 14, 1988. The accident scenarios involved several electrical events in which two of three SI pumps would become inoperable due to a single failure. The reports documenting these inspections were sent to you by letters dated March 14 and April 27, 1988. As a result of these inspections, failures to comply with NRC regulatory requirements were identified; and accordingly, NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on March 30, 1988. The report documenting this conference was sent to you by letter dated April 25, 1988. The violation de m ibed in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involved the failure of your 10 CFR Part 50, Appendix K required evaluation model to reflect the most damaging single failure relative to the ECCS safety injection (SI) subsystem. It appears that evaluations for certain single failures were not performed which resulted in the erroneous assumption that two of the three SI pumps would be operable during design basis accidents. The January / February 1988 re-evaluation conducted by 3ou identified several electrical scenarios wherein two of the three SI pumps would become inoperable in the event of those single failures, rendering the SI function unavailable during an accident, while the evaluation model and related accident analyses described in the H. B. Robinson Updated Safety Analysis Report assumed two SI pumps required to be operable to accomplish the ECCS-SI function. We are aware that, on the basis of your further re-evaluation of the SI system electrical design, you performed analyses after discovery of the single failure problem which indicate that only one of the three SI pumps may be needed to meet the ECCS requirements of 10 CFR 50.46. This notwithstanding, the fact remains that your earlier evaluation cf the SI system failed to identify several i NUREG-0940 I.A-32

Carolina Power and Light Company -2 JUN 15198R single failures that would leave the plant in an unanalyzed condition with only one SI pump being operable. The NRC considers the previous plant operation with potentially only one SI pump operable rather than two pumps to be a significant reduction in the margin of safety. To emphasize the importance of proper evaluation of ECCS system. I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions " in 10 CFR Part 2, Appendix C (1988) (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 no adjustment has been deemed appropriate, j We understand that you are developing a design basis reconstitution program, the purpose of which is to verify the accuracy of the plant design basis, and that this action is being taken in view of the several design deficiencies identified during the Safety System Functional Inspection (SSFI) conducted byj the NRC in April 1987. The significance of the enclosed violation and those . j design deficiencies identified during the SSFI serves to highlight the need $ l for this program, and we encourage you to place priority on its timely completion. 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 Managenent and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Sincerely, p .

                                                                          ,  J. Nelson Grace
                                                                         /   Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl: G. P. Beatty, Jr., Vice President Robinson Nuclear Project Department R. E. Morgan, Plant General Manager NUREG-0940 I.A-33

NOTICE OF VIOLATION AND PROPOSED IMPOSITIDTOF CIVIL PENALTY Carolina Power & Light Company Docket No. 50-261 , H. B. Robinson Unit 2 License No. OPR-23 EA 88-88 l During NRC inspections conducted on January 11 - February 10, March 7, and February 11 - March 10, 1988, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2 Appendix C (1988), the Nuclear Regulatory Conunission 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. l The violation and associated civil penalty are set forth below: -) i 10 CFR 50.46 (a) (1) requires that emergency core cooling system (ECCS)  ! cooling performance be calculated in accordance with an acceptable l evaluation model. 1 10 CFR Part 50, Appendix K sets forth standards for an acceptable model..  ; Appendix K, Section D.1, " Single Failure Criterion" requires that in the!. i accident evaluation the combination of ECCS subsystems assumed to be i operative be those available after the most damaging single failure of j ECCS equipment has taken place. 1 Contrary to the above, as of January 29, 1988, the combination of ECCS subsystems assumed to be operative in the evaluation model in the I H. B. Robinson Undated Safety Analysis Report (USAR) did not reflect certain more damaging single failures of ECCS equipment, particularly the Safety Injection (SI) system. Certain single failures could have rendered two of the three SI pumps inoperable while the H. B. Robinson USAR evaluation model assumed at most one SI pump being inoperable I after the most damaging single failure. The four scenarios in which the SI safety function could have been lost only leaving one SI pump operable are (1) a single failure of the sequencer relay in the safeguard sequencing logic, (2) a single failure of the emergency diesel generator (EDG) field flash circuit after loss of offsite power and loss-of-coolant conditions, (3) a single failure of the DC control power during safeguard sequencing, and (4) a single active failure in the EDG system controls. This is a Severity Level IIL violation (Supplement I). r Civil Penalty - $50,000 Pursuant to the provisions of 10 CFR 2.201, Carolina Power & Light Company (licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a

                                                                      " Reply to a Notice of Violation" and should include for each violation:

(1) admission or denial of the 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 this Notice, an order may be issued to show cause why the license.s.hould not be modified, NUREG-0940 1.A-34

l Notice of Violation suspended, or revoked or why such other action as may be proper should not be i taken. Consideration may be given tn extending the response time for good cause I shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, the licensee may pay the civil penalty by letter addressed to the 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 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 Conmission. Should the licensee i fail to answer within the time specified, an order imposing the civil penalty I 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 not be imposed. In addition to protesting the i civil penalty, such answer may request remission or mitigation of the penalty. ( l In requesting mitigation of the proposed penalty, the five factors addressed Section V.B of 10 CFR Part 2, Appendix C, (1988) should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may ir. corporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citirg page and paragraph numbers) to avoid repetition. The attention of the licensee l 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 natter may be referred to the Attorney General, ad 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, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II, and a copy to the NRC Inspector at the H. B. Robinson Plant. FOR THE NUCLEAR REGULATORY COMMISSION c}

                                  .0}-)        (    /m
                                       ' J. Nelson Grace cw Regional Administrator Dated at Atlanta, Georgia this/54dayofJune1988 NUREG-0940                               1.A-35

                                                                        +#          o                            UNITED STATES l

l ['; r, N  ; NUCLEAR REGULATORY COMMISSION wassimoTon. o. c. 2osss l

                                                                           *****J' EAR 1 7 1989 l

l Docket No. 50-261 License No. DPR-23 EA 88-88 Carolina Power & Light Cosipany ATTN: Mr. E. E. Utley Senior Executive Vice Presicent Power Supply and Engineering and Construction Post Office Box 1551 , Raleigh, North Ca'rolina 27602 ' i Gentlemen:

SUBJECT:

ORDER IltPOSING A CIVIL NONETARY PENALTY This refers to ycur letter dated July 15, 1988, in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you by our letter dated June 15, 1988. Our letter and hotice describe a violation involving the failure of your 10 CFR Part 50, Appendix K required evaluation model to rcflect the most dama Cooling System (ECCS)gingSafety single failure Injection (SI) relative to theThe subsystem. Emergency violation Core was identified as a result of an NRC request for additional information on January 14, 1988 regarding the automatic bus transfer (ABT) scheme utilized to power SI pump B after we identified a similar deficiency for the Auxiliary Feedwater System. The full scope of the SI system problem was not fully developed until after we raised additional questions on January 29, 1988 about other types of electrical system faults that could result in only one of the l three 50% capacity SI pumps being available to mitigate the consequences of a design basis accident. It was at that time thdt your staff idtr.tified several other single failure scenarios and the decision was made by you to shut down H. B. Robinson Unit No. 2. To empha:;ize the importance of proper evaluation of the ECCS, a civil penalty of Fifty Thousand Dollars ($50,000) was proposeo. In your response of July 15, 1988 you deny the violation and request full miti- l gotion of the proposed civil penalty. You stated that H. B. Robinson Unit No. 2 ccrplied with the requirements of 10 CFR 50.46 and Appendix X as they relate to the original design criteria described in the Updated Final Safety Analysis Report and other previously submitted documents. This design criteria, which only considereo a single active failure, was believed by you to be appropriate as it was repeatedly provided to the staff and not questioned during the staff's  ! various reviews. Your reply made no mention of the single active failure examples  ; identified in the Notice of Violation. l We 'o not accept your position that the ECCS is required to be designed for only a : .ngle active failure for components of electricai syste:ms. The design of the ECCS to withstand a single worst failure, be it active or passive components of electrical systems, is a clear requirement necessary to protect the public health and safety. This definition of single failure for electrical systems was NUREG-0940 I.A-36

Carolina Power & Light Company l codified in 10 CFR Part 50, Appendix A prior to promulgation of the 1974 ECCS j rule. The inadequacy of your original design criteria for application to the ECCS rule should have been identified during your review of your various submittals. Under the circumstances of this case and for the reasons given in the evaluation attached to the enclosed order, we have decided to modify the enforcement action as described in the Notice of Violation by deleting scenarios (2) and (3) of the violation. Nevertheless we have concluded, for the reasons in the Appendix attached to the enclosed Order Imposing Civil Monetary Penalty, that the violation occurred as described in the Notice, without considering scenarios (2) and (3), and that a sufficient basis for mitigation of the proposed civil penalty has not been provided. Deletion of the two scenarios does not lessen the safety significance of the violation. Accordingly, we hereby serve the enclosed Order on Carolina Power & Light Company imposing a civil penalty in the amount of Fifty Thousand Dollars ($50,000). We will review the effective-ness of your corrective actions during a subsequent inspection. The NRC believes that based on good engineering judgment and industry dialogue concerning ECCS design in the 1974 time frame, you should have known that, regardless of the history of your submissions on ECCS requirements, you are required to implement 10 CFR 50.46 and Appendix K which do not distinguish between f ailures of active and passive components for electrical systems. We are concerned that your response to the Notice raised a broader safety issue regarding what you considered to be the most damaging single failure used in the original design basis of the plant and backfitted to meet the 1974 ECCS rule (e.g., in your response, "1. Denial of Alleged Violation," you stated that,

                                      "...Therefore, failures of batteries and wires breaking are failures of passive corrponents which are outside the scope of the original design basis."). Conse-quently, under the provision of 10 CFR 50.54(f), you are required to provide the Office of Nuclear Reactor Regulation, within 30 days of receipt of this letter, a written submittal outlining those actions taken or planned to assure that the H. B. Robinson Unit 2 facility complies with the single worst failure require-ment of 10 CFR 50.46 and Appendix K. Because of the past problems with the           ,

Auxiliary Feedwater System ABT scheme, your submittal should also address your l plans to identify and correct single electrical failure (as defined in 10 CFR  ! Part 50, Appendix A) vulnerability problems associated with other safety systems. This information is sought by the NRC to verify compliance with the current licensing basis of your f acility and must be submitted as specified in Section 50.4, Written Statements, and signed under oath or affirmation. In accordance with Section 2.790 of the HRC'st" Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy"of this letter and the enclusure l will be placed in the NRC's Public Document Room. 1 Hus L. Thompson, r. Dt. ty Executive irec or for Nuclear Materials Safet , Safeguards and Operations Support

Enclosure:

Order w/ Appendix cc w/ encl: See Next Page NUREG-0940 1.A-37

                                                                                                                          )

UNITED STATES NUCLEAR REGULATORY COMMISSION 1 1 1 In the Matter of Docket No. 50-261 -l Carolina Power & Light Company License No. DPR-23  ! H. B. Robinson Steam Electric EA 88-88 ' Generating Plant Unit 2 ORDER IMPOSING CIVIL MONETARY PENALTY I I Carolina Power & Light Company (CP&L/ licensee) is the holder of Operating ) License No. DPR-23 issued by the Nuclear Regulatory Commission (Commission /NRC) on July 31, 1970. The license authorizes the licensee to operate the H. B.  ! l Robinson Steam Electric Plant, Unit No. 2, in accordance with the conditions  ! specified therein. II i i NRC inspections of the licensee's activities under the license were conducted on January 11 - February 10, 1988, with a followup inspection conducted February 11 - March 10,1988, at the H. B. Robinson Steam Electric Plant, Unit No. 2, Hartsville, South Carolina. The results of these inspections indicated that the licensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalty was served upon the licensee by letter dated June 15, 1988. The Notice stated the nature of the violation, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalty proposed for the violution. The licensee responded to the Notice of Violation and NUREG-0940 1.A-38

Proposed Imposition of Civil Penalty by letter dated July 15, 1988 denying the violation and requesting full mitigation of the civil penalty. III j

                                                                                                                                                                              )

After consideration of the licensee's response and the statements of fact, explanation, and argument for mitigation contained therein, the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support has determined, as set forth in the Appendix to this Order, that the violation . l, \ l occurredasstatedwithoutconsideringscenarios(2)and(3)andthatthe penalty proposed for the violation designated in the Notice of Violation and Proposed Imposition of the Civil Penalty, as amended by withdrawing two failure scenarios ((2)and(3)),shouldbeimposed. IV l In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act ' of 1954, as amended (ACT), 42 U.S.C. 2282 and 10 CFR- 2.205, IT IS HEREBY 1 ORDERED THAT: , 1 The licensee pay a civil penalty in the amount of Fifty Thousand Dollars ($50,000) within 30 days of the date of this Order, by check, draft, or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555. NUREG-0940 I.A-39

V The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing shall be clearly marked as a " Request for an Enforcement Hearing" and shall be addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region II, 101 Marietta Street, N.W., Atlanta, Georgia 30323, and a copy to the NRC Resident Inspector, H. B. Robinson Steam Electric Plant. If a hearing is requested, the Comission will issue an Orcer 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 to tnis 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 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 referend and amended in Section III above, 6nd NUREG-0940 I.A-40

(b) whether, on the basis of such violation, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION flu f L. Thomps J. D ty Executi D r ctor for N lear Materials afety, Safeguards, and Operations Support Dated at Rockville, Maryland this day of March 1989 NUREG-0940 I.A-41

APPENDIX EVALUATION AND CONCLUSIONS On June 15, 1988, a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for a violation identified during NRC inspections. Carolina Power & Light Company (CP&L) responded to the Notice on July 15, 1988. In its response, the licensee denies the violation as stated in the Notice, and requests mitigation of the proposed civil penalty. The NRC's evaluation and conclusion regarding the licensee's arguments are as follows:

1. Restatement of Violation "10 CFR 50.46 (a)(1) requires that emergency core cooling system (ECCS) cooling performance be calculated in accordance with an acceptable evalua-tion model.

10 CFR Part 50, Appendix K, sets forth standards for an acceptable model. Appendix K, Section D.I., " Single failure Criterion" requires that in the accident evaluation the combination of ECCS subsystems assumed to be operative be those available after the most damaging single failure of ECCS equipment has taken place. Contrary to the above, as of January 29, 1988, the combination of ECCS subsystems assumed to be operative in the evaluation model in the H. B. Robinson Undated

• Safety Analysis Report (USAR) cio not reflect certain more damaging single failures of ECCS equipment, particularly the Safety Injection (SI) System. Certain single failures could have rendered two of the three SI pumps inoperable while the H. B. Robinson USAR evalua-tion model assumed at most one SI pump being inoperable after the most damaging single failure. The four scenarios in which the SI safety function could have been lost only leaving one SI pump operable are (1) a single failure of the sequencer relay in the safeguard sequencing logic, (2) a single failure of the emergency diesel generator (EDG) field flash circuit after loss of offsite power and loss-of-coolant conditions, (3) a single failure of the DC control power during safeguard sequencing, and (4) a single active failure in the EDG system controls."

Summary of licensee's Response to Violation The licensee denies the violation occurred. CP&L believes it was in compliance with 10 CFR 50.a6(a)(1) and 10 CFR Part 50, Appendix K. CP&L states that analyses submitted to demonstrate coinpliance were within the scope outlined in Section 3.1 of the Updated Final Safety Analysis Report (UFSAR), "Conformance with General Design Criteria," specifically Sec-tion 3.1.2.41, which requires that the Engineered Safety Features (ESF) perform their intended functions while accommodating the failure of any

*This was a typographical error in the original Notice which should have read
 " Updated" rather than " Undated."

NUREG-0940 I.A-42

Appendix single active component (emphasis added). Thus, a failure of one Emergency Diesel Ecii"eHtor was identified by the licensee as the most limiting single active failure. The licensee further states that " failures of batteries and wires breaking are failures of passive components which are outsioe the scope of the original design basis." Subsequently, the Appendix K model and analyses were submitted to the Atomic Energy Commission (AEC) in Novemtwr 1974; and the AEC issued the Order for Modification of License on December 27, 1974 accepting the diesel failure as the worst-case single failure of ECCS performance. As a result of these documents and the lack of any additional questions from the AEC, the licensee asserts that it concluded that the original single failure scenarios, as accepted by the AEC, were appropriate. In July 1984, a new single failure analysis as part of the Appendix K submittal for Technical Specification revisions associated with Cycle 10 operations was submitted and again the NRC l accepted the appropriateness of the single failure scenarios used for Appendix K analysis in the SER for Licensee Amendment 87. NRC Evaluation 10 CFR 50.46 and Appendix K require that ECCS cooling performance be calculated in accordance with an acceptable evaluation model. Appendix K sets forth certein required features of evaluation inodels that include an analysis of possible failure modes of ECCS equipment and their effect on ECCS performance. The combination of ECCS subsystems allowed to be assumeo operable are those available after the most damaging single failure of ECCS equipment has taken place. Appendix K has never distinguished between active and passive failures in determining the most damaging single failure. 10 CFR 50.46 fur ther requires that the ECCS cooling performance design comply with Criterion 35 of 10 CFR Part 50, Appendix A, General Design Criteria, to assure that the safety system function can be accomplished, assuming a single failure. The applicable definition for single failure is contained in the Definitions and Explanations Section of Appendix A. Fluid and electrical systems are considered to be designed against an assumeo single failure if neither (1) a single failure of any active component (assuming passive components fucction properly), nor (2) a single failure of any passive component (assuming active components function properly), results in the loss of the capability of the system to perform its safety functions. In other words, there is no distinction made beteen failures of active and passive components for electrical systems. The Notice of Violation contains two scenarios where the feilure of an active component (EDG system controls and ECCS sequencer relay) could render two of the three 50 percent capacity safety injection pumps inoper-dble. The other tWo scenarios contained in the Notice involve a malfunc-tion of what the licensee contends are passive components in the EDG field flash circuit and DC control power, that could also render two safety injection pumps iaoperable. The licensee's response did not address the other two active component failure scenarios, and therefore did not provide any new information not already considered. NUREG-0940 1.A-43

Appendix The licensee's response focused on the assertion that H. B. Robinson Unit I No. 2 was licensed to operate prior to the promulgation of 10 CFR 50.46 and Appendix K, and that its submitted analysis reiterated that the original ECCS design basis was e single active failure. Staff reviews of those ar.alyses did not identify this variance from the regulations, but instead found the generic evaluation model to be appropriate and applicable for use in evaluation of the ECCS performance for H.B. Robinson Unit 2, as the sensitivity study for three-loop plant designs included a worst single failure assumption. Licensee submittals for the July 1984 Cycle 10 analysis also maintained that the ECCS was designed for a single active failure. The variance was not acted upon again, and the licensee indicates that the staff's tacit approval of consideration of only active failures may be deemed to be an implied exemption. Because of this circumstance, for purposes of this enforcement action, the staff has decided not to focus upon the two scenarios which the licensee claims are passive failures which could render the safety injection pumps inoperable. Resolution of passive failure design criteria will be pursued separately. 1 Notwithstanding the above, though CP&L believes that it communicated to the NRC that the ECCS could only meat single active failures, it is the licensee's responsibility to identify the worst case single failure and to consider the need to design against such a single failure which may result in the loss of capability of a safety system to perform its intended function. The original worst case single failures identified by CP&L were in error in that the postulatec failure resulted in the inoperability of only one  ; safety injection pump. Subsequent evaluations found four scenarios in ' which the single failure could render two of the three 50 percent capacity safety injection pumps inoperable. Each individual failure is therefore significant in iti, elf. II. Sumary of Licensee's Request for Hitigation The licensee states that even if the staff cisagrees with CP&L's cenial, that there are extenuating circumstances per 10 CFR Part 2, Appendix C, Section V.B., that justify mitigating the proposed civil penalty in full. CP&L argues that justification for full mitigation is based on:

1. prompt reporting of the identified single failures to the NRC,

2. prompt and aggressive corrective actions including shutdown of the plant,

3. results of a subsequent analysis, approved by the NRC, that demonstrated that at no time did a hazard to the public exist, 4 prior good performance in providing analyses in accordance with 10 CFR 50.46, and in not previously being cited for any violation rela 9d to 10 CFR 50.46, and

5. imp s.untation of a formal Design Basis Reconstitution Program at H. B. Robinson.

NRC Evaluation

1. The violation described in this enforcement action was not identified as the result of a licensee initiative. Rather, the violation was identified as a result of an NRC request for additional information regarding the B safety injection pump auto transfer scheme (NRC letter K. Eccleston to NUREG-0940 I.A-44

Appendix E. Utley, January 14,1988) and subsequent inquiries by NRC inspectors on January 29, 1988 concerning plant response to certain other types of electrical system faults.

2. On January 29, 1988, the licensee's initial corrective action, after identifying that an unanalyzed condition existed, was to initiate a plant shutdown at 10 percent per hour such that the plant would be in hot shutdown in eight hours as required by Technical Specification ACTION STATEMENT 3.0. The licensee's review of the normal breaker configuration for powering the "B" SI pump from either of the two emergency buses revealed that realignment of the normal breaker configuration would prevent the problem. A procedure change was made, the breakers realigned, and the shutdown was terminated at 40 percent full power, with full power operattors resumed less than six hours later. Less than six hours after the rcturn to full power, the NRC Resident Inspector requested information concerning certain other types of faults in the electrical system which could also have a potential for resulting in automatically starting only one SI pump. One of the questicr.s dealt with what effect a loss of the "A" battery bus would have on EDG "A" after having successfully loaded, i.e., SI pumps A and B, sequenced into it. While preparing an answer to this and other questions, the licensee identified another single failure, which with the nora l plant configuration, would also result in only one SI pump being automatically available. At the time, the licensee decided that another procedure fix, though available, was unacceptable and elected to shut down the unit until a comprehensive single failure review could be perf orreo and appropriate corrective action taken. Subsequently, four scenarios were identified which required plant procedure or equipment changes.

Thus, the initial correction for an unanalyzed condition was to make a procedure change without an in-depth analysis of the issue. Although initially this provided an acceptable solution for the then identified condition, had in-depth analyses been performea initially, the additional scenarios would have been identified.

3. The f act that subsequent analyses indicated the need for only one of the three SI pumps is not a basis f or n.itigation of the civil penalty in this case as it does not go to the central issue in this action; that is, the fact that an adequate technical evaluation model did not consioer all possible damaging single failures of ECCS equipment.

4 In developing this enforcement action, the NRC considered, but ry ected, escalation of the civil penalty based on the licensee's prior perforn.ance under the provisions of 10 CFR Part 2, Appendix C, V.B.3. The NRC identi-fied a number of design deficiencies during the Safety System Functional Inspection conducted in April 1987, and noted a lack of aggressive effort by CP&L to correct those deficiencies. l

5. The policy allows mitigation to be considered when a violation is identified by a licensee audit program. The violation was not identified as a result of the referenced program activities, but rather through NRC reqbests for edditional information. 1 NUREG-0940 1.A-45

J Appendix .g. Conclusion The staff concludes that the violation occurred as modified above by withdrawing scenarios (2) and (3) described in the violation, and that a sufficient basis for mitigation of the civil penalty has not been provided. The basis for the civil penalty in this case was the failure to comply with 10 CFR 50.46 and not solely the number of individual failure scenarios described. The remaining, two tingle failure scenarios are a sufficient basis to warrant issuance of a civil penalty. Consequently, the proposed civil penalty of $50,000 should be imposed. 1 i i

                                                                                                                         )

NUREG-0940 I,A-46

l pa nec UNIT ED STATES

                                     /                                 'o                  NUCLEAR REGULATORY COMMisslON
                                                                     ~

y" n REGION il 101 MARIETTA STREET NW. y j s ATLANT A.GEORGd A 30323

                               %, *... /

E 16 E Docket No. 50-325 , License No. DPR-71 4 EA 88-316 i Carolina Power and Light Company l ATTN: Mr. E. E. Utley l Senior Executive Vice President l Power Supply and Engineering and Construction Post Office Box 1551 Raleigh, North Carolina 27602 Gentlemen:

SUBJECT:

NOTICE OF VIOLA 7'ON AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTI0ft (EPORT NO. 50-325/87-45) This refers to the Nuclear Regulatory Comission (NRC) inspection conducted on f December 14-21, 1988, at the Brunswick Steam Electric Plant. The inspection I included a review of two simultaneous events that individually resulted in the loss of Unit 1 secondary containment integrity during the period of December 11-14, 1988. The report documenting this inspection was sent to you by letter dated December 30, 1988. Significant failures to comply with NRC regulatory require-ments were identified as a result of this inspection.- We discussed the inspec-tion findings with you in an Enforcement Conference held on January 13, 1989. A summary of this conference was sent to you by letter dated January 30, 1980 The enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) describes Technical Specification violations which resulted in the loss of secondary containment integrity while irradiated fuel assemblies were being moved to conduct fuel sipping operations. Secondary containment integrity is necessary whenever irradiated fuel is handled to ensure that, in the event of a dropped assembly, any radioactive gases released are processed through the standby gas treatment (SBGT) system prior to elevated dispersal to minimize any ground level releasp. Both an operable SBGT system and operable reactor building ventilati,pn secondary containment isolation dampers (SCID) are required to perform this safety function. The first violation involved an inoperable SBGT system. On December 14, 1988, the resident inspector noted that the inlet isolation valve for SBGT train B did not indicate open at its respective motor control center (MCC). Subsequent review revealed that the inlet isolation valves on both trains of the SBGT system were only 5 percent open, rendering the system inoperable. Factors. contributing to this problem included deficiencies in design, training, procedures, and operator actions. In 1984, you were awcre that Unit I differed from Unit 2 in that the Unit.1 isolation valves did not automatically open on SBGT initiation. Had the Unit I design been updated to conform with Unit 2 NUREG-0940 I.A-47

l Carolina Power' & Light Company MR i 61989 t.h,is particular situation would not have resulted in an inoperable SBGT system. In addition, the confusing control room design for the inlet valve position l indication contributed directly to the operators believing the valves were open. Notwithstanding the confusing design, this event could still have been prevented had the operators been better trained on the anomaly between the misleading valve indication in the control room and at the local control board, and the actual valve indication found on the respective MCC and locally at the valve. Although the procedure for SBGT operation has contained a caution for this indication anomaly since 1983, neither the fuel sipping procedure nor the periodic SBGT filter leak test, which was performed just prior to the time of the event, informed the operators about this potential pitfall or referenced the SBGT operating procedure for valve alignment purposes. Lastly, we agree with the statement made in the enforcement conference by your plant manager that routine operator plant tours should have identified the " intermediate" position indication on the MCC prior to its being disccvered by our resident inspector. The second violation involved all four 72-inch reactor building ventilation SCIDs (two supply and two exhaust in series) being inoperable during the same time-frame as the fuel handling evolution which took place while SBGT was inoperab Operators discovered this problem when one damper failed to reposition during,le.- testing on December 16, 1988. Subsequent review revealed that the portion of the instrument air system needed to reposition these dampers had been inadver - tently isolated on December 9,1988, due to a licensed operator who failed to do an adequate operations clearance review. This clearance review was apparently quite complicated and required several hours to complete. The number and complexity of drawings that the operator had to refer to contributed to the error of isolating the air supply to the SCIDs. Although accumulators are provided to reposition these dampers in case instrument air is lost, subsequent leak checks by your staff revealed that all four dampers would not have received sufficient air pressure to assure that they would have shut and remained sealed during the entire fuel handling evolution. Each of the events which resulted in the violations individually rendered Secondary Containment Integrity inoperable at a time when it was required by Technical Specifications. Even though we recognize that a postulated fuel handling accident with the conditions present at the time of these events would result in only- a minor radioactive release within 10 CFR Part 100 limits, we are concerned about -the broad breakdown of checks and balances that allowed this to happen. It ' order to emphasize the significance of safety systems being unable to perform their intended function, I have been authorized, after consultation with the Director, Office of Enforcement, and Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, to l issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty  ! in the amount of One Hundred Fifty Thousand Dollars ($150,000) for the violations  ! described in the enclosed Notice. In accordance with the " General Statement of  ! Policy and Procedures for NRC Enforcement Actions," in 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violations described in the enclosed Notice have each been categorized as a 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 for each violation as discussed below. NUREG-0940 I.A-48

E 16 M Carolina Power & Light Company The inoperable SBGT system was identified by the resident inspector after numerous operator plant tours had the opportunity to identify the problem, but failed. The NRC believes that you should have reasonably identified this violation through the routine operator tours, and the base civil penalty is therefore escalated by 50 percent. Your corrective actions discussed at the enforcement conference focused on the design deficiencies, but did not adequately address indicated weaknesses in your training program. We believe operator training should focus on design differences between the two units, and more significantly, on those system design anomalies that are counter to accepted plant convention. Therefore, no mitigation or escalation was applied to this factor. Your past performance is considered weak. Though you have initiated plans to conduct safety system functional inspections to identify other possible design problems as a long term solution for system and hardware deficiencies, personnel error and inatten-tion to detail at Brunswick remains a concern to the NRC. An escalated enforce-ment action was taken in July 1988 because operator error and inattention to detail resulted in a second uncontrolled plant heatup within four months. To emphasize our continued concern, the base penalty has been increased by another 50 percent for poor past perfonnance. No further escalation or mitigation dus to prior notice or duration is considered appropriate. The second violation, inoperable SCIDs, was identified on December 16, 1988, when your operators attempted to reposition the dampers to test a design modi-fication. No mitigation is considered appropriate for identification because the condition existed for 10 days and was not found until after the fuel sipping was complete. No further escalation or mitigation was deemed appro-priate based on your corrective actions and past performance. Your stated plans that include the upgrade of your equipment clearance process and correction of various design deficiencies identified by you are offset by a continuing concern with operator attention to detail. You are required to respond to this lett,e and should follow the instructions specified in the enclosed Notice when pn paring your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. Your response should address what actions are being taken to sensitize your staff on the conduct of plant tours, to review the need-to improve your procedures and drawings used for establishing equipment clearances, and to ensure that your system engineering staff becomes involved in the design review of plant systems. After reviewing your response to this Notice, including your proposed corrective actions and the results of further inspections, the NRC will determine whether further enforcement action is necessary to ensure ccepliance 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. NUREG-0940 1.A-49

Carolina Power'& Light Company ll$t i g ggg 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 ouestions concerning this letter, please contact us. Sincerely, j!' & , j stpl*O  :) l Stewart D. Ebneter Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl: R. B. Starkey, Jr., Manager Brunswick Nuclear Project J. L. Harness, Plant General Manager State of North Carolina l i l NJREG-0940 I.A-50

NOTICE OF VIOLATION AND PROPOSED IMPOSITIUR 0F CIVIL PENALTY l Carolina Power & Light Company Docket No. 50-325 Brunswick Steam Electric Plant License No. OPR-71 Unit 1 EA 88-316 As a result of the Nuclear Regulatory Commission (NRC) inspection conducted l on December 14-21, 1988, violations of NRC requirements were identified that  ! I each individually resulted in the loss of Secondary Containment Integrity when it was required. In accordance with the " General Statement of Policy l and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The violations and associated civil penalties are set forth below: A. Technical Specification 3.6.6.1 requires that two independent standby gas treatment trains be _ operable when irradiated fuel is handled in the secondary containment. Contrary to the above, both trains of the standby gas treatment system were inoperable while irradiated fuel was handled in the secondary containment from December 11-14, 1988. Both standby gas treatment inlet isolation dampers, IC-BFV-RB and IG-BFV-RB, were shut, isolating both trains. This is a Severity Level III violation. (Supplement I) (Civil Penalty - $100,000) B. Technical Specification 3.6.5.2 requires that the secondary containment isolation dampers 1A-BFIV-RB, IB-BFIV-RB, IC-BFIV-RB, and ID-BFIV-RB be operable when irradiated fuel is being handled in the secondary containment. Contrary to the above, the secondary containment isolation dampers were i j open with air' isolated from their actuators, rendering the dampers inoperable while fuel was being handled in the secondary containmer,t  : from December 11-14, 1988. l This is a Severity Level III violation. (Supplements) 4 (Civil Penalty - $50,000) Pursuant to the provisions of 10 CFR 2.201, Carolina Power and Light Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within NUREG-0940 1.A-51

                                                                            ^

Notice of Violation  !

                                                           .30 days of the date of this Notice. This reply should be clearly marked as a     j
                                                             " Reply to a Notice of Violation" and should include: (1) admission or denial of the vinlations, (2) the reasons for the violation if admitted, (3) the           !

corrective steps that have been taken and the results achieved, (4) the correc-tive 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 a affirmation. Within the sam ~e 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 4 Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a ] check, draft, or money order payable to the Treasurer of the United States in ) { the amount of the civil penalty proposed above, or may protest imposition of ' the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory 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 not be imposed. In addition to protesting the civil penalty, such answer may ' request remission or mitigation of the penalty. In requesting mitigation of the proposed penalt 5ection V.B of 10 CFR Part 2, Appendix C (1988)y, the five

                                                                                                              , should     factors addressed be addressed. Any in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition.       The attention of the Licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil-penalty.

1 I 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 l i 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. , 1 l The responses to the Director, Office of Enforcement, noted above (Reply to a j Notice of Violation, letter with payment of civil penalty, and Answer to a NUREG-0940 I.A-52

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, Region II, and a copy to the NRC Resident Inspector at the Brunswick Steam Electric Plant. FOR THE NUCLEAR REGULATORY COMMISSION a Ebneter Regional Administrator Dated at Atlanta, Georgia this/6thday of March 1989 NUREG-0940 1.A-53

                                 , s *

• e c y, UNI T E D STATES

            ,,*$                                  %,                    NUCLEAR REGULATORN COMMISSION Af CION til
   - [ -Y g                                         i 5                       1 f                          799 ROOSE VEL T ROAD GLEN ELLYN, ILLINot5 60137
          $                                        e7
               %, = . '
                                                ,E
                                              ..'                                        gr,     r .; . -

Docket No. 50-249 License No. DPR-25 EA 87-81 Commonwealth Edison Company ATIN: Mr. James J. O'Connor President Post Office Box'767 Chicago, Illinois 60690 Gens,emen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N05. 50-237/86013; 50-249/86015) This refers to the NRC inspection conducted May.19 throug.h 23, 1986, at Dresden Station, Morris, IL, of activities authorized by NRC License No. DPR-25. The inspection was conducted by a special environmental qualification (EQ) inspection team to assess the program implemented at Dresden Station to meet the EQ requirements of 10 CFR 50.:9. This inspection i'cluded examination of Dresden EQ records to verify that they contained appropriate analysis and documentation to support the environmental qualification of electrical equipment installed in the plant. A copy of the inspection report was sent to you by letter dated September 8, 1986. The results of the inspection were

                                                                 ~

discussed on June 4,1987, during an enforcement conference held in the Region III office between Mr. L. DelGeorge and others of your staff and Mr. C. J. Paperiello and the NRC staff. The violation in the enclosed Notice of Violation and Proposed Imposition of' Civil Penalty (Notice) for the Dresden Unit 3 facility involved the failure to provide documentation of adequate testing and/or analysis as specified 1.n 10 CFR 50.49 to support the environmental qualification of AMP nylon-insulated butt splices. These splices were used in a moderate number of systems important to safety. During the inspection at Dresden Station,.it was identified that AMP nylon-insulated butt splices, used in General Electric F01 containment penetration enclosures in Unit 3, were unqualified for this application, in that the appropriate EQ files failed to demonstrate the similarity between the tested - I and installed components. Severe degradation of these splices apparently due to aging and temperature excursions had already been identified by Commonwealth Edison Company at Dresden Unit 2 in September 1985. The.EQ information provided 1 to the NRC regarding these degraced splices in Unit 2 did not accurately reflect i the actual splices installed. All Unit 2 AMP nylon splices had been replaced  : with qualified Raychem splices in penetration enclosures prior to the EQ deadline of November 30, 1985. i NUREG-0940 1.A-54 4

Commonwealth Edison Company 2- IfR E 5 GBS l 1 Subsequent.to the NRC inspection, Commonwealth Ecisor Company conducted a qualification test series at Wyle Laboratory, curing wrich -all four samples of AMP nylon splices tested exhibited excessive leakage currents. Details of the , 1 Oyle testing were documented in NRC Information Notice 86-104 Based on the failures of tne samples curing tne 'f e tests, tnese splices were cec:ared i inoperable and repaired at Dresden Unit 3. Commonwealth Edison clearly should have known that these splices were not qualified because (1) severe degradation of these splices had been identified in January and September 1985 in Dresden Unit 2 due to aging and a high j temperature event inside containment (the licensee replaced these splices with a different type in Unit 2 but only initiated a monitoring program for Unit 3), (2) the DDR EQ guidelines mention nylon material as being suspect due to its j inherently poor characteristics under postulated nuclear power plant environmental conditions, and (3) while some vendor EQ test reports used to qualify the penetration and splices existed in the qualification file, these reports were clearly inadequate in that the tests failed to demonstrate that the installed nylon AMP splices or a suitable similar material had been tested. The test l report and subsequent correspondence described a nylon-type splice, but did not specify the manufacturer nor the formulation and material properties of the I nylon which was tested. These factors are considered crucial to demonstrate the similarity of the tested and installed materials. Thus, Commonwealth Edison had no reasonable bases to conclude that the AMP splices installed had similar properties to those tested. I To emphasize the importance of environmental qualification, I have been i authorized, after consultation with the Commission, and the Deputy Executive j Director for Regional Operations, to issue the Notice of Violation and Proposed 1 Imposition of Civil Penalty (Enclosure 1) in the amount of One Hundred Fifty Thousand Dollars ($150,000) for the violation described in the enclosed Notice. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49," contained in Generic Letter 88-07 (Enclosure 2), the violation described in the enclosed Notice has been determined to be moderate and to have affected some systems and components, and therefore is consicered to be an EQ Category B violation. The base value of a civil penalty for an EQ Category B violation l is $150,000. In determining the civil penalty amount, the NRC considered the four factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49," for  ; escalation and mitigation of the base civil penalty amount. These factors l l J l i 1

                                                                                                                              )

NUREG-0940 I.A-55 , _ _ _ . _ _ - _ . -_ _-_-___ - _ _ _ a

Commonwealth Edison Company 3 6 2E'E

        'c'ensist of (1) identification and prcmpt reporting of the EQ deficiencies

(:50%); (2) overall best efforts to complete EQ within the deadline (:50%); (3) corrective actions to result in full compliance (250'); and (4) duration cf a violation which is s4prificantly below 100 days (-50!). With respect to the first factor, escalation of the base civil penalty by 50 percent is appropriate because the NRC identified this violation and the licensee failed to take advantage of the identification of the degrading splices in Dresden Unit 2 to resolve the qualification issue of identical splices installed in Dresden Unit 3. With respect to the second factor, citigation of the base civil penalty by 50 percent is appropriate for the licensee's best efforts in EQ. With respect to the third factor, while the licensee did shut down the operating unit upon learning of the test failure and repair these splices prior to putting Dresden Unit 3 back into operation, these actions were not done in a reasonable time in that the plant operated from May to December 1966 with splices for which qualification could not be i demonstrated. Therefore, on balance neither mitigation nor escalation is I deemed appropriate considering the licensee's corrective actions. With respect to the fourth factor, mitigation is inappropriate because these EQ violations existed in excess of 100 days. Therefore, on balance, no adjustment to the i base civil penalty amount is appropriate. j 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 l response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether or not further NRC enforcement ' action is necessary to ensure compliance with NRC regulatory requirements. 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. NUREG-0940 1.A l Commonwealth Edison Company 4 PR 2 S 1983 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 c' J A. Bert avis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Generic Letter 88-07

3. Inspection Reports Nos.

No. 53-237/86013; No. 50-249/86015 cc w/ enclosures: D. L. Farrar, Director of Nuclear Licensing I J. Eenigenburg, Plant Manager, Dresden l R. L. Bax, Plant Manager, Quad Cities Licensing Fee Management Branch Senior Resident Inspector, Dresden Senior Resident Inspector, Quad Cities Phyllis Dunton, Attorney General's Office, Environmental Control Division I NUREG-0940 I.A-57

Enclosure 1 i NOTICE OF VIOLATION

                                           -AND i

PROPOSED IMPOSITION OF CIVIL PENALTY j

' Commonwealth Edison Company                                            Docket No. 50-249 Dresden Station, Unit 3                                                 License No. OPR-25 EA 87-81 During an NRC inspection conducted on May 19 through 23',- 1986, a violation of NRC requirements was identified. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, the Nuclear Regulatory Commission proposes to in' pose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205.       The particular violation and associated civil penalty are set forth below:

10 CFR 50.49(f). requires each item of electrical equipment important to safety to be environmentally qualified by-testing-and/or analysis. 10 CFR 50.49(k) specifies that requalification of electric equipment important to safety is not required if the Commission has previously required qualification in accordance with " Guidelines for Evaluating Environmental Qualification of Class IE Electrical Equipment in Operating Reactors," November 1979 (DOR Guidelines). DOR Guidelines, Section 5.2.2, states that type tests should only be considered valid for eautpment identical in design and material l construction to the test specimen and any deviations should be evaluated i as part of the qualification documentation.

                                                                                                      )

Contrary to the above, as of December 6,1986, AMP nylon-insulated butt splices, used in numerous items of electrical equipment important to safety, were not properly envi'ronmentally qualified in accordance wit.h ' 00R Guidelines by type testing. While a type test was done, the tested splices were not demonstrated to be identical to the installed AMP splices and this deviation was not evaluated as part of the documentation in the qualification file. This is an EQ Category B violation. Civil Penalty - 5150,000 (This EQ violation existed in excess of 100 days of plant operation). NUREG-0940 I.A-58

Notice of Viniation 2 APR 2 S Gb9 1 Pursuant to the provision of 10 CFR 2.201, Commonwealth Edison Corrpany is hereby required to submit a written statemert 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 rerked as a " Reply l to a Notice of Violation" and should include for each alleged violation: l (1) admission or denial of the alleged violation, (2) the reasons for the i violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance was or will be achieved. If an adequate reply is not recei Md within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, f 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 l cause shown. Under the authority of Section 182 of the Act, U.S.C. 2232, this j 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 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 i if more than one civil penalty is proposed, or may protest imposition of the I civil penalty in whole or in part by a written answer addressed to the virec.ar, l Office of Enforcen,ent, U.S. Nuclear Regulatory Comission. Should the Licensee , fail to answer within the time specified, ar. order imposing the civil penalty I will be issued. Should the Licensee elect to file an answer in accordance with 10 CFP 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 factors addressed in

" Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualification of Electric Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may                               j incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g.,                                   '

citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil peralty. l l l l l NUREG-0940 1.A-59

Notice of Violation 3. APR 2 51985 Upon failure te 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 Attorrey 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. ZZ62c. 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 III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, IL 60137, and..a copy to the NRC Resident Inspector, at the facility which is the subject of.this Notice. FORTHENUCLEARREGULATQRYCOMMISSION b,,/ A. Be Davi Regional Administrator Dated at Glen Ellyn, Illine s thisJgdayofApril1988. e i ll NUREG-0940 I.A-60 i l

                                                                                                   ?

l l 8 o,, UNITED STATES 8 o NUCLEAR REGULATORY COMMISSION

             $                                   $                  WASHINGTON, D. C. 20665 b
              \.%..+l                                                  MAY 031989                                            I Docket No. 50-249 License No. DPR-25 EA 87-81 Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, Illinois 60690 Gentlemen:

SUBJECT:

ORDER IMPOSING CIVIL MONETARY PENALTY (DRESDEN) This refers to your letters dated June 28 and July 1,1988, in response to the Notice of Violation and Proposed Imposition of Civil Penalty (Notice) sent to you by our letter dated April 29, 1988. Our letter and Notice describe one violation of environmental qualification requirements identified by the NRC. ( To emphasize the importance of environmental qualification of electrical equip- i ment important to safety, a civil penalty of One Hundred Fifty Thousand Dollars ($150,000) was proposed. In your response, you admitted that, based on testing performed during December , 1986, the AMP splices involved in the violation were not 2 environmentally quali- l fied; however, you did not agree that the documentation of qualification was i inadequate to demonstrate qualification. In addition, if the NRC concluded the i violation occurred, you requested mitigation of the proposed civil penalty based on the initial treatment of the issue by the NRC as a minor problem, your actions , taken to test the splices, the implementation of a monitoring program for iden- I tification of splice degradation, and an error in the NRC staff's determination of the length of time the plant operated with unqualified splices. Further, you question the fairness of the NRC's policy to not consider operability arguments in assessing the safety significance of a violation. , After consideration of your response, we have concluded, for the reasons given in the Appendix attached to the enclosed Order Imposing Civil honetary Penalty, that you did not provide sufficient basis for withdrawal of the violation or ' for mitigation of the proposed civil penalty. Accordingly, we hereby serve the enclosed Order on Connonwealth Edison Company imposing a civil monetary penalty in the amount of One Hundred Fif ty Thousand Dollars ($150,000). We will review the effectiveness of your corrective actions during a subsequent inspection. NUREG-0940 I.A-51

Commonwealth-Edison Company In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Fed 1 Regulations, a copy of this letter and the enclosures will be placed in the k C's Public Document Room. Sincerely, Hu hiL. Thompso ., De y Executive Dire r for Nuclear Materiils Safety, Safeguards, and Operations Support

Enclosure:

Order Imposing Civil Monetary Penalty with Appendix cc w/ enc 1: Cordell Reed, Senior Vice President H. Bliss, Nuclear Licensing Manager J. Eenigenburg, Plant Manager Richard Hubbard J. W. McCaffrey, Chief, Public Utilities Divisfon I 1 O NUREG-0940 1.A-62

i UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket No. 50-249 Commonwealth Edison Company ) License No. DPR-25 Dresden Station, Unit 3 ) EA 87-81 ORDER IMPOSING CIVIL MONETARY PENALTY i I Commonwealth Edison Company (licensee) is the holder of Operating License No. DPR-25 issued by the Nuclear Regulatory Comission (NRC/Comission) on March 2, 1971. The license authorizes the licensee to operate the Dresden Station, Unit 3, in accordance with the conditions specified therein. II A special safety inspection of the licensee's activities was conducted during the period May 19 through 23, 1986. 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 j

                                                                                            \

Penalty (Notice) was served upon the licensee by letter dated April 29, 1988. l The Notice stated the nature of the violation, the provisions of the NRC's I requirements that the licensee had violated, and the amount of the civil penalty i proposed for the violation. The licensee responded to the Notice by letters dated June 28 and July 1, 1988. In its response, the licensee made a qualified ) admission to the violation but believes that the imposition of a civil penalty in this case is not consistent with the NRC's Modified Enforcement Policy. The licensee also requested that, if the NRC concluded that the violation occurred, the NRC staff reconsider its analysis of the mitigation / escalation factors, as set forth in the Nodified Enforcement Policy (Generic Letter 88-07). NUREG-0940 1.A-63

III l l After consideration of the licensee's response and the statements of fact, I explanation, and argument for mitigation contained therein, the Deputy Executive Director for Nuclear Materials Safety, Safeguarcs, and Operations-Support has determined, as set forth in the Appendix to this Order, that (1) the violation occurred as stated, (2) the Modified Enforcement Policy has been properly applied, and (3) 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 1954, 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 One Hundred Fifty Thousand Dollars ($150,000) within 30 days of the date of this Order, by check draft, or money order, payable to the Treasurer of the United States and mailed to the Director of Enforcement, U.S. Nuclear l Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. 20555. NUREG-0940 1.A-64

V 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, U.S. Nuclear Regulatory Commission ATTN: Document Control Desk, Washington, D.C. 20555, I with copies to the Assistant General Counsel for Enforcement, U.S. Nuclear Regulatory Comission, Washington, D.C. 20555, Regional Administrator, Region III, 799 Roosevelt Road, Glen Ellyn, Illinois, 60137, and the NRC Resident Inspector, Dresden Station. 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 payment has not been made at 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: (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 i l 1 NUREG-0940 I.A-65

i (b) whether, on the basis of the violation, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION I fk Hu fA L. Thompson,Ar. l Dep ty Executive Dire for Nuclear Materials Safety, Safeguards, l and Operations Support Rockville, Maryland DatedagdayofMay1989 this3" l l NUREG-0940 1.A-66

APPENDIX EVALUATION AND CONCLUSION On April 29, 1988, a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued for Dresden Unit 3 for a violation identified during an NRC inspection. Commonwealth Edison Company (Ceco / licensee) responded to the Notice on June 28 and July 1,1988. In its response, CECO admitted it was unable to demonstrate that the AMP splices were environmentally qualified based on the results of testing conducted at Ceco's initiative in December 1986. However, the licensee does not agree that documentation in its files as of December 6, 1986 was inadequate to demonstrate that the AMP splices were properly qualified in accordance with the DOR Guidelines by type testing and analysis. In addition, the licensee requests reduction of the civil penalty based on the consideration of the factors of identification and reporting and corrective actions. The violation is restated below, followed by a summary of ' the licensee's response, the NRC evaluation, and the conclusion.

1. Restatement of Violation 10 CFR 50.49(f) requires each item of electric equipment important to safety be qualified by testing and/or analysis.

10 CFR 50.49(k) specifies that requalification of electrical equipment important to safety is not required if the Commission has previously required qualification in accordance with " Guidelines for Evaluation of Environmental Qualification of Class IE Electrical Equipment in Operating i Reactors," November 1979 (00R Guidelines).

                                                                                           ]

00R Guidelines, Section 5.2.2, states that type tests should only be considered valid for equipment identical in easign and material construc-tion to the test specimen and any deviations should be evaluated as part of the qualification documentation. Contrary to the above, as of December 6,1986, AMP nylon-insulated butt I splices, used in numerous items of electrical equipment important to safety, ' were not properly environmentally qualified in accordance with DDR Guide-lines by type testing. While a type test was done, the tested splices were i not demonstrated to be identical to the installed AMP splices and this deviation was not evaluated as part of the docu.nentation in the qualification file.

2. Summary of Licensee's Response Ceco admits it was unable to demonstrate that the AMP splices were environmentally qualified based on the results of testing conducted in December 1986, but does not agree that documentation in its files as of December 6,1986 was inadequate to demonstrate qualification. Ceco also

           -contends that the imposition of the proposed civil penalty in this case is not consistent with the NRC's " Modified Enforcement Policy Relating to 10 CFR 50.49" (Modified Enforcement Policy) principally because the-NRC staff's finding that Commonwealth Edison Company clearly should have known l            that the AMP splices were not qualified is in error and is largely based on " impermissible hindsight." The licensee also argues that the cmount of NUREG-0940                                    I.A-67

any civil penalty imposed should be reduced. This is because the analysis in the NRC staff's April 29, 1988 letter of some of the mitigation / escalation factors set forth in the Modified Enforcement Policy is flawed by the improper use of hindsight, by a factual error relating to the length of time.Dresden Unit 3 operated with the AMP splices, and by-failure to give any credit to-commonwealth Edison Company for taking the initiative in testing the AMP splices. The licensee also questions the fairness of the NRC's Modified Enforcement Policy in not considering operability arguments when assessing the safety significance of EQ violations.

3. NRC Evaluation of Licensee's Response

a. Hindsight In regard to hindsight, the licensee asks:

(1) Did the NRC Staff Expect the AMP Splices to Fail the December 1986 Tests? Ihe NRC staff does not believe it relevant to consider whether it expected failures to occur during testing in establishing whether the licensee clearly should have known of the AMP splice deficiency.- The NRC' staff concludes that the facts of the AMP splice issue, as detailed below, establish that CECO clearly I should have known of the splice qualification deficiencies. 1 As documented in the Region III March 24-25, 1986 inspection report (50-237/86006 and 50-249/86009), eighteen of three hundred Dresden Unit 2 splices were replaced in 1983 due to insulation embrittlement. In January 1985, further splice insulation degradation was observed in Unit 2 and in October 1985 all splices in Unit 2 were replaced because the embrittled

                            . insulation was cracking and " falling off" when the splices were moved. This inspection report stated that the NRC was concerned that the AMP splices may have a shorter qualified life than cal-culated by the licensee and that future failures in Unit 3 could  l occur during plant operation.                                     l The intent of the March 24-25, 1986 limited inspection was to review the licensee's immediate corrective action in regard to the degraded AMP nylon splices in Unit 2.. The inspectors identi-fied EQ concerns and informed the licensee that a more detailed inspection would be performed during the upcoming NRC EQ team-inspection in May 1986. The inspectors did not have any ismediate safety concerns because (1) similar degradation had not yet been identified in Unit 3 and (2) the licensee insisted that the installed splices were in-fact identical in material ano con-struction to testeo splices that had properly passed qualifi-cation tests, and that they could demonstrate through additional documentation that the AMP splices were qualified.

NUREG-0940 I.A-68

During the subsequent NRC team inspection in May 1986, the NRC staff concluded that similarity between the tested and installed butt splices was not established by the information in the i licensee's qualification files. CECO maintained the splices  ; were qualified by the GE F01 (R.M. Schuster, April 30,1971) i penetration qualification test. This test documentation indicated insulated splices were used in the penetration test performed under the DDR Guidelines and that the circuits functioned through-out the test. However, the GE F01 qualification test did not describe the splices. The NRC staff's concern was that there was no documentation linking the splice tested by GE with those supplied with the F01 penetrations and in use in Dresden Unit 3. Ceco has indicated that information was obtained from GE indica-ting that nylon insulated butt splices were used in the test but this information was not included in the licensee's environmental qualification file. The documentation reviewed during the May 1986 NRC inspection did not support qualification of the AMP splices in that similarity could not be established. The viola-tion which is the subject of the Notice was identified at this time and was unaffected by subsequent developments. Unit 3 was not operating at the time and the licensee committed j to corrective action prior to startup. In a letter dated June 12, 1986, CECO stated that additional information would be added to the EQ file to show qualification of these splices. The NRC letter dated September 8, 1986 transmitted the NRC inspection ] report and acknowledged the commitment made by Ceco in the June - 12, 1986 letter. The NRC letter also stated that the additional infora tion woulo be reviewed during a future inspection. The 4 licensee's additional information was subsequently reviewed  ! during an NRC inspection at Quad Cities Station in June 1987 l where identical splices existed and the information was found to be inadequate. Had the NRC staff reviewed these analyses prior to the December 1986 tests, the NRC staff would have required the licensee to follow the requirements of Generic Letter 86-15. In conclusion, a documented test and/or analysis was needed to determine if the AMP splices would perform as intended during an accident. Based on the inadequate documentation in the licensee's files at the time of the NRC EQ site inspections, an  : environmental qualification violation occurred and the licensee's corrective actions were inadequate. (2) If the AMP Splices Had Passed the Tests, Would the NRC Staff Now be Proposing a 5150,000 Civil Fenalty7 If the AMP splices had passed the tests, the enforcement action proposed in the Notice would remain unchanged. The NRC's policy in the EQ area has been presented in Generic Letters (GL) 85-15 and 88-07. Both Generic Letters state that unqualified equipment means equipment for which there is not adequate documentation to establish that this equipment will perform its intended functions in the relevant environment. While in certain cases, the ability NUREG-0940 1.A-69

to quickly obtain documentation may result in a violation of reduced severity level, this provision does not apply to testing. The NRC's position provided in Generic Letter 88-07 is that the results of testing done after deficiencies are identified would not be considered. The NRC staff's position is that 10 CFR 50.49 required licensees to assure that electrical equipment important to safety is qualified for its application prior to the November 30, 1985 ceadline. Sufficient documentation to assure qualification was required to be contained in the EQ files prior to the dead-line. As such, testing conducted af ter the the identification of deficiencies after the deadline has no bearing on whether a violation occurred. For the case at Dresden Unit 3, the NRC staff contends that the AMP splices were not demonstrated to be qualified due to inade-quate documentation in the EQ files. The NRC staff identified environmental qualification concerns in March 1986 and again in May 1986. Regardless of whether the AMP splices had passed the December 1986 tests, the licensee had not demonstrated the splices to be qualified prior to the November 30, 1985 EQ ceadline or during or shortly thereafter the NRC inspections of March and May 1986. Any subsequent testing by the licensee, whether favorable or unfavorable, has no bearing on the application of the Modified Enforcement Policy. The NRC staff considers it appropriate to propose a civil penalty in this case based on the failure by the licensee to have adequate EQ documentation for AMP splices, a deficiency wh ch the licensee clearly should have known existed as of November 30, 1985.

b. Application of the Clearly Should Have Known Test l l

The licensee argues that it was not reasonable for the NRC staff to conclude that it clearly should have known that its EQ documentation was inadequate prior to December 1986. The following considerations , support the staff's findings.  ! (1) In January 1985, the licensee identified degraded nylon AMP splices in Dresden Unit 2. In September 1985, severe degrada-tion was identified in the remaining Dresden Unit 2 nylon AMP splices and the splices were replaced with Raychem Heat Shrink i Tubing (HST). The licensee clearly should have known these splices were unqualified since they had degraded significantly before reaching their qualified life. The cause of the degra-dation of the splices in Unit 2 was attributed to a high temperature event in 1970 which consisted of a peak tempera-ture, claimed by the licensee to be 320 degrees F, for less than one hour. Because the splices in Unit 3 had not been exposed to an event of this type, the licensee did not consider the degradation of Unit 2 splices as applicable to the Unit 3 splices. The event in Unit 2 alone shoulc not have been con-sidered by the licensee as an adequate basis for differentiating between the conditions in Unit 2 and 3. It was not a particu-larly severe event relative to the service conditions for which NUREG-0940 1.A-70

1 the splices were to be qualified. The licensee did not present analyses tu determine if the event was'in fact severe enough to have caused the observed difference in degradation and cause possible accelerated aging of these splices in Dresden Unit 2. Thus, the licensee did not present sufficient evidence to conclude that similar' degradation would not occur under accident conditions in Unit 3. The licensee's inspection of the Unit 3 splices did not reveal similar degradation. Dresden Unit 3 splices were not replaced prior to November 30, 1985. Instead,_a. surveillance (monitoring) program was established. However, it was inappropriate to rely on a monitoring program to provide assurance that, during an accident in which a harsh environment would exist including high temperature, radiation, and steam, these splices would function i as intended. Monitoring for degradation would not likely have alerted licenses personnel to potential splice failures in that these failures would likely only occur during accident conditions and not during normel operations. The position stated in D0R Guidelines was intenden to provide that surveillance and main-tenance records be reviewe6 to identify and correct equipment exhibiting age related degradation, as an early indicator of a problem. This position was also based on the assumption het the equipment was properly qualified by tests or test and analy-sis. Therefore, the use of a surveillance program is irrelevant to the issue of whether the licensee " clearly should have known" of the deficiency. The degradation of these splices in Unit 2 served as prior notice that qualification deficiencies existed for these splices. (2) Appendix C of the 00R Guidelines identifies nylon as being susceptible to radiation damage at a threshold dose as low as 10E5 rads. Nylon is further identified as a material that has a potential for significant aging within ten years under normal operating conditions. Therefore, it should have been concluded that the nylon splices could degrade under plant service and accident conditions. Notwithstanding the above, the NRC staff agrees with the licensee contention that'the use of nylon is not prohibited. However, because the licensee sought to qualify the Dresden Station equipment in accordance with the DOR Guide-  ! lines, there was clear evidence that these splices using nylon material'were potentially degradable and needed special attention to establish and maintain qualification. However, the qualifica-tion file was inadequate to demonstrate qualification.  ! The 1971)GE F01 on relied penetration by Ceco test reportthe to qualify (R.AMP M. Schuster,licesApril nylon sp 30, indicated that the splices were not exposed to radiation and  ; did not test splices made by AMP. This matter was discussac in i GE letter G-EBO-8-121 cated April 28, 1978. Therefore, the licensee, in accordance with the DOR Guidelines, had to provice separate radiation qualification for these splices. However, AMP test r'eport (No. 110-11004, February 1982), relied on by the licensee to qualify the splices for radiation, did not NUREG-0940 1.A-71 1

1 r i document testing of AMP nylon splices. The report was in fact for Kynar, a dissimilar material. Thus, the licensee clearly did not have valid EQ documentation to qualify these splices ) and did not perform adequate reviews to resolve the inadequacy of these documents. In summary, the GE F01 Penetration test report and subsequent correspondence between GE and CECO indicated that GE had tested some kind of nylon splice for harsh temperature and pressure conditions and that it did pass the test. However, this test did not adequately qualify the , nylon splice for an environment where radiation and steam would I be present at the same time. The licensee clearly should have known through prior EQ reviews that this test did not identify the formulation of the nylon tested and that the tests did not simulate the plant accident conditions of the Dresden Station. Clearly, the licensee did not have vender supplied documentation in its EQ file that demonstrated that AMP splices were qualified. In sum, a knowledgeable engineer familiar with EQ requirements and information available to the licensee clearly should have known prior to the November 30, 1985 deadline that the qualification file for the AMP splices was deficient. l (3) The licensee argues it had other information on-site which I established similarity. A GE Series 100 penetration test report, as described in GE letter G-EBO-2-031 dated February 9, 1982, was subsequently submitted by the licensee during the enforcement conference on June 5, 1987 and during the Region III Quad Cities Station EQ inspection of June 8-12, 1987 to substitute for the inadequate AMP (No. 110-11004) and GE (R. M. , Schuster, April 1971) test reports. Documentation submitted by { the licensee indicated that this report was in the licensee's i files before November 30, 1985. The licensee's intent of using l the GE Series 100 report was to address the qualification of l the AMP splices for radiation. The NRC staff raised questions at that time regarding various references in this report. One such reference was a GE letter (GE-EBO-2-192, dated 9/7/82) that forwarded to the licensee an electrical penetration environ-mental information study, dated 8/27/82, conducted by GE for the Dresden and Quad Cities Stations. The list of components in this study identified shrinkable tubing and, under Note 2 listed as applicable to this item, indicated that the tubing was used as a " cover for insulated splice." The nylon splice vendors listed included AMP. The additional information provided by the licensee failed to establish which kind of splice used in production was actually tested and it appeared that whichever splice had been tested had been protected f rom the harsh environment by the tubing (apparently intended to be installeo on production penetration assembly splices as well). This information was confirmed in discussions with GE personnel in December 1986. Thus, the tested splices were not only protected from some environmental NUREG-0940 I.A-72 l

l 1 degradation during testing, but also were prevented from causing electrical faults under accident conditions by moisture intru-sion or gross failure of their insulation. The splices installed l in the F01 penetrations in Dresden Unit 3; however, were unpro-l tected. This report was therefore not valid to demonstrate qualification of the splices for the oostulated accident radiation exposure. (4) The licensee argues that a previous NRC inspection in 1978 is additional information which supports its conclusion that it should not have clearly known of the splice qualification deficiencies. The licensee asserts that the 1978 inspection accepted the qualification of the AMP splices. The NRC staff agrees that the inspector in 1978 reached that conclusion. However, the qualification of the splices was accepted based on statements made in a GE letter dated April 28, 1978 and the fact that the test configuration was in accordance with the guidance of IE Circular 78-08. The test conditions did not include exposure to radiation and steam simultaneously, which was subsequently required by the 00R Guidelines (issued as an attachment to IE Bulletin 79-018) to be either included during testing or a separate analysis performed (testing combined with analysis). Therefore, after issuance of the D0R Guidelines the licensee clearly should have known that the inspoctor's basis for acceptance of qualification was no longer necessarily valid. Based on the above, the NRC staff concludes that the licensee clearly should have known the AMP splices were not qualified.

4. Licensee's Request for Consideration of Mitigation / Escalation Factors The licensee asks the NRC staff to reconsider its analysis of the first and third mitigation / escalation factors which are addressed in the Modified Enforcement Policy. These factors were addressed in the NRC's April 29, 1988 letter to CECO. The first mitigation / escalation factor is for identification and prompt reporting. The licensee agrees that the NRC staff first identified the AMP splice issue and, in retrospect, admits it might have taken advantage of the identification of degrading splices in Dresden Unit 2 to repair or replace identical splices in Dresden Unit 3; however, the licensee does not believe these facts merit escalation of the base civil penalty because NRC and the licensee considered the deficiency to be a minor documentation problem until the test failure. The licensee contends that the NRC did not give credit for its testing efforts and prompt reporting of the test failures.

With regard to the third mitigation / escalation factor, corrective actions, l the licensee contends it did not operate with unqualified splices for a i period of six montns os indicated in the NRC's April 29, 1988 letter and that the licensee took the corrective actions called for by the NRC staff (supplying adoitional documentation and analyses in accordance with the established schedule). l 1 NUREG-0940 I.A-73

1 l

5. NRC Evaluation of Licensee's Response In regard to the first factor, the NRC staff notes that Ceco agrees that the AMP splice issue was identified by the NRC. In addition, Ceco had nume '" opportunities to identify and correct this problem since it was ,

aware that splices in Dresden Unit 2 were seriously degraded and identical ' splices were installed in Dresden Unit 3. In view of the above arguments, the NRC staff concludes that there is no adequate basis for changing the NRC staff's position regarding the first factor and concludes 50 percent escalation of the base civil penalty based on this factor is appropriate. The licensee's arguments regarding the NRC staff's categorization of the AMP splice qualification deficiencies as a minor documentation problem l' and credit for the testing performed by the licensee are more appropriately considered under the factor of corrective actions. In regard to the third factor of corrective actions, the NRC staff does not agree that the AMP splice qualification deficiencies were considereo to be minor. Once the splice deficiencies were identifiec, rather than requiring an immediate shutdown, the NRC staff allowed the licensee some time to pursue the identification and collection of additional information which could prove qualification of the splices. Continued discussions with the NRC staff failed to demonstrate to the NRC staff that qualifica-tion had been shown. The NRC staff agrees that Dresden Unit 3 did not operate for six months with unqualified splices; however, it did operate for more than 100 days (August 24, 1986 to December 6, 1986) and the vio-lation existed from November 30, 1985 (EQ deadline) until December 6, 1986, a period of more than a year. In addition, the NRC staff has concluded that the time expended in making an operability or qualification deter-mination, the quality of the supporting analysis (prior to December 4-5, 1986), and the nature and extent of the licensee's efforts to come into compliance were deficient and do not provide a basis for mitigation of l the civil penalty. A careful review of the file should have revealed the ' deficient nature of the qualification file. The NRC staff considers it inappropriate to either mitigate or escalate the base civil penalty in regard to this factor recognizing the licensee did shutdown operating units upon learning of the test failures, but also recognizing the extended period of time during which the plant operated with splices for which qualification was not demonstr6ted.

6. Licensee's Request for Consideration of Safety Significance The licensee expressed its concern as to the fairness of the NRC's enforcement policy not to consider operability arguments in assessing the safety significance of an EQ violation.

7. NRC Evaluation of Licensee's Response The Modified Enforcement Policy is based on the requirement that licensees were to establish a master list of equipment which identified all electrical equipment important to safety. Equipment on this list is required to be environmentally qualified. If a component is on this list, or should have been on the list, the component has safety significance (importance to safety). Consequently, the f ailure to demonstrate qualification for such NUREG-0940 1.A-74 l

1

                                                                                    )

a component has safety significance. The NRC staff believes that to further explore and assess the safety significance of the failure or potential degradation of components for which a significant qualification deficiercy was found would not be productive and diverts attention away from the root cause of the EQ violation.

8. Conclusion The NRC staff concludes the violation occurred as stated and no adequate l

basis has been provided for withdrawing the violation or reducing the amount of the proposed civil penalty. Therefore, the NRC concludes that I a $150,000 civil penalty should be imposed. 1 I l NUREG-0940 1.A-75

km RfCg UNI T E D STATES

                                 .ff         ([gg                    NUCLEAR REGULATORY COMMISSION atolON IH f                                             199 ROOSE VE LT R O AD                           j 5*    '      <. I GLE N ELLYN, ILLINOt5 60137 4,

OCT 2 01989 Docket Nos. 50-254 and 50-265 Licenses Nos. DPR-29 and DPR-30 EA 87-82 Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, Illinois 60690 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 50-254/86021(DRS); 50-265/86021(DRS)) (NRC INSPECTION REPORT NOS. 50-254/87011(DRS); 50-265/87021(DRS)) This refers to the NRC special inspections conducted on December 9, 1986, and June 8 through July 28, 1987, at Quad Cities Nuclear Power Station, Cordova, Illinois, of activities authorized by NRC Licenses No. DPR-29 and DPR-30. The June 8 through July 28, 1987 inspection was conducted by a special environmental qualification (EQ) inspection team to assess the program implemented at Quad Cities Station to meet the EQ requirements of 10 CFR 50.49. This inspection included an examination of EQ records to verify that they contained appropriate analysis and documentation to support the environmental qualification of the plant's electrical equipment. Copies of the inspection reports were sent to you by letters dated December 19, 1986 and September 1, 1987, respectively. These issues were discussed on June 4, 1987, during an enforcement conference held in the Region III office between Mr. L. DelGeorge and others of your staff and Mr. C. J. Paperiello and the NRC staff. 3 l The violation described in the enclosed Notice of Violation and Proposed l Imposition of Civil Penalty (Notice) for Quad Cities, Units 1.and 2, involved the installation of numerous AMP nylon-insulated splices, used in low voltage l power control circuits without providing documentation of adequate testing and/ or analysis, as specified in 10 CFR 50.49, to support the environmental qualifi-cation of these splices before the November 30, 1985 EQ deadline. These splices were used in a moderate number of systems important to safety. During the inspection at Dresden Station, it was identified that AMP nylon-insulated butt splices, used in General Electric F01 containment penetration enclosures in Unit 3, were unqualified for this application, in that the appropriate EQ files failed to demonstrate the similarity between the tested and installed components. Severe degradation of these splices apparently due to aging and temperature NUREG-0940 1.A-76 L__-____________-__-___-______-__-

Commonwealth' Edison Company 2 OCT 2 01989 excursions had already been identified by Commonwealth Edison Company at Dresden Unit 2 in September 1985. All the Dresden Unit 2 AMP nylon splices had been replaced with qualified Raychem splices prior to the EQ deadline of November 30, 1985. Although similar unqualified AMP splices were in use at Quad Cities Station, Unit 2 continued in operation until October 11, 1986 and Unit I continued in operation until December 6, 1986, at which time the splices were repaired. l Subsequent to the NRC inspection at Dresden, Commonwealth Edison sent four sample splices removed from Quad Cities to Wyle Laboratory to substantiate their qualification for use in a harsh-environment. These splices were identical to those in use at Dresden. During the test on December 4-5, 1986 all four samples of amp nylon splices tested exhibited excessive leakage currents. Details of the test were documented in NRC Information Notice 86-104. Based on the failures of the samples, these splices were declared inoperable and, repaired at Quad Cities, Units 1 and 2. Commonwealth Edison clearly should have known that these splices were not qualified because (1) severe degradation of these splices had been identified in January and September 1985 in Dresden Unit 2 due to aging and a high temperature event inside containment (the licensee replaced Dresden Unft 2 splices and initiated a monitoring program for the Dresden Unit 3), (2) the DDR EQ guidelines state that nylon is susceptible to signficant radiation and thermal aging damage when exposed to postulated nuclear power plant environmental conditions, and (3).while some vendor EQ test reports used to qualify the penetration and splices existed in the qualification file, these reports were clearly inadequate in that the tests failed to demonstrate that installed nylon AMP splices or a suitable similar material had been tested. The test report and subsequent correspondence described a nylon-type splice, l but did not specify the manufacturer nor the formulation and material properties of the nylon which was tested. These factors are considered crucial to demonstrate the similarity of the tested and installed materials. Thus, , Commonwealth Edison had no reasonable basis to conclude that the nylon AMP ' splices installed had similar properties to those tested. l Tc emphasize the importance of environmental qualification and meeting regulatory ' deadlines, I have been authorized, after consultation with Director, Office of Enforcement and the Deputy Executive Director for Regional Operations, to issue 4 the Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) in the amount of One Hundred Fifty Thousand Dollars (5150,000) for the violation doscribed in the enclosed Notice. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49," contained in Generic Letter 88-07 (Enclosure 2), the violation described in the enclosed Notice has been determined to be moderate and to have affected some systems and components, and therefore is NUREG-0940 1.A-77

Commonwealth Edison Company 3 OCT 2 01988 considered to be an EQ Category B violation. The base value of a civil penalty for an EQ Category B violation is 5150,000. In determining the civil penalty amount, the NRC considered the four factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49," for escalation and mitigation of the base civil penalty amount. These factors consist of (1) identification and prompt reporting of the EQ deficiencies (250%); (2) overall best efforts to complete EQ within the deadline ( 50%); (3) corrective actions to result in full compliance (250%); and (4) duration , of a violation which is significantly below 100 days (-50%). With respect to l the first factor, escalation of the base civil penalty by 50 percent is appropriate because the NRC identified this violation and the licensee failed to take advantage of the identification of the degrading splices in Dresden Unit 2 to resolve the qualification issue of identical splices installed in Quad Cities, Units 1 and 2. With respect to the second factor, mitigation of the base civil penalty by 50 percent is appropriate for the licensee's best efforts in EQ. 'While the licensee's EQ program was deficient in resolving the nylon AMP splice issue, the overall EQ program demonstrated the licensee's best efforts to complete EQ within the deadline. With respect to the third factor, while the licensee did shut down Unit 2 on October 11, 1986 and Unit 1 on December 6, 1986 and repair the splices, these actions were not done in a reasonable time in that the unqualified splices were identified at Dresden in May 1986. Therefore, on balance neither mitigation nor escalation is deemed appropriate considering the licensee's corrective actions. With respect to the fourth factor, mitigation is inappropriate because these EQ violations existed in excess of 100 days. Therefore, on balance, an adjustment to the base civil penalty amount is 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 specified actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether or not further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. Because the problem at Quad Cities is essentially the same as that for which l a Notice was issued at Dresden, the NRC intends to defer its response to your June 28 and July 1,1988 letters concerning the Dresden Notice until your response to this Notice is received. l In accordance with Section 2.790 of the NRC's " Rules of Practice," part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. i NUREG-0940 1.A-78

1 l l Commonwealth Edison Company 4 007 2 0 1985 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,

                                       .             J 4    A. Bert Davis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Generic Letter 88-07

3. Inspection ' Reports No. 50-254/86021(DRS);

No. 50-265/86021(DRS); No. 50-254/87011(DRS); No. 50-265/87011(DRS) See Attached Distribution I l l 1 1 l NUREG-0940 1.A-79

                                                                                                                       )

i _ _ . _ _ _ _ _ _ _ ________ _ ___ _ _________ __J

NOTICE OF VIOLATION AND  ! PROPOSED IMPOSITION OF CIVIL PENALTY Commonwealth Edison Company Docket Nos. 50-254 and 50-265 Quad Cities Station, Units 1 and 2 Licenses Nos. DPR-29 and DPR-30 EA 87-82 During NRC inspections conducted at Quad Cities Nuclear Power Station, Units 1 and 2, on December 9, 1986 and June 8 through July 28, 1987, a violation of NRC requirements was identified. In accordance with the Modified Enforcement Policy Relating to 10 CFR 50.49, " Environmental Qualification of Electrical Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below: 10 CFR 50.49(f)' requires each item of electrical equipment important to safety to be environmentally qualified by testing and/or analysis. J l 10 CFR 50.49(k) specifies that requalification of electric equipment important  ! to safety is not required if the Commission has previously required ) qualification in accordance with " Guidelines for Evaluating Environmental Qualification of Class IE Electrical Equipment in Operating Reactors," November 1979 (00R Guidelines). 00R Guidelines, Section 5.2.2, states that type tests should only be considered valid for equipment identical in design and material construction to the test specimen and any deviations should be evaluated as part of the qualification documentation. Contrary to the above, from November 30, 1985 until December 6, 1986, AMP nylon-insulated butt splices, used in numerous items of electrical equipment important to safety, were not properly environmentally qualified in accordance with DDR Guidelines by type testing. While a type test was done, the tested splices were not demonstrated to be identical to the installed AMP splices and this deviation l was not evaluated as part of the documentation in the qualification file. This is an EQ Category B violation. Civil Penalty - $150,000 (This EQ violation existed in excess of 100 days of plant operation). NUREG-0940 I.A-80

                ~

OCT 2 01989 Notice of Violation 2 Pursuant to the provision of 10 CFR 2.201, Commonwealth Edison Company is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance was or will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 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 i the amount of the civil penalty proposed above, or the cumulative amount of l the civil penalties if more than one civil penalty is proposed, or may protest l imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violation (s) listed in this Notice in whole or in part; (2) demonstrate extenuating circumstances; (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the factors addressed in Modified Enforcement Policy Relating to 10 CFR 50.49, " Environmental Qualification of Electric Equipment Important to Safety for Nuclear Power Plants," contained in Generic Letter 88-07, should be addressed. Any written answer in a,ccordance 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 l 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. l I i l l 1 i I i i NUREG-0940 1.A-81

Notice of Violation 3 OCT 2 01988 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, Off' .e 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 III, l U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, IL 60137, and a copy to the NRC Resident Inspector at Quad Cities Station. I FOR THE NUCLEAR REGULATORY COMMISSION A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois thisAC M day of October 1988 I NUREG-0940 I.A-82

I I

                  /                            o,,                                                 UNITED STATES
               !                                   n                                      NUCLEAR REGULATORY COMMlfslON g                                                                                 WASHINGTON. D. C. 20555 l
                *s.,...../                                                                          MAY 031989                           ;

1 Docket Nos. 50-254 and 50-265 l Licenses Nos. DPR-29 and DPR 30 EA 87-82 Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, Illinois 60690-0767 Gentlemen:

SUBJECT:

ORDER IMPOSING A CIVIL MONETARY PENALTY (QUAD CITIES) This refers to your letters dated November 21, 1988 and December 19, 1988 in response to the Notice of Violation and Proposed Imposition of Civil Penalty (Notice) sent to you by our letter cated October 20, 1988. Our letter and i Notice describe one violation identified by the NRC at the Quad Cities Nuclear Power Stetion. To emphasize the importance of environmental qualification of electrical equipment important to safety, a civil penalty of One Hundred and Fifty ThousandDollars($150,000) was proposed. In your response, you made a qualified aamission of a violation of 10 CFR 50.49 requirements but you contended that Commonwealth Edison Company (CECO) should not clearly have known of the violation. Additionally, you asserted that, sho:uld the NRC staff conclude that you clearly should have known of the violation, mitigation of the proposed civil penalty is appropriate. Finally, you claiined that the proposed penalty is inconsistent with the Modified Enforcement Polfcy because the NRC is penalizing Ceco twice by issuing identical violations to Dresden and Quad Cities and the amount of the penalty is unfair because another licensee received a lower penalty for the same violation. After consideration of your response, we have concluded, for the reasons given in the Appendix attached to the enclosed Order Imposing Civil Monetary Penalty, that you did not provide sufficient basis for withdrawal of the violation. However, after reconsidering the escalation and mitigation factors, the NRC has concluoed that the escalation of the base civil penalty by 50% when considering the factor of identification and reporting, was inappropriate. Accordingly, we have concluded a 50% reduction of the proposed civil penalty to be appropriate and hereby serve the enclosec Order on Commonwealth Edison Company imposing a civil penalty in the amount of Seventy-five Thousand Dollars ($75,000). We will review the ef festiveness of your corrective actions during a subsequent inspection. CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.A-83

Commonwealth Edison Company In accordance with Section 2.790 of the NRC's " Rules for Practice," Part 2, i

. Title 10, Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room.                                j Sincerely,                             )

i

                                                 ?

Hu .. Thompson i for De y Executive Direc Nuclear Materials Safety. Safeguards and Operations Support

Enclosure:

Order Imposing Civil Monetary Penalty with Appendix cc w/ enclosure: 4 Cordell Reed, Senior Vice President  ! H. Bliss, Nuclear Licensing Manager i R. L. Bax, Plant Manager l Resident Inspector, RIII  ; J. W. McCaffrey, Chief, Public ' Utilities Division I NUREG-0940 I.A-84

l' UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket Nos. 50-254 and 50-265 , Commonwealth Edison Company ) Licenses Nos. DPR-29 and DPR-30 l l Quad Cities, Units 1 and 2 ) EA 87-82 ORDER IMPOSING CIVIL MONETARY PENALTY I Connonwealth Edison Company (licensee) is the holder of Operating Licenses No. DPR-29 and No. DPR-30 issued by the Nuclear Regulatory Commission (NRC or Commission) on October 1, 1971 and March 13, 1972, respectively. The licenses authorize the licensee to operate the Quad Cities Nuclear Power Station, Units 1 and 2, in accordance with the conditions specified therein. II Special safety inspections of the licensee's activities were conducted on December 9,1986 and during the period June 8 through July 28, 1987. The results of the inspections indicated that the licensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was served upon the licensee by letter dated October 20, 1988. The Notice stated the nature of the violation, the provisions 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 by two letters dated November 21, 1988 and an additional letter dated December 19, 1988. In its response, the licensee made a qualified admission that a violation of 10 CFR 50.49 requirements occurred, but argued that the imposition of a civil penalty in this case would not be NUREG-0940 1.A-85

consistent with the NRC's Modified Enforcement Policy because the licensee I should not clearly have known of the violation. The licensee also requested that the NRC staff reconsider its analysis of the mitigation factors, as set forth in the Modified Enforcement Policy (Generic Letter 88-07). Finally, the l licensee claimed that the proposed penalty is also inconsistent with the 4 Modified Enforcement Policy because the NRC is penalizing Commonwealth Edison

                                                                                                ]

Company twice by issuing identical violations for Dresden and Quad Cities and the amount of the penalty is unfair because another licensee received a lower penalty for the same violation. III l l After consideration of the licensee's response and the statements of fact, i explanation, and argument for mitigation contained therein, the Deputy Executive l Director for Nuclear Materials Safety, Safeguards, and Operations Support has determined, as set forth in the Appendix to this Order, that (1) the violation occurred as stated, (2) the NRC has properly applied the " clearly should have known" test of the Modified Enforcement Policy, and (3) that the penalty proposed for the violation designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be reduced by 50% of the base civil penalty. IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT: NUREG-0940 1.A-86

The licensee pay a civil monetary penalty in the amount of Seventy-Five Thousand Dollars ($75,000) within 30 days of the date of this Order, by  ! check, draf t, or money order, payable to the Treasurer of the United States and meiled to the Director of Enforcement, U.S. Nuclear Regulatory  ! Comission, ATTN: Document Control Desk, Washington, D.C. 20555. V 1 I The licensee may request a hearir.g 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, U.S. Nuclear Regulatory Comission ATTN: Document Control Desk, D.C. 20555, alth copies to the Assistant General Counsel for Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555, the Regional Administrator, Region III, 799 Roosevelt Road, Glen Ellyn, Illinois, 60137, and the NRC Resident Inspector, Quad Cities Nuclear Power Station. If a hearing 15 requested, the Commission will issue an Order designating the time and place of the hearing. If the licensee fails to request a hearing aithin 30 days of the date of this Order, the provisions of this Order shall be effective without further proceedings. If payment has not been made at that time, the 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: NUREG-0940 I.A-87

l (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 i (b) whether, on the basis of the violation, this Order should be sustained. l l FOR THE NUCLEAR REGULATORY COMMISSION

                                                                           /M1 Hu    L. Thompson J r.

De ty Executive Direc for . Nuclear Materials Safety, Safeguards  ! and Operations Support i Dated agRockv111e, Maryland this3 day of May 1989  ; l 1 1 NUREG-0940 I.A-88

APPENDIX EVALUATION AND CONCLUSION In its November 21, 1988, response to the October 20, 1988 Notice of Violation and Proposed Imposition of Civil Penulty (Notice) for the Quad Cities Stations, Units 1 and 2, Commonwealth Edison Company (CECO) aamits that it was unable to demonstrate that the AMP splices were environmentally qualified, based on the results of tu ting conducted at Ceco initiative in December 1986. The licensee , does not ag"ee that the documentation in its files as of December 6, 1986, was so inadequate that it should have clearly known that the AMP splices were not properly qualified in accordance with the DOR Guidelines by type testing and analysi s. The violation is restated below, followed by a summary of the licensee's i response, the NRC's evaluation, and the conclusion.

1. Restatement of Violation l 10 CFR 50,49(f) requires each item of electrical equipment important l to safety to be environmentally qualified by testing and/or analysis.

10 CFR 50.49(k) specifies that requalification of electrical equipment important to safety is not required if the Commission has previously , required qualification in accordance with " Guidelines for Evaluation l of Environmental Qualification of Class IE Electrical Equipment in Operating Reactors," November 1979 (00R Guidelines). 00R Guidelines, Section 5.2.2, states that type tests should only be consioered valid for equipment identical in design and material construction to the test specimen and any deviations should be evaluated as part of the qualification documentation. Contrary to the above, from November 30, 1985 until December 6, 1986, AMP nylon-insulated butt splices, used in numerous items of electrical equipment important to safety, were not properly environmentally qualified in accordance with 00R Guidelines by type testing. While a type test was done, the tested splices were not demonstrated to be identical to the installed AMP splices and this deviation was not evaluated as part of the documentation in the qualification file.

2. Summary of Licensee's Response CECO made a qualified admission that a violation of the requirements of 10 CFR 50.49 occurred, but Ceco argued that the imposition of the proposed civil penalty in this case is not consistent with the NRC's " Modified j

Enforcement Policy Relating to 10 CFR 50.49" (Modified Enforcement Policy), principally because the NRC's staff's finding that CECO " clearly should have known" that the AMP splices were not qualified is largely based on impermissible hindsight. In adoition, the licensee claimed that the pro-posed penalty is inconsistent with the Modified Enforcement Policy because I the NRC it penalizing Ceco twice by issuing identical violations for Dresden and Quad Cities; and that the amount of the penalty is unfair because Iowa Electric (Duane Arnolo) received a lower penalty of $50,000 for the same violation. The licensee stated that in the alternative, the amount of the proposed civil penalty should be reduced. This is because NUREG-0940 I.A-89

l l Appendix  ; i the analysis in the NRC staff's October 20, 1988 letter of the four mitigation I and escalation factors set forth in the Modified Enforcement Policy is  : flawed by the improper use of hindsight and by the failure to give any l credit to Ceco for its initiative in testing the AMP splices, i

3. NRC Evaluation of Licensee's Response 1

a. Hindsight In regard to hindsight, the licensee asks:

(1) Did the NRC Staff Expect the AMP Splices to Fail the December 1986 Tests 7 The NRC staff finds that considering whether it expected failures to occur during testing is not relevant to establishing whether the licensee clearly should have known of the AMP splice deficiency. The NRC staff concludes that the facts of the AMP splice issue, as detailed below, establish that. CECO clearly should have known of the splice qualification deficiencies. As documented in the Region III March 24, 1986 inspection, eighteen of three hundred Dresden Unit 2 splices were replaced in 1983 due to insulation embrittlement. In January 1985, further splice insulation degradation was observed in Dresden j Unit 2 and in October 1985, all splices in Dresden Unit 2 were l replaced due to embrittled insulation cracking and " falling off" when the splices were moved. The NRC's March 24, 1986 Inspection Reports No. 50-237/86006(DRS) and No. 50-249/86009(DRS) stated that the NRC was concerned that the AMP splices might have a shorter qualified life than calculated by the licensee and that future failures in Unit 3 could occur during plant operation. > E The intent of the March 24, 1986, limited inspection at Dresden Wds to review the licensee's imediate Corrective action in regard to the degraded AMP nylon splices in Unit 2. The documentation in the licensee's files et that time was confusing and not auditable. The inspectors identified EQ concerns and informed the licensee that a more detailed inspection would be performed during the upcoming NRC EQ team inspection in May 1986. The inspectors did not have any 1 mediate safety concerns' because (1) no degradation had yet been-identified in Unit 3; and (2) the licensee insisted that the installed splices were in fact identical in material and construction to the tested splices, and that they could demonstrate through additional documentation that the AMP splices were qualified. During the NRC team inspection at Dresden in May 1986, the staff concluded that the tested splices were not sufficiently similar to the installed butt splices to qualify them. Unit 3 was not operating and the licensee committed to resolve the qualification issues prior to startup. Later the licensee informed the NRC that NUREG-0940 I.A-90

Appendix similarity analysis qualified the splices prior to plant startup. This corrective action was to be re~ viewed by the NRC during a future inspection, as stated in the cover letter of NRC Inspection Reports No. 50-237/86013 and 50-249/86015. The licensee's corrective action was subsequently reviewed as part of an NRC inspection at Quad Cities Station during the period June 8, through .luly 28, 1987 and was found to be inadequate. If the MRC had reviewed this corrective action prior to the December 1986 tests, the NRC would hao required the licensee to follow the requirements of Generic Letter 86-15. In conclusion, a documented test and any necessary analysis was needed to determine if the AMP splices would perform as intended during an accident. Based on the inadequate documentation in the licensee's files at the time of the NRC Dresden EQ site inspections and based on the observed degradation of the splices . during 1983 through 1985 in Dresden Unit 2, the NRC staff concluded I there were significant questions as to whether these splices I were qualified and that the licensee clearly should have recogni::ed these questions. (2) If the AMP Splices Had Passed the Tests, Would the NRC Staff Now be Proposing a 5150,000 Civil Penalty? If the AMP splices had passed the tests, the enforceirent uaion. proposed in the Notice would have been the same. The NRC's policy l in the EQ area has been presented in Generic Letters (GL) 85-15 l and 88-07. Both GLs state that unqualified equipment means l equipment for which there is not adequate documentation to establish that such equipment will perform its intended functions l in the relevant environment. While in certain cases, the ability to quickly obtain documentation may result in a violation of reduced severity levels, this provision does not apply to testing. The NRC's position provided in GL 88-07 is that the results of testing done after deficiencies are identified would not be considered. The NRC staff's position is that 10 CFR 50.49 required licensees to assure that electrical equipment important to safety was qualified for its application prior to the November 30, 1985 deadline. Sufficient documentation to assure I qualification was required to be contained in the EQ file prior to the deadline. As such, testing conducted after identification of the deficiencies after the deadline ha no bearing on whether a violation occurred. The NRC identified this deficiency in March 1986 and again in May 1986. Even if the AMP splices had passed the December 1986 tests, the licensee had not demonstrated the splires to be qualified prior to the November 30, 1985 EQ deadline or during or shortly thereafter the NRC inspections of March and May 1986. Any subsequent testing or analysis whether demonstrating qualification or not does not affect the application of the Modified Enforcement Policy. NUREG-0940 1.A-91

r Appendix l

b. Application of the Clearly Should Have Known Test.

The licensee argues that it is not reasonable to conclude that it clearly should have known that its EQ documentation was inadequate prior to December 1986. The following facts refute its argument. (1) The licensee's response referenced previous NRC inspection findings (Inspection Report 50-254 and 50-265/78-25). The licensee asserted that those findings accepted the environmental qualification of AMP pre-insulated butt connectors (nylon window splices). While it is correct that the inspector reached that conclusion, the basis of his acceptance needs to be considered. The qualification of the splices was accepted based on statements i made in a General Electric letter dated April 28, 1978 and the i fact that the test configuration was in accordance with the guidance of IE Circular 78-08. However, that test configuration did not include exposure to radiation and steam environments simultaneously, which was subsequently required by the 00R Guidelines (issued as an attachment to IE Bulletin 79-018) to be included either during testing or by performing a separate analysis (testing combined with analysis). Therefore, after. issuance of the D0R Guidelines the licensee clearly should have recognized that the inspector's basis for acceptance of qualb fication was no longer necessarily valid. (2) In January 1985, the licensee identified degraded nylon AMP splices in Dresden Unit 2. In September 1985, severe degradation was identified in all remaining Dresden Unit 2 nylon AMP splices, such that all the s Shrink Tubing (HST)plices had to clearly The licensee be replaced shouldwith haveRaychem known Heat that qualification of these splices would need further review since 'they had degraded prior to their qualified life. Since the same splices were installed at Quad Cities the same questions should have been examined there as the NRC expects licensees to evaluate problems..at one site for applicability at others. With respect to this ahgument, the discussion in the Appendix to the Order Imposing Civil Penalty for violations of 10 CFR 50.49 occurring at Dresden Station, Unit 3, issued this same date, is incorporated herein. (3) The 00R Guidelines identify nylon as degradable, and as a material that has a potential for significant aging within ten years under normal operating conditions. The licensee qualified its equipment to D0R Guidelines in both Dresden and Quad Cities Stations, and clearly shculd have known that these splices were degradable and needed special attention during qualification. The GE F01 penetration test report I (R. M. Schuster, April 30,1971) on which Ceco relied to qualify the AMP nylon splice for radiation did not test the splices for radiation and did not test splices made by AMP. This matter was discussed in GE letter G-EB0-8-121 dated April 28, 1978. The AMP test report (No. 110-11004, February 1982) presented by the licensee to qualify the splices for radiation did not test any AMP nylon splices. Thus, the licensee cleurly did not h6ve valid EQ documentation to qualify these splices and did not NUREG-0940 I.A-92

Appendix perform adequate reviews to resolve the inadequacy of these documents. The GE F01 penetration test report and subsequent correspondence between GE and Ceco inoicated that GE did test a kind of nylon splice and that these splices did pass the test; l however, this test only qualified a nylon splice for an environment where radiation and steam were not present simul-taneously. The licensee should have known tnis test did not identify the formulation of the nylon tested and that the tests did not simulate the plant conditions at Quad Cities Station. Clearly, the licensee did not have vendor supplied documentation l in its EQ file that demonstrated that AMP splices were qualified. (4) A GE Series 100 penetration test report, as described in GE letter G-EBO-2-031 was submitted by the licensee during the enforcement j conference on June 5, 1987 and it was also discussed during the i Region III Quad Cities EQ inspection of June 8-12, 1987. The l I licensee argued that the Series 100 report, which was in the licensee's files before November 30, 1985, adequately addressed the NRC staff's concerns about the earlier AMP (No. 110-11004) and GE (R. M. Schuster, April 1971) test reports relating to radiation qualification and therefore demonstrated the qualifi- , cation of the installed splices. The licensee clearly should  ; have known that the existence of the report in its files prior 1 to November 30, 1985 did not demonstrate qualification of the installed splices. If prior to the deadline the licensee had adequately reviewed the references provided in the report, questions would have arisen concerning the' adequacy of the report. One such reference was a GE letter (GE-EB0-2-192 dated 9/7/82) that forwtrded to the licensee an electrical penetration environmental study, dated 8/27/82, conducted by GE for the Dresden and Quad Cities Stations. The list of components in this study identified shrinkable tubing and, under Note 2 listed as applic,able to this item, indicated that the tubing was used as a " cover for insulated spifce." The nylon splice vendors listed included AMP. It was not established which kind of splice used in production was actually tested and it appeared that the splice which had been tested had been protected from the harsh environment by the tubing (apparently intended to be installed on production penetration assembly splices as well). Thus, the tested splices were not only protected from some environmental degradation during testing, but also were prevented from causing electrical faults resulting from moisture intrusion or gross failure of their insulation under accident conditions. The splices installed in the penetrations in Quad Cities however, were unprotected. Based on the above facts, the NRC staff concludes the licensee clearly should have known the AMP splices were unqualified. NUREG-0940 1.A-93

j i Appendix c. Ceco Penalized Twice For A Single Alleged Violation The licensee argued that should the NRC staff conclude that Ceco clearly should have known of the violation, a civil penalty should not be proposed for Quad Cities because the identical issue was cited at Dresden. In the licensee's view the assessment of two civil penalties for identical violations at two separate facilities is inconsistent with the Modified EQ Enforcement Policy. The following shows that Ceco has not been penalized twice for a single alleged violation. Each CECO nuclear facility is separately licensed and is required to follow 10 CFR Part 50 regulations and the conditions of its license. Therefore, as a matter of law, a CECO facility would not be exempt from an escalated enforcement action simply because it could be shown that a similar or identical problem or violation had occurred at another Ceco facility. That the Dresden and Quad Cities EQ programs were largely developed independently leads the NRC staff to conclude that rather than one mistake this was the same mistake made twice. The NRC staff acknowledges that the licensee does have a corporate EQ engineering staff but the EQ staffs at the individual plants along with their consultants (Sargent and Lundy at Dresden and Bechtel and WESTEC at Quad Cities) made independent EQ decisions relating to the qualification of individual components and equipment. Furthermore, the Modified Enforcement Policy permits l separate enforcement actions for violations occurring at separate I facilities, whether these violations are independent or not. The Modified Enforcement Policy does not suggest that licensees are not responsible for identical violations occurring at two separate faci- i lities. In short, what the NRC found at the Dresden and Quad Cities i facilities was not a single violation, but two separate violations. l Therefore, having reviewed all the above considerations, the NRC staff concludes that separate violations and proposed civil penalties are appropriate.  !

c. Proposed Civil Penalty unfair Given the Civil Penalty Proposed in A Similar Case The licensee claimed that the $150,000 proposed penalty is unfair, given that Iowa Electric received a proposed civil penalty of only

           $50,000 for the same. violation. As with all enforcement actions, the nature of the particular violation merely establishes the severity level at which it will be considered.        Once the severity level is determined, the escalation and mitigation factors must be applied to the base civil penalty. Thus, given the same violation under different circumstances it is probable that a different proposed civil penalty will result.       Both the Quad Cities and the Duane Arnold enforcement actions were categorized as Category B violations under the Modified EQ Enforcement Policy. In the Quad Cities case, CECO was aware of the severe nylon AMP butt splice failures at Dresden Unit 2 carly in January 1985 which resulted in the Dresden Unit 2 splices being replaced in October 1985. In spite of this awareness, CECO did not question its EQ testing program or replace splices at NUREG-0940                              1.A-94

i I Appendix , Quad Cities Units 1 and 2. Iowa Electric, however, was not aware of the Dresden Unit 2 1985 splice failures, and when alerted to the AMP , test failures in December 1986. Iowa Electric imediately replaced l all AMP splices inside and outside the drywell at Duane Arnold,  ! including the AMP Kynar splices. (Kynar splices were later found to l' be also unqualified). Therefore, once Iowa Electric learned of the problem it was significantly more responsive to imediate safety concerns regarding its plant than CECO was when it first had reason-able indication of a problem. 4 Other Mitigation / Escalation Arguments The licensee questioned the NRC's failure to give credit to CECO for the corrective acttons taken, including taking the initiative in testing the AMP splices. The corrective actions mitigating factor, as defined in Generic Letter 88-07, places emphasis on (1) the time taken to make an operability or qualification determination; (2) the quality of any supporting analysis; and (3) the nature and extent of the Itcensee's efforts to come into compliance. The licensee's performance in the first two of these areas was unacceptable. Earlier in this Appendix the NRC staff established that Ceco should reasonably have known of the problem at Quad Cities and acted to correct it based on the NRC's concerns at Dresden. Although the licensee did take the initiative in testing the AMP splices, this was not fully accomplished untti more than a year after the EQ deadline for qualification. Moreover, Ceco tested the AMP splices only in response to the NRC's questions about qualification of the splices. 4 When the splices subsequently failed during testing, the corrective actions l necessary following this self-disclosing event were obvious. Additionally, j following the NRC inspection at Dresden, the licensee's efforts to come 1 into compliance by supporting its analysis were founc unacceptable and the NRC staff's concerns relating to the adequacy of the analysis were made known to the licensee at various times after the deadline. The licensee incorporated into its answer to the Notice other arguments regarding the mitigation and escalation factors that it made in its answer to the Notice of Violation and Proposed Imposition of Civil Penalty that the NRC issued to the licensee for violations at Dresden, Unit 3. With respect to these other arguments, such as the NRC considering this a minor documentation deficiency, the discussion in the Appendix to the Order Imposing Civil Penalty for violations of 10 CFR 50.49 occurring at Drescen Unit 3, issued this same date, is incorporated nerein. In sumary, although the extent and nature of the licensee's efforts to come into t.ompliance ultimately resulted in the problem being corrected, the NRC staff finds no basis for mitigation for corrective actions. In reevaluating the application of the mitigation and escalation factors in this case, the NRC has determined that escalation for the failure to identify the violation at Quad Cities is not appropriate. While the licensee's staff at Quad Cities should reasonably have identified the AMP splice problem well before Ceco's test made the problem self-evident, the NRC did not identify the AMP splice problem at Quad Cities. Accordingly, the NRC finds that neither escalation ner mitigation based on identification is warranted and the NRC's proposal to escalate the proposed civil penalty by 50% is withdrawn. NUREG-0940 1.A-95

Appendix 5. Conclusion This violation occurred as stated, and an adequate basis for withdrawing the violation has not been provided. After reconsidering the escalation and mitigation factors, it has been concluded that the previous escalation of the civil penalty by 50% because the licensee failed to identify the violation was inappropriate. Consequently, the proposed civil penalty in the amount of $150,000 should be reduced by 50% and a $75,000 civil penalty should be imposed. l NUREG-0940 I , A-96,

j me UeflTED STATES NUCLEAR REGULATORY COMMisslON I nemo= e.. E . .. ... v. o r .. oLaw attvn,et u mois e.:s,

                *****                                                         May 24, 1989
                                                                                                                                    )

Docket No. 50-454 License No. NPF-37 EA 88-266 Commonwealth Edison Company ATTN: Mr. J. J. O'Connor Chief Executive Officer Post Office Box 767  : Chicago, Illinois 60690 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRCINSPECTIONREPORTN0.50-454/88019(DRP)) This refers to our letter dated October 12, 1988, which forwarded the results of a special safety inspection conducted on September 19 through 28, 1988 to reviewthecircumstancessurroundingthelossofonetrainoftheresidueI heat removal system (RHR) while the water level in the reactor coolant system was being lowered on September 19, 1988. On October 21, 1988, we held an enforcement conference with members of your staff during which the apparent violations, the root causes and your corrective acti~ons were discussed. The inspection results show that when the event discussed above' occurred the unit was operated contrary to the requirements of 10 CFR Part 50. Appendix B, Criterion V, as implemented by Commonwealth Edison Company's Quality Assurance Manual, Quality Requirement 5.0, which requires that' activities affecting quality be prescribed by documented procedures of a type appropriate to the  ; circumstances. Byron Operating Procedure BOP RH-9, Revision 51A, " Pump Down of j the Reactor Cavity to the RWST " was inadequate in that it did not specifically i require the use of any means of Reactor Coolant System (RCS) level indication during draining of the reactor cavity below the reactor vessel flange. In addition, Byron Operating Procedure BOP RC-4a, Revision 51, " Reactor Coolant System Drain," which contains instructions for installation of'the tygon hose level indication system, was inadequate because it failed to ensure that the tygon 12 vel hose was an accurate indication 'of RCS level. i In a letter to ou dated October 4,1988, we described our concern that you  ! were apparently failing to factor previous industry lessons learned, transmitted  ! by NRC generic correspondence, into plant procedures and practices. In reply, you advised us that both your corporate and individual plant staffs routinely  ;' review generic correspondence to ensure that lessons learned from events are - l ovaluated for applicability and that a determination is made of whether actions 1 to preclude such occurrences are warranted at your facilities. However, Inform. tion Notices 86-01, 87-23, 87-46, and 88-36 as well as Generic NUREG-0940 I.A-97  ; _____j

Commonwealth Edison Company 2 May 24, 1989 Letter 87-12 address issues applicable to this event. Had you taken adequate action in response to those issuances, the loss of decay heat removal capability during low reactor coolant level operations may have been prevented. Further, it is evident that the plant operators were relying upon a makeshift procedure that had not been properly developed and reviewed. This event, therefore, represents a serious concern regarding your staff's ability to ensure the operability of safety-related systems. The NRC has considered your argument that the operators reasonably should not have been expected to recognize the phenomenon that caused the loss of RCS level. The NRC has concluded that how the loss of level occurred is not a primary concern in this case. Rather, there are two issues of immediate concern to the NRC based on the S'eptember 19, 1988 event. First, an undetected loss of level occurred and no matter what the reason for it, that is unacceptable. Further, the reliance on only direct visual indication to monitor RCS level did not provide for an accurate method of level indication had the RCS level decreased below the vessel flange for reasons as simple as the operator failing to or improperly securing the draindown. The need to consider and anticipate all possible scenarios as well as the need to maintain the availability of redundant indicators are concepts that are basic to safe plant operations. Moreover, it is of concern that your procedures required the availability of the tygon level hose as a prerequisite but then did not provide for its use. , l To emphasize the importance of ensuring that critical plant parameters and l systems are ;ontrolled in accordance with appropriate station procedures and that necessary corrective actions are taken in response to generic communica- l tions, I have been authorized, after consu tation with the Director, Office of 1 Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, , Safeguards and Operations Support, to issue the enclosed Notice of Violation l and Proposed Imposition of Civil Pentity in the amount of Fifty Thousand Dollars ' ($50,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13,1988) (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 although escalation for prior notice could have been applied, it was not, given that none of the previously cited generic issuances specifically address the type of problem under consideration here. Nevertheless, when those documents are considered in total, it is clear that the NRC expects careful RCS level control and monitoring in all situations. Additionally, as discussed above, had your staff taken edequate action in response to those issuances, this problem may have been prevented. 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-98

i Commonwealth Edison Company 3 May 24, 1989 l 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 10 CFR 2.790 of the Ocesttston's regulations, a copy of this letter, the enclosures, and your resphnse to this letter will be placed in the NRC Public Document Room. The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the#.0ffice of Management and Budget asrequiredbythePaperworkReductionActpf1980,PL96-511. Sincerely h ub 00

• A. Bert Davis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Inspection Report No. 50-454/88019(DRP) cc w/ enclosures:

T. J. Maiman, Vice President, l PWR Operations l H. Bliss, Nuclear Licensing Manager  ! R. Pleniewicz, Station Manager DCD/DCB (RIDS) Licensing Fee Management Branch Resident Inspector, RIII Byron Resident Inspector, RIII Braidwood D. W. Cassel, Jr., Esq. Richard Hubbard J. W. McCaffrey, Chief, Public Utilities Division Diane Chavez, DAARE/ SAFE L. Olshan, NRR LPM H. S. Taylor, Quality Assurance Division NUREG-0940 1.A-99

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Commonwealth Edison Company Docket No. 50-454 Byron Station Unit 1 License No. NPF-37 EA 88-256 As a result of an inspection conducted during the period September 19 through 28, 1988, a violation of NRC requirements was identified. In accordance with the

 " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR    l Part 2. Appendix C 53 Fed. Reg. 40019 (October 13,1988), the Nuclear Regulatory Comission propo.ses to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205.

The particular violation and associated civil penalty are set forth below: 10 CFR Part 50, Appendix B, Criterion V, as implemented by Commonwealth Edison Company's Quality Assurance Manual, Quality Requirement 5.0, requires that activities affecting quality be prescribed by documented procedures of a type appropriate to the circumstances. Contrary to the above, on September 19, 1988, it was determined that activities affecting quality were not adequately prescribed by documented procedures of a type appropriate to the circumstances, as noted by the following examples: (1) Byron Operating Procedure BOP RH-9, Revision 51A, " Pump Down of the Reactor Cavity to the RWST," was inadequate in that it did not specifically require the use of any means of Reactor Coolant System (RCS) level indication during draining of the reactor cavity below the reactor vessel flange. While the procedure specified that the operator " ENSURE that the tygon hose connection, for RCS level indication, is in place," it did not require that the tygon hose, or any other means of level indication, be utilized during the drain down process. (2) Byron Operating Procedure BOP RC-4a, Revision 51, " Reactor Coolant System Drain," which contains instructions for the installation of the tygon hose level indication system, was inadequate in that it did not provide appro-priate guidance for ensuring that the tygon hose was an accurate indication of RCS level, such as verifying that the hose was installed vertically, that there were no loop seals, or that the elevation markings were accurate. This is a Severity Level III violation (Supplement I). (454/88019-01(DRP)) Civil Penalty - $50,000. Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company, is hereby equired to submit a written statement or explanation to the Director, Office f 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: NUREG-0940 I.A-100

Notice of Violation 2 (1) admission or denial of the alleged violation; (2) the reasons for the violation if admitted; (3) the corrective actions that have been taken and the results achieved; (4) the corrective actions that will be taken to avoid further violations; and (5) the date when full compliance will be achieved. 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 affimation. Within the same time as provided for the resphnse required under 10 CFR 2.201, the Licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty p'roposed above, or may protest imposition of the civil penalty

                                                                                                                                 )

in whole or in part by a written answer addressed to the Director, Office of l Enforcement, U.S. Nuclear Regulatory Commission. l 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 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., 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 provision of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant tc Section 234c of the Act 42 U.S.C. 2282c. The respenses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, NUREG-0940 1.A-101

i i

                                                    ~

Notice of Violation 3  ! j l U.S. Nuclear Regulatory Consission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region III U.S. Nuclear Regulatory Consission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137 and a copy to the NRC Inspector at Byron. l FOR THE NUCLEAR REGULATORY COMMISSION oh & A. Bert Davis Regional Administrator Dated t Glen Ellyn, Illinois this day of May 1989 l l l NUREG-0940 I.A-102

UNITED STAf ts i [po neo o NUCLEAR REGULATORY COMMisSloN  ! p

                 ,                           REGION ll a                 g                    101 MARIETTA STREET.NN.

o ATLANTA,OGORGIA 30333 %....*/ APR11less I Docket Mos. 50-269, 50-270, and 50-287 - l License Nos. DPR-38, DPR-47, and OPR-55 ' EA 89-32 Duke Power Company ATTN: Mr. H. 8. Tucker, Vice President Nuclear Production Department 422 South Church Street Charlotte, North Carolina 28242 Gentlemen: 4

      $UBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (INSPECT NN REPORT NOS. 50-269/88-35,50-270/88-35AND50-287/88-35)

This refers to the Nuclear Regulatory Comission (NRC) inspection conducted at the Oconee Nuclear Plant on December 17, 1988 - January 16, 1989. The inspec-tion included a review of the circumstances surrounding the inoperability of :. the Reactor Building Cooling Unit (RSCU) dropout plates. The report documen6 ing this inspection was sent to you by letter dated February 3,1989. As a result of this inspection, a significant failure to comply with NRC regulatory requirements was identified, and accordingly, NRC concerns relative to the ) inspection findings were discussed in an Enforcement Conference held on February 10, 1989. The letter summarizing this Conference was sent to you on February 22, 1989. The violation described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty involved failure to maintain two independent reactor building cooling unit trains operable under required conditions. RBCU fusible linked dropout plates on Unit I failed testing on January 6-7,- 1989, while Unit I was in a refueling outage. On January 7, 1989, the RBOUs for all three units were declared inoperable due to failure of the fusible link dropout plates to perfonn as described in the facility's Safety Analysis  ! Report. Subsequently, you detennined that a dropout plate on Unit I had metal 1 links installed instead of the required fusible links, which would negate the ability of the plate to drop out if called upon. Apparently, problems with dropout plates had existed since initial operation of each of the three Oconee units. As your staff noted during the Enforcement Conference, the underlying  ! cause of this violation of Technical Specifications was failure to perform 1 functional verification tests and failure to conduct periodic inspection or j maintenance to ensure operability of the dropout plates. ' To emphasize the need for testing and maintenance to assure the availability of safety systems if called upon, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Matericls Safety, Safeguards, and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) in the amount of Twenty-Five Thogsand Dollars ($25,000) for the violation described in the enclosed Notied. In accordance with the " General Statement NUREG-0940 I.A-103

Duke Power Company gg g g of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, t 53 Fed. Reg. 40019 (October 13, 1988) (Enforcement Policy), the violation described in the enclosed Notice has been categorized as a Severity Level III violation. 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. Mitigation for identification was deemed inappropriate because the NRC staff concluded that this problem should have been identified earlier. Once you identified the violation, your corrective actions to prevent recurrence were prompt and comprehensive justifying 50 percent mitigation of the base penalty. In that regard we are encouraged by your recognition of the need to have further attention focused on the more subtle design features of Oconee and your i continued effort to more clearly understand the design basis and address associated problems. Your good past overall performance justifies a reduction of 100 percent of the base civil penalty. However, the full mitigation which would have been applied for these factors is offset by escalation for the added I significance r'esulting from the duration of the violation. The violation has l existed since initial operation and given the system's unique design; the need  : to periodically test and maintain the system is apparent. Therefore, 100 percent I escalation of the base penalty is warranted for its duration. On balance, the base penalty has been mitigated 50 percent to $25,000. ' You are required to respond to this letter and the enclosed Notice and should follow the instructions specified therein when preparing your response. In  ! your response, you should document the specific actions taken and any additional j 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 enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and 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, Public Law No. 96-511. Sincerely, Stewart D. Ebneter Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl: M. S. Tuckman, Station Manager State of South Carolina NUREG-0940 I.A-104

NOTICE OF VIOLATION AND PROPOSED IMPOSITIUN~0F CIVIL PENALTY Duke Power Company Docket Nos. 50-269, 50-270, 50-287 Oconee Nuclear Plant License Nos. DPR-38, DPR-47, DPR-55 Units 1, 2, 3 EA 89-32 During the Nuclear Regulatory Comission (NRC) inspection conducted on December 17, 1988 - January 16, 1989, 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, 53 Fed. Reg. 40019 (October 13,1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below: Technical Specification (TS) 3.3.5b(1) requires when the Reactor Coolant System (RCS) with fuel in the core is in a condition with pressure equal to or greater than 350 psig or temperature equal to or greater than 250 degrees F and subcritical that two independent reactor building cooling - (RBC) trains, each comprised of an RBC fan, cooling unit and associated; Engineered Safety Features (ESF) valves shall be operable. > TS 3.3.5c(1) requires that when the reactor is critical, in addition to the above requirements, the remaining RBC fan, associated cooling unit and ESF valves shall be operable. Contrary to the above, it was discovered on January 7, 1989, that all of the fusible linked dropout plates on the Reactor Building Cooling Unit (RBCU) ductwork would not perform their intended function if required. l The units had each operated, since licensing, in all operational l conditions with the plates inoperable. Under certain analyzed accident conditions, the failure of these plates to drop free of the ductwork j would render the RBC system inoperable. ' This is a Severity Level III violation (Supplement I). Civil Fenalty - $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 Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include: (1) admission or denial of the violation. (2) the reasons for the violation if admitted. (3) the corrective steps that have been taken and the results achieved. (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified l 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 thd'" authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affinnation. NUREG-0940 I.A-105

Notice of Violation Within the same time as provided for the response required above under i 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above or 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 j the Licensee fail to answer within the time specified, an order imposing the i 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 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 factors addressed in { Section V.B of 10 CFR Part 2, Appendix C, should be addressed. Any written l 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 1 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, remit-ted, 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 the Regional Administrator, Region II and a copy to the NRC Resident Inspector, Oconee Nuclear Plant. j FOR THE NUCLEAR REGULATORY COMMISSION  ! Stewart D. Ebneter l Regional Administrator  ! Dated at Atlanta, Georgia this / /V/t day of April 1989 NUREG-0940 I.A-106

ja** " At UNITED STATES l g ' *; NUCLEAR REGULATORY COMMISSION  ;

:I nsaion w k.%,

s11 MYAN PLAZA oRtVE, SUITE 1000 Anuwarou.rixAs mti i MAR I T 1989 1 l Docket No. 50-498 J License No. NPF-76 EA 89-01 l Houston Lighting & Power Company , ATTN: J. H. Goldberg, Group Vice  ! President, Nuclear l Post Office Box 1700 Houston, Texas 77001 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-498/88-73 & 50-499/88-73) This is in reference to a Nuclear Regulatory Commission (NRC) inspection conducted November 1-30, 1988, at Houston Lighting & Power Company's South Texas Project (STP) nuclear power plant, to HRC's discussions with HL&P i officials at an enforcement conference in our offices on January 26, 1989, l and to additional discussions between HL&P and NRC officials following the i enforcement conference. On November 29, 1988, HL&P reported that it had discovered that vortex i suppressors (stainless steel gratings) had not been installed, although they i had been relied upon in the design of the STP Unit I containment building e:nerency sumps. The discovery of this apparent violation of NRC requirements resulted in HL&P declaring a Notification of Unusual Event, a declaration that the emergency cooling subsystems that relied on these suppressors were inoperable and the initiation of an orderly shutdown cf STP Unit 1, which was operating at the time.  ; The fact that'the vortex suppressors were missing is viewed as significant. l They were relied upon in the design of the plant to prevent vortexing from occurring under specific emergency conditions during which the safety injection or containment spray pumps would draw cooling water from the containment emergency sumps. Should vortexing occur, degradation of pump performance could i CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 1.A-107

i MAR I T 1989 Houston Lighting & Power Company occur because of air ingestion and these important safety systems could be degraded. Not only did HL&P take credit for the suppressors in the plant's Final Safety Analysis Report (FSAR), but also took credit for them in a request to NRC to dispense with certain startup tests of the safety injection and containment spray systems. In the NRC's view, the significance of this matter is increased by the recognition that the intended location of these devices, if not installed in accordance with the FSAR, greatly reduced both the opportunity to discover and the likelihood of discovering the fact they were missing. HL&P stated during the enforcement conference that under no circumstances  ; would pump degradation significant enough to prevent system functioning have occurred. The NRC determined that HL&P's preliminary conclusions were based on a number of non-conservative assumptions and therefore the NRC concluded that the HL&P position had not adequately been supported by analysis. Additional analysis, performed for HL&P by consultants using different methodology, reached a conclusion similar to that originally arrived at by HL&P. Further assessment of this problem by the NRC leads us to conclude that it is unlikely that a full loss of system function would have resulted from the failure to have the vortex suppressors installed. We further conclude that a degradation , rather than a loss of safety function would have occurred had these safety ' systems been called upon to draw water from the emergency sumps. Nevertheless, a significant violation of NRC requirements occurred and it is only fortuitous that it did not result in loss of a safety function. In accordance with the

  " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR                       l Part 2, Appendix C (1988) (Enforcement Policy), the violation described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) has been classified at Severity Level III.

To emphasize the importance of verifying that equipment that is relied upon in the design of the. plant is in fact installed and available, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Materials Safety, Safeguards and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of I Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violation described in the enclosed Notice. The base value of a civil penalty for a Severity Level III violation is $50,000. The NRC Enforcement Policy allows for increasing or reducing a civil penalty under certain circumstances. In this case, no adjustment of the base civil penalty was deemed appropriate. The NRC recognizes that HL&P discovered this condition, reported it to NRC and implemented prompt and extensive corrective actions. Because HL&P took credit for the suppressors in the plant's Final Safety Analysis Report and in a request to the NRC to dispense with certain startup tests of the safety injection and containment spray systems, it should have been aware that the suppressors were not installed. For that reason miti-gation for your identification and corrective action was offset by the duration of the violation. It should be noted that the NRC is concerned that your certification of the readiness of the plant to operate has been shown in this case to have been inaccurate. We wish to make it known that such statements could, under certain NUREG-0940 I.A-108

MAR l T 1989 Houston Lighting & Power Company circumstances, constitute a violation of the " accurate and complete information" requirement of 10 CFR 50.9, and we wish to emphasize that any inaccurate information provided to the NRC in the future may result in a violation and appropriate enforcement action. 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, c (H Robert D. Martin Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty ec: See attacheo i NUREG-0940 I.A-109

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Houston Lighting & Power Company Docket No. 50-498 South Texas Project, Unit 1 License No. NPF-76 Bay City, Texas EA 89-01 During a Nuclear Regulatory Commission (NRC) inspection conducted November 1-30, 1988, a violation of NRC requirements was identified. In accordance with the

                                                                        " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below:

10 CFR Part 50, Appendix B, Criterion III, Design Control, requires, in part, that measures be established to assure that the plant design basis is correctly translated into specifications, drawings, procedures, and instructions. Contrary to the above, adequate measures had not been established to assure , the plant design basis was correctly translated into specifications, drawings, l procedures, and instructions in that the vortex suppression devices which are a part of the plant design basis as described in Section 6.2.2 of the Final Safety Analysis Report were not installed. This condition existed from March 1988, when the plant achieved initial criticality, to November 1988, when the licensee discovered the suppression devices had not been installed. This violation has been classified as a Severity Level III violation (Supplements). Civil Penalty - $50,000 Pursuant to the provisions of 10 CFR 2.201, Houston Lighting & Power Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a

                                                                       " Reply to a Notice of Violation" and should include for each alleged violation:

(1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved (4) the corrective steps that will be taken to avoid further violations,and(5)thedatewhenfullcompliancewillbeachieved. If an adequate reply is not received within the time specified in this Notice, an  ; order may be issued to show cause why the license should not be modified, d suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S C. 2232, this response shall be submitted under oath or affirmation. I NUREG-0940 1.A-110 1 b

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 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, in whole or in part by a writter 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 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 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 penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, , should the factors addressed be addressed. Any in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing l page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due which subsequently has been determined l 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, l remitted, 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 civil penalty and answer to a i 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 if applicable, a copy to the NRC Resident Inspector, at the South Texas Project. FOR THE NUCLEAR REGULATORY COMMISSION h k hZt ~ Robert D. Martin Regional Administrator Dated at Arlington, Texas, This 17th day of March 1989. NUREG-0940 I.A-111

s

                   !(p*
                     +
                            *sa og-o UNITED STATES NUCLEAR REGULATORY COMMISSION
                   .              j                       wAsHmcTom, o. c. rosss
                   \,*****/

JUN 3 61999 Docket No. 50-498 License No. NPF-76 EA 89-01 Houston Lighting & Power Company i ATTN: J. H. Goldberg, Group Vice i President, Nuclear Post Office Box 1700 Houston, Texas 77001 Gentlemen: j

SUBJECT:

WITHDRAWAL OF PROPOSED CIVIL PENALTY This refers to your letter dated April 12, 1989 in response to the Notice of I Violation anc Proposed Imposition of Civil Penalty sent to you by our letter deteo March 17, 1989. Our letter ano Notice discussed HL&P's failure to install vortex suppressors in the South Texas Project Unit I containment emergency sumps. To emphasize the importance of verifying that equipment relied upon in the design of the plant is in fact installed and available, a civil penalty of Fifty Thousand Dollars ($50,000) was proposed. In response, HL&P admitted that a violation of NRC requirements occurred but stated that the violation was improperly classified at Severity Level III. HL&P also sought mitigation of the proposed penalty on grounds that the NRC failed to give adequate consideration to HL&P's good performance in the functional area of quality assurance and that the NRC gave undue consideration to the duration of the violation. Af ter considering your response we have concluded that a violation of 10 CFR 1 Part 50, Appendix B, Criterion III did occur and that it was properly categorized  ! at Severity Level III. While the NRC agrees that other criteria of 10 CFR  ; Part 50, Appendix B, such as Criterion VI may also have been violated, it stands by the determination that Criterion III was violated. In particular, the l architect engineer's failure to distribute the crawings to the implementing organization is seen as the final step of the design centrol process, whicn is covered by Criterion III. If the crowing had been provided to the imple-menting organization, then the failure to ensure the drawings "are distributed to and used at the location where the prescribed activity is performed" woulo be a violation of Criterion VI. With regard to the severit.y level of the violation, the NRC did not base it primarily on the actual safety significance as determined by an after-the-fact analysis but on the regulatory significance of failing to install devices, which were relied upon in the design of the plant, without prior assurance that their absence would not adversely impact safe operations. The NRC considers HL&P's failure in this case to be significant in that HL&P in designing the plant, relied upon the vortex suppressors to assure the operation of important safety-systems under specific emergency conditions. Moreover, HL&P took creoit for the vortex suppressors during the licensing process. - NUREG-0940 1.A-112

Houston Lighting & Power Company' Even if the NRC accepts HL&P's position today that the suppressors were not necessary and that no safety systems would have been adversely affected by their absence, the NRC cannot ignore the irrportance of f ailing to install them in the first place. The NRC considers this violation "cause for significant concern" in accord with the general description of Severity Level III violations in the Enforcement Policy and finos its significance is on a par with other examples of Severity Level III violations in the supplen:ents to the Policy. Further, had HL&P not been able to demonstrate the low actual safety significance of the failure to Install the vortex suppressors, the NRC would have considered a Severity Level 11 violation for a system designed to mitigate serious safety events being unable to perform its intenced function. Thus, the NRC acheres to its original position that the violation is of significant concern and properly categorized at Severity Level III. After considering HL&P arguments for mitigation of the civil penalty the NRC finds they have merit. With regard to past performance the NRC agrees that too little consideration was given to HL&P's performance in construction and quality assurance activities. With regard to the application of the duration factor, the NRC acknowledges that, based on the information provided efter the problem was discovered, the failure to install the vortex suppressors did not result in a condition of high actual safety significance, with respect to the operability of plant equipment. Therefore, notwithstanding the signi-ficance of the initial failure the NRC agrees that escalation of the civil penalty because of duration is not warranted. Baseo on the above considerations, the NRC concludes that full mitigation of the civil penalty is appropriate. In sunrnary, the NRC concludes that a Severity Level III violation of 10 CFR Part 50, Appendix B, Criterion III occurred but that the proposed civil penalty should be withdrawn af ter reconsidering the past performance and duration adjustment factors. Your corrective actions will be examined during future inspections. In accorodnce with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Coce of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room. Sincerely, fl H - James Liebernian, Director Office of Enforcement cc: See Service List NUREG-0940 I.A-113

p **c u, / + C, UNITED ST ATES ! [' ei [k NUCLEAR REGULATORY COMMIS$10N REGION 1

   % ' wa                                         /                           475 ALLENDALE ROAD             '
                           *****                                                       PENNSYLV ANIA 19406 KING OF PRUSSIA,13,1989 March Docket No.            50-333 License No. OPR-59 EA 88-304 New York Power Authority James A. FitzPatrick Nuclear Power Plant ATTH: Mr. John C. Brons Executive Vice President Nuclear Generation 123 Main Street                                                             I White Plains, New York 10201 Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (INSPECTION NO. 50-333/88-23 AND 50-333/88-17)- This refers to two NRC inspections conducted on August 8 - October 5, 1988 and October 6 - November 25, 1988 at the FitzPatrick Nucle'ar Power Plant, Lycoming, New York, of activities authorized by NRC License No. DPR-59. The inspection reports were forwarded to you on November 3,1988 and December 20, 1988, respectively. During the inspections, the NRC reviewed the circumstances associated with the inoperability of the ECCS pump room unit coolers, as well as the operation of the reactor with service water temperature in excess of the design limits. As a result of these inspections, five violations of NRC requirements were identified. The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), were discussed at an enforcement conference held with you and other members of your staff on January 13, 1989. The first three violations set forth in the enclosed Notice involve the inoperability of the ECCS unit coolers for an undetermined period of time prior to October 1988, because of reduced or totally impeded cooling flow in the coolers and the failure to detect the deficiency during periodic surveil-lance tests. Although the surveillance procedure was periodically performed, the procedure was inadequate because it did not verify the coolers' ability to perform their intended safety function. Specifically, the procedures did not require a determination of the heat removal capacity of the units. NRC concern regarding the inoperability of the coolers is heightened because of your failure to take corrective action based on information which indicated a significant operability issue. Specifically, a report prepared by a contractor in July 1987 identified that the cooling coil cores in the units may have been obstructed, and a subsequent review of this report by your Mechanical Design and Analysis Group in January 1988 confirmed this finding. Nevertheless, the CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 I.A-114

New York Pc er Authority I operability of the coolers was not evaluated and appropriate corrective actions were not taken until October 1988, following plant shutdown for a refueling l outage. The two other violations, which are set forth in the enclosed Notice, involve operation of the reactor in a condition outside those set forth in the Final Safety Analysis Report (FSAR) without (1) having completed a written safety evaluation to assure that this condition did not create an unreviewed safety question, and (2) without notifying the NRC Operations Center of this condition. Specifically, the reactor operated at power for approximately two weeks in August 1988 with inlet service water temperature exceeding the design limits assumed in the FSAR. These violations represent a significant failure to ensure (1) the timely and systematic evaluation of plant operational conditions, to ensure that the facility is operated in accordance with the technical specifications and trithin the design limits set forth in the FSAR; and (2) proper coordination and communication is exercised throughout your organization to ensure that safety issues are promptly identified and corrected. To emphasize the need to improve performance in these areas I have been authorized, after consulta-tion with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Seventy-Five Thousand Dollars ($75,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy I and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (Enforcement Policy) (1988), the violations described in the enclosed Notice have been f.ategorized as a Severity level III problem. The base civil penalty for a Severity Level III problem is $50,000. The NRC escalated the civil penalty based on these multiple examples of a failure to adequately disposition potential safety issues. Escalation for prior r,otice tras also considered but since those concerns were previously considered in the NRC's assessment of the significance of the violations, and assignment of severity level, further escalation for prior notice was deemed inappropriate. Nevertheless, because you did have significant prior notice it warrants restate-ment. As discussed earlier, prior notice of the problem with the coolers was provided by a contractor's report which was subsequently reviewed by your Mechanical Design and Analysis Group. In the case of the elevated service water temperatures, prior notice was provided 'n NRC Information Notice 87-65

                               " Plant Operation Beyond Analyzed Conditions." Additionally, given the wide-spread nature of the elevated service water temperature problem in the summer of 1988, including your Indian Point 3 facility, the NRC staff concludes that you should have been aware of the potential for a problem at FitzPatrick. The other factors set forth in the policy were also considered, and no further adjustment to the civil penalty 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 NUREG-0940 I.A-115

New York Power Authority I plan to prevent recurrence. Your response should also describe the actions you have taken or plan to take to assure safety issues are identified and . resolved in a timely. manner. After reviewing your response to this Notice, I 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. j In accordance with 10 CFR 2.790 of the NRC's " Rules and Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be plac,ed in the NRC's Public Document Room. 1 The responses directed by this letter and accompanying Notice are not subject I to the clearance procedures of the Office of Management and Budget as required  ; , by the Paperwork Reduction Act of 1980, PL 96-511. i William T. Russell Regional Administrator

Enclosure:

I Notice of Violation and Proposed i Imposition of Civil Penalty  ; i cc w/ enc 1: l J. Phillip Bayne, President A. Klausmann, Senior Vice President - Appraisal and Compliance Services R. L. Patch, Quality Assurance Superintendent George M. Wilverding, Manager Nuclear Safety Evaluation Gerald C. Goldstein, Assistant General Counsel R. E. Beedle, Vice President Nuclear Support S. S. Zulla, Vice President Nuclear Engineering R. Burns, Vice President Nuclear Operation Dept. of Public Service, State of New York State of New York, Department of Law Licensing Project Manager, NRR Public Document Room (PDR) Local Public Document Room (LPDR) Nuclear Safety Infomation Center (NSIC) NRC Resident Inspector State of New York NUREG-0940 I.A-116

l I NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY . 1 New York Power Authority Docket No. 50-333 FitzPatrick Nuclear Power Station License No. OPR-59 EA 88-304 During NRC inspections conducted on August 8 - October 5,1988 and October 6 - l November 25, 1988, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Action," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose 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: I. VIOLATIONS ASSOCIATED WITH INOPERABLE ROOM COOLERS A. Technical Specification Limiting Condition for Operation (LCO) I 3.11.B requires that crescent area ventilation and cooling equipment shall be operable on a continuous basis whenever certain Emergency Core Cooling System (s) (ECCS) are required to be operable in accordance with Technical Specification LC0 3.5.A, 3.5.B and 3.5.C. Further, if more than one unit cooler serving ECCS components in the same compartment are made or found to be inoperable, all ECCS components in that compartment shall be considered to be inoperable, and appropriate action shall be taken in accordance with Technical Specifications 3.5.A, 3.5.C, or 3.5.D to place the reactor in the cold shutdown condition within 24 hours. Contrary to the above, for an indeterminate period of time prior to October 1988, more than one crescent area unit cooler serving the  ! ECCS components were inoperable in each of the two compartments because of inadequate heat transfer capability; however, the affected ECCS components were not declared inoperable and action was not taken to shut down the reactor within 24 hours. B. Technical Specification Surveillance Requirement 4.11.B requires that )' the crescent area unit coolers be checked once every three months to verify their ability to perform their intended function. Contrary to the above, the tests of the crescent area unit coolers performed prior to October 1988 were inadequate to verify that the unit coolers would perform their intended safety function. The tests were inadequate in that they only ensured that the fans were operating and the filters were not clogged, but did not verify that the coolers had adequate cooling water flow to ensure that the capability existed for removing their design heat load from the crescent areas during certain design basis accidents. NUREG-0940 1.A-117 l l

NOTICE OF VIOLATION i l C. 10 CFR Part 50, Appendix 8, Criterion XVI requires, in part, that measures shall be established to assure that conditions adverse to , quality are promptly identified and corrected. Contrary to the above, in July 1987, a report of a ventilation study of unit cooler rooms performed by Flakt, Inc. a licensee contractor, indicated th.at service water flow to the reactor building crennt area unit coolers may have been obstructed, and the licensee's Mechanical Design and Analyses Group confirmed this finding in January 1988; however, as of October 1988, action had not been taken to correct this problem. II. VIOLATIONS ASSOCIATED WITH EXCESSIVE SERVICE WATER TEMPERATURE A. 10 CFR 50.59(a) allows the holder of a license to make changes in the facility as described in the safety analysis report (SAR) l without prior Commission approval unless it involves a change in the Technical Specifications or an unreviewed safety question. 10 CFR 50.59(b) requires, in part, that records of these changes be main-tained, and these records shall include a written safety evaluatiot which provides the basis for the determination that the change doep not involve an unreviewed safety question. E Section 6.5.1 of the Fitzpatrick Final Safety Analysis Report (FSAR) lists the assumptions used to calculate the suppression pool tempera-ture and minimum containment pressure following the design basis LOCA, and states that the maximum assumed inlet temperature for safety related service water systems is 77'F. l l Contrary to the above, between August 3-17, 1988, a change was made to the facility as described in the FSAR in'that the reactor was operated when the safety related service water inlet temperature was above 77'F (as high as 79.5'F), and prior to or during that time, a written safety evaluation did not exist to verify that the condition did not involve an unreviewed safety question. B. 10 CFR 50.72(b)(ii)(B) requires, in part, that the licensee shall i notify the NRC Operations Center within one hour of any event or condition during operation that results in a condition that is outside the design basis of the plant. Contrary to the above, between August 3-17, 1988, the reactor operated in a condition outside the design basis of the plant (as set forth in Violation II. A above), and during that time, the NRC Operations Center was not notified of this condition. Collectively, the violations set forth above have been categorized in the aggregate as a Severity Level III problem. (Supplement 1) Civil Penalty - $75,000 (Assessed equally among the violations) NUREG-0940 I.A-118

1 l l l NOT]CE OF VIOLAT10W ) Pursuant to the provisions of 10 CFR 2.201, Power Authority of the State of l New York is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within j 30 days of the date of this Notice. This reply should be clearly marked as a l

                                       " 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 vio-lation 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 viola-tions, 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. Consi-deration 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 may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, 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 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) demonstate extenu-ating 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 (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provision of 10 CFR 2.205 regarding the procedure for imposing a civil penalty. 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 I 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-119

N0ilCE OF VIOLATION l l The responses to the Director, Office of Enforcement, noted above (Reply to a i Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406 and a copy to the NRC Resident Inspector, at FitzPatrick. FOR THE NUCLEAR REGULATORY COMMISSION l { William T. Russell Regional Administrator Dated at, King of Prussia, Pennsylvania this/3Mday of March 1989 l I l C i l l NUREG-0940 I.A-120

2 y[ )og UNITED STATES y v g NUCLEAR REGULATORY COMMISSION { REGION i 475 ALLENDALE ROAD

           /                    KING OF PRUSSIA, PENNSYLVANIA 1s406 April 21, 1989 Docket Nos. 50-245 and 50-336 License Nos. DPR-21 and DPR-65 EA 88-254 Northeast Nuclear Energy Company ATTN:      Mr. E.~J. Mroczka Senior Vice President - Nuclear                                                                     ,

Engineering and Operations Group i Post Office Box 270 i

                                                         #                                                        I Hartford, Connecticut 06141-0270 Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Combined Inspection Reports Nos. 50-245/87-17; 50-336/87-15; and 50-245/88-14; 50-336/88-20; and 50-245/85-30; and 50-336/85-35) This refers to the NRC inspections conducted on November 18-22, 1985, July 15-17, 1986 and August 16-19, 1988 to review the program for the envi-ronmental qualification (EQ) of equipment at Millstone Units 1 and 2. The inspection reports were sent to you on April 15, 1986, November 19, 1987 and October 14, 1988, respectively. During the inspections, violations of NRC requirements which were identified by your staff involving the lack of quali-ficatiun of certain items of electric equipment used in both units, were also reviewed. On November 9, 1988, en enforcement conference was conducted with you and members of your staff to discuss the significance and extent of the violations, causes of the violations, and the corrective actions taken or planned. Further, the enforcement considerations set forth in Generic Letter 88-07 were also considered. One of the violations, which is described in Section I of the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), consists of examples of failure to maintain, for certain items of electric equipment, a file of documentation to demonstrate that the items were qualified to perform their intended function (s) during the postulated environmental conditions. These items, which were identified by your staff, included PE/PVC cables, General Electric EB-5 terminal blocks, Honeywell microswitches and 3M Scotch-lock wire nuts associated with the Standby Gas Treatment System (SGTS) in Unit 1 and Ideal, Model 74B, wire nuts on the termination of one ASCO solenoid valve which controls the atmospheric steam dump valve on Unit 2. The SGTS components are required to operate in a high radiation environment during j I postulated accident conditions. The items were unqualified in that the SGTS components were never tested for the harsh environment nor the material analyzed to determine its ability to withstand high radiation without substantial  ; degradation. Further, the documentation in the qualification file did not . support qualification of the Ideal, Model 74B, wire nuts for operability in a l high energy line break (HELB) environment of 320F peak temperature. j l NUREG-0940 I.A-121 i J

l Northeast Nuclear Energy Company }

   ' These deficiencies clearly should have been known to you prior to November 30, 1985. With respect to the SGTS components, you clearly should have known of these deficiencies because the high radiation field associated with the internal.
   ' filter was a design feature of the original equipment and should have been a consideration for material selection. The basis for the NRC staff's acceptance of the qualification of the SGTS, which was described in your various submittels, was our understanding based on those submittals, that the modifications made to the reactor building isolated the SGTS from the EOCA and HELB environments. In the staff's view such harsh environments clearly include radiation considerations.

The fact that a data table supplied in one of the submittals contained information that conflicted with the statements the NRC staff relied on in accepting the SGTS does not alter our conclusion. In fact, the existence of the conflicting infor-mation supports the NRC staff's position that you clearly should have known of the deficiencies. It is understandable that an NRC reviewer might not identify the problem of the conflicting data given the general statements previously made, while the document preparer should have identified the problem because the data conflicted with his conclusion. I

  ' With respect to the Ideal wire nuts (Model 74B), you clearly should have known of the deficiency because the associated solenoid valves were required to be environmentally qualified and in order to maintain that qualification replace-ment parts should have been verified as acceptable for the environment in which they are to be used. Further, given that the associated solenoid valves were specifically replaced for EQ considerations in the 1979-80 time period it is reasonable to expect that replacement instructions would have assured qualification of the valves and interfaces were maintained.

The NRC staff considered your argument that the installation of the unqualified wire nuts is a maintenance procedure problem rather than an EQ deficiency. It is the NRC staff's position that EQ is not solely an engineering function. , Rather, when the failure to properly install or maintain a piece of equipment can adversely affect the equipment's qualification., an EQ deficiency. exists. While a flawed procedure was the reason that unqualified wire nuts were installed { in this particular instance, the fact the procedure was not properly reviewed  ! with respect to FC makes this an EQ deficiency.  ! i Further, it was reasonable to expect that a licensee would perform field i

 ~     verification for electrical equipment, including the SGTS components and the Ideal Model 74B wire nut terminations for the ASCO solenoid valve, to assure         l 4

proper qualification and installation. This violatior demonstrates that sufficient attention was not provided to the EQ program at Millstone, as evidenced by the inadequate engineering review of the SGTS and inadequate Quality Control of these activities. Accordingly, I have been authorized, after consultation with the Director of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support to issue a proposed civil penalty in the amount of Fifty Thousand Dollars ($50,000) for Violation I described in the enclosed Notice. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49," (Modified Policy) contained in Generic Letter 88-07

• (Enclosure 2), Violation I has been detemined to be small and to have affected a few systems and components, and therefore is considered to be an EQ Category C violation. The base value of a civil per.alty for an EQ Category C violation is $75,000.

NUREG-0940 I.A-122

I Northeast Nuclear Energy Company fn determining the civil penalty amount, the NRC considered the four factors set forth in the Modified Policy, for escalation and mitigation of the base civil penalty amount. These factors consist of (1) identification and prompt reporting of the EQ deficiencies (:50'.); (2) best efforts to complete EQ within the deadline (250*;); (3) corrective actions to result in full compliance (t50'.); and (4) duration of a violation which is significantly below 100 days (-50*s). With respect to the first factor, 50*J mitigation'.is appropriate since both examples were identified by your staff. With respect to the second factor, no mitigation is appropriate because your f ailure to identify and establish qualification files for the Standby Gas Treatment System represents a signi-l ficant oversight in your control of engineering activities affecting EQ that was not identified and corrected until an independent reverification program disclosed it after the EQ deadline. Further, Section II of the enclosed l Notice documents a number of other less significant EQ violations which existed at the time of the EQ deadline and therefore, given the total number of environ-mental qualification violations set forth in the enclosed Notice, it is clear that the best efforts were net exhibited prior to the EQ deadline to ensure compliance with the requirements. With respect to the third factor, 50% mitigation is appropriate since comprehensive corrective actions were taken, once the violation was identified. With respect to the fourth factor, mitiga-tion is inappropriate since these EQ violations existed in excess of 100 days. Therefore, on balance, 100'. reduction of the base civil penalty amount would be appropriate. However, in accordance with Section IV.8 of the Modified Policy, the minimum 550,000 civil penalty is being assessed. Although the policy permits full mitigation under certain conditions, full mitigation is inappro-priate here because of your lack of best efforts to complete EQ within the deadline. In addition to the violation assessed a civil penalty, Section II of the enclosed Notice contains two less significant violations. Since the NRC finds that the items discussed in Violation II.A were shown to be qualified I or qualifiable during the inspection or shortly thereafter classification of the violation at Severity Level IV is 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. in accordance with Section 2.790 of the NRC's " Rules of Practi'c e, Fart 2,  ; 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-123

i Northeast Nuclear Energy Company i The responses directed by this letter and the enclosed Notice are not subject I to the clearance procedures of the Office of Management and Budget, otherwise  ! required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Sincerely, l 4 t'7 . A i gh' liiam T. Russell v Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Generic Letter 68-07 C cc w/enti:

W. D. Romberg, Vice President, Nuclear Operations S. E. Scace, Station Superintendent D. O. Nordquist, Director of Quality Services R. M. Kacich, Manager, Generation Facilities Licensing Gerald Garfield, Esquire Public Document Room (PDR) Local Public Document Room (LPDR) Nuclear Safety Information Center (NSIC) NRC Resident Inspector l l NUREG-0940 1.A-124 L_____--_----_---_-___-__-------_-----_------.

i i I NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF. CIVIL PENALTY Northeast Nuclear Energy Company Docket Nos. 50-245 and 50-336 Millstone 1 and 2 License Nos. DPR-21 and DPR-65 EA 88-254 ) During NRC inspections conducted on November 18-22, 1985, July 15-17, 1987 and August 16-19, 1988, the NRC reviewed the licensee's program for environmental qualification (EQ) of equipment, as well as the circumstances associated with EQ deficiencies identified by the licensee in 1986-1987. In accordance with the " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental , Qualification of Electrical Equipment Important to Safety of Nuclear Power 4 Plants," contained in Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy i Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The parti-  ! cular violations and associated civil penalty are set forth below: I. VIOLATION ASSESSED A CIVIL PENALTY ) 10 CFR 50.49 (f), and (j), respectively, require, that (1) each item of electric equipment important ta safety shall be qualified by testing and/or analysis of identical or similar equipment, and the qualification based on similarity shall include a supporting analysis to show that the equipment to be qualified is acceptable; and (2) a record of the qualifi-cation shall be maintained in an auditable form to permit verification that each item of electrical equipment important to safety is qualified and that the equipment meets the specified performance requirements under postulated environmental conditions. Contrary to the above, as of November 30, 1985, certain environmental qualification files did not include the required documentation to demon-i strate environmental qualification, as evidenced by the following examples.

1. On June 5, 1987, it was disclosed that the qualification of the PE/PVC cables, GE EB-5 terminal blocks, Honeywell microswitches and 3M " Scotch lock" wirenuts used in the Standby Gas Treatment System at Unit I had not been established under certain environmental conditions in that documentation did not exist to support qualification of these components for operation in a high radiation environment; and

2. On September 20, 1986, it was discovered that the qualification of a Ideal Model 74B wirenuts, used for the electrical termination of one ASCO solenoid valve which controls an atmospheric steam dump valve at Unit 2 had not been established under certain environmental condi-tions in that documentation did not exist to support qualification of the wirenuts for operation in an High Energy Line Break (HELB) environment under accident conditions.

This violation constitutes an EQ Category C violation. Civil Penalty - 550,000 (This EQ violation existed in excess of 100 days of plant operation). NUREG-0940 I.A-125

Notice of Violation II. VIOLATIONS NOT ASSESSED A CIVIL PENALTY A. 10 CFR 50.49(d)(f) and (j) respectively require that (1) the licensee shall prepare a list of electrical equipment important to safety covered by this section; (2) qualification of each item of electrical equipment be based on testing or experience with identical equipment or with similar equipment with supporting analysis to show that the equipment is acceptable; and (3) a record of the qualification shall be maintained in an auditable form to permit verification that each item important to safety is qualified and that the equipment meets the specified performance requirements under postulated environmental conditions. Contrary to the above, these requirements were not met as evidenced by the following examples:

1. between November 30, 1985 and June 5, 1987, the qualification of six Crane Teledyne Motor Operated Valves located outside the Drywell in Unit I and required to function for a LOCA was not established in that documentation did not support qualification of the valves for operation in a harsh radiation environment.

2. between November 30, 1985 and June 5,1987, the qualification of six electrical penetration terminations located in the reactor building outside the drywell in Unit I was not estab-lished in that documentation did not demonstrate qualification of the terminations for operation under postulated accident environmental conditions.

3. between November 30, 1985 and September 20, 1986, the qualifica-tion of terminations for containment spray pumps P-43A and P-43B located in the ESF rooms outside containment in Unit 2 was not established in that documentation did not support qualification of the terminations for operation in a harsh environment.

4. be' ween November 30, 1985 and September 20, 1986, the.qualifica-tion of six Raychem splices, used for connectir.g the field cable to the Conax seals associated with the Rosemount transmitters in Unit 2 was not established in that the installed cable seal length of one and one-half (1h) inches was less than the tested cable seal length of two (2) inches.

5. between November 30, 1985 and September 20, 1986, the Enclosure Building Filtration System Fan Motor Terminations in Unit 2 electrical equipment important to safety, were not on the EQ Master List, and so qualification was not established for these terminations.

6. between November 30, 1985 and September 20, 1986, the quali-fication of splices used in twelve Limitorque valve operators l in Unit 2 was not established in that docume1tation did not I

support qualification of these splices for operation under postulated accident enviror. rental conditions. NUREG-0940 I.A-126

Notice of Violation 7. between November 30, 1985 and September 20, 1986, the qualif-cation of the motor terminations of' two auxiliary feedpumps and two switchgear room fans in Unit 2 was not established in that documentation did not support qualification of the termination for operation under postulated accident environment conditions

8. between November 30, 1985 and September 20, 1986, the qualifica-tion of eight solenoid operated valves used in the MSIV rooms in Unit 2 was not established in that documentation did not support qualification of the valves for operation under postulated accident environmental conditions.

9. between November 30, 1985 and September 20, 1986 the qualification of 6 Limitorque motor operators, located inside the containment and used on isolation valves, was not established in that the operators did not have the required T-drains installed.

I This is a Severity Level IV violation. (Supplement I) B. 10 CFR 50, Appendix B, Criterion III states, in part, that measures for the identification and control of design revisions affecting quality shall be accomplished in accordance with instructions and

           , procedures.

Contrary to the above, as of November 22, 1985, the requirements of licensee procedure GE-EQ-1, for maintaining EQ documentation files, were not properly implemented in that numerous unsigned and undated markups and corrections were found in various System Component Evaluation Worksheets (SCEW) which are critical to documentation of component qualification. This is a Severity Level V violation (Supplement I). Pursuant to the provisions of 10 CFR 2.201, Northeast Nuclear Energy Company 1 Company (Licensee) is hereby required to submit a written statement of explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for 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 f was or will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or.why such other action as may  ! be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. 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 NUREG-0940 1.A-127

Notice of Violation money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, l such answer may request remission or mitigation of the penalty. l In requesting mitigation of the proposed penalty, the mitigation factors in the

                                                                                            " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualifi-cation of Electrical Equipment Important to Safety for Nuclear Power Plants,"

contained in Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. 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 1 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, a copy to the Regional Administrator, U. S. Nuclear Regulatory Commission, 475 Allendale Road, King of Prussia, PA, 19406 and a copy to the NRC Senior Resident Inspector at Millstone. FOR THE NUCLEAR REGULATORY COMMISSION M, ' 111am T. Russell Regional Administrator Dated ap King of Prussia, pennsylvania j thisgjWayofApril1989.  ! l t l NUREG-0940 1.A-128

[ ~% UNITED STATES NUCLEAR REGULATORY COMMIS$10N g i neocow v 1450 MARLA LANE,sulTE 210 t, WALNUT CREE K, CALIFORNIA 946e6 APR 0 41989 ) Docket No. 50-344 License No. NPF-1 EA 89-16 Portland General Electric Company ATTN: Mr. David W. Cockfield Vice President, Nuclear 121 S. W. Salmon Street TB-17 Portland, Oregon 97204 Gentlemen: l

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N05. 50-344/88-39 AND 50-344/08-46) This refers to the inspection conducted on August 8-12, Octcber 24-27, and < November 28 - December 1, 1988, at the Trojan Nuclear Plant, and inspection-related telephone conversations between Region V and your personnel on January 18, J and 19, 1989. TNr inspection focused on the implementation of your procurement and vendor interface program. The reports documenting these inspections were sent to you by letters dated September 13, 1988 and January 24, 1989. During these inspections, violations of NRC requirements were identified. The apparent violations, their causes, and your corrective actions were discussed with you during an enforcement conference held in this office on January 26, 1989. The summary of the enforcement conference was sent to you on February 14, 1989. The violations in the enclosed Notice of Violation and Proposed Imposition of j Civil Penalty (Notice) involved failures to adequately assure the quality of I installed materials. Specifically, on numerous occasions in 1987, you l purchased and installed commercial grade replacement pipe, pipe fittings, and weld material in the safety-related portion of the Main Feedwater Sysi.em inside containment without adequately evaluating the suitability of the materials for use in these applications. You neither purchased the piping and I welding materials from a vendor with a Quality Assurance (QA) program i consistent with 10 CFR Part 50, Appendix B, nor performed adequate testing or examinations to verify the adequacy of the materials for the intended application. Similarly, Violations 2 and 3 involve a commercial grade Agastat  ; time delay relay installed in the diesel driven auxiliary feedwater pump system, and a commercial grade pressure regulator valve installed in the emergency diesel air start system for which proper evaluations were not made to assure their suitability in the intended applications. Specifically, appropriate critical characteristics were not properly evaluated and. specified. These violations resulted from deficient procurement practices similar to those that were identified by the NRC at your facility in 1985 and for which a previous notice of violation of NRC requirements was sent to you regarding procurement of commercial grade items. Although several opportunities arose to do so, you ft11ed to prevent this type of violation from recurring. These opportunities included reviews of procurement practices by your QA and mechanical engineering group. C.ERTIFIED 1%IL R,ETURN RECEIPT REQUESTED NUREG-0940 1.A-129

i l 1 APR 04198g  ! l Portland General Electric Company  ! In particular, we are troubled that your Nuclear Quality Assurance Department (NQAD) failed to recognize a number of very clear indications of problems in the procurement area, and that NQAD became so involved with the formulation of your procurement process that they stopped performing their intended function of providing critical and independent oversight of procurement activities. In addition, following our inspection and in preparation for the enforcement conference held in part to discuss the status of the Main Feedwater piping, NQAD performed a review of those actions taken which would provide assurance that the piping was acceptable for service. During and subsequent to the , enforcement conference, it became clear that the NQAD review was incomplete, j requiring further action by your engineering personnel to ascertain the accurate status of the piping. This event has generally served to underscore our previous perception that your QA organization is not functioning as a demanding and critical oversight group. I To emphasize the need to maintain a strong independent Quality Assurance organization, and to properly evaluate and procure materials and equipment  ! to be used in safety-related structures, systems, and components, I have been  ! authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and  ; Operational Support 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 af the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem. The base value of a civil penalty for a Sev'erity Level III problem is $50,000. The escalation and mitigation factors of the Enforcement Policy were considered. With regard to your corrective actions, you changed your QA program and tested materials, but you failed to complete your QA review to ascertain the accurate status of the piping at the time of the enforcement conference. This demon-strates the failure of the QA department and management to clearly focus on this important issue. Therefore, on balance neither mitigation or escalation it appropriate for this factor. Because of the number of examples of procurement violations, 50% escalation of the base civil penalty was considered warranted. The other factors of the Enforcement Policy were considered not applicable for the circumstances at Trojan in this case. 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 the Notice, including your proposed corrective actions and the results of future inspections, the hRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. I NUREG-0940 1.A-130

APR 04133 l Portland General Electric Company 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 I subject to the clearance procedures of the Office of Management and Budget as I required by the Paperwork Reduction Action of 1980, Pub. L. No. 95-511. Sincerely, 1

                                                          .       n >QL
                                                                     ~
                                                             ,  a rt i n'~ '

f '# Regional Administrate

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enclosure: T. D. Walt, General Manager, Technical Functions C. P. Yundt, General Manager, Trojan Nuclear Plant L. A. Girard, Vice President and General Counsel W. Dixon, DOE (Oregon) l i k l l l I NUREG-0940 1.A-131

i I NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Portland General Electric Company Docket No. 50-344 l Trojan Nuclear Plant License No. NPF-1 EA 89-16 j During the NRC inspections conducted on August 8-12, October 24-27, November 28 l - December 1,1988 and January 18-19, 1989, 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, 53 Fed. Reg. 40019 l (October 13, 1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as j amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations j and the associated civil penalty are set forth below: l 10 CFR Part 50, Appendix B, Criterion III, " Design Control," requires, in part, that measures shall be established to assure that applicable l regulatory requirements and the design basis are correctly translated I into specifications, drawings, procedures, and instructions. These measures shall include provisions to assure that appropriate quality standards are specified and included in design documents and that deviations from such standards are controlled. Measures shall also be established for the selection and review for suitability of application of materials, parts, equipment, and processes that are essential to i the safety-related functions of the structures, systems, and components. i 1 10 CFR Part 50, Appendix B, Criterion IV, " Procurement Document Control," i requires that measures be established to assure that applicable regulatory l requirements, design bases, or other requirements which are necessary to  ! assure adequate quality are suitably included or referenced in the documents for procurement of material, equipment, and services. To the extent necessary, procurement documents shall require contractors or subcontractors to provide a quality assurance program consistent with the pertinent provisions of' Appendix B.

                                     \

10 CFR Part 50, Appendix B, Criterion X, " Inspection," requires, in part, that examinations, measurements, or tests of material or products processed shall be performed for each work eparation where necessary to assure quality. Contrary to the above, the licensee installed commercial grade components at the Trojan Nuclear Plant without adequately assuring their suitability for use in safety-related applications:

1. During the 1987 outage, in response to Maintenance Request No. 87-4129, 14-inch Schedule 60 piping and fittings purchased from Liberty Equip-ment and weld metal purchased from Oxarc were installed inside con-tainment to replace eroded Main Feedwater System piping. The licensee failed to assure the proper selection and review for suitability of application of these materials for this safety-related application.

The licensee purchased these materials commercial grade without ade-quate audits to assure that the vendors fabricated the materials under a QA program consistent with the pertinent requirements 10 CFR Part 50, Appendix B, and without performing tests or examinations to assure the quality of these materials. NUREG-0940 1.A-132

                                                                                                      )

Notice of. Violation 2. Between August 1987 and June 1988, the licensee installed a time delay , relay per Maintenance Request No. 87-5412. The licensee had failed l to assure adequate design control for the proper selection and review for the commercial grade purchase of the Agastat time delay relay

                                                                                                      ~

(PO No. NQ-04064-05) used in the diesel-driven auxiliary feedwater i pump in that critical characteristics of the relay were not properly j evaluated and specified.

3. Between May 2 and May 4, 1986, the licensee installed a pressure regulator valve per Maintenance Request No. 86-2180. The licensee had failed to assure adequate design control for the proper selection and review for the commercial grade purchase of the pressure regulator valve (PO No. NQ-02468) used in the emergency diesel air start system in that critical characteristics of the valve were not properly evaluated and specified.

This is a Severity Level III problem (Supplement I). Cumulative Civil Penalty - $75,000 (assessed 75% for Violation 1 and 25% ) equally divided between Violations 2 and 3). ' Pursuant to the provisions of 10 CFR 2.201, Portland General Electric Compafty (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 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 offireation. 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 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 Reguhitory 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 cccordance 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 cddition to protesting the civil penalty, such answer may request remission er mitigation of the penalty. l NUREG-0940 1.A-133 1 1

Notice of Violation In requesting mitigation of the proposed penalty, the 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 i statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate l parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and -l 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 1 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 Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region V, 1450 Maria Lane, Suite 210, Walnut Creek, California 94596, and a copy to Mr. R. Barr, Senior Resident Inspector, at the Trojan Nuclear Plant. FOR THE NUCLEAR REGULATORY 'C0094ISSION goRegional WaA0 F. wartln Administ Dated at Walnut Creek, CA l on this N day of April 1989. NUREG-0940 I.A-134

l

                    / p ara     %,

UNITED STATES i W g NUCLEAR REGULATORY COMMISSION Ia " E REGION 1 q - j[ 475 ALLENDALE ROAD

                        ##***                        KING OF PRUSStA, PENNSYLVANIA 19408                                  !

April 21,1989 Docket Nos. 50-272 and 50-311 License Nos. NPF-70 and NPF-75 EA 88-238 Public Service Electric and Gas Company ATTN: Mr. Steven E. Miltenberger Vice President and Chief Nuclear Officer Post Office Box 236 Hancocks Bridge, New Jersey 08038

                                                                                                                          ]

Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Combined Inspection Report Nos. 50-272/86-23; 50-311/86-23) ) l This refers to the NRC inspection conducted on August 11-15, 1986 to review ' the program for the environmental qualification (EQ) of equipment at Salem Nuclear Generating Station Units 1 and 2. The inspection report was sent l to you on November 13, 1986. During the inspection, the NRC reviewed viola- I tions of NRC requirements which were identified by your staff. The violations involved the lack of environmental qualification of certain items of electric equipment used in both units. On September 29, 1988, an enforcement conference was conducted with you and members of your staff to discuss the significance and extent of the violations, the causes of the violations, and the corrective actions taken or planned. Further, the enforcement considerations set forth in Generic Letter 88-07 were also considered. One of the violations, which is described in Section I of the enclosed Notice - of Violation and Proposed Imposition of Civil Penalty (Notice), included the l f ailure to maintain, for one type of item of electric equipment, file documenta- j tion to demonstrate that the item was qualified to perform its intended function j during the postulated harsh environmental conditions. This item, which was i identified by your staff, involved eight solenoid operated valves in the Unit 1 ) Post Accident Sampling System (PASS). These valves were unqualified in that  ! they did not have the required Conax connectors installed, and the documentation l qualification file did not support qualification in the installed configuration. ) l This deficiency clearly should have been known by you prior to November 30, i 1985, which was the deadline for being in compliance with the EQ requirements, i because specific installation instructions were provided to you but not followed.  ! In addition, it is reasonable to expect that a licensee would perform appropriate j verification of these components to assure proper installation since the equip- j i ment was qualified under specific installation procedures. j 1 - This violation demonstrates that sufficient attention was not provided to l the EQ program at Salem Unit 1 prior to November 30, 1985, as evidenced by  ! inadequate consideration of vendor installation information, and inadequate l l NUREG-0940 I.A-135

                                                                                                             -- ------- a

4 Public Service Electric and Gas' Company Quality Control of these activities. Accordingly, I have been authorized, after consultation with the Director of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Enclosure 1) in the amount of Fifty Thousand Dollars (550,000) for the viola-tion described in the enclosed Notice. In accordance with the " Modified Enforcement Policy Relating to 30 CFR 50.49," attached in Generic Letter 88-07 (Enclosure 2), the violation described in the enclosed Notice has been determined to be isolated and to have affected one system and a few components, and therefore, is considered to be an EQ Category C problem. The base value of a civil penalty for an EQ Category C problem is 575,000. In determining the civil penalty amount, the NRC considered the four factors set forth in the " Modified Enforcement Policy Relating to 10 CFR 50.49" (Modified EQ Policy), for escalation and mitigation of the base civil penalty amount. These factors consist of (1) identification and prompt reporting of the EQ deficiencies ( 50%); (2) best efforts to complete EQ within the deadline ( 50%); (3) corrective actions to result in full compliance ( 50%); and (4) duration of a violation which is significantly below 100 days (-50%). j 1 With respect to the first factor, 50% mitigation is appropriate since the item was identified by your staff and promptly reported to the NRC. With respect 4o i the second factor, mitigation is inappropriate. Section II of the enclosed i Notice documents a number of less significant EQ violations which were considered along with the number of deficiencies identified during the inspection that j ultimately did not result in violations as indications of a lack of best efforts. l Further, the EQ training for engineering personnel was not completely satisfactory. 1 ! Finally, other activities the NRC normally considers as evidence of best efforts such as additional "walkdowns of installed equipment were not performed l until after the November 30, 1985 deadline and therefore can be considered as l evidence of such efforts. With respect to the third factor, 50% mitigation is appropriate since you'r corrective actions, upon identification, were both prompt and extensive. With respect to the fourth factor, mitigation is inap-propriate since these EQ violations existed in excess of 100 days. Therefore, on balance, 100% mitigation of the base civil penalty is appropriate. However, in accordance with Section IV.B of the Modified EQ Policy, the minimum civil penalty of $50,000 is being assessed. Although the policy permits full miti- , gation under certain conditions, full mitigation is inappropriate in that, for l the reasons stated above, your EQ verification program did not constitute best efforts to complete Environmental Qualification within the deadline of November 30, 1985. In addition to the violation assessed a civil penalty, we are also issuing a Severity Level IV violation related to the identification of (1) four i auxiliary feedwater system flow transmitter connectors being terminated on l terminal blocks rather than qualified Raychem splices; (2) nineteen Limitorque motor operators (eleven in Unit I and eight in Unit 2) not installed with required T-drains; (3) sixteen junction boxes (seven in Unit I and nine in Unit 2) were not properly sealed; and (4) various Limitorque motor operators were installed without required gear case grease reliefs. Since the NRC finds that these items could have been qualified or shown to be qualifiable within a reasonable period following identification, classification of this violation at Severity Level IV is appropriate. l NUREG-0940 1.A-136 L__._____________.____

Public Service Electric and Gas Company 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 documcat the specific actions taken and any additional sctions 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. l In accordance with Section 2.790 of the NRC's " Rules of Practice " Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its 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, otherwise required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Sincerely,

                                                                       ,           )l {.

liam T. Russell Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Generic Letter 88-07 cc w/encis:

Jack Urban, General Manager, Fuels Department, Delmarva Power & Light Co. L. K. Miller, General Manager - Salem Operations B. A. Preston, Manager, Licensing and Regulation General Manager - Nuclear Safety Review l M. J. Wetterhahn, Esquire R. Fryling, Jr. , Esquire Scott B. Ungerer, Manager, Joint Generation Projects Department, Atlantic Electric Company Licensing Project Manager, NRR Public Document Room (POR) Local Public Document Room (LPDR) Nuclear Safety Information Center (NSIC) NRC Resident Inspector State of New Jersey NUREG-0940 1.A-137

I NOTICE OF VIOLATION AND i PROPOSED IMPOSITION OF CIVIL PENALTY Public Service Electric and Gas Company Docket No. 50-272; 50-311 Salem Units 1 and 2 License Nos. OPR-70; OPR-75 EA 88-238  ! During an NRC inspection conducted on August 11-15, 1986, of the licensee's program for environmental qualification (EQ) of equipment, violations of NRC requirements were identified. In accordance with the " Modified Enforcement i Policy Relating to 10 CFR 50.49, Environmental Qualification of Electrical Equipment Important to Safety of Nuclear Power Plants," attached to Generic Letter 88-07, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: I. VIOLATION ASSESSED A CIVIL PENALTY 10 CFit 50.49 (f), and (j), respectively, require, that (1) each item of electric equipment important to safety shall be qualified by testing identical or similar equipment under environmental conditions identical or similar to those postulated for an accident, and the qualification , based on similarity shall include a supporting analysis to show that the  ! equipment to be qualified is acceptable; and (2) a record of the qualifi-  ! cation shall be maintained in an auditable form to permit verification that each item of electrical equipment important to safety is qualified and that the equipment meets the specified performance requirements under postulated environmental conditions. Contrary to the attve, from November 30, 1985 until April 8, 1986, eight tolenoid operated valves in the Unit 1 Post Accident Samplying System components important to safety, were not qualified in that the valves did not have the required Conax connectors installed and qualification of the valves without the Conax connectors was not demonstrated. This violation constitutes an EQ Category C violation. Civil Penalty - 550,000 (This EQ violation existed in excess of 100 days of plant operation.) II. VIOLATION NOT ASSESSED A CIVIL PENALTY 10 CFR 50.49 (f), and (j), respectively, require, that (1) each item of electric equipment important to safety shall be qualified by testing and/or analysis of identical or similar equipment under environmental conditions identical or similar to those postulated for an accident, and the qualification based on similarity shall include a supporting analysis to show that the equipment to be qualified is acceptable; and (2) a record of the qualification shall be maintaired in an auditable form to permit verification that each item of electrical equipment important to safety is qualified and that the equipment reets the specified performance requirements under postulated environ ental conditions. NUREG-0940 I.A-138

l i i l Notice of Violation Contrary to the above, at various amounts of time beginning November 30, 1985, components important to safety were not qualified including the following examples:

1. As of May 3, 1986, the qualification of terminal blocks used to terminate eight auxiliary-feedwater transmitters was not demonstrated in that the qualified configuration of the associated junction boxes specified Raychem splices.

2. As of April 8,1986, nineteen (eleven in Unit I and eight in Unit 2)

Limitorque motor operated valves inside containment, affecting, among i others, the safety injection system, residual heat removal system and 3 Reactor Coolant System, did not have T-Drains installed in the nperator housings to prevent moisture accumulation in a harsh  ! environment and qualification of the valve operators without the T-Drains was not demonstrated;  !

3. As of April 8, 1986, sixteen junction boxes (seven in Unit 1 and 9 in Unit 2) affecting, among others, the Main Steam System and the Main Steam Isolation Valve indication limit switches for both units, did not have properly sealeo conduit connectors and qualification of the junction boxes without properly sealed conduit connectors was i not demonstrated; and

4. As of August 15, 1986 various Limitorque motor operated valves inside )

containment did not have gear case grease relief valves and qualifi-cation of the valve operators without grease reliefs was not demonstrated. This is a Severity Level IV violation. (Supplement I) Pursuant to the provisions of 10 CFR 2.201, Public Service Electric and Gas Company (Licensee) is hereby required to submit a written statement of l explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory

Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each alleged violation

(1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance was or will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or af firmation.

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 i NUREG-0940 1.A-139 j

Notice of Violation civil penalty proposed above, or may protest imposition of the civil penalty Tn whole or in part by a written answer addressed to the Director, Office of Enfor. cement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the mitigation factors in the

 " Modified Enforcement Policy Relating to 10 CFR 50.49, Environmental Qualifi-cation of Electrical Equipment Important to Safety for Nuclear Power Plants,"

contained in Generic Letter 88-07, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. 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. The responses to the. Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555, a copy to the Regional Administrator, U. S. Nuclear Regulatory Commission, 475 Allendale Road, King of Prussia, PA, 19406 and a copy to the NRC Resident Inspector, Salem 1 and 2. FOR THE NUCLEAR REGULATORY COMMISSION W liam T. Russell egional Administrator Dated at King of Prussia, Pennsylvania this;j'bayofApril1989. NUREG-0940 1.A-140

j6 4

              %                  NUCLEAR REGULATORY COMMISSION O'                                           REGION II
        #'      8                     101 MARIETTA STRE ET, N.W.

E 3 f ATLANTA,otoRol A 30322

 \,...../                                NAR 0 2 1989 I

l Docket No. 50-395 License No. NPF-12 EA 88-305 South Carolina Electric & Gas Company ATTN: Mr. O. S. Bradham l Vice President, Nuclear Operations Virgil C. Summer Nuclear Station Post Office Box 88 Jenkinsville, South Carolina 29065 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY l (NRC INSPECTION REPORT NO. 50-395/88-31)

                                                                                                                       )

This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by Ms. O. Masnyk at the V. C. Summer Nuclear Station on November 28 - DecembeF 2, 1988. The inspection included a review of the circumstances surrounding the identification of significant problems in the management and implementation of the security program and failure to maintain an adequate perimeter intrusion detection system. The report documenting this inspection was sent to you by , letter dated December 23, 1988. As a result of this inspection. Significant l failures to comply with NRC regulatory requirements were identified, and NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on January 6, 1989. The letter summarizing this Conference was sent to you on January 18, 1989.  ; 1 The violations described in tne enclosed Notice of Violation and Proposed  ! Imposition of Civil Penalty (Notice) involved significant f ailures of the security force at all levels to implement the security program and failure of I management to properly oversee the security program. To emphasize the need for adeauate management and implementation of security requirements, I have been authorized, af ter consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Sixty-Two Thousand Five Hundred Dollars (562,500) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violations described in Section I of the enclosed Notice have been categorized in the aggregate as a Severity Level III problem j and the violation described in Section II has been categorized as a separate  : Severity Level !!! problem because they represent separate breakdowns in the access control program at the Summer Nuclear Station. The base valutt of a civil penalty for a Severity Level III violation or problem is $50,000. The NRC Enforcement Policy allows for reduction of a civil penalty under certain NUREG-0940 1.A-141

I South Carolina Electric & g g g 3 1909 Gas Company circumstances. With respect to the violations in Section I of the enclosed Notice, the civil penalty has been mitigated 25 percent due to identification of the violation and 50 percent due to corrective action taken by you once the violation was identified. The full 50 percent mitigation for identification was not provided because of the lack of timely identification of the violations. In addition, further mitigation that might have been warranted due to your past  ! performance was offset by the number of similar violations occurring within a short period. Full mitigation was considered for the civil penalty assessed for the violation in Section II of the Notice due to your past good performance in the area of security. However, this mitigation was complete'y offset by the l serious breakdown in access control as reflected by the failures that combined to make this event possible, the number of security force members and super-visors involved in the incident, and the failure of the security organization, including supervisors, to take action once it recognized that an unauthorized person was in the protected area. The violation in Section III of the enclosed Notice involved the failure to maintain an adequate perimeter intrusion detection system. This violation has been categorized as a Severity Level IV violation. In addition, the adequacy of your closed circuit television assessment system was discussed with you l during a telephone call on January 19, 1989 and is categorized as an Unresolved l Item. I In accordance with 10 CFR 2.790(d) and 10 CFR 73.21, safeguards activities and security measures are exempt from public disclosure. Therefore, the enclosure to this letter, will not be placed in the NRC Public Document Room. The responses directed by this letter and its' enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Should you have any questions concerning this letter, please contact us. Sincerely, r Malcolm L. Ernst Acting Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty .} l cc w/ encl: J. L. Skolds, General Manager Nuclear Plant Operations J. B. Knotts, Jr. Bishop, Cook, Purcell & Reynolds NUREG-0940 1.A-142

1 j UNITED STATES eHsg NUCLEAR REGULATORY COMMisslON f

   #        kg                              nEcion m a            e                        ,,e moosavatt mono otsu stova. itu ois ..or
     .....                              April 21, 1989 Docket No. 50-346 j

License No. NPF-3 EA 89-49 l Toledo Edison Company ATTN: Mr. Murray R. Edelman President Edison Plaza 1 300 Madison Avenue Toledo, Ohio 43652 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-346/88037[0RP]) This refers to an NRC inspection conducted during the period December 1, 1988 through February 10, 1989, which included review of an imprcper reactor startup event on December 18, 1988, at the Davis-Besse Nuclear Power Station in Oak Harbor, Ohio. The results of the inspection were described in the . inspection report sent to you on February 24, 1989. On March 3, 1989, we held an enforcement conference with Mr. D. Shelton and others of your staff to discuss the violations, root causes, and corrective actions. On December 18, 1988, at 0358, the Davis-Besse reactor was operating at approximately two percent power when the control rod Group 3 safety rods dropped into the reactor core as a result of a personnel error during j maintenance troubleshooting. Operators in the Control Room erroneously assumed ' that the reactor was critical and started to recover the Group 3 rods despite indications that the reactor remained subcritical. As temperature decreased ' to approximately 525'F, the operators realized that this was the minimum temperature allowed by Technical Specifications for a critical reactor and at 0405 inserted the Group 3 rods into the core. At 0406 the operators proceeded to shut down the reactor. Four violations of NRC requirements were identified as a result of the inspection conducted following this event and include: (1) failure to follow the Davis-Besse " Approach to Criticality" procedure; (2) failure to establish a procedure for mispositioned control rods; (3) failure to provide sufficient information in narrative logs to enable reconstruction of events, and (4) failure to properly log late entries. The violations cited are indicative of a significant breakdown in the control of licensed activities in the Control Room. The NRC is particularly concerned with the performance of individuals in the Control Room during the event. All Control Room personnel at the time of the Group 3 rod drop, assumed the reactor NUREG-0940 I.A-143

F l i Toledo Edison Company 2 April 21, 1989 Ns still critical despite indications to the cor.trary. The Shift Supervisor I directed that the Group 3 rods be latched and withdrawn even though the Shift Technical Advisor had recommended that the plant be tripped since it was in a condition not covered by procedures. Once the Duty Operations Manager arrived in the Control Room, he observed that the reactor was subcritical and that a cooldown of RCS was in progress. However, after making his initial assessment, he made no recommendations to the Shift Supervisor contributing to the crew's failure to recognize the event and take appropriate actions. While the i technical aspects of this event were not of high safety significance, we believe the performance of the crew in responding to the event was seriously l ' ) deficient. After this event, you removed the involved shift supervisor from his control room operating crew responsibilities, and presently are re-evaluating his  ! performance as shift supervisor. On March 10, 1989, we issued a Confirmatory ' Action Letter confirming your commitment to inform the NRC Region III office of your basis for returning that Shift Supervisor to operating crew licensed responsibilities. l To emphasize the importance of operator attention and maintaining control ' of Itcensed activities in the Control Room, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support, to j 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 i in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988) (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 has been deemed appropriate. The violation in Section II of the enclosed Notice was not specifically discussed at the enforcement conference. However, after considering your interpretation of the words "during operation", contained in 10 CFR 50.72(b)(1)(11), the NRC concluded that it was improper. Operation of the plant involves many activities that take place prior to the plant achieving criticality, which is the point at which you assert " operations" begins. Clearly, withdrawing control rods in order to achieve criticality is a significant evolution which ' involves operating the plant. Given that this evolution was performed at Davis-Besse on December 18, 1988, without proper procedural guidance, it should have been reported to the NRC within one hour pursuant to 10 CFR 50.72 (b)(1)(11)(C). 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 compitance with NRC regulatory requirements. NUREG-0940 I.A-144

l l

                                                                                                                               ~

Toledo Edison Company 3 April 21, 1989 In accordance with Sectibn 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 l will be placed in the NRC Pubite 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,

                                                                                                                                    -t?h u L -E. U n A G

[%.BertDavis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Inspection Report No. 50-346/88037(DRP))

l cc w/ enclosures: Donald Shelton, Vice President, Nuclear L. Storz, Plant Manager DCD/DCB(RIDS) Licensing Fee Management Branch Resident Inspector, RIII Harold W. Kohn, Ohio EPA James W. Harris, State of Ohio Roger Suppes, Ohio Department of Health State of Ohio, Public Utilities Commission i I 1 I NUREG-0940 1.A-145 j ___ _ _ _ - _ _ _ _ - _ - - _ _ _ _ - _ _ _ _ _ _ - _ - _ _ - _ _ _ _ - _ _ - _ _ - _ _ _ _ _ - - - _ - _ _ _ - _ - _ _ - _ _ _ ____ __ ___ A

NOTICE OF VIOLATION' AND PROPOSED IMPOSITION OF CIVIL PENALTY Toledo Edison Company Docket No. 50-346 Davis-Besse Nuclear Power Station License No. NPF-3 EA 89-049 During an NRC inspection conducted during the period December 1,1988 through February 10, 1989, 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, 53 Fed. Reg. 40019 (October 13,1988) the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. .The particular violations and associated civil penalty are set forth below: I. VIOLATIONS ASSESED A CIVIL PENALTY A. Failure to Follow procedures 10 CFR Part 50, Appendix B, Criterion V, requires, in part, that activities affecting quality be prescribed by documented instructions, procedures, or drawings. The activities shall be accomplished in accordance with these instructions, procedures, or drawings.

1. Davis-Besse Procedure DB-PF-06203, " Approach to Criticality" outlines the steps necessary to take the reactor from Hot Standby (Mode 3) to Startup (Mode 2) including the requirement that all regulating rods be inserted, estimated critical position be calculated, and the Mode 2 checklist be completed.

Contrary to the above, at 0404, on December 18, 1988, with the reactor subcritical (Mode 3), Control Room personnel _ withdrew the Group 3 rods without first inserting regulating rods 5-7, thus failing to follow the steps outlined in DB-PF-06203,

                       " Approach to Criticality." Specifically, with the reactor subcritical, the licensee should have inserted all regulating rods, estimated critical position, and completed the Mode 2 checklist prior to taking the reactor critical.

2. Davis-Besse Procedure DB-OP-00005, " Operator Logs and Reading Sheets," outlines the instructions for maintaining narrative logs to ensure that day-to-day operation of the plant is properly documented.

l l NUREG-0940 1.A-146

Notice of Violation 2

a. Section 6.1.4 of DB-0P-00005, "Logkeeping," requires that late entries into the log be made by entering the words

                       " late entry" or "LE" to the left of the margin.

Contrary to the above, on December 18, 1988, during an incident where the Group 3 Safety Control Rods unexpectedly dropped into the core, the Shift Supervisor made a late entry, pertaining to the plant's entry into Mode 3, into the logbook, which did not specify " late entry" or "LE" to the left of the margin. Specifically, the Shift Supervisor entered a statement at 0358 which read, " Group 3 safety rods dropped - Plant entered Mode 3."

b. Section 6.1.1 of DB-OP-00005 requires that narrative logs shall be written in sufficient detail to enable the reconstruction of events which have occurred.

Contrary to the above, the Reactor Operator log did not contain sufficient detail to enable reconstruction of the December 18, 1988 Group 3 Safety Control Rod drop event. Specifically, the log had only two entries relating to the event. The two entries were that the rods had dropped into-the core and that Tave was less than 525*F. The log did not contain other occurrences such as the withdrawal of Group 3 rods, the subsequent insertion of those rods, and the insertion of the regulating rods. B. Failure to Estabitsh Procedures Technical Specification 6.8.1.a requires that written procedures be established for combating emergencies and other significant events, , including events involving mispositioned control rods as Itsted in Appendix A of Regulatory Guide 1.33, November 1972. Contrary to the above, on Decenber 18, 1988, the licensee experienced a multiple control rod drop event and was unable to recover.using Abnormal Procedure DB-OP-02516, "CR0 Malfunctions." Specifically, DB-0P-02516 was inadequate, in that it did not contain guidance on how to recover from multiple rod drop events as listed in Regulatory Guide 1.33, Appendix A. This is a Severity Level III problem (Supplement I). Cumulative Civil Penalty - $50,000 (Assessed as follows: Violation A.1

      $30,000, Violations A.2.a and A.2.b $5,000 each, and Violation B $10,000.)

1 NUREG-0940 I.A-147

Notice of Violation 3 II. VIOLATION NOT ASSESSED A CIVIL PENALTY 10 CFR 50.72(b)(1)(ii)(C) requires that the licensee shall notify the NRC ' as soon as practical and in all cases within one hour of any event or condition during operation that results in the nuclear power plant being in a condition not covered by the plant's operating and emergency procedures. Contrary to the above, on December 18, 1988 with the plant in Mode 3, a recovery from a multiple dropped control rod event, a condition not covered by plant operating and emergency procedures, was initiated and the NRC was not notified of that condition within one hour. This is a Severity Level IV violation (Supplement I) Pursuant to the provisions of 10 CFR 2.201, Toledo 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 actions that have been taken and the results achieved; (4) the corrective actions that will be taken to avoid further violations; and (5)'the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an Order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other 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 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 cumulative amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fall 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 reraission or mitigation of the penalty. NUREG-0940 I.A-148

i 4 Notice of Violation In requesting mitigation of the proposed penalty, the 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., 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 provision of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, , er 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 civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, 3 U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137 and a j copy to the NRC Inspector at Davis-Besse. FOR THE NUCLEAR REGULATORY COMMISSION

                                         $ltuAs $ bA

['"A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois l thisgj4dayofApril1989 l f i NUREG-0940 1.A-149

UNITED STATES

   /p meegDo,                     NUCLEAR REGULATORY COMMISSION                                ,

3

• REGION 11 h 101 MARIETTA STREET, N.W.
• ATLANTA, CEORGIA 30321

        * ..*                                MAY 181989 i

Docket Nos. 50-280 and 50-281 ' License Nos. DPR-32 and DPR-37 EA 88-296 Virginia Electric and Power Company ATTN: Mr. W. R. Cartwr19ht, Vice President, Nuclear Operations 5000 Dominion Boulevard Glen Allen Virginia 23060 Gentlemen:

SUBJECT:

NOTICE OF VIOLATIONS AND PROPOSED IMPOSITION OF $500,000 CIVIL PENALTIES: (NRC INSPECTION REPORT NOS. 50-280/88-32 AND 50-281/68-32, 50-280/88-34 AND 50-281/88-34, 50-280/88-41 AND 50-281/88-41, 50-280/88-45 AND f 50-281/88-45, 50-280/88-51 AND 50-281/88-51, 50-280/89-06 AND 50-281/89-06) l J This refers to the NRC Augmented Inspection Team (AIT) inspection conducted from September 1-3, 1988; the NRC Safety System Functional Inspection (SSFI) conducted ) from September 12-16, Seotember 26-30, and November 14-18, 1988; and the inspec-tions conducted by the NRC Resident Inspectors from Octob2r 2 - November 5, 1988 November 6 - December 17, 1988, December 18, 1988 - January 28, 1989, and January 29-March 4,1989 at the Surry Power Station, Units 1 and 2. The AIT inspection was conducted to review the facts and circumstances surrounding the i failure of the Unit I refueling cavity seal in May 1988. The SSFI focused on  ! the safety-related service water system and the recirculation spray system, including associated electrical systeins. The reports documenting these inspec- , tions were sent to you by letters dated September 30, 1988, December 15, 1988, l l November 30, 1988, January 17, 1989 February 23, 1989, and April 3, 1989. As ' a result of the above referenced inspections, significant failures to comply i with NRC regulatory requirements were identified. Accordingly, NRC concerns ' relative to the inspection findings were discussed at an Enforcement Conference held on January 26, 1989. The report documenting this conference was sent to you by letter dated March 2, 1989. The NRC is particularly t.oncerned about the adequacy of your past safety evalua-tions and implementation of your corrective action program. Since 1988, a ' significant number of safety problems have been found at Surry that appear to be due to inadequate or untimely corrective actions. For many of the violations ioentified as a result of the above inspections, as well as the violations described in four previous escalated enforcement actions, information was available that, if properly evaluated and acted upon, should have prevented, or led to earlier correction of, those violations. Other violations relate to I significant design and evaluation issues. The findings described in the enclosed Notice of Violations and Proposed Impesition of Civil Penalties (Notice) have been grouped into five sections. Section I considers the violations associated with the cavity seal failure Section !! involves corrective actions; Section III involves design issues; Section IV deals NUREG-0940 1.A-150 l l l

l Virginia Electric & Power Company EYI81989 with the failure to meet technical specification operability requirements for emergency service water pumps; and, Section V addresses the remaining SSFI identified violations. Each of these findings are discussed below. Section I of the Notice involves a significant event that occurred on May 17, 1988 with the sudden failure of the Unit I reactor cavity seal and loss of i approximately 30,000 gallons of water from the refueling cavity. Violation I.A focuses on inadequate implementation of your design controls for the passive

  'J-seal' which resulted in your operation of the facility since initial licensing in noncompliance with your FSAR. The design of the passive sealing feature was not adequate to preclude seal failure and leakage from the reactor cavity when the seal deflated. In addition, after the NRC issued IE Bulletin 84-03, Refueling Cavity Water Seal, to alert all licensees of a cavity seal failure that occurred   i at another plant, you did not properly evaluate the unique Surry cavity seal design and assure that appropriate cavity seal ring tolerances and installation    ,

instructions were provided. Once the seal failed, as described in Violation f A.2, the design deficiency was not identified. We are concerned that a significant event occurred and that your initial evaluation mis-categorized the sudden seal failure as a slow leak, despite the availability of contrary data. ft was not until two days after the event that a Station Deviation Report was initiated. Even then, your reviews failed to identify the true scope of the failure. Additionally, we were not informed of the significance of this event  ! until the resident inspectors became aware of the Independent Offsite Evaluation Review report on August 30, 1988. The failure to perform a proper evaluation j and take timely corrective action resulted in the plant being placed in an unanalyzed condition when the core was reloaded on May 21-23, 1988, while using the deficient cavity seal design. Violation I.B concerns a number of procedure problems. Significantly contributing to the sudden seal failure was the fact that the inflatable portion of the seal lost pressure when instrument air was isolated and the backup nitrogen bottles were not correctly aligned. Your 1984 seal design evaluation and 1985 modifica-tions failed to assure that procedures and drawings were established for operation of both the backup nitrogen pressure system and that portion of the instrument air system dedicated to the inflatable seal. Additionally, while abnormal procedures were revised in accordance with recommendations resulting from your IE Bulletin 84-03 review, these procedural changes were inappropriately deleted in April 1987 during a procedure revision. The third problem concerns a failure to use procedures. After the reactor cavity leak was terminated, your licensed operators elected to recover the refueling cavity water level by opening the i fuel transfer tube isolation valve on May 17 and 18, 1988. This action was not i contained in an approved procedure and resulted in dropping the plant spent fuel pool level. Except under emergency conditions, not the case here, it is inappro-pritte for station personnel to perform significant plant evolutions without. approved procedures. Your line supervision should not have permitted this to happen. An NRC investigation was conducted to determine whether Virginia Electric & i Power Company officials intentionally and deliberately failed to comply with reporting requirements when they did not advise the NRC of the May 17, 1988 NUREG-0940 1.A-151 i

1 I Virginia Electric & Power Company -3 MAY 181989 refueling cavity seal leak incida t. The investigation concluded that the incident was processed openly, and that it did not appear that licensee i officials intentionally failed to comply with NRC reporting requirements. A ' Synopsis of the Office of Invest;gations Report No. 2-88-008 is enclosed. Based on this finding, and the fact that a citation is being issued for your inadequate evaluation of this matter, i.e. Violation I.A an additional citation will not i be issued for this violation of reporting requirements. I i Section II involves a number of other problems that were not properly evaluated and corrected. The NRC concludes each of these events to be significant because in each case you had information available, either through NRC correspondence or your internal deficiency reporting system, that should have prompted you to act in a more timely manner. These events raise significant questions concerning the safety attitude of your staff. Violation II.A involves the evaluation and disposition of Infor1mation Notice (IN) 88-91, Potential Gas Binding of High Head Safety Injection Pumps. An ultrasonic inspection of selected piping high points found actual gas voids on August 23, 1988. After consultation with the pump vendor, the system engineer concluded in a memorandum to his supervisors, dated August 29, 1988, that "the operability of the HPSI pumps during an emergency is in question." No Station Deviation Report was prepared, and plant supervision did not followup on the memorandum. The significance of the issue was not l recognized until October 12, 1988. Both Surry units,had operated until mid-September with this safety issue unresolved. Violation II.B concerns a Station Deviation Report written on November 20, 1987 for inadequate capacity of the Control Room - Relay Room Ventilation Chillers. The Station Deviation Report specifically noted that the chillers did not meet the 90-ton capacity specified in the Updated Final Safety Analysis Report (UFSAR), and a 10 CFR 50.59 evaluation was not performed until the resident inspectors raised the issue on April 11, 1988. That evaluation subsequently determined that the design function could only be accomplished as long as service water temperature remained below 70'F. The station had previously been operated in an unanalyzed condition with service w ter temperature greater than 70*F. Violation II.C concerns the entire Control Room and Emergency Switchgear Room l Ventilation System. For an undetermined oeriod of time, the station had to run i two chillers and both trains of the air handling units to maintain acceptable room temperatures. This degraded condition existed at least since 1986 but corrective actions were not initiated to repair the ventilation system until a Station Deviation Report was written about September 9, 1988. g Violations 11.0 through G concern a nutnber of other deficiencies related to your corrective action system. Violation II.D addresses the inadequate corrective action taken in 1983 to purge your warehouse of unqualified replacement parts and the subsequent discovery in 1988 of the use of those parts in safety-related applications. Violation II.E focuses on inadequate long-term corrective action to prevent the repeated wetting of your emergency auxiliary feedwater pump motors due to leakage of rain water through inadequately sealed roof-plugs. Violations II.F and G represent other individual corrective action program deficiencies associated with assuring that QC inspection deficiencies and QA audit findings l are adequately resolved, i 1 NUREG-0940 1.A-15?

4 I l Virginia Electric & Power Company MAY 181989 Section III of the Notice concerns a number of design deficiency and system performance problems, some of which impacted the station's ability to maintain the ultimate heat sink. Though the hardware deficiencies may have originated during plant construction, they represent ongoing problems that were not identified during your original startup test program nor through your continuing operational surveillance testing. Violation III.A addresses a number of errors made during your design change and modification process calculations supporting the 1988 recirculation spray heat exchanger (RSHX) replacement. The calculation results were deficient in that many of the design inputs contained errors and nonconser-vatisms concerning the ability to maintain the upper level intake canal inventory. Violation III.B refers to the failure to consider the effects of extreme temperature ranges on Emergency Service Water components, Violation III.C refers to failure to control 125 VDC vital bus loads, and Violation III.D concerns the failure to consider component cooling water heat exchanger minimum wall thickness. Your design change and modification process should have identified these errors and nonconservatisms. After initial identification by the NRC, additional errors in several of the revised calculations were found. If left uncorrected, these errors would again have caused the station to operate outside of UFSAR assumptions. Violation IV concerns the operability of the Emergency Service Wat'er (ESW) pumps. Though both the Technical Specification basis and the UFSAR specify ESW pump capacity at 15,000 gpm each, your operational surveillance test only required that a 12,000 gpm capacity be demonstrated, which was the current capacity of these pumps. This degraded system performance apparently occurred over a time span of at least several years during which your test procedure accei:nnce criteria was revised without updating either the UFSAR or Technical Specifications. We believe your Operations and Quality Assurance Departments should have recognized this deficiency. Section V of the Notice contains a number of Severity 1.evel IV violations identi-fied during the SSFI review of ongoing maintenance and testing activities. Problems included: (A) stroke testing safety-related MOVs in the wrong direction due to a deficient procedure, (B) inadequate acceptance criteria b battery test i procedures, (C) maintenance procedures failed to incorporate ver.09r-recommended l torque values for fasteners, (D) replacement parts were not identified with material control tags, and (E) a post-maintenance test was not conducted for a  ; safety-related valve. fn addition to the violations included in the Notice, there have been four escalated enforcement actions involving the Surry facility during the previous year. In February 1988, NRC Resident Inspectors identified a failure to 4 maintain and verify operability of heat trace circuitry for boric acid flow paths. This problem existed for an extended period of time without station personnel questioning the reason for continuously lit annunciators. In March 1988, a significant potential for overexposure of a licensee employee occurred during work to free an incore detector from a thimble tube. The event resulted  ! from a breakdown in the management control systems which were in place to prevent such an occurrence. The civil penalty was escalated because of manage-ment's inadequate response to the event, the failure to make an adequate root cause determination, and a pattern of poor performance regarding procedural compliance. Also, in May 1988, a contractor employee exceeded the quarterly total occupational dose limits to the whole body. One of the root causes of WUREG-0940 1.A-153

Virginia Electric & Power Company MAY 181N9 this violation was inadequate management support of the radiological control program. Again, the civil penalty in that action was increased because of prior poor performance in that area and inadequate corrective actions associated with a previous exposure event. Finally, in June 1988, your staff reported finding foreign material in Surry Power Station Units 1 and 2 containment sumps. Although the specific cause of this violation was a lack of adequate cleanliness controls when working on safety-relatW systems, a broader issue was the general I ' control of maintenance activities 'that permitted foreign material problems to go undetected for an extended period of time. In addition to the issues described above, a number of other problems occurred at Surry during the past year that, when taken together, reinforce our concern over both the design and the corrective action problems at the plant. The vacuum priming system, classified as nonsafety related, is required to maintain full flow through the component cooling water heat exchangers at minimum levels in intake canal. The vacuum priming system is not seismically qualified and would constitute a single failure to all four component cooling water heat exchangers during a seismic event. (Inspection Report No.280,281/88-14.) Your actions in response to NRC Information Notice 85-91, Load Sequence for Emergency Diesel Generators,.was untimely in that an internal engineering review identified this as a potential concern for Surry in June, 1986, but a followup investigation at the site was not conducted until September 1988. (Inspection Report No. 280,281/88-36.) 1 Corrective action for a 1987 citation regarding inventory of special nuclearfor baseline material was the nuclear inadequate material. in that (Inspection it did Report No. 280, not 281/88-41. establish an inv An adequate root cause evaluation of the failure mechanism of a containment , isolation valve was not performed as committed to in a Licensee Event Report, l because the defective parts were discarded prior to any engineering evaluation. (Inspection Report No. 280,281/88-45.) Finally, we are also concerned about recently identified programmatic problems relating to past maintenance practices on motor operated valves. These deficiencies include poor workmanship, material problems, assembly problems, missing parts, undersized actuators, electrical wiring and other problems. We will continue i to monitor your actions in this area and will address any enforcement issues after completion of our inspections. Collectively, the multiple examples of violations identified in the attached Notice, the multiple examples of past escalated enforcement actions, and other problems which have been identified in the past year represent a major breddown in the control of licensed activities at the Surry Power Station. Accordingly, in order to emphasize the significance the NRC places on the ability of this ahd other licensees to self-identify deficiencies, conduct appropriate evaluations, 6hd institute prompt and adequate corrective action, I have been authorized, after consultation with the Commission, to issue the enclosed Notice of Violations and Proposed Imposition of Civil Penalties in the amount of Five Hundred Thousand NUREG-0940 I.A-154 I

MAY 181989 Virginia Electric & Power Company Dollars ($500,000) for the violations described in the enclosed Notice. The Severity Levels of the violations described in the enclosed Notice are in accordance with the " General Statement of Policy and Procedures for NRC Enforcement Actions," in 10 CFR Part 2, Appendix C (1988) (Enforcement Policy). The escalation and mitigation factors in the Enforcement Policy were considered, and the base civil penalty was modified for each violation as discussed below. Violations I. A.1, I. A.2, and B address the reactor cavity seal event. As to Violation I.A.1, your original design did not meet the performance capabilities specified in the UFSAR and the engineering evaluation performed in response to IE Bulletin 84-03 was inadequate. Also, your design control and implementation process was deficient in that drawings and procedures for the support systems installed for the inflatable portion of the seal were not developed; the nitrogen backup system was installed as a temporary modification; and operators were not adequately trained in the use of these support systems. The basic design of the passive J-seal could not meet its intended safety function due to a lack of specified design tolerances, inadequate inspection and installation procedures, and the lack of a backplate support. Once the cavity seal failed, your evaluation did not identify the seal design deficiency as described in Violation I.A.2. As a result, three days later core reload activities were comenced that exposed the plant to the risks and consequences of another failure of the defective cavity seal. These two violations have been classified in an aggregate as a Severity Level III problem. The base civil penalty for this Severity level 111 problem is $50,000. In considering the circumstances of this case, the base civil penalty has been increased to $100,000 because this n tter represents a significant breal-down in management control to identify and correct design deficiencies. Apart from that, we were not informed of the event until three months after it happened. The initial reluctance demonstrated by Surry station management to promptly provide us with a copy of your preliminary investigation report was unacceptable. In view of your extensive corrective actions discussed in the Enforcement Conference to enhance your staff's sensitivity to this concern, no further action will be taken in this natter. Violation I.B has been classified as a Severity Level III violation. Had you developed and implemented adequate procedures for the inflatable seal pressuri-zation systems, this event would not have happened. You had the opportunity to do so in response to modifications and your own staff's recommendations that resulted from the bulletin review. The base civil penalty has been increased to $100,000 because the violation represents a significant breakdown in manage-ment control particularly in view of the duration of the procedural deficiencies as well as the notification you had based on your staff's review of the bulletin. Several additional violations where ybur corrective action for known or suspected l deficiencies was not timely are contained in Section II. Violation II.A i concerns your staff's failure to take prompt corrective action after identifi-cation of gas voids in a portion of the safety injection (SI) piping. This has been classified as a Severity Level Ill violation for which the base civil penalty is $50,000. The base civil penalty is escalated 100 percent because of duration. Six weeks passed after the initial engineering evaluation detennined that pump operability dur4ng an emergency was in doubt before appropriate levels of management recognized the problem. A 50 percent mitigation factor is being applied for your extensive hardware corrective actions. Therefore, the total civil penalty for this violation is $75,000. NOREG-0940 1.A-155

Virginia Electric & Power Company MAY 181989 i Violations II.B and C are considered a Severity Level III problem because they both concern the same safety system. The base civil penalty is $50,000. Though i the NRC recognizes the limited safety significance of the ventilation system's i degraded condition, our concern is that your staff identified in one case, and i should have identified in the other case, a deficiency in system performance ' that required an engineering evaluation to define the scope of the problem. Though your corrective actions, once complete, will adequately address this j problem, the time it took for you to initiate those actions exceeded that which t is reasonably expected and, therefore, mitigation is n)t warranted for those actions. Violations 11.D, E, F, and G are considered a Severity Level III problem for which the base civil penalty of $50,000 is being assessed. Though the significance of the individual deficient conditions may be limited, when taken together, they show a breakdown in the implementation of your corrective action program. No escalation or mitigation was deemed appropriate. The violations in Section III represent a Severity Level III problem with your design controls. Violation III. A addresses several calculations perfomed to_ support the 1988 recirculation spray heat exchanger replacement. After the 15tC identified the use of inaccurate or nonconservative design inputs, a subsequent review of your calculations found additional errors. Violations III.B. III.C, , and III.D encompass a broad range of engineering design disciplines: environ-mental effects on safety-related components, control of electrical loads, and control of mechanical specifications. These violations have been classified as a Severity Level III problem, for which the base civil penalty is $50,000. The civil penalty is being mitigated by 50 percent because of your corrective actions which include an extensive design reconstitution and configuration control program. No other mitigation or escalation factors are considered ) appropriate and a $25,000 civil penalty is assessed for this problem. Violation IV concerns inoperability of the emergency service water (ESW) pumps. We believe that you should have identified the failure of pump performance l to meet the values referenced in the Technical Specification bases and UFSAR. i This violation has been classified at a Severity Level III with a base civil penalty of $50,000. Escalation of 100 percent for the duration of this defi- i cient condition is being applied because the violation existed for a number of years. The quarterly performance test acceptance criteria were changed several times to accommodate the degrading pump condition. You had the opportunity to identify this problem at those times but failed to do so. Therefore, a $100,000 civil penalty is warranted. In sum, the number and nature of the above violations raise significant regulatory concerns. Your perfomance demonstrated by these violations cannot be tolerated. We recognize that you have initiated significant corrective actions and made l recent management changes. But for those actions, additional enforcement action would have been taken. You are required to respond to the enclosed Notice and you should follow the instructions specified therein when preparing your response. Your response should specifically address the corrective actions taken or planned to prevent recurrence. That response should address the scope and proposed schedule for your Configuration Management Program, nuntu u:mu I.A-156

MAY 181989 Virginia Electric & Power Company In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. The responses directed by this letter and the enclosed Notice is not subject to the clearance procedures of the Office of Management and Budget as reauired by the Paperwork Reduction Act of 1980, PL 96;511. Sincerely. u

                                  -         Stewart D. Ebneter Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalties

2. 01 Synopsis Case No. 2-88-008 cc w/encls:

M. R. Kansler, Station Manager R. F. Saunders, Manager - Nuclear Programs and Licensing Public Document Room (POR) Commonwealth of Virginia l I NUREG-0940 1.A-157

ENCLOSURE I NOTICE OF VIOLATIONS AND PROPOSED IMPOSITION OF CIVIL PENALTIES Virginia Electric and Power Company Docket Nos. 50-280 and 50-281 i Surry Power Station Units 1 and 2 License Nos. DPR-32 and DPR-37 l EA 88-296 During the Nuclear Regulatory Commission (NRC) inspections conducted September 1-3, 12-16, 26-30; Octobfr 2 - November 5, November 6 - December 17; November 14-18; and, December 18, 1988 - January 28, 1989 and January 29-March 4,1989; violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions", 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Comission proposes to impose civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalties are set forth below:

1. Cavity Seal Failure A.I.10 CFR 50.59, Changes, Tests and Experiments, allows a licensee to make a change to the facility as described in the safety analysis report without prior Comission approval, unless the proposed change l involves a change in the Technical Specifications or an unreviewed safety question. A change is deemed to involve an unreviewed safety question, in part, if the probability of occurrence or the consequences of an accident or malfunction of equipment important to safety previously evaluated in the safety analysis report may be ircreased. Further, the licensee must maintain records that include a written safety ,

evaluation which provides the bases for the determination that the l change does not involve an unreviewed safety question. Where an un- J reviewed safety question is involved, the licensee shall submit an application for amendment of his license. Surry Power Station (SPS) UFSAR Section 9.12.3.1, Refueling Cavities, states that the reactor vessel flange is sealed to the bottom of the l refueling cavity by an inflatable pneumatic seal ring that prevents i leakage of refueling water from the cavity. Should the seal deflate, its passive sealing design will preclude failure and leakage. Contrary to the above, operation of the facility until September 3, 1988 without an adequate passive sealing design that would preclude failure and leakage should the seal deflate, constitutes a change to the facility as described in the FSAR. No written safety evaluation was performed to provide the bases for this change in the refueling cavity seal design. This change represents an unreviewed safety question in that the probability of occurrence of a refueling cavity seal failure previously evaluated in the safety analysis report was increased as were the consequences of such an event in that rapid draining of the refueling cavity could expose irradiated fuel assembles, resulting in a radioactive release greater than that assumed in the FSAR. A.2.10 CFR Part 50, Appendix B, Criterion XVI, Ccrrective Action, requires that measures be established to assure that conditions adverse to NUREG-0940 1.A-158 l

Notice of Violation quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the significant condition adverse to quality, the cause of the conditipn, and the corrective action taken shall be documented and report ~ed to appropriate levels of management. Contrary to the above, notwithstanding the Unit I seal failure draining about 30,000 gallons of water from the refueling cavity which occurred on May 17, 1988, the deficiency in design was not identified and corrected because an inadequate evaluation was performed. The true nature of the seal failure was not determined (slow leak rather than sudden failure). The two violations have been classified in the aggregate as a Severity Level III problem (Supplement I). Cumulative Civil Penalty - $100,000 (assessed equally between the violations). B. 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires that activities affecting quality shall be prescribed by documented instructions, procedures or drawings of a type appropriate to the circumstances. Contrary to the above, the licensee failed to adhere to Criterion V as evidenced by the following examples:

1. After completion of the reactor cavity seal modifications for Units 1 and 2 on April 4,1985 until the September 1-3, 1988 AIT inspection, the licensee failed to establish instructions, procedures and drawings to assure proper operation of the inflatable seal portion of the instrument air system and backup nitrogen bottle pressurization system.

2. From April, 1987 until September 3, 1988, abnormal operating procedures did not provide adequate instructions for a rapid loss of refueling canal level as many of the necessary actions developed in response to IE Bulletin 84-03, Refueling Cavity Water Leak, were deleted during procedure revisions.

3. On May 17 and 18, 1988, in order to recover refueling cavity level, operators opened the fuel transfer tube isolation valve resulting in lowering the spent fuel pool water level without the use of written procedures.

This is a Severity Level III violation (Supplement I). Civil Penalty - $100,000 NUREG-0940 1.A-159

Notice of Violation II. Additional Corrective Action Violations 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, requires ) that measures be established to assure that conditions adverse to quality, l l such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and non-conformances are promptly identified i' and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification l of significant conditions adverse to quality, the cause of the condition. l and the corrective action taken shall be documented and reported to appropriate levels of management. A. Contrary to the above, on August 29, 1988, an engineering review of test data taken in response to Information Notice 88-91, Potential Gas Binding of High Pressure Safety Injection Pumps, determined that the operability of the High Head Safety Injection (HHSI) pumps during an emergency was not assured. This significant condition adverse to quality was not identified in a Station Deviation Report nor entered into the plant corrective action system. The lack of documentation resulted in the failure to notify appropriate levels of management. Consequently, Unit I continued to operate at power until September 14 and Unit 2 operated until September 10, 1988, in an unanalyzed fondition. This is a Severity Level III Violation (Supplement I). Civil Penalty - $75,000 B. Contrary to the above, a Station Deviation Report was written on November 20,.1987 to identify the inadequate capacity of the Control Room Ventilation Chillers to meet the 90 ton capacity specified in , UFSAR Section 9.13.3.6, Control Room Ventilation System. No safety evaluation of this condition adverse to quality was performed until April 11, 1988, at which time it was determined that Surry had been operated with this system outside its design basis. i C. Contrary to the above, from an undetermined date in 1986 to September 9, l 1988, both trains of the Control Room and Emergency Switchgear Room l Ventilation system were required to be run simultaneously to maintain l acceptable room temperatures. This degraded condition is contrary to SPS UFSAR Section 9.13.3.6 which specifies that each train shall be independent and capable of maintaining acceptable Control Room and

Emergency Switchgear Room Temperature. This condition adverse to l

quality was not documented on a Station Deviation Report until l September 9, 1988. These two violations have been categorized in the aggregate as a Severity Level III problem (Supplement I). Cumulative Civil Penalty - $50,000 (assessed equally between Violations B and C). NUREG-0940 I.A-160

Notice of Violation D. Contrary to the above, the licensee identified the use non-qualified replacement parts for safety-related components as a conaition adverse to quality in 1983 but failed to take adequate corrective action to remove those parts from its supply system until January,1989. This resulted in.use of non-qualified replacement parts on the two Unit 1 inside recirculation spray pumps during the 1988 refueling outage and the identification of non-qualified replacement parts installed on one of the Unit 1 low head safety injection pumps prior to August, 1988. E. Contrary to the above, the licensee failed to take adequate corrective action to prevent the recurrence of a significant condition adverse to quality. For an undetermined period of time up to and including November 17, 1988, during periods of heavy rain, water repeatedly leaked through improperly sealed Safeguards Building roof plugs, wetting safety-related electrical components, such as the auxiliary feedwater pump motors, rendering them inoperable. Corrective actions taken by the licensee were not effective in preventing recurrence. F. Contrary to the above, Quality Control (QC) inspection logs identified a number of deviations and non-conformances for' Jobs 62913, 67316, 65335, DC 88-01 and DC 87-22 for which the cause of the deviations and corrective actions were not documented to assure proper resolution. G. Contrary to the above, the licensee failed to correct a condition adverse to quality identified in QA Audits S84-21, S86-09, and S88-21 from 1984 until 1988. This condition involved the failure to implement a portion of ANSI Std. N18.7-1976 committed to by the licensee for establishment of a component failure trending and root cause analysis program. The recurrent audit finding was closed each time without implementing an effective program to meet the ANSI standard commitment and correct the deficient program. These four violations have been categorized in the aggregate as a Severity level III problem (Supplement I). Cumulative Civil Penalty - $50,000 (assessed equally among Violations D, E. FandG). III. Design Control 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires, in part, that measures be established to assure that applicable regulatory requirements and the design basis are correctly translated into specifi-cations, drawings, procedures and instructions. These measures shall include provisions to assure that appropriate quality standards are specified and included in design documents and that deviations from such standards are controlled. Contrary to the above, the licensee failed to meet Criterion III as evidenced by the following examples: A. The licensee failed to correctly translate the design basis for operability of the new safety-related recirculation spray heat NUREG-0940 I.A-161

Notice of Violation . exchangers (RSHXs) into specifications. The design inputs for calculations ME-179, 180, and 187 dated September 9, 1988, and MC-166 dated October 10, 1988 performed to determine the level of the upper level intake canal (Surry ultimate heat sink) necessary to ensure operability of the RSHXs were inadequate in that they did not include:

                                                                 -     accuracy of canal level instrumentation
                                                                 -     accurate emergency service water pump flow data
                                                                 -     accurate pipe fouling effects
                                                                 -     loss of canal water inventory by siphoning effects through the circulating water lines
                                                                 -     accurate water loss rates through other operating loads.

B. The licensee failed to correctly translate the design basis for operability of emergency pump house equipment into specifications. The design inputs for calculation ME-139, dated September 23, 1988, did not include the effects of extreme temperature ranges on Emergency Service Water System diesels and batteries. C. The licensee failed to assure that applicable regulatory requiremen~ts and the design basis were correctly translated into specifications. The design inputs for Calculation 14937.16-E-2, dated May 21, 1986, did not adequately include the effects of added loads on the 125 VDC Vital Bus battery sizing. D. The licensee failed to assure that applicable regulatory requirements and the design basis were correctly translated into specifications in that Calculation ME-79, dated November 17, 1988, did not adequately include the effects of minimum wall thickness for Component Cooling Water Heat Exchanger 1-CC-E-18. This is a Severity Level III Violation (Supplement I). Civil Penalty - $25,000 IV. Technical Specification 3.14.A.4 requires that the reactor shall not be taken critical unless at least two Emergency Service Water (ESW) pumps are operable. Technical Specification 3.144 Basis states that the long term ESW flow requirement for each pump is 15,000 gpm. The three ESW pumps must each have a capacity of 15,000 gpm to be considered operable. Contrary to the above, as of September 29,1988, the capacity of each of the three ESW pumps was determined either through observation or review of records to be approximately 12,000 gpm each, as measured by the Quarterly Performance Test (PT 25.3). Consequently, none of the ESW pumps were operable. This condition existed for an undetermined period of time, exceeding several years, during which the reactors were operated. This is a Severity Level III Violation (Supplement I). Civil Penalty - $100,000 NUREG-0940 1.A-162

Notice of Violation V. Other SSFI Violations A. 10 CFR 50.55a(g)(4)(ii) requires that inservice testing to verify operational readiness of pumps and valves comply with the requirements of Section XI of the ASME Boiler and Pressure Vessel Code. The licensee is committed to the 1980 Edition, Winter Addendum. Subsection IWV, Article IWV-3212, Exercising Procedures, and Article IWV-3413, Power Operated Valves of the Winter Addendum, requires that safety-related valves be exercised to the position required to fulfill their function and that that stroke time be measured. Recirculation Spray Heat Exchanger Inlet Isolation valves 1-MOV-SW-104 A, 8, C, and D, and Outlet Isolation valves 1-MOV-SW-105 A, B, C, and D are required to open to perform their safety function. Contrary to the above, on July 7,1988, the valves were not tested as required by Article IWV-3212 and Article IWV-3413 in that they were tested and stroke-timed from the open position to the closed position rather than vice-versa. This is a Severity Level IV violation (Supplement I). B. 10 CFR Part 50, Appendix B, Criterion V, and the licensee's accepted QA Program (Virginia Electric and Power Company, Topical Report, Quality Assurance Program, Operations Phase, VEP-1-5A, Updated) Section 17.2.5, collectively require that activities affecting quality be prescribed by procedures and accomplished in accordance with these procedures. It further requires that procedures include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished. Contrary to the above, as of the date of the SSFI inspection, procedures in effect did not include appropriate qualitative or quantitative acceptance criteria, as evidenced by the following examples:

1. PT-23.7D, ESW Pump Batteries Weekly Check, did not include acceptance criteria for electrolyte temperature, did not compensate battery voltage for temperature, and did not specify the correct voltage to indicate an adequate battery charge.

2. PT-23.14D, Emergency Service Water Pumps Battery Replacement, did not specify the correct voltage to indicate an adequate battery charge.

3. PT-23.90, Emergency Diesel Service Water Pump Batteries Quarterly Test, did not include adequate acceptance criteria for specific l gravity, and did not provide for correcting the specific gravity I measurement for temperature.

4 Procedure EMP-C-EPDC-62, Replacement of Batteries on Diesel Driven Fire Pumps, ESW Pumps and Security Emergency Diesel, dated March 25, 1986, did not include adequate acceptance criteria for specific gravity requirements. NUREG-0940 I.A-163

1 Notice of Violation 5. Procedure W P-CG-228, Thirty Inch Jamesbury IM0-302 Valves, RS-MOV-SW-103 A, B, C, and D, and RS-MOV-SW-203, A, B, C, and D, dated January 30, 1987, did not include appropriate acceptance crit'eria for checking the disc to seat clearances. This is a Severity Level IV violation (Supplement I). l C. 10 CFR 50, Appendix B, Criterion V, and the licensee's accepted QA J' Program, Section 17.2.5, collectively require that activities affecting quality be prescribed by procedures and accomplished in accordance with those procedures. Contrary to the above, procedures were not established to control i j proper torquing of system closure fastenings as evidenced by the following examples of overtorquing fasteners during work performed on equipment:

1. For Work Order (WO) 25253, body to bonnet fasteners on pressure control valve 01-SW-PCV-1000 were torqued to 590 foot-pounds (ft-lbs). The vendor-specified torque values for these fasteners is 400 ft-lbs.

2. For WO 58398, Charging Pump Lubricating 011 Cooler Service Water l Pump 01-SW-P-108, the pump casing capscrews (Item 370) and the )

gland seal nut plate nuts (Item 355) were torqued to 83 ft-lbs and 18 ft-lbs, respectively. The vendor-specified torque values for these fasteners is 50 ft-lbs and 10 ft-lbs, respectively. )

3. For WO 29791, valve 1-RS-MOV-155A, the body to bonnet fasteners.

were torqued to 150 ft-lbs. The vendor-specified torque values for these fasteners is 120 to 135 ft-lbs. 4 For WO 29791 valve 1-RS-MOV-115B, the body to bonnet fasteners were torqued to 150 ft-lbs. The vendor-specified torque values for these fasteners is 120 to 135 ft-lbs. This is a Severity Level IV violation (Supplement I). D. 10 CFR Part 50, AppendiW B, Criterion VIII, and the licensee's accepted  ; QA Program, Section 17.2.8, collectively require that measures be i established for the identification and control of materials, parts, and components. Surry Administrative Procedure SU ADM-M-16, Operation of Maintenance Department, requires that material traceability be provided for safety relcted parts by use of a material control tag. Upon installation of the safety related part, the material control tag is to be attached to the work order. NUREG-0940 I.A-164

Notice of Violation Contrary to the above, adequate measures were not established for identifying and controlling materials, parts, and components, as evidenced by the following examples:

1. WO 25253 replaced the valve body, bonnet, and stem disc assembly for Pressure Control Valve 01-SW-PCV-100B, and material control tags for these replacement parts were not attached to the work order.

2. WO 58398 replaced the rotating assembly of Charging Pump Lubricating 011 Cooler Service Water Pump 02-SW-P-108, and material control tags for these replacement parts were not attached to the work order.

3. WO 56035 replaced Intermediate Seal Heat Exchanger 02-SW-E-1A, and material control tags for this replacement part was not attached to the work order.

This is a Severity Level IV violation (Supplement I). E. 10 CFR Part 50, Appendix B, Criterion XI, and the licensee's accepted QA program Section 17.2.11, collectively require that a test program be established to assure that all testing required to demonstrate that structures, systems, and components will perform satisfactory in service is identified and performed. The licensee's accepted QA program, Table 17.2.0, 'comits to Regulator Assurance Requirements - (Revision 2, 2/78)y Guide which 1.33,ANSI endorses Quality N18.7-1976, Administrative Controls and Quality Assurance for the Operating Phase of Nuclear Power Plants. Paragraph 5.2.7 of this Standard requires that a suitable level of confidence in structures, systems, and components on which maintenance has been performed shall be attained by appropriate performance testing. Contrary to the above, Pressure Control Valve 01-SW-PCV-100B's valve body, bonnet, and stem disc assembly were replaced by Work Order 25253, and performance testing was not conducted following this maintenance activity. This is a Severity Level IV violation,(Supplement I). Pursuant to the provision of 10 CFR 2.201, Virginia Electric & Power Company (licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a

" Reply to a Notice of Violations" and should include: (1) admission or denial of each violation (2) the reason for the violation if admitted. (3) the correc-tive steps which 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. 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. Under the authority NUREG-0940                              I.A-165

Notice of Violation 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 j the amount of the civil penalties proposed above, or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee 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 a " Answer to a Notice of Violations" and may: (1) deny the violations listed in this Notice for which a civil penalty is proposed 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 penalties, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalties, the six factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set fourth 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. Up'on failure to pay the penalties due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter will be referred to the Attorney General, and the penalties, unless compromised, remitted, I 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 l Notice of Violations, letter with payment of civil penalties, and Answer to { Notice of Violation) should be addressed to: Director, Office of Enforcement, j U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, DC l 20555, with a copy to the Regional Administrator, Region II,101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, and the NRC Senior Resident Inspector at the Surry Power Statior.. FOR THE NUCLEAR REGULATORY COMMISSION g Stewar7 0. Ebneter

                               /       Regional Administrator Dated at Atlanta, Georgia this/#(day of May 1989 NUREG-0940                              1.A-166

UNITED STATES

    /p orcb                      NUCLEAR REGULATORY COMMISslON b              S                              REGION H

[ o 101 MARIETTA STREET. N A. 5 f ATLANT A. GEORGt A 30323 ( * "v/ ** APRir ifPT Docket Nos. 50-338 and 50-339 License Nos. NPF-4 and NPF-7 EA 88-311 Virginia Electric and Power Company ATTN: Mr. W. R. Cartwright Vice President, Nuclear Operations 5000 Dominion Boulevard Glen Allen, Virginia 23060 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 50-338,339/86-28; 50-338,339/87-01; 50-338,339/87-19, 50-338,339/88-02; 50-338,339/88-31, AND 50-338, 339/88-36) This refers to the Nuclear Regulatory Comission (NRC) inspections conducted on November 17, 1986 - January 11, 1987; January 12 - February 20, 1987; June 17 - August 18, 1987; January 25-29 and February 8-12, 1988; September 17 - , November 4,1988; and December 31, 1988 - February 2, 1989, at the North Anni Power Station. The inspections included a review of the degradation of several safety systems which revealed inadequacies in your corrective action process. These events are further discussed below. The reports documenting these insi;ec-tions were sent to you by letters dated January 29, 1987; March 12, 1987; September 10, 1987; May 26, 1988; December 26, 1988; and March 27, 1989. As a result of these inspections, significant failures to comply with NRC regulatory requirements were identified, and accordingly, NRC concerns relative to the inspection findings were discussed in Enforcement Conferences held on January 18 and r ebruary 7, 1989. A summary of these conferences was sent to you by letters dated February 16 and March 1, 1989. a The enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) identifies a violation of 10 CFR Part 50, Appendix B, Criteria XVI as evidenced by two examples of failure to identify and promptly correct significant conditions adverse to quality. Due to the nature of the examples described below, it is apparent that your staff's awareness and followup on potential operability issues involving equipment deficiencies lacked the management attention necessary to ensure such issues were promptly addressed and appropriately resolved. The first example cited in the violation involved your failure to adequately evaluate and subsequently correct problems that rendered several of your control room habitability systems inoperable. Specifically, there were two Technical Specifications violations that were identified which were not adequately evaluated or promptly corrected. NUREG-0940 I.A-167 ,

Virginia Electric & Power Company APR 2115 First, the control room emergency ventilation system flow rate did not meet Technical Specification requirements for operability from June 1986 until identified by the survey team in December 1986. This problem would have been identified by your staff had plant personnel performed post maintenance testing following maintenance on the emergency ventilation system in June 1986. Second, the control room bottled air system surveillance test, required by Technical Specifications to ensure operability of the bottled air portion of the habita-bility system, was identified by the team to be inadequate in that the accep-tance criteria allowed the readings from the Differential Pressure (D/P) test gauges to be averaged. This resulted in the completion of the test during the years prior to December 1986 with results meeting the acceptance criteria but allowing the D/P between the control room and several of the adjacent compart-ments to be outside the Technical Specification limit. The inoperability of either of these. two systems required the plant to be in a cold shutdown action statement per Technical Specification 3.7.7.1. The . Technical Specification violations are a significant concern; however, enforcement action is not being taken for those, in part, because you volunteered to participate in the NRC's Control Room Habitability Survey. Your failure to properly evaluate and correct the problems once they were identified is the more fundamental safety concern. Although you imediately resolved the emergency i ventilation system flow rate problem, complete resolution of the control room ' bottled air system problem was not prompt. With respect to the problem of  ! averaging the control room envelope D/p instrumentation readings instead of using discrete readings, your Technical Specification interpretation was unrealistic and not based on sound technical judgment. Corrective action was also not as rapid as the problem warranted. After taking compensatory measures to assure adequate air supply and pressure, you performed the D/P test successfully in August 1987 (after two failures in June and July 1987) using the correct inter-pretation. But in October 1988, a test failure due to your use of a combination of turbine building exhaust and supply blowers revealed that your corrective action in this matter was not comprehensive enough to assure satisfactory test results under all conditions. The second ew.aple cited in the violation involved a failure to promptly correct a degradation of your instrument air system resulting from water and oil contamination. On April 24, 1987, the plant had an event which resulted in a service water intrusion into the instrument air system. The corrective action involved blowing down the instrument air system at the low points and testing safety-related equipment affected by the water intrusion to ensure operability. This corrective action was completed in April 1987; however, in September 1988, and again in January 1989, you discovered water in an auxiliary feedwater system control valve which, when sampled, indicated that a portion of the water had resulted from the service water event. In addition, in March 1988 you identified, based on samples of the instrument air system, that the air was contaminated with oil, to a level greater than that permitted by either the ANSI /ISA standards or the vendor recommendations. In June 1988, you initiated a Safety System Functional Inspection (SSFI) of the instrument 4 air system as a result of these and other instrument air problems. This j review revealed that you had allowed the system to degrade over the years to  ; the point where the original oil free compressors for the instrument and I service air systems were no longer considered operable. Consequently, NUREG-0940 1.A-168 i

Virginia Electric & Power Company APR 211990 instrument air and service air were being maintained by compressors (Sullair and construction air) that are oil lubricated and do not meet many of the requirements in the Updated Final Safety Analysis Report. Your review of NRC Information Notices and INP0 Significant Operating Event Reports on air system problems should have resulted in more aggressive action in identifying and correcting the contamination sources for your instrument air system. Although the SSFI was a positive action on your part and instrumental in identifying the compressor replacement deficiencies, we believe that your lack of appropriate sensitivity to the problems with your instrument air system resulted in your failure to promptly identify and take appropriate corrective actions. Even with the invaluable information provided to you from the SSFI, you continued to operate the instrument air system with the dryer out of service until September 1988, and the oil filter out of service until December 1988. Not until water was discovered in the auxiliary feedwater control valve in January 1989 did you appear to take adequate actions to aggressively resolve the degradation of your instrument air system. The NRC staff considers the deficiencies in your corrective action process to have potentially significant safety implications and that any problem identi-fied by your staff that involves the poter..ial degradation of safety equipment should be given the utmost attention by your management. We understand that you have taken action to assess your corrective action program and are developing a more thorough root cause evaluation program. In order to emphasize the need to take lasting, effective action to assure prompt identification and resolution of equipment deficiencies, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of 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," in 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988) (Enforcement Policy), the violation described in the enclosed Notice has been categorized as a 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 base civil penalty amount has been decreased by 50 percent in recognition of your prompt and extensive corrective actions once you were aware that these deficiencies had not previously been properly addressed. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your  ; response, you should document the specific actions taken and any additional l actions you plan to prevent recurrence. After reviewing your response to this 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. NUREG-0940 I.A-169

l l l Virginia Electric & Power Company MR 2 i M The resp ~onses directed by this letter and the enclosed Notice are not subject ; to the clearance procedures of the Office of Management and Budget as required j l Dy the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. 1 Should you have any questions concerning this letter, please contact us. Sincerely, Stewar D. Ebneter

                                                                 . -f Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enc 1: G. E. Kane, Station Manager R. F. Saunders, Manager - Nuclear Programs and Licensing Commonwealth of Virginia l J l l NUREG-0940 I.A-170

NOTICE OF VIOLATION AND PROPOSED IMPOSITI F 0F CIVIL PENALTY Virginia Electric & Power Company Docket Nos. 50-338 and 50-339 North Anna Power Station License Nos. NPF-4 and NPF-7 Units 1 and 2 EA 88-311 As a result of the Nuclear Regulatory Comission (NRC) inspections conducted on November 17, 1986 - January 11, 1987; January 12 - February 20,1987; June 17 - August 18, 1987; January 25-29 and February 8-12, 1988; September 17 - November 4,1988; and December 31, 1988 - February 2, 1989, 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, 53 Fed. Reg. 40019 (October 13,1988), the Nuclear Regulatory Commission proposes to impose a Civil Penalty pursuant to Sectinn 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The violation and associated civil penalty are set forth below: 10 CFR Part 50, Appendix B, Criterion XVI, requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material 1 and equipment, and nonconformances are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action is taken to preclude repetition. Contrary to the above, the licensee failed to implement that portion of its Quality Assurance Program dealing with Criterion XVI of Appendix B, in that conditions adverse to quality were not promptly identified and corrected as evidenced by the following examples:

1. In June 1986, the licensee failed to identify and correct a control room emergency ventilation system flow rate that did not meet the requirements of Technical Specification 3.7.7.1. Additionally, prior to December 1986, the licensee failed to identify and between December 1986 and January 1989, the license failed to correct deficiencies in the control room bottled air system which resulted in differential pressures between the control room and several adjacent compartments being outside the limits of Technical Specification 3.7.7.1.

2. Between April 1987 and January 1989, the licensee failed to take adequate corrective actions to correct the degraded air quality in the instrument air system. Specifically, following an April 1987 water intrusion event, the licensee failed to adequately address the presence of water in the system and failed to identify the potential for and later correct the presence of an excessive level of oil.

This is a Severity Level III violation (Supplement I). Civil Penalty - $25,000 Pursuant to the provisions of 10 CFR 2.201, Virginia Electric and Power Company (licensee) is hereby required to submit a written statement or explanation to NUREG-0940 1.A-171 1

Notice of Violation the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 dayr of the date of this Notice. This reply should be clearly marked as a

               " Reply to a Notice of Violation" and should include: (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved. (4) the correc-tive 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 shell be submitted under oath or affirmation.

Within the same time as provided for the response required above undtr 10 CFR 2.201, the licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory 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 not be imposed. In addition to l protesting the civil penalty, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the 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 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 the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, NUREG-0940 I.A-172

Notice of Violation U.S. Nuclear Regt latory Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, Region II and a copy to the NRC Resident Inspector at the North Anna Power Station. FOR THE NUCLEAR REGULATORY COMMISSION Stewart D. Ebneter Regional Administrator Dated at Atlanta, Georgia this$/Efday of April 1989 NUREG-0940 I.A-173

1 I

                                                                                  )

4 1 I i 1 e i

I l 4 I.B. REACTOR LICENSEES, SEVERITY LEVEL III VIOLATION, NO CIVIL PENALTY r +$ NUREG-0940

e s 3* m ase ,q\ UNITED STATES y  ; NUCLEAR REGULATORY COMMISSION

                                       %                                                                    REGION 11 101 MARIETTA ST., N.W.

[tr ATLANT A, OEOROLA 30323 APR 0 61989 Docket No. 50-261 License No. DPR-23 l EA 89-02 Carolina Power & Light Company , ATTN: Mr. L. W. Eury Executive Vice President Power Supply and Engineering and Construction l Post Office Box 1551 Raleigh, North Carolina 27602 l l Gentlemen:

SUBJECT:

NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 50-261/88-36 AND 50-261/88-38) This refers to the Nuclear Regulatory Commission (NRC) inspections conducted on December 19-22, 1988, and on Decemt'er 11, 1988 - January 10, 1989, at the H. B. Robinson Nuclear Plant. These inspections included a review of the circumstances surrounding several licensee identified items not in compliance with NRC Regulations. The reports documenting these inspections were sent to you by letters, dated January 24, 1989, and February 6,1989, respectively. As a result of these inspections, significant failures to comply with NRC regulatory requirements were confinned, and NRC concerns relative to the inspections were discussed in an Enforcement Conference held on February 9, 1989. The letter documenting this Conference was sent to you on February 22, 1989. The violations described in the enclosed Notice of Violation concern failures to: (1) perform an adequate analysis for electrical overcurrent on motor control centers (MCC)-5 and -6 which involved an initial plant design error; and (2) provide procedures appropriate for pressure testing the turbine g:nerator which resulted in the introduction of hydrogen gas into portions of the station and instrument air systems. Violation A of the encloted Notice involved an electrical design deficiency which, under certain postulated accident conditions, could have resulted in the itss of all 480 volt safety-related MCCs. Specifically, had a loss of coolant accident occurred while the plant was in hot shutdown with off-site power available, and there was a single failure of either MCC-5 or MCC-6, the remaining MCC feeder breaker could have tripped on overload. As a result, this could have resulted in emergency core cooling systems being in a degraded condition. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988)(EnforcementPolicy)violationAdescribedintheenclosedNoticehas been classified as a Severity Level III violation. NUREG-0940 I.B-1

I Carolina Power & Light Company -2_ APR 0 61999 Normally, a civil penalty is considered for a Severity Level III violation.

   ' However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Material Safety, Safeguards, and l     Operations Support, I have decided that a civil penalty will not be proposed in this case because it was identified as a result of your Design Basis Reconstitution Program on October 5, 1988 and compensatory actions were implemented on October 6, 1988 to reduce the electrical loads on the MCCs.

The issue was discussed with NRC on October 7, and was formally reported on October 10, 1988. Permanent corrective actions, which included removal of non-vital loads from the MCCs, were subsequently taken during the November 12, 1988 refueling outage. Violation B of the enclosed Notice involved the intrusion of flammable concentrations of hydrogen into the station and instrument air systems, due to personnel error while conducting a turbine generator pressure test on l January 6-7, 1989. Although classified as a Severity Level IV violation, this was an event with potentially serious consequences to personnel and plant equipment. The cross connecting of plant air to the turbine generator hydrogen cooling cystem underscores our concerns expressed to you in our most recent SALP report of relying on personal knowledge instead of detailed written procedures. Aside from revealing both a lack of system knowledge by the turbine testing crew involved and a lack of a detailed procedure which would have most probably prevented the occurrence, this event also revealed a lack of management control, inadequate communication, and poor work practices. Accordingly, this event should serve to heighten your sensitivity to the potential impact of interfacing safety-related systems with nonsafety-related systems, as well as prompt you to thoroughly evaluate your control over such activities. The two environmental qualification (EQ) violations (88-36-02 and 88-36-03) described in NRC Inspection Report No. 50-261/88-36 have been classified as additional examples of previously cited violations B.1 and C. respectively, in the Notice of Violation and Proposed Imposition of Civil Penalty sent to you by letter dated June 16, 1988. As a matter of discretion under Section V.G.5 of the Enforcement Policy no additional enforcement action will be taken relative to these examples. ThefirstoftheseissuesconcernstheEQdeficiencyinvolving the Crouse-Hinds electrical penetration splices for the Reactor Containment Fan Coolers. This deficiency was identified as a result of your ongoing EQ Program Assessment effort. It was promptly reported and the plant was placed in Hot Shutdown on October 28, 1988, for repairs that upgraded the splices to a qualified configuration. With respect to the second issue, on September 14, 1988, while the plant was in cold shutdown, you discovered that the Reactor Vessel Head Vent solenoid operated valves were not properly installed to meet EQ requirements and were not included on the Robinson Master EQ List. This was discovered while investigating a similar generic issue identified at your Shearon Harris Plant in August 1988. The necessary corrective actions were taken to place the solenoid valves in a qualified configuration prior to restart and this problem was reported in a licensee event report (LER) on October 14, 1988. As the corrective actions for both of the above EQ issues have already been addressed in the associated LERs, and these two issues are being considered as NUREG-0940 I.B-2

Carolina Power & Light Company APR46 tog additional examples of violations previously cited, a separate. response is not required. However, sir.ce the previous violations were cited under the

 " Modified Enforcement Policy Relating to 10 CFR 50.49", any information relating to these additional examples that you may submit will be considered, under the criteria of that policy, along with the infonnation you have already provided.

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 Roem. The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Should you have any questions concerning this letter, please contact us. Sincerely, Stewart D. Ebneter Regional Administrator

Enclosure:

Notice of Violation cc w/ encl: C. R. Dietz, Manager i Robinson Nuclear Project Department R. E. Morgan, Plant General Manager i' State of South Carolina i NUREG-0940 I.B-3

l NOTICE OF VIOLATION Carolina Power & Light Company Docket No. 50-261 H. B. Robinson License No. DpR-23 EA 89-02 i During the Nuclear Regulatory Commission (NRC) inspection conducted on December 19-22, 1988 and December 11, 1988 - January 10, 1989, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, i 53 Fed. Reg. 40019 (October 13,1988), the violations are listed below: ) 1 A. 10 CfR Part 50.46, Appendix K, Section D.1, " Single Failure Criterion," requires an analysis of possible failure modes of ECCS equipment and of their effects on ECCS performance. In carrying out the accident evaluation, the combination of ECCS subsystems assumed to be operative shall be those available after the most damaging single failure of ECCS equipment has taken place. J Contrary to the above, on October 5, 1988, the licensee discovered, through a Design Basis Reconstitution program, that a potential electrical overcurrent condition could exist for safety-related motor control centers 5 and 6 which could result in ECCS equipment being in a degraded condition. This previously unanalyzed condition relates to load flow for the mitigation of a loss of coolant accident (LOCA) without loss of off-site power concurrent with a single failure that will render one of the motor control centers inoperable. This in turn could result in overloading and tripping of the remaining motor control center. This is a Severity Level III violation (Supplement I). B. Technical Specification 6.5.1.1.1.a requires written procedures be established for procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Item 9.a of Appendix A requires maintenance that can affect the performance of safety-related equipment be performed in accordance with written procedures appropriate to the circumstances. Pressure testing of the turbine generator is a maintenance activity which can affect the performance of safety-related equipment by using air systems which also supply safety-related equipment. Contrary to the above, procedures appropriate to the circumstances were not established for maintenance activities on January 6,1989, in that no written procedure was established to perform pressure testing of the turbine generator. This resulted in the introduction of flammable hydrogen gas mixtures into portions of the station air systems which supply air to safety-related equipment. This is a Severity level IV violation (Supplement I). NUREG-0940 1.B-4

I l Notice of Violation Pursuant to the provisions of 10 CFR 2.201, Carolina Power & Light Company is hereby required to submit to this Office within 30 days of the date of the letter transmitting this Notice a written statement or explanation in reply including for each violation: (1) admission or denial of the violation, (2) the reason for the violation if admitted, (3) the corrective steps which l 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. 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. FOR THE NUCLEAR REGULATORY COMMISSION , I ' Stewart D. Ebneter Regional Administrator Dated aj Atlanta, Georgia , this d m day of April 1989 ] I l NUREG-0940 1.B-5

UNITED STATES  ; [,c,# *%,'\ NUCLEAR REGULATORY COMMISSidN  !

                                                         .f 8

REGloN IV 611 RYAN PLAZA DRIVE. SUITE 1000 l

                                              *o                                ARLINGTON. TEXAS 79011                              ;

i M 201915 i i Docket No.- 50-298 License No. DPR-46 i EA 89-56 l l l Nebraska Public Power District ATTN: George A. Trevors Division Manager - Nuclear Support Post Office Box 499 Columbus, Nebraska 68502-0499  ; I Gentlemen:

SUBJECT:

NOTICE OF VIOLATION (NRC INSPECTION REPORT NO.'89-09) This is in reference to the February 13-16. 1989 NRC inspection at the Cooper Nuclear Station following a February 13, 1989 failure of Emergency Diesel Generator (EDG)flo.1. The report documenting this inspection was sent to you l by letter dated March 3, 1989. As a result of this inspection,'a significant failure to comply with NRC regulatory requirements was identified. Accordingly . NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on March 23, 1989. The violation described in the enclosed Notice of Violation (Notice) involves  ! a failure to take adequate corrective action following a loss of control air pressure for EDG No. I on January 17, 1989 due to a crack in a tube fitting. A replacement fitting of the same wall thickness was not available on site and, based on an inadequate evaluation, the cognizant engineer concluded that a fitting of about half the wall thickness was acceptable, based solely on its pressure rating. The replacement fitting subsequently failed during another operational test of the No.1 EDG on February 13, 1989, rendering the EDG inoperable after less than 7 hours run time since the repair. The NRC is concerned that a decision was made to use a less substantial component in this application despite a known history of vibration induced problems. While NRC cannot conclude that EDG No. I was inoperable from January 17 to February 13, 1989, CERTIFIED MAIL RLIURN RECEIPT REQUESTED NUREG-0940 I.B-6

2 0 1989 Nebraska Public Power District as we had indicated in our inspection report on this matter, your corrective action following the January 17 diesel failure was insufficient to preclude a second failure. Despite sufficient evidence regarding the nature of the January fitting failure and other vibration induced EDG problems, the engineering evaluation failed to properly correct the control air system's deficiency. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (53 Fed. Reg. 40019, October 13,1988), the violation described in the enclosed Notice has been classified at Severity Level III. A base civil penalty of $50,000 is normally considered for a Severity Level III violation. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, I have decided that a civil penalty will not be proposed for this case based on your prompt reporting of the diesel failure, and the immediate and extensive corrective actions that specifically include replacement of EDG support system tubing in a vibration resistant configuration and planned upgrades to your root cause analysis program. You are required to respond to this letter and should follow th9 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 whethe- further NRC enforcement action is necessary to ensure compliance with JRL 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 l will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject i to the clearance procedures of the Office of Management and Budget as required I by the Paperwork Reduction Act of 1980 Pub. L. No. 96-511. l l l Sincerely, 1 1

                                                               .L /0 obert D. /               '

Regional Adm161s rator l Enclosure. 4 Notice of Violation cc: Nebraska Radiation Control Program Director NRC Public Document Room NUREG-0940 1.B-7

NOTICE OF VIOLATION Nebraska Public Power Sistrict Docket No. 50-298 Cooper Nuclear Station License No. DPR-46 EA 89-56 During an NRC inspection conducted on February 13-16, 1989 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, 53 Fed. Reg. 40019 (October 13,1988), the following violation is listed below: 10 CFR Part 50, Appendix B, Criterion XVI, requires that measures be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected. In the case of significant conditions adverse to quality the measures shall assure that the cause of the condition is datermined and corrective action taken to preclude repetition. Contrary to the above, Emergency Diesel Generator (EDG) No. I at Cooper Nuclear Station failed on January 17, 1989, due to a cracked fitting in the control air system, and the licensee did not tahe adequate corrective action to preclude repetition. EDG No. I failed again on February 13, 1989 when the replacement fitting, a thinner-walled component than that which had been i replaced, was found cracked during an operational test of the diesel. l This is a Severity Level III violation (Supplement I). Pursuant to the provisions of 10 CFR 2.201, Nebraska Public Power District is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, Region IV, and if applicable, a copy to the NRC 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 the 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 b b ' J obert D. 1%wW, Regional Adminis4fator Dated at Arlington, Texas, this 20th day of April 1989. NUREG-0940 I.B-8

y ff - [0g g-UNITED STATES NUOLEAR REGULATORY COMMISSION % j WASHINGTON, D. C. 20$55 o, a i

 %, * * * * * /                        DM 21 jg Docket Nos. 50-390 and 50-391 License Nos. CPPR-91 and CPPR-92 EA 88-253 Tennessee Valley Authority ATTN: Marvin T. Runycn Chairman of the Board 6N 38A Lookout Place 1101 Market Street Chattanooga, Tennessee 37402-2801 Centlemen:

SUBJECT:

NOTICE OF VIOLATION I This refers to the inspection and investigation conducted at the Tennessee Valley Authority beginning December 3, 1986. .These efforts were undertaker as a followup to your submission of a letter dated March 20, 1986 responding to a NRC inquiry as,to whether or not the requirements of 10 CFR Part 50, Appendix , B, were being met at the Watts.Bar Nuclear Plant and the submission of a sub- 1 sequent letter of June 5, 1986 furtner describing this issue. The NRC has determined that the conclusions in the March 20, 1986 letter, at best, did not adequately Jortray the nature and extent of the review conducted concerning compliance wit 1 Appendix B at the Watts Bar Nuclear Plant. Enclosure 1 provides background information with regt.rd to the March 20 letter. In a letter dated May 16, 1986, NRC informed TVA that NRC could not agree with the conclusions contained in the March 20 letter. The NRC's letter of May 16. 1986 provided TVA with an opportunity to reexamine its position. TVA responded , with a letter signed by Mr. White on June 5, 1986. In this letter, TVA repeated and reemphasized the conclusion made in the March 20, 1986 letter concerning compliance with Appendix B at Watts Bar. In the June 5, 1986 letter, TVA added two significant statements which were i clearly intended to bolster earlier statements made to NRC and to allay the , staff's concerns. In the first, Mr. White advised that he had " assembled a i group of outside individuals with significant and extensive nuclear QA experience in the areas questioned and directed them to conduct a review of l each one of the perceptions." The second stated that "In addition, I had a group of highly experienced non-TVA experts review this group's findings." Both of these statements are false. The effort of the first group was of insufficient scope or depth to support the conclusion that a review of each perception was undertaken. Mr. White, notwithstanding the second statement, did not form a second group to conduct the stated review process. In fact, j there never was a second group. NUREG-0940 1.B-9

Tennessee Valley Authority These statements clearly conveyed the impression that Mr. White was in charge, that he knew what was happening, and that the March 20, 1986 letter could be relied on because TVA had performed two formal reviews of the information provided to assure its validity. However, his lack of familiarity with the review process and his statement concerning the " group" of "non-TVA experts", which did not exist as a review group, indicate that the "non-TVA experts" statement was made with careless disregard for the truth. This indifference to accuracy was demonstrated again in Mr. White's sworn testimony to 01 investigators on July 14 and 15,1987 concerning that review process. When asked about the group of non-TVA experts, Mr. White named nine individuals and stated that "yes, in effect" they reviewed the findings of the group of the outside individuals, but that he did not know what they did in order to review those findings. When asked how he got the results of their review, Mr. White stated "I got them from direct conversations." Of the individuals named, one reviewed the findings and discussed them with fir. White, another did a . cursory review but did not discuss it with Mr. White, and the other seven neither reviewed the findings nor discussed them with Mr. White. Thus, Mr. White's testimony concerning the actions of the non-TVA experts was false. In a further letter to the NRC on the subject, dated January 11, 1987, in re-ferring to the review conducted by the " group of cutside individuals", Mr. White used the phrase " Based on a limited review of the 11 issues...", whereas that limitation had not been included in the earlier correspondence, and in fact, the opposite impression was conveyed in the March 20 and June 5,1986 letters. These TVA communications with the staff regarding the quality of work at Watts Bar did not fully convey the extent of the problems and led the staff to believe that TVA's r?anagement did not understand the magnitude of the issues confronting TVA. This failure required the NRC to put considerably more effort and resources into inspections and review at Watts Bar during calendir year 1986. It is obviously of concern that, after TVA in 1985 had certified Watts Bar as ready for licensing, there had been breakdowns in the construction process that had been undetected as of 1986 by TVA's quality assurance program. However, NRC is also very concerned that in preparing the March 20, 1986 letter TVA, did not state it was not in a position yet to judge whether its QA program was effective, but instead developed a response to the January request to justify that the program was good enough when it wasn't. Time has shown that the QA program was not effective in all areas. There were sub-sequently reported breakdowns in inspection of structural welding and in radiograph interpretation. TVA has in the past reflected an attitude, spec-ifically, a tendency to do things in its own way, and has failed to recognize the importance of meeting or exceeding national standards. It was our expec-tation that Mr. White and his advisors would change this attitude at TVA. TVA has expressed its desire to achieve excellence in performance. Although some improvements in attitude have been seen, TVA must continue these improvements in order to attain the level of performance expected of one of the largest U.S. ruclear utilities. NUREG-0940 I.B-10

Tennessee Valley Authority ' The regulatory system requires submission of a large amount of information by licensees on a continuing basis. You should be aware that the regulatory process is by its nature an audit. The NRC, with its limited resources, cannot monitor all activities of a licensee. Therefore, the NRC must be confident that it can rely on the information furnished by a licensee. If the answer to an NRC inquiry is that the licensee does not know or is not yet ready to respond because of lack of information, the licensee must so state. The regulations imposed by this agency are imposed to be met. A licensee cannot expect NRC to carry out its function when faced with ambiguities and highly qualified statements. The holder of a license from the NRC must be complete and accurate in communicating with the NRC and its staff. Anything less than accurate and complete statements to the Commission cannot and will not be tolerated. Enforcement action is appropriate for this matter. While the conclusions in the March letter and their reit'eration in the June letter were, at least, incomplete and inaccurate, the Comission has decided not to take action on them as a matter of prosecutorial discretion. The Commission has determined that the enforcement action being thken herein, based on the additional statements in the June letter and the statements made to the Commission's investigators, is sufficient to emphasize its concerns with TVA's communications. Therefore, separate action on the conclusions in the March letter and the reiteration in the June letter is not necessary'to convey to TVA the need for accurate communications with the NRC. It is recognized that Mr. White's tenure at TVA is coming to an end. Although TVA has made organizational changes, these changes in TVA's management do not remove TVA's responsibility for the material false statements set forth in the ' l Notice of Violation involved in this case. TVA management as a whole is responsible for the quality of communications with the NRC. Mr. White was the l executive resposible for the communications involved in these violations. However, it was TVA's responsibility as an organization to give Mr. White the quality of support necessary in the NRC's regulatory environment. Both the individuals involved and the organization must share responsibility for the actions giving rise to these violations, but the fundamental premise of our regulatory system makes TVA, as the licensee, ultimately responsible. Therefore, this action is being taken notwithstanding Mr.' White's expected departure from TVA. The violations associated with the communications at issue are described in the attached Notice of Violation. These violations have been aggregated into a Severity Level Il problem because the statements concerning the "non-TVA experts" in the letter and during the investigation were made in at least careless disregard for the accuracy of the information, because of the level of Mr. White's position, and because the three statements are related in that their intent was to influence the agency to accept the t' arch 20, 1986 position. However, the Commission has concluded under the circumstances, that a civil penalty for this matter is not necessary to further focus the attention of either TVA or the industry on the importance of complete candor in dealing with the NRC. NUREG-0940 1.B-11

Tennessee Valley Authority You are required to respond to this letter and should follow the instructions specified in the enclosed Notice of Violation when preparing your response. In your response, you should document the specific actions taken and as.y additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is tiecessary to ensure compliance with NRC regulatory requirements. In at.cordance 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, s M. Taylor eputy Executive Director for Regional Operations

Enclosures:

Background and Notice of Violation ' cc: See next page NUREG-0940 1.B-12

Background Concerning March 20, 1986 Letter l On December 19, 1985, TVA's Nuclear Safety Review Staff (NSRS) made a presentation to NRC Commissioner James Asselstine regarding the NSRS perceptions of the I quality and status of construction at the Watts Bar Nuclear Plant (WBN). These perceptions included 11 issues and a " bottom line" that the requirements of 10 CFR Part 50, Appendix B were not being met at WBN. At the time of the presentation, the presenter noted that HSRS management had not seen the slide depicting these issues and thus the slide did not necessarily convey the TVA corporate position. In a letter dated January 3,1986, the NRC asked TVA to furnish under oath or affirmation "TVA'c corporate position with respect to whether or not 10 CFR Part 50, Appendix B requirements are being met at the Watts Bar facility." On March 20, 1986, TVA submitted a notarized response to the staff's inquiry. The cover letter stated: On the bas.is of a review of the issues identified in the NSRS Perceptions, as reflected in the enclosure, I find that there has been no pervasive breakdown of the quality assurance (QA) program; that problems have been identified; and that TVA has remedied or will remedy all identified design / construction deficiencies and noncompliance, and that accordingly, the overall QA program is in compliance with 10 CFR Part 50, Appendix B. The response contained attachments that addressed each of the 11 NSRS perceptions. At the time that the letter was being delivered to the NRC, Mr. S. A. White, Manager of Nuclear Power, discussed the letter in a telephone call with Mr. Denton. This contemporaneous phone call was apparently intended to assure that the March 20, 1986 letter responded to the NRC's inquiry of January 3, 86. At the time of the January 3,1986 letter, the NRC had concerns with regard to TVA's performance at its nuclear facilities. The concerns included: (1) As of August 1985, TVA had placed all of its licensed operating plants in administrative shutdown due to extensive technical and managerial problems. TVA agreed not to restart these plants without NRC authorization. In addition, numerous deficiencies had been identified at the Watts Bar facility by TVA and through its Employee Concern Program. (2) On September 17, 1985, the NRC issued the fifth Systematic Assessment of Licensee Performance (SALP) of TVA facilities and headquarters functions. The SALP found significant and continuing weaknesses in performance in many aspects of TVA nuclear activities. In addition to the poor SALP performance in many areas at several sites, the NRC letter noted the multiple escalated enforcement actions, including a large accumulation of civil penalties, and numerous significant events at TVA facilities. The letter of September 17, 1985 indicated that the underlying causes of these problems were programmatic and management deficiencies. F.ecause of the " ineffective management of its nuclear program," TVA was asked in that letter to provide information relating to various aspects of its nuclear program, including QA, pursuant to 10 CFR 50.54(f). NUREG-0940 I.B-13

Enclosure During this time period TVA made significant management changes at all levels, including measures to keep the Board of Directors informed and involved, establishment of corporate controls for tracking commitments to the NRC, and procedures for escalating Quality Assurance audit findings. In light of these actions, senior TVA management, including those people new j to TVA, should have recognized by March 1986 that serious problems existed l throughout the QA program. QA programs were fragmented and deficient. Senior management should also have recognized that the large number of employee concerns regarding construction deficiencies at Watts Bar was further evidence of the likelihood of serious QA problems at that plant. The corrective action program was weak and known to be deficient, in that it did not identify root causes or prevent recurrence of identified problems. Similarly, there was evidence that the welding program was seriously deficient. Starting as early as 1980, questio'ns were raised as to the quality of welds and the weld inspection process. The problem was first noted at Bellefonte Nuclear Plant, but was found to be generic to all TVA plants under construction'. While there was regular contact between TVA and NRC after 1980, in 1985 and January 1986, the level of interaction was very high, with frequent meetings and letters to address increasingly serious concerns over the welding program and inspection practices. TVA then engaged an outside contractor to address the welding , problems.

                   ~

In the face of the background described above, and the examination of TVA in the fall of 1985 by Mr. White and some of his advisors, TVA senior management failed to assure that a thorough review of the NSRS perceptions was conducted. In addition, they failed to involve those in TVA who were in positions to accurately portray conditions. Individuals in this group had prepared earlier drafts of a response to the NRC inquiry of January 3,1986 which would have put j them in a meaningful position to comment on the response that was being prepared. l Instead, the advisors' submitted to Mr. White a response that used language drafted, in part, by outside counsel without critically reviewing it for accuracy, clarity, and application to the matter at hand. As a result, the March 20, 1986 letter , i and its attachments, at best, did not adequately portray the nature and extent I of the review conducted. This response conveyed a broad review to support broad findings and omitted the limitations of the review. Specifically, the response ' (1) did not describe that TVA only conducted a limited review of the specific bases provided by NSRS for the issues in its perceptions, (2) did not describe the limited time frame of the review being reported (suggesting past history rather than contemporaneous QA activities, i.e. since Mr. White.came to TVA on January 13,1986), and (3) used highly qualified and ambiguous terms such as the "overall QA program" and " pervasive", resulting in a misleading breadth of review. There was apparent concern within TVA that stating the problem clearly would have created an adverse impact on TVA, as demonstrated by key managers comparing the TVA situation to Zimmer. Mr. Kelly, the QA manager, would not have concurred in this letter if the letter had said there was no " widespread breakdown." In sum, the March 20, 1986 letter conveyed a sense that the l problems were of a lesser magnitude than was known to be the case. NUREG-0940 1.B-14

Enclosure On May 16, 1986, the NRC wrote TVA advisir.g that the NRC was "not prepared to agree with your conclusion on the TVA position regarding Appendix B requirements." This was because NRC's final position with regard to Appendix B requirements relative to the 11 NSRS issues would depend on: (1) evaluation and resolution j of issues raised in the employee concern program, (2) evaluation of the position of the NSRS staff, and (3) evaluation and resolution of allegations by NRC. TVA, through Mr. White, has stated that it intended the March 20, 1966 letter to cover current Appendix B performance. NRC clearly did not read the letter that way and was concerned about past work as well as current efforts. Thus, the May 16, 1986 NRC letter advised that, as to past work related to the NSRS Perceptions, the NRC could not agree with the conclusions of TVA, and, as to ongoing work, the NRC would continue to review the adequacy of such work during inspections. The NRC also requested additional information as to the apparent inconsistency between the March 20, 1986 response and the withdrawal of certification of readiness for fuel load at Watts Bar. t i l I NUREG-0940 I.B-15

                                                                                                                                                                        ~

NOTICE OF VIOLATION Tenn'essee Valley Authority Docket No. 50-390/50-391 1 6N 38A Lookout Place License No. CPPR-91 and CPPR-92 1101 Market Street EA 88-253 Chattanooga, TN 37402-2801 As a result of an NRC inspection and an investigation conducted beginning December 3, 1986, certain violations of NRC requirements have been identified. In accordance with the " General Statement of Policy and Procedure for HP.C Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the particular vi~olations are set forth below. In a letter dated January 3,1986, the NRC requested the Tennessee Valley Authority (TVA) to " furnish under oath or affirmation, TVA's corporate position with respect to whether or not 10 CFR Part 50, Appendix B j requirements are being met at the Watts Bar facility." In a letter dated March 20, 1986 and signed under oath by S. A. White, Manager l of Nuclear Power, the TVA responded to the question propounded by the NRC as follows: On the basis of a review of the issues identified in the NSRS [ Nuclear I Safety Review Staff] Perceptions, as reflected in the enclosure, I find that there has been no pervasive breakdown of the quality assurance (QA) program; that problems have been identified; and that TVA has remedied or , will remedy all identified design / construction deficiencies and ' noncompliance, and that accordingly, the overall QA program is in compliance with 10 CFR Part 50, Appendix B. , In a letter dated June 5, 1986 and also s;gned by S. A. White, Manager of Nuclear Power, TVA reiterated the previon conclusion stating: I think it is important to repeat that conclusion. 'On the basis of a review of the issues identified in~the NSRS Perceptions, as reflected in the enclosure, I find that there has been no pervasive breakdown of the quality assurance (QA) program....' Also in the June 5, 1986 letter, TVA, through Mr. White stated: In order to respond to that specific request, (the NRC January 3 inquiry) I assembled a group of outside individuals with significant and extensive nuclear QA experience in the areas questioned and directed them to conduct a review of each one of the perceptions. In addition, I had a l group of highly experienced non-TVA experts review this group's findings. These efforts were separate from and in addition to the overall corrective actions which I began taking to restructure and strengthen TVA's entire QA program. In sworn testimony given to the Office of Investigations (01) investi on July 14 and 15, 1987 (Tr. pp. 158-9 and pp. 198-201, respectively)gators , Mr. White testified that he had a group of nine non-TVA experts review the "Lundin" group's findings. fir. White twice named nine individuals whom he considered to be the NUREG-0940 1.B-16

Notice of Violation group of non-TVA experts. They were Messrs. Kelly, Huston, Drotleff, Kirkebo, Wegner, Stone, Sullivan, Sisken, and Brodsky. He characterized the manner in which the review was conducted "I bounced things off of them" and indicated that they "in effect" reviewed the findings. He indicated that he did not know what they had done to perform the review or whether it was documented. Of the . nine individuals named, Mr. Kelly reviewed the findings and discussed them l with Mr. White. Mr. Brodsky did a cursory review but did not discuss it with Mr. White. The remaining seven neither reviewed the findings nor discussed j them with Mr. White.

Section 186 of the Atomic Energy Act of 1954, as amended, obligates licensees l to ensure that all submissions to the NRC are complete and accurate in all material respects.

A. Contrary to Section 186, the statement made in the June 5,1986 letter that "... I assembled a group of outside individuals with significant and extensive nuclear QA experience in the areas questioned and directed them  ; to conduct a review of each one of the perceptions" constitutes a { material false statement. The statement is false in that it states that an independent group actually conducted a review of each of the perceptions. Instead, the independent group merely assessed the review of the perceptions i actually conducted by members of the line organization. The report of this review, known as the "Lundin effort," was only two pages long and contained only one paragraph of substance. The group leader, Mr. Lundin, never spoke to Mr. White about it, and also stated that the review was not iatended to determine compliance with Appendix B. The statement is material in that it was made for the purpose of influencin the NRC's evaluation of the TVA response to a specific question reis"d by the NRC on a significant regulatory issue that was importent for the NRC to resolve in regard to its decisions as to authorizing iiel load and subsequent l licensing of the plant. 1 B. Contrary to Section 186, the statement made in the June 5, 1986 letter that "In addition, I had a group of highly experienced non-TVA experts review this group's findings" is a material false statement. It is false in that there was no second group. No one identified by Mr. White as being a member of the second group understood there to be such a group. Of the nine members Mr. White identified as being in this group, one reviewed the findings and one did a cursory review. None of the other seven reviewed the findings. The statement is material in that it was made for the purpose of influencing the agency's evaluation of the response to a specific ouestion posed by the NRC on a significant safety issue that was important for the NRC to resolve in regard to its decisions as to authorizing fuel load and subsequent licensing of the plant. C. Contrary to Section 186, the statements made to the OI investigators on July 14 and 15, 1987 as to the review were material false statements. They were false, because there was no second group and because of the nine individuals that Mr. White names as being in that group, only one reviewed the findings and discussed them with Mr. White, one performed a cursory NUREG-0940 I.B-17

Notice of Violation review but did not discuss it with Mr. White, and the remaining seven

      ~

neither reviewed the findings nor discussed them with Mr. White. The statements are material because they had the capability to and, in fact, did affect the direction of a properly authorized investigation being

conducted by the Commission.

Violations A., B., and C. are considered in the aggregate to be a single Severity Level II problem (Supplement VII). Pursuant to the provisions of 10 CFR 2.201, Tennessee Valley Authority (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 achieve'd, (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. The response to the Director, Office of Enforcement should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Al M: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, Region. II, U.S. Nuclear Regulatory Commission 101 Marie aa Street, Atlanta, GA 30323 and a copy to the Director, Offic; of Special Projects, U.S. Nuclear Regulatory Commission, Washington, Du 20555. FOR THE NUCLEAR REGULATORY COMMISSION

                                                      -?       [
                                                  =w W
                                              .es M. Taylor Deputy Executive Director for Regional Operations Dated at Rockville, Maryland this2 p3 day of October 1988 NUREG-094D                              I.B-18

e* a'c

          #g                                         oq'o "g                        UNITED STATES
   !"                                                    n            NUCLEAR REGULATORY COMMISSION h..                                                   : C                   WASHINGTON, D. C. 20555
    %                                                  g                         June 5, 1989 e...+

Docket Nos. 50-390 and 50-391 License Nos. CPPR-91 and CPPR-92 EA 88-253 Mr. Marvin Runyon, Chairman , Board of Directors Tennessee Valley Authority Knoxville, Tennessee 37902

Dear Mr. Runyon:

In your letter of November 21, 1988, to James Lieberman, Director of the NRC's Office of Enforcement, you indicated that the TVA did not intend to challenge the staff's October 21, 1988 Notice of Violation or seek further review of the issue. Your letter, together with the letter of March 24, 1989 from O. D. Kingsley, Jr., Senior Vice President, Nuclear Power, described corrective measures to ensure that TVA's submittals to the Comission meet high standards of completeness and accuracy. Your actions were acknowledged by Mr. Lieberman's letter dated April 20, 1989. As you are aware, Steven A. White, TVA's former Senior Vice President-Nuclear Power, and his attorneys submitted a separate resporse to the NOV, which we have consioered carefully. As a result of this reconsideration, the Commission has issued a restatement of the Notice of Violation. The restated flotice of Violation and accompanying letter to Mr. White are enclosed. The three viola-tions stated in the original NOV have been restated and combined into a single violation. No further reply from TVA regarding the violation is required, nor do we requira any further response regaroing the corrective actions. 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 will be placed in the NRC Public Document Room. l l Sincerely, k Mj W

                                                                                    ! gh L. Thompson, dr. /f D> y Executive Direcpr for huclear Materials Saf ety, Safeguards, and Operations Support

Enclosure:

As stated cc: Service List Watts Bar Mr. Steven A. White NUREG-0940 1.B-19

SERVICE LIST FOR WATTS BAR cc: General Counsel Honorable Johnny Powell Tennessee Valley Authority County Judge ' 400 West Sumit Hill Drive Meigs County Courthouse E11 B33 Route 2 Knoxville, Tennessee 37902 Decatur, Tennessee 37322 Mr. F. L. Moreadith Mr. Michael H. Mobley, Director Vice President, Nuclear Engineering Division of Radiological Health Tennessee Valley Authority T.E.R.R.A. Building, 6th Floor l 400 West Sumit Hill Drive 150 9th Avenue North W12 A12 Nashville, Tennessee 37219-5404 l Knoxville, Tennessee 37902 Regional Administrator, Region II U.S. Nuclear Regulatory Comission Vice President and Nuclear 101 Marietta Street, N.W. Technical Director Atlanta, Georgia 30323 Tennessee Valley Authority SN 1578 Lookout Place Mr. Glenn Walton Chattanooga, lennessee 37402-2801 Senior Resident Inspector Watts Bar Nuclear Plant Mr. M. J. Ray, Acting Director U.S. Nuclear Regulatory Comission Nuclear Safety and Licensing Route 2, Box 700 Tennessee Valley Authority Spring City, Ter.nessee 37381 SN 1578 Lookout Place Chattanooga, Tennessee 37402-2601 Dr. Henry Myers, Science Advisor Comittee on Interior 11r. R. A. Pedde anc Insular Affairs Site Director U.S. House of Representatives Watts Bar Nuclear Plant Washington, D.C. 20515 Tennessee Valley Authority P. O. Box 800 Tennessee Valley Authority Spring City, Tennessee 37381 Rockville Office 11921 Rockville Pike Mr. D. E. McClouc Suite 402 Site Licensing Manager Rockville, Maryland 20852 Watts Bar Nuclear Plant Tennessee Valley Authority P. O. Box 800 Spring City, Tennessee 37381 Mr. Richard F. Wilson Vice President, New Projects Tennessee Valley Authority 6N 3CA Lookout Ploce Chattanooga, Tennessee 37t02-2801 Honwable Robert Aikman Cou..t> Judge Rhea County Courthouse Dayton, Tennessee 37321 NUREG-0940 1.B-20

l g maag'o UNITED STATES NUCLEAR REGULATORY COMMISSION [ E W ASHINGTON, D. C. 20555

 \...../

CHAIRMAN June 5, 1989 i l Mr. Steven A. White c/o Deborah B. Charnoff Shaw, Pittman, Potts and Trowbridge 2300 N Street, N.W. Washington, D.C. 20037

Dear Mr. White:

In my letter to you of December 13, 1988, I indicated that, although you as an individual are not an NRC licensee and the licensee, TVA, did not j contest the violations, we would review your counsel's November 21, 1988 1 reply to the October 21, 1988 enforcement action. We have now completed l our review of that response, as well as your request that we rescind the l Notice of Violation (NOV) or, in the alternative, grant you a hearing on  ! the NOV. As a result of our deliberation, the Commission has decided that the NOV should not be rescinded but that it should be recast. You i will find our restatement of the violation attached to this letter. We  ! have concluded that your request for a hearing should be denied. We believe that this restatement of the NOV focuses more precisely on the Comission's concern about the unqualified remarks in the June 5,1986 letter regarding the review of the Nuclear Safety Review Staff's (NSRS) perceptions leading to the development of the March 20, 1986 letter. While there are disagreements between you and the NRC staff over the significance that should be ascribed to the usage of certain words in the June 5 letter, i the assertions in the letter appear to us to require far more explanation to clarify or qualify the limits of these assertions. We believe the June 5 letter overstates the nature and thoroughness of the review of the NSRS perceptions. The issuance of the NOV was intended to emphasize that it is not acceptable for a licensee to overstate a position to influence the staff, and we do not believe that a retraction of the NOV is warranted. However, in this context, it should be understood that while TVA was cited in the NOV for a material false statement, the term " false" does not necessarily mean that an erroneous statement is made deliberately to deceive. We want to emphasize that the NRC did not find that either you or TVA deliberately made statements to deceive the NRC. NUREG-0940 1.8-21

Mr. Steven A. White Concerning your request for a hearing, the Atomic Energy Act does not provide a right to a hearing in this matter. The Commission's regulations do not provide a formal hearing, even for licensees, for violations not associated with a civil penalty or order. In these cases, consideration of written correspondence is adequate to resolve differences. The circumstances of this matter are not such that you would be entitled to a hearing as a matter of due process. We have also carefully considered your request under our discretionary authority, and based on your submittals and our evaluation of them, we have concluded that a hearing is not necessary to appropriately consider the issues in this matter nor is it warranted in the public interest. Thus, the request is denied. Our decision not to withdraw the NOV should not be taken as minimizing our recognition of the success of the efforts you had made in turning around the nuclear program at TVA. Commissioner Curtiss did not participate in this response. Sincerely, N. . Lando W. Zech, J . cc: Service List for Watts Bar NUREG-0940 I.B-22

RESTATEMENT OF THE VIOLATION CONTAINED IN THE NOTICE OF VIOLATION OF OCTOBER 21, 1988, ISSUED PURSUANT TO 10 CFR 2.201 Contrary to Section 186, TVA, in its June 5,1986 letter, by not being sufficiently accurate in its phraseology concerning the review of the enclosures to the March 20, 1986 letter, misled the NRC staff as to the nature and thoroughness of the review of the Nuclear Safety Review Staff's(NSRS)" perceptions"inthat: (1) The letter suggests that a more comprehensive' and structured review of the NSRS perceptions was conducted by the two " groups" gescribed in the letter than actually occurred; and-(2) The letter does not readily suggest that the second " group of highly experienced non-TVA experts" consisted merely of a number of individuals who, without any particular understanding that they had been gathered as a unit to review the results of the Lundin group's review, had reviewed drafts of the March 20, 1986 letter and responses to the NSRS perceptions. The statements were material to evaluation of TVA's response to the question NRC believed it had raised in its January 3,1986 letter, which had a bearing on the-resolution of safety issues regarding the licensing of Watts Bar and caused the NRC staff to expend additional resources to determine the actual situation existing at Watts Bar with respect to the NSRS " perceptions". This is considered a Severity Level II violation. NUREG-0940 I.B-23 l l

1 m s UNITED STA1ES

                                                            /n *8e ,qk                                           NUCLEAR REGULATORY COMMISSION 8                                          P,                              nEcios m 5                                            l                         no moosevett noao

• oLen eLLvw iLLawoes som May 23, 1989

                                                                                    .....                                                                                  ]

Docket No. 50-341 l License No. NPF-43 l EA 89-006 The Detroit Edison Company ATTN: Mr. Walter J. McCarthy Chairman of the Board and Chief Executive Officer i 2000 Second Avenue Detroit, Michigan 48226 Gentlemen: 1

SUBJECT:

NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 50-341/89003(DRS)) This refers to the inspection conducted during the period January 5-6, 13-14, and 25, 1989 at the Fermi 2 facility. The inspection was initiated in  ! response to the January 4, 1989 failure of the B train recirculation pump motor generator field breaker. A copy of the inspection report was mailed to you on February 1, 1989. An enforcement conference was held on February 8, 1989 in the Region III Office between myself and Mr. B. Ralph Sylvia as well j as other members of our respective staffs to discuss the event, root causes, , and corrective actions, ) i The violationf, described in the enclosed Notice of Violation (Notice) involve a significant failure to implement timely corrective action in response to identified deficiencies as well as personnel error. NRC views the failure to properly initiate and complete timely corrective action in response to concerns from the manufacturer, NRC, and your own staff as unacceptable. Specifically, your staff was n'otified of the need to incorporate the manufacturer's recommendations for lubrication, maintenance, and maintenance intervals for all AK type circuit breakers by letter dated December 23, 1986 and failed to include such information in preventive maintenance procedures on the GE Type AKF-2-25 field breaker untti November 1988. Such information should have been incorporated prior to the performance of preventive maintenance in March 1988. The maintenance performed in March 1988 was inadequate due to inadequate procedures and personnel error and ultimately led to the failure of the breaker on January 4,1989. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988), the violations described in the enclosed Notice have been classified as a Severity Level III problem. A civil penalty is considered for a Severity Level III violation or problem. However, after consultation with the NUREG-0940 I.B-24

i l The Detroit Edison Company 2 May 23, 1989 Commission, the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, and the Director, Office of Enforcement, I have decided that a civil penalty will not be imposed in this case because this most recent event is another example of a previously identified failure to establish measures to implement timely corrective actions in response to recognized deficiencies. On January 6, 1989, NRC issued a Fifty Thousand Dollar (550,000) civil penalty, in part, for programmatic weaknesses which resulted in failure to take timely corrective actions. Since it is the NRC position i that the broad corrective actions that you have already proposed should eliminate future problems of this type, it has been decided that discretion should be exercised in this case and therefore a civil penalty will not be proposed. However, further examples of this type of problem will likely result in further enforcement action. 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 Document Room. The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. J l Sincerely,

                                                  .R-

! A. Bert Davis l Regional Administrator

Enclosures:

l 1. Notice of Violation

2. Inspection Report i No. 50-341/89003(DRS)

See Attached Distribution NUREG-0940 I.B-25

NOTICE OF VIOLATION Detroit Edison Company Docket No. 50-341 Fermi 2 Nuclear Power Station License No. NPF-43 EA 89-006 During an NRC inspection conducted on January 5-6, 13-14, and 25, 1989, 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, 53 Fed. Reg. 40019 (October 13,1988),the violations are listed below: A. 10 CFR Par't 50, Appendix B, Criterion XVI, requires that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective materials and equipment, and nonconformances are promptly identified and corrected. Contrary to the above, on at least four occasions between December 23, 1986 and February 23, 1988, the licensee was notified of conditions adverse to quality and failed to correct such conditions in a timely manner. Specifically, the licensee was informed of the need to incorporate the manufacturer's recommendations for lubrication, maintenance, and maintenance intervals for all AK type circuit breakers. Hcwever, the licensee failed to include such information in preventive maintenance procedures on the GE Type AKF-2-25 field breaker until November 1988 even though the maintenance was scheduled to be performed during this period. B. 10 CFR Part 50, Appendix B, Criterion V, requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. MI-M037, " Recirculation Pump Generator Field Breaker (GE TYPE AKF) General Maintenance," Revision 1 contained the licensee's approved instructions and checklist for " General Cleaning, Inspection, and Lubrication." Contrary to the above, on March 16, 1988, when preventive maintenance was performed on the B recirculation pump motor-generator field breaker, the actual performance of such preventive maintenance was inadequate because lubricant was not added in the cam follower slot of the breaker as required by Procedure MI-M037, Revision 1. These violations have been categorized in the aggregate as a Severity Level III problem (Supplements). NUREG-0940 1.8-26

Notice of Violation 2 Pursuant to the provisions of 10 CFR 2.201, Detroit Edison 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 Administ'rator, Region III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137, and a copy to the NRC Resident Inspector at Fermi 2 within 30 days of the date of the letter transmitting this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted; (2) the corrective actions that have been taken and the results achieved; (3) the corrective actions that will be taken to avoid further violations; and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time. If an adequate 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. FOR THE NUCLEAR REGULATORY COMMISSION W i I A. Bert Davis Regional Administrator , I Dated at Glen Ellyn, Illinois this p # day of May 1989 . i i l NUREG-0940 I.B-27 i

I I 1 I I l II.A. MATERIALS LICENSEES, CIVIL PENALTIES AND ORDERS-i 1 i i l i l

                                                                                                                     'O NUREG-0940

l pnafcp UNITED STATES g 'o, NUCLEAR REGULATORY COMMisslON y $ REGION ll 101 MARIETTA STREET,N.W. y j At LANTA,CEORGI A 33323

,             'g J
%, * * * * * /                          MAR 16 M                                       j l

Docket No. 030-20234 j License No. 45-16452-01 EA 88-315 Advex Corporation ATTN: Mr. B. Barnett, President 121 Floyd Thompson Drive Hampton, VA 23666-1307 1 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 45-16452-01/88-02) This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by Mr. R. Brown at your facilities in Hampton, Virginia, on December 16, 1988. . The inspection was conducted to review the circumstances associated with the i licensee's reported overexposure of a radiographer during a radiographic operation at the National Aeronautics and Space Administration (NASA) Langley facility, in Hampton, Virginia. The inspector also accompanied your personnel to NASA Langley Steam Plant to recreate the incident and perform dose estimates with TLDs on January 3, 1989. The report documenting this inspection was sent to you by letter dated January 13, 1989. As a result of this inspection, signifi int failures to comply With NRC regulatory requirements were identified. NRC concerns relative to the inspection findings were discussed in an Enforcement Conference held on January 19, 1989, and a letter summarizing this Conference was sent to you on January 23, 1989. The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty involve exceeding the NRC occupational radiation dose limits and a failure to perform an adequate radiation survey after a radiographic exposure to determine that the sealed source had been returned to its shielded position. Had the radiographer in this case performed an adequate survey, ttre overexposure may not have occurred. The NRC views this violation as welllas the overexposure as significant. Collectively, these

                   ~

violations demonstrate a need to improve the administration and control of your radiation safety program to ensure adherence to NRC requirements and safe performance of licensed activities. To emphasize the importance of these matters and the need to ensure implementation of effective controls of your licensed program, I have been authorized, af ter consultation with the Director, Office of Enforcement, and the Deputy Executive Director of Nuclear Materials Safety, Safeguards and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty .in the amount of Two Thousand Dollars ($2000) for the violations described in the enclosed Notice. In accordance with the

     " General Statement of Policy and Procedure for NRC Enforcement Actions,"

NUREG-0940 II.A-1

l 1 i Advex Corporation R$$.161989 .

   '10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the. violations                 i described in the enclosed Notice have been categorized as a Severity Level II           '

problem. The base value of a civil penalty for a Severity Level II problem is $8000. The escalation and mitigation factors in the Enforcement Policy were considered. The base civil penalty has been reduced by 75 percent in recognition of your corrective actions in response to the event and your i prompt reporting to the NRC. Further mitigation for your good past performance j was balanced by the escalation warranted by prior notice provided'by NRC regarding other personnel exposures resulting from failure of radiographer to  ! properly survey for retraction of sources. 1 You are required to respond to this letter ari the enclosed Notice and should j follow the instructions specified therein when preparing your response. In  ; your response, you should document the specific actions taken and any additional j actions you plan to prevent recurrence. After reviewing your response to this i Notice, including your proposed corrective actions and the results of future j inspections, the NRC will determine whetbar further NRC enforcement action is j necessary to ensure compliance with NRC regulatory requirements. j In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and its enclosure are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Should you have any' questions concerning this letter, please contact us. l Sincerely,

                                             / W65t/

Stewart D. Ebneter Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty ec w/ encl: Commonwealth of Virginia NUREG-0940 II.A-2

i NOTICE OF VIOLATION AND PROPOSED IMPOSITIUT0F CIVIL PENALTY Advex Corporation Docket No. 030-20234 Hampton, VA License No. 45-16452-01 EA 88-315 i During the Nuclear Regulatory Commission (NRC) inspection' conducted on December 16, 1988, and January 3, 1989, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcerant Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: A. 10 CFR 20.101(a) requires, except as provided in paragraph (b) of this section, that no licensee possess, use, or transfer licensed material in such a manner as to cause any individual in a restricted area to receive in any calendar quarter from radioactive material and other sources of radiation, a total occupational dose in excess of 1.25 rems to the whole.  ; body or lens of- the eyes. 10 CFR 20.101(b) allows an occupational dose to the whole body of 3 rems per calendar quarter provided that specified conditions are met. Contrary to the above, on December 8,1988, a radiographer engaged in activities within the licensee's restricted area received a calculated occupational dose to the lens of the eyes of 6.4 rems and a measured whole body dose of 3.05 rems. The radiographer received a total whole body dose of 6.47 rems for the fourth calendar quarter of 1988 and the conditions of 10 CFR 20.101(b) were not met. B. 10 CFR 34.43(b) requires a licensee to ensure that a survey is~made with a , radiation survey instrument after each radiographic exposure to determine l that the sealed source has been returned to its shielded position. It  ! further requires that the entire circumference of the exposure device be  ! surveyed; and;-if the device has a source guide tube, that the survey include the gide tube. Contrary to the above, on December 8, 1988, while performing radiography j at the National Aeronautics and Space Administration Langley facilities in Hampton, Virginia, an adequate survey was not made to determine that l the sealed source was returned to its shielded position in a radiography  ! exposure device, following completion of the first radiographic exposure l of the evening. Specifically, the survey was inadequate, in that, the  ; source guide tube was not included as part of the survey. The above violations have been categorized in the aggregate as a Severity Level II problem (Supplement IV). Cumulative Civil Penalty - $2000 (assessed equally between the violations). NUREG-0940 II.A-3 .

Notice of Violation I Pursuant to the provisions of 10 CFR 2.201, Advex Corporation (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 I 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, ar, 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 licencee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Conunission, with a check, draft, or money orc'er payable to the Treasurer of the United States in. 4 the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear P.egulatory 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 Viola-tion" 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 mitiga-tion of the penalty. In requesting mitigation of the proposed penalt I Section V.B of 10 CFR Part 2 Appendix C (1988)y, the factors

                                                    , should        addressed be addressed. Anyin 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          1 incorporate parts-of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraphmumbers) 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.

i Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act 42 U.S.C. 2282. NUREG-0940 II.A-4

Notice of Violation . The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to 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, USNRC Region II, l 801 Marietta Street N.W., Suite 2900, Atlanta, Georgia 30323. l FOR THE NUCLEAR REGULATORY COMMISSION C'601/ t D. Ebneter Regional Administrator Dated at Atlanta, Georgia this Itedt day of March 1989 a l l NOREG-0940 II.A-5

y

       >m atou                               UNITEo STATES k                  NUCLEAR REGULATORY COMMISSION S                               REGlDN lli 5             'E 799 ROOSEVELT ROAD
 $                                     CLEN ELLYN. ILLINOIS 60137 9
        ...+$                              March 8, 1989                                 J l

Docket No. 030-28773 License No. 48-24533-01 EA 89-014 Computerized Medical Imaging, Inc. ATTN: Mr. Bill Stengl , President  ! 2010 Esmond Road Eau Claire, WI 54701 l l i Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 030-28773/89001(DRSS)) This refers to the inspection conducted during the period January 9-24, 1989, at your Manitowoc, Wisconsin facility. The inspection included a review of the circumstances associated with the theft of approximately 75 mil 11 curies of sodium pertechnetate (technetium-99m) from an unlocked vehicle that was parked overnight at the home of one of your technologists. The theft was identified by the technologist on January 7,1989 and was reported to the NRC the same i day. The report of.the inspection was forwarded to you by letter dated i February 3,1989. During the inspection, violations of NRC requirements were . I identified. The violations, the causes, and your corrective actions were i discussed during an enforcement conference in the Region III office on Janua ry 27, 1989 between you and Mary Moriarty of your staff and C. E. Norelius and other members of the Region III staff. Although several violations were identified during the inspection, Violation A, the loss of unsecured radioactive material from one of your vehicles, provides, by itself, sufficient basis for an escalated enforcement action. In addition, after considering the three violations: failure to secure used generators that

                                                                        ~

were stored in an unrestricted area; failure to properly evaluate personnel radiation doses; and failure to use lab coats or other protective clothing when handling radioactive material, we have concluded there exists a significant lack of control over your radiation safety program. During the January 27, 1989 enforcement conference you described you? cole in the menagement of the radiation safety program. We are concerned the. you have delegated significant parts of that program function to members of your staff l NUREG-0940 II.A-6

Computerized Medical Imaging, Inc. 2 March 8, 1989 without verifying or ensuring that these activities were being accomplished. Also, during the conference, you described the technologist who was involved in the January 7,1989 incident as technically competent but lacking in judgement and in a willingness to follow orders. The NRC views these characteristics as I a matter of serious concern and requests that you explain why you believe such an individual should be permitted to handle licensed radioactive material and what steps you have taken or plan to tale to ensure that in the future that individual as well as all other employees will conduct licensed activities in a safe manner. To emphasize the importance of ensuring that in the future you will exercise greater control over all NRC licensed activities, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Two Thousand Five Hundred Dollars (52500) for the violations described in the enclosed Notice. In accordance with the

    " General Statement of Policy and Procedure for NRC Enforcement Actions,"                                l 10 CFR Part 2, Appendix C (1988) (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 problem is $2500. The escalation ard 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. In addition, please confirm that in the future all licensed radioactive material from your Eau Claire and Manitowac, Wisconsin facilities will be secured in a locked box in the back of

 . the vehicle, as described in your license application, and will never be transported in the passenger compartment.      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.                                        1 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 II.A-7 ,

Computerized Medical Imaging, Inc. 3 March 8, 1989 The responses directed by-this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. l Sincerely, Q dW A. Bert Davis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Inspection Report No. 030-28773/89001(DRSS)

                                                                                                     \

l l I i i I NUREG-0940 II.A-8 l l

1 NOTICE OF VIOLATION 1ND PROPOSED IMPOSITION OF CIVIL PENALTY Computerized Medical Imaging, Inc. Docket No. 030-28773 Eau Claire, Wisconsin License No. 48-24533-01 EA 89-014 During an NRC inspection conducted during the period January 9-24, 1989, ' four violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10.CFR Part 2, Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act) 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: A. 10 CFR 35.80(c) requires that a licensee providing mobile nuclear medicine service secure or keep under constant surveillance and immediate control all byproduct material when in transit or at an address of use. Contrary to the above, on December 6,1988, the licensee failed to secure or keep under constant surveillance and immediate control a package containing approximately 75 m1111 curies of technetium-99m. The package was left in the unlocked passenger. compartment of a vehicle that was parked at the residence of a licensee employee, an unrestricted area. B. 10 CFR 20.207(a) requires that licensed materials stored in an unrestricted area be secured from unauthorized removal from the place of storage. Contrary to the above, as of January 9, 1989, the licensee had stored six used Molybdenum-99/ Technetium-99m generators in an unrestricted area in the basement of a building in Manitowoc, Wisconsin, a basement in which the licensee also maintains a hot lab facility. The materials were not secured from unauthorized removal from the place of storage. C. 10 CFR 20.201(b) requires that each licensee make such surveys as (1) may be necessary to comply with the regulations in 10 CFR Part 20 and (2) are i reasonable under the circumstances to evaluate the extent of radiation hazards that may be present. As defined in 10 CFR 20.201(a), " survey" l means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presence of radioactive materials or other sources of radiation under a specific set of conditions. License Condition 15 requires that all licensed materials be possessed and used in accordance with statements, representations, and procedures contained in application dated June 1, 1985. NUREG-0940 II.A-9

Notice of Violation 2 Item 24 of this application states that personnel monitoring devices (film badges or TLDs) will be exchcnged at a monthly frequency. Contrary to the above, during the periods September 1987 through February 1988; April through June 1988; and September through November 1988 surveys were not made to ensure compliance with 10 CFR 20.101 which limits the occupational dose to any individual in a restricted area. Specifically, the licensee failed to:

1. Return exposed personnel monitoring film and TLD badges worn during November 1987, January, February, September, October, and November of 1988 to the supplier at the required monthly frequency so that val.id determinations could be made of occupational doses; and

2. Evaluate occupational doses received by licensee's employees whose badges were determined to be tot old to be accurately read by the licensee's vendor for the months of September, October, and December 1987; and April, May, and June of 1988.

D. License Condition 15 requires that all licensed materials be possessed and used in accordance with statements, representations, and procedures contained in application dated June 1,1985. Item 15 of this application states that Appendix G procedures in  ! Regulatory Guide 10.8, October 1980, will be followed as " General Rules for the Safe Use of Radioactive Material." -) Item 1 of Appendix G requires that laboratory coats or other protective clothing be worn at all times in areas where radioactive materials are used. Contrary to the above, during the NRC inspection on January 9, 1989, a licensee nuclear medicine technologist stated he does not wear a  ! laboratory coat or other protective clothing when he uses radioactive material.  ! Collectively, these violations have been classified as a Severity Level III problem (Supplements IV and VI). Cumulative Civil Penalty - $2500 (assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, Computerized Medical Imaging, 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 should include for each alleged violation: (1) admission or denial of the alleged violation; i NUREG-0940 II.A-10

l l Notice of Violation 3 (2) the reasons for the violation if admitted; (3) the corrective actions that have been taken and the results achieved; (4) the corrective actions that will be taken to avoid further violations; and (5) the date when full compliance t1111 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 i 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 provi6a for the response required under 10 CFR 2.201, the Licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an Order imposing the civil penalty will be issued. Should the Licensee elect to file an; answer in accordance with ) 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and any: ) (1) deny the violations listed in this Notice in whole or in part; 1 (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 six factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the licensee i 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 provision of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c. 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  ; NUREG-0940 II.A-11

Notice of Violation 4 Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Kegional Administrator, Region III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137. FOR THE NUCLEAR REGULATORY COMMISSION A. Bert Davis Regional Administrator Dated at Glen Ellyn, Illinois this 8th day of March 1989 l l NUREG-0940 II.A-12

l l

                          #* *

• 4 , t UNITED STATES

                       -                '*            NUCt. EAR REGULATORY COMMISSION 3                        S                                                                  l
                 *;                       y                          REGION IV D                      of               611 RYAN PLAZA DRIVE, SUITE 1000 o            ,8                       ARLINGTON. TEXAS 70011 M -51989 i

Docket No. 30-20326 License No. 15-23161-01 EA 89-15 Cornish Wireline Service, Inc. ATTN: James E. Cornish President Post Office Drawer H Chanute, Kansas 66770 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 30-20326/88-01) l This refers to the inspection conducted on December 14, 1988, at your facility in Hominy, Oklahoma and to our inspection of Cornish Wireline's records on l February 1, 1989, in our Arlington, Texas offices. Our report on the , December 14 inspection was issued on January - 23, 1989. The apparent violations of NRC requirements disclosed by that inspection and our review of your records were discussed with you during an enforcement conference on February 1, 1989, in our Arlington office. We have reviewed all of the information available to us and have concluded that, as described in Section I of the enclosed Notice of Violation and Proposed ' Imposition of Civil Penalty.(Notice), you failed to equip individuals with film badges or other personal radiation monitoring devices. NRC discovered during j the February I review of your records that Cornish had failed to equip ( well-logging operators with film badges from February 1987 to September 1988. i l We note you resumed use of film badges before the NRC inspection. Failure to use film badges was not only a violation of the Commission's requirements but l was also inconsistent with your required training program which addressed use of film badges. While the potential for a significant radiation exposure to individuals involved in this kind of work may be low, this violation is made i i more significant by the fact that you knew your dosimetry service had been cancelled, yet you did not take immediate steps to restore that service or - stop work involving radioactive materials. You attribute the duration of this violation to Cornish's financial difficulties during that period. i CERTIFIED MAIL RETURN RECEIPT REOUESTED NUREG-0940 II.A-13

MAY -51989 Cornish Wireline Service, Inc. NRC is most concerned that, by your own admission, you willfully permitted this safety requirement to be neglected for 19 months. Willful violation of NRC requirements for financial considerations cannot be tolerated by the Commission. This is because the NRC inspection program is one of audits. We cannot continuously inspect licensees. NRC must depend on the integrity of licensees to conduct activities in good faith. When a licensee deliberately violates requirements, suspension of a license is considered. Therefore, pursuant to Section 182 of the Atomic Energy Act of 1954, as amended, please provide within 30 days of the date of this letter to the Regional Administrator, USNRC Region IV, a written statement under oath or affirmation explaining why, in view of your deliberate violation, NRC should have confidence in your complying with NRC requirements in the future and that you will not operate in violation of  ; your license regardless of your financial condition. Upon review of this j response we will decide whether to initiate a proceeding to suspend your ' license. An isolated failure to equip individuals with film badges or other personal radiation monitoring devices wou]d normally be classified as a Severity Level IV violation. However, thp NRC has concluded that the deliberate nature of this violation over an extended period warrants an increase in its i l significance and therefore has classified this violation at Severity Level III in accordance with the " General Statement of Policy and Procedures for NRC EnforcementActions(EnforcementPolicy" (October 13,1988) . 10 CFR Part 2, A pendix C, 53 To emphasize the importance of meeting all requirements associated with the safe use of radioactive materials and the importance of discontinuing the use ' of licensed materials when those requirements cannot be met, I have been authorized, after. consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support, to issue the enclosed Notice of Violation and Proposed { Imposition of Civil Penalty in the amount of Five Hundred Dollars ($500) for l the violation described in Part I of the enclosed Notice. The base value for I a Severity Level III violation is $500. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. Other violations identified during the inspection and our February 1 review as delineated in Section II of the Notice include: the inappropriate conduct of licensed activities under the provisions of 10 CFR 150.20 which resulted in the ust of licensed material at an unauthorized location, failure to calibrate radiation survey instruments at the required frequency, failure to test sealed radioactive sources for leakage at the required frequency, and failure to main- l tain complete records of the use of radioactive materials. Violation II.A. is of concern because moving a location of storage of licensed material without notice interferes with the ability of the NRC to perform inspections. Additionally the violation is important in that it is related to a common problein; the reluctance of licensees to contact NRC when they NUREG-0940 II.A-14

i NAY -51989 Cornish Wireline Service, Inc. f encounter situations in which they find themselves in noncompliance or in an l uncertain situation regarding compliance. As we stressed during the enforcement conference, our policies are designed to encourage licensees to identify and i report these problems to us. Had you contacted us regarding your licensing dilemma in late 1988, it is very likely that we could have processed an amendment to your license very promptly. We recognize in this case that the i 1 use of reciprocity under the provisions of 10 CFR 150.20 appears to have been a good-faith effort on your part to avoid noncompliance with NRC requirements. The violations in Section II not assessed a civil penalty are classified at , Severity Level IV or V. In addition to the response required pursuant to Section 182 of the Atomic Energy Act, you are required to respond to the enclosed Notice and should follow the instructions specified in the Notice when preparing your response, in your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. Your response should also address why your corrective actions described in your September 11, 1987 letter were not adequate. 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 ffanagement and Budget as required l by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Sincere 1y, j ~

                                                                                                 /        ,.          i
                                                                                                       .h[k6NY Robert D. Martin Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc: Oklahoma Radiation Control Program Director Kansas Radiation Control Program Director NUREG-0940 II.A-15 , l

                                                                                                                                     ----- A

MAY -51989 NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Cornish Wireline Service, Inc. Docket No. 30-20326 Chanute, Kansas License No. 15-23161-01 EA 89-15 During a Nuclear Regulatory Comission (NRC) inspection conducted on December 14, 1988, and February 1, 1989, 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, 53 Federal Register 40019 (October 13,1988), 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: I. Violation Assessed a Civil Penalty 10CFR39.65(a) states,inhrt,thatthelicenseemaynotpermitan individual to act as a logging supervisor or logging assistant unless that person wears, at all times during the handling of licensed radioactive materials, either a film badge or a thermoluminescent dosimeter (TLD). Contrary to the above, from February 1987 to September 1988 the licensee  ; willfully permitted individuals working as either a logging supervisor or 1 a logging assistant to handle licensed radioactive materials without  ! wearing film badges or TLDs. This is a Severity Level III violation. (SupplementVI) , Civil Penalty - $500. II. Violations Not Assessed a Civil Penalty i A. License Condition 10 states, in part, that licensed raaterial may be used at Cornish Wireline Service, Inc., 511 East Gum, Henryetta, Oklahoma, and at temporary job sites. Contrary to the above, in November and December of 1988, after the licensee had discontinued the use of its permanent field office in Henryetta, Oklahoma, the licensee had conducted licensed activities near Hominy, Oklahoma, under the reciprocity provisions of 10 CFR 150.20. This location was neither a temporary job site nor an NUREG-0940 II.A-16

MAY -51989 Notice of Violation authorized field station, as defined in NRC regulations. (Since 10 CFR 150.20 is not intended to be used by licensees to circumvent the controlling specific NRC license conditions applicable to their activities in non-agreement states, this is a violation of License Condition 10.) This is a Severity Level IV violation. (SupplementVI) B. 10 CFR 39.33(a) states, in part, that the licensee shall keep a l calibrated and operable radiation survey instrument to make the radiation surveys required by Parts 20 and 39. th 10 CFR 39.33(c)(1) instrument required bystates, 10 CFRin39.33 part,(a)atshall the radiation survey be calibrated at intervals not to exceed 6 months. Contrary to the above, the licensee's G. E. Smith survey instrument, Model GS-1000A, Serial Number 1488, was calibrated on November 2, 1987, and again on June 8, 1988, a period which exceeds 6 months. This survey instrument was used on May 12 and 23, 1988, when the meter was beyond the 6-month calibration period. This is a Severity Level IV violation. (SupplementVI) C. 10 CFR 39.35(c) states, in part, that the licensee shall test each sealed source for leakage at intervals not to exceed 6 months. Centrary to the above, the licensee had been using a Gulf Nuclear, Model NEE-AmBe-71-1, Serial Number 71-1-42-0B, sealed source containing 3 curies of americium-241'that had been leak tested on April 15, 1987, but not again until December 2, 1987, a period which exceeds 6 months. This is a Severity Level IV violation. (SupplementVI) D. 10 CFR 39.39(a)(1) states, in part, that the licensee shall maintain records for each use of licensed material showing the make and model number of each sealed source used. Contrary to the above, since July 20, 1987, the date of the last inspection, none of the licensee's use records contained the make or the model number of each sealed source used. This is a Severity Level V violation. (SupplementVI) NUREG-0940 II.A-17

MAY - 51989 Notice of Violation I l Pursuant to the provisions of 10 CFR 2.201, Cornish Wireline Service, 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 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)thedatewhenfullcompliancewillbeachieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, I suspended,, or revoked or why such other action as may be proper should not be l taken. Consideration may be given to extending the response time for good cause shown. ' Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, 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 shculd 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 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., 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 II.A-18 i

M -51989 Notice of Violation The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty and answer to 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 Commission, Region IV. I U FOR THE'MUCLEAR REGULA, TORY COMMISSION r~ . h tt  % ' bd$ > Robert D. Martin Regional Administrator Dated at Arlington, Texas, I This 5th day of May 1989 i I l NUREG-0940 II.A-19

o#* "% UNITED STATES yx /; NUCLEAR REGULATORY COMMISSION

                           $'                            f                                        REGION IV                                                                                       j S                      af                                   $11 RYAN PLAZA ORIVE. SUITE 1000
                             %,       8                                                    ARLINGTON. TEXAS M11
                                                                                                                                                                                                  ]

AE 2419M l Docket No. 30-19606 License No. 30-17283-02 EA 88-172 Department of the Army U.S. Army Engineer District Albuquerque ATTN: Major Phillip L. Smith Post Office Box 1580 Albuquerque, New Mexico 87103 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 30-19606/88-01) This refers to the inspection of NRC-licensed activities conducted on June 22, 1988 at your offices and at the VA Medical Center Annex construction site in Albuquerque, New Mexico. The inspection disclosed six violations of HRC and ticense requirements that were discussed with you at an enforcement conference on July 19, 1988 in NRC Region IV's offices in Arlington, Texas. The violations,moisture NRC-licensed all associated with.theincluded: density gauges, Army Er.g(ineer

1) failureDistrict's to adequately possession of secure one gauge against unauthorized removal, (2) utilizing a Radiation Protection Officer (RPO) nct listed on the license and one who had not received the requisite training, (3) failure to conduct physical inventories of licensed material, (4) failure to maintain records pertaining to the receipt of licensed material, (5) failure to complete leak tests of sealed sources of radioactive material removed from storage, and (6) failure to post copies of several necessary documents.

Based on the information gained during the inspection and provided by you during the enforcement conference, it appears that many of these violations can  ! be attributed, at least in part, to the fact that the RP0 named on your NRC license discontinued RPO duties when another individual who was to become the RPO was hired. However, this transfer of duties occurred without the RP0- l designate having received the necessary training. Of particular concern to us is the fact that your organization lost control of one licensed gauge in that it was being stored at a location not under your control and that it no longer appeared on your inventory of licensed gauges. Had your response to a previous violation regarding the conduct of inventories of material been effective, this problem may not have occurred. Up until the date of the enforcement conference, you had not taken steps to secure this gauge against unauthorized removal. Collectively, these violations indicate a breakdown in the management of your NRC-licensed activities. CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-20

Department of the Army i l To emphasize the importance of ensuring that requirements essential to radiation safety are met and the importance of improving the oversight of your licensed , programs, I have been authorized, af ter consultation with the Director, Office l of Enforcement, and the Deputy Executive Director for Regional Operations, to l issue the enclosed Notice of Violation and Pro in the amount of One Thousand Dollars ($1,000) posed for the Imposition violations of CivilinPenalty described the enclosed Notice. In accordance with the " General Statement of Polic Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988)y and ' (Enforcement Policy), the violations described in the enclosed Notice have been categorized at a Severity Level III. The base value of a civil penalty for a Severity Level III violation is $500. The escalation and mitigation factors in the Enforcement Policy were considered. The (1) inadequate base civil penalty amount corrective hasfor actions been increased these by 2) violations, 100 p(ercent multiple because of examples of some of these violations, and (3) your failure to implement corrective action for a violation identified during the last inspection regarding the conduct of inventories. Effective corrective action could have prevented a repeat of 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. After reviewing your response to this Notice, including your proposed corrective actions andethe 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, i Title 10, Code of Federal Regulations, a copy of this letter and its enclosure I 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. Since ely, Iu t r- -,., Robert D. Martin Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc: New Mexico Radiation Control Program Director l NUREG-0940 II.A-21

l

                                                                                                                      )

i' NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Department of the Army, Docket No. 30-19606 Engineer District License No. 30-17383-02  : Albuquerque, New Mexico EA 88-172

                                                                                                                     ]

During an NRC inspection conducted on June 22, 1988, and collection of additional information on June 23, 1988, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC  ; Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the Nuclear Regulatory 1 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:

1. 10 CFR 20.207(a) requires that licensed materials stored in an unrestricted area shall be secured from unauthorized removal from the place of storage.

Contrary to the above, a moisture density gauge, Serial Number 10010, containing two sources of a nominal 10 millicuries of cesium-137 and 50 millicuries of americium-241 had been stored in a location which was not secured by the licensee to prevent unauthorized removal. The gauge j had been stored in an unrestricted area near Carlsbad, New Mexico, from sometime in 1987 to the date of the inspection and was not under the licensee's control.

2. License Condition 17 requires, in part, that the licensee shall conduct 1 its program in accordance with t% statements, representations, and 1987. Item 7 of procedures contained the application in the names the app inProtection Radiat;.n tion datedOfficer March 10,(RPO) and provides his training and experience.

Contrary to the above, from April 1987 to the date of the inspection, the responsibilities of the RP0 were performed by an individual not specified 3 in the license as the RPO. j i License Condition 15 requires that the licensee conduct a physical inventory 3. every 6 months to account for all sources and/or devices received and possessed under the license. Records of inventories shall be maintained for 2 years from the date of each inventory. Contrary to the above, from June 1985 to the date of the inspection, physical inventories had not been conducted to account for three gauges with serial numbers 4425, 10010, and 11323. This is a repeat violation. l

4. 10 CFR 30.51(a) requires, in part, that each person who receives byproduct material shall keep records showing the receipt, transfer, and disposal of such byproduct material.

NUREG-0940 II.A-22 1

Notice of Violation l Contrary to the above, the licensee had not maintained records showing the receipt of two moisture density gauges containing byproduct material, Serial Numbers 11323 and 10010, which were received since the time of the previous inspection on November 1, 1983.

5. License Condition 12(a)(1) requires, in part, that sealed sources shall i be tested for leakage and/or contamination at intervals not to exceed six months. License Condition 12.B. requires, in part, that any source in storage and not being used need not be tested. When the source is removed from storage for use or transfer to another person, it shall be tested before use or transfer.

Contrary to the above, the required leak tests for sealed sources contained in two moisture density gauges, Serial Numbers 11323 and 4425, had not been completed prior to use when they were removed from storage.

6. 10 CFR 19.11(a), (b), and (c) requires, in part, that each licensee shall post current copies of the regulations in Parts 19 and 20, operating procedures, and the license or a notice specifying where such documents may be examined, and Form NRC-3.

Contrary to the above, neither the regulations, license, procedures, notice, nor Form NRC-3 were posted at the time of the inspection. Collectively,theaboveviolationshavebeencytegorizedintheaggregateasa Severity Level III problem (Supplement VI). I 4 Cumulative Civil Penalty $1,000 (assessed equally among the violations). j Pursuant to the provisions of 10 CFR 2.201, Department of the Army, Army Engineer 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 to a Notice of Violation" and should include for clearly each marked alleged as a " Reply (1) admission or denial of the alleged violation, 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 takentoavoidviolations,and(5)thedatewhenfullcompliancewillbe achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draf t, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear NUREG-0940 II.A-23

Notice of Violation 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 penalt Section V.B of 10 CFR Part 2, Appendix C (1988)y, , shouldthe befive factors addressed addressed. Any in written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. 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. 2282cn o The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty and answer to a l 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 Wl, G o Robert D. Martin Regional Administrator Dated at Arlington, Texas, This 24th day of August 1988. i NUREG-0940 II.A-24

to aseg'o UNITED STATES g 8 e NUCLEAR REGULATORY COMMISSION r,,  ; WASHWGTON, D. C. 20055

  %,*..**/                               APR o 7 jggg l

Docket No. 30-19606 License No. 30-17283-02 EA 88-172 l 1 Department of the Army i U.S. Army Engineer District, Albuquerque ATTN: Major Phillip L. Smith Post Office Box 1580 Albuquerque, New Mexico 87103 Gentlemen: l This is in reference to our Notice of Violation and Proposed Imposition of Civil Penalty (Notice) dated August 24, 1988, and to the Army Engineering i District's responses dated September ?8, 1988 and November 10, 1988. I NRC's evaluation of your responses and our conclusions are enclosed. Based on the new information in your responses we have concluded that Violation 1 as ' stated in the August 24, 1988, Notice should be withdrawn. Because this violation  ! was considered significant and because it provided the principal basis for  ! categorizing the violations in the aggregate as e Severity Level III violation with the associated proposed $1,000 civil penalty, the violations have been 1 recategorized and the civil penalty has been withdrawn.  ! Nevertheless, the NRC is concerned with the state of your recordkeeping and that l you lacked a qualified radiation safety officer at the time of the inspection. l We have, based on your submitted information, reissued Violations 1 and 4 as stated in the Enclosure. You are required to submit to the NRC Region IV office within thirty days of the date of this letter a written statement of explanation in reply, including for each reissued violation: (1) the corrective actions that have takenbeen taken to avoid and results further achieved; violations; and (3 (2))the corrective the date when fullactions that will compliance willbe be achieved. We note t. hat another inspection of your licensed activities was conducted on March 9, 1989, and no violations were found. Sincerely, xyz ames Lieberman, Director Office of Enforcement

Enclosure:

As stated cc: New Mexico Radiation Control Program Director NUREG-0940 II.A-25 l

l ENCLOSURE EVALUATIONS AND CONCLUSION On August 24, 1988, a Notice of Violation and Proposed Imposition of Civil Penalty was issued for violations identified during the June 22, 1988, routine, unannounced inspection at the Department of the Arnty, Federal Building, Albuquerque, New Mexico. In response to the Notice of Violation, the Department of the Ariny provided letters dated September 28 and November 10, ' 1988. The letters provide information not available at the time of the NRC inspection and subsequent enforcement conference held on July 19, 1988. The letters also request that the proposed civil penalty be rescinded based on the , Department of the Army's responses. The NRC evaluation and conclusion regarding the licensee's arguments are as follows: , Restatement of Violation 1 10 CFR 20.207(a) requires that licensed materials stored in an unrestricted area shall be secured from unauthorized removal from the place of storage. Contrary to the above, a moisture density gauge, Serial Number 10010, containing two sources of a nominal 10 millicuries of cesium-137 and 50 mil 11 curies of americium-241 had been stored in a location which was  ; not secured by the licensee to prevent unauthorized removal. The gauge had been stored in an unrestricted area near Carlsbad, New Mexico, from sometime in 1987 to the date of the inspection and was not under the licensee's control, i Summary of Licensee's Response " The licensee was unable to dispute the findings at the time of the July 19, 1988, enforcement conference. Subsequent investigation by the licensee i determined that the subject licensed gauge, which was received on October 4, 1983, under the licensee's license, and used and controlled under this license until about July 30, 1986, was dropped from the Department of Ariqy Corps of Engineers (DOA-COE) property inventory and'was, in fact, the property of the Department of Energy (DOE). The licensee further stated that the gauge should I never have appeared on its property inventory because it was purchased with DOE funds for use by DOA-COE on a DOE-funded project. A paper transfer of custody and ownership was not effected until August 8, 1986. The licensee stated that confusion surrounding the custo(y, ownership, and transfer of the gauge was caused by changes in pursonnel and by difficulty locating pertinent . records. The licensee also stated that the DOE facility to which the gauge i was transferred was under tight security. The licensee stated that DOA-COE used and had control of the gauge during the referenced period despite its being owned by DOE. i NRC Evaluation of Licensee's Res;onse 10 CFR 30.41(b)(1) authorizes the transfer of byproduct material to DOE. NRC considers that, since the gauge was purchased from the vendor using the licensee's license authority, a transfer from DOA-C0E to DOE was required. According to the licensee's response, this transfer should have been completed NUREG-0940 II.A-26

Appendix , on the date the gauge was received (October 4, 1983). However, the gauge was used by and under the control of DOA-COE until approximately July 30, 1986, and therefore until that date DOA-COE was responsible for the gauge under its license conditions. The violation as stated should be withdrawn and replaced with a citation for failure to have available for inspection, records maintained of the transfer of Gauge 10010 to DOE as required by 10 CFR 30.41(b)(1)in accordance with 10 CFR 30.51(a). This violation is of some concern because the licensee did not at the time of the inspection realize it was not the owner of the source and was not taking proper precautions. REISSUED VIOLATION 1 10 CFR 30.52(b) requires that each licensee make available to the Commission for inspection, upon reasonable notice, records kept by him pursuant to the regulations in this chapter. 10 CFR 30.51(a) requires, in part, that each licensee keep records showing the transfer of licensed material. Contrary to the above, on the date of the inspection, June 22, 1988, the licensee was not able to produce records ,howing the transfer of Gauge 10010 to DOE on or about July 30, 1986, and reasonable notice had been given. This is a Severity Level V violation. (SupplementVI) Restatement of Yiolation 2 License Condition 17 requires, in part, that the licensee shall conduct its program in accordance with the statements, representations, and procedures contained in the application dated March 10, 1987. Item 7 of the application names the Radiation Protection Officer (RPO) 6nd provides his training and experience. Contrary to the above, from April 1987 to the date of the inspection, the responsibilities of the RPO were performed by an individual not specified in the license as the RP0. Summary of Licensee's Response The licensee stated that the cause of the violation was the retirement of the former RPO and the assumption of many of his duties by the new safety officer. The new safety officer was not qualified by training to assume those duties nor had his credentials been submitted in an amendment request to be approved by the NRC as the RPO. Since the inspection, the licensee's safety manager has been trained appropriately to function as RPO and his credentials to be RPO have been submitted in a license amendment request for approval by the NRC. NRC Evaluation of Licensee's Response No information is presented that would alter the violation. The violation is reclassified as a Severity Level IV violation (Supplement VI). NUREG-0940 II.A-27

I Appendix . 1 Restatement of Violation 3 License Condition 15 requires that the licensee conduct.a physical inventory i overy 6 months to account for all sources and/or devices received and possessed - under the license. Records of inventories shall be maintained for 2 years from 'the date of each inventory. l Contrary to the above, from June 1985 to the date of the inspection,' physical inventories had not been conducted to account for three gauges with Serial Numbers 4425, 10010, and 11323.  ! This is a repeat violation. Summary of Licensee's Response The licensee was unable to dispute the findings at the time of the July 19, 1988, enforcement conference. In the licensee's first response, the licensee denied the violation and attempted to support this denial with a record showing that Gauges 4425 and 11323 were inventoried once each during 1987 and 1988. The licensee subsequently responded with previously unavailable records showing that leak tests were performed in January 1987 on Gauges 4425 and 11323 and undocumented inventories were performed concurrent with the leak tests. NRC Evaluation of Licensee's Response License Condition 15 requires that records of 6-month physical inventories be maintained for 2 years from the date of the inventory. Unlike most physical inventory license conditions, License Condition 15 does not require that the physical inventory list the location of the material. at the time of the inventory. Therefore, NRC considers aL leak test record to suffice as an inventory record in this case. As best as can be determined from the licensee's responses, inventories and/or leak tests were performed on the i subject gauges on the following dates going back 2 years prior to the date of - the inspection on June 22, 1988: l Gauge 4425: 4/27/88,4/17/87,1/30/87 I Gauge 11323: 5/6/88,9/28/87,1/30/87 Based on the available information, it appears that Gauge _4425 was not inventoried for a 12-month period from 4/17/87 to 4/27/88 and that Gauge 11323 was not inventoried for an 8-month period from 1/30/87 to 9/28/87. Further, the NRC does not consider that the records of inventories have been maintained if it takes, as in the DOA-COE case, nearly 5 months to retrieve them. The .; NRC finds that the violation should stand as modified for the above dates and deleting reference to Gauge 10010. The violation is reclassified as a Severity Level IV violation (Supplement VI).  ; NUREG-0940 II.A-28

l Appendix Restatement of Violation 4 10 CFR S0.51(a) requires, in part, that each person who receives byproduct material shall keep records showing the receipt, transfer, and disposal of such byproduct material. Contrary to the above, the licensee had not maintained records showing the receipt of two moisture density gauges containing byproduct material, Serial Numbers 11323 and 10010, which were received since the time of the previous inspection on November 1, 1983. Summary of Licensee's Response The licensee submitted a record of receipt for Gauge 10010 and a hand receipt ' identifying the DOA-COE custodian for Gauge 11323. The licensee subsequently responded with a receipt record for Gauge 11323 which was retrieved from the Corps' Fort Worth District Office. NRC Evaluation of Licensee's Response Receipt records for Gauges 10010 and 11323 were turned up by the licensee over a period as long as 5 months from the date of the inspection. NRC believes the violation should be reissued on the basis that the licensee was not able;: to produce a the time of the inspection receipt records maintained to show receipt of these gauges to verify compliance and reasonable notice had been given. The violation is reissued at a Severity Level V REISSUED VIOLATION 4 10 CFR 30.52(b) requires that each licensee make available to the Commission for inspection, upon reasonable notice, records kept by his pursuant to the regulations in this chapter. I 10 CFR 30.51(a) requires, in part, that each person who receives byproduct ] material shall keep records showing the receipt of such byproduct material. l Contrary to the above, on the date of the inspection, June 22, 1988, the licensee was not able to produce records that it had maintained showing the receipt of two moisture density gauges containing byproduct material, Serial Numbers 11323 and 10010, which were received after October 3,1983, and reasonable notice had been given. This is a Severity Level V violation (Supplement VI) 1 Restatement of Violation 5 License Condition 12(a)(1) requires, in part, that sealed sources shall be I tested for leakage and/or contamination at intervals not to exceed 6 months. License Condition 12.8 requires, in part, that any source in storage and not being used need not be tested. When the source is removed from storage for use or transfer _ to another person, it shall be tested before use or transfer. Contrary to the above, the required leak tests for sealed sources contained in  ; two moisture density gauges, Serial Numbers 11323 and 4425, had not been completed prior to use when they were removed from storage. NUREG-0940 II.A-29

Appendix Sumary of Licensee's Response

 ..Since the inspection, the licensee leak tested Gauge 4425 and placed Gauge 11323 in storage in lieu of leak testing and committed to leak test it prior to continued use. The licensee committed to implementing a Standard Operating Procedure which requires the inventorying and leak testing of gauges at 6-month intervals in accordance with D0A-00E Regulation ER385-1-80.

NRC Evaluation of Licenree's Response NRC concludes that the violation is accurate as cited. The violation is reclassified as a Severity Level IV violation (Supplement VI). i i Restatement of Violation 6 10 CFR 19.11(a), (b), and (c) requires, in part, that each licensee shall post current copies of the regulations in Parts 19 and 20, operating procedures, and the license or a notice specifying where such documents may be examined, and Form NRC-3. Contrary to the above, neither the regulations, license, procedures, notice, , nor Form NRC-3 were pcsted at the time of the inspection. Sumary of Licensee's Response 1 The licensee has posted the required documents as stated in Reference 4. ] NRC Evaluation of Licensee's Response NRC concludes that the violation is accurate as cited. The violation is reclassified to a Severity Level V violation (Supplement VI). Licensee's Recuest to Rescind the Civil Penalty The licensee has stated that, in view of the responses provided, the civil penalty be dismissed. NRC Evaluation of Licensee's Request to Rescind the Civil Penalty With the significant revision of Violation 1, the existing violations do not represent either individually, or in the aggregate, a Severity Level III problem. Therefore, the proposed imposition of civil penalty should be rescinded. NRC Conclusion The NRC staff has concluded that Violation 1 should be significantly revised and that the proposed civil penalty should be rescinded. In addition, Violation 4 was also revised and reissued. The licensee will be requested to respond to the reissued violations. All other violations have been reclassified at the appropriate severity level. NUREG-0940 II.A-30 \

i l 1 i ma mac

 /          o                        UNITED STATES l'         [,t              NUCLEAR REGULATORY COMMISSION                                                                             J

{ E waswincron. o. c. rosss

 %.....#                               idAR 17 NB9 Docket No. 030-19378 License No. 37-13604-02(expired)

EA 89-52 Michael F. Dimun, M.D. 135 East Hall Plaza i Carnegie, Pennsylvania 15106 Gentlemen:

SUBJECT:

ORDER TO CEASE AND DESIST USE OF REGULATED MATERIAL, EFFECTIVE l IMMEDIATELY Enclosed is an Order, effective immediately, requiring that you (1) cease and desist use of regulated byproduct material in your possession (2) promptly store the material in a safe storage location, (3) transfer the material to an authorized recipient within 30 days of the date of this Order, (4) notify the NRC by telephone at ledst or,e working day prior to the actual transfer, and (5) certify to the NRC, under oath or affirmation, that all byproduct material has been transferred to an authorized recipient within 10 days after such transfer. This Order is being issued because you do net have a license, as required by the NRC, to possess this material. Your previous license authorizing such possession expired in February 1987, and you did not file a request for timely renewal. Furthermore, you informed the NRC that you have no intention of seeking another license. Should you have questions concerning this Order, please direct them to Dr. Malcolm R. Knapp, Director, Division of Radiation Safety crid Safeguards in the NRC Region I office at (215) 337-5000. 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 Order will be placed in the NRC's Public Document Room. Willful failure to comply with the terms of this Order could result in criminal prosecution. Sincerely, AUW Hu h L. Thompson r De .y Executive 01 or fo Materials Saf ety, Safeguards, and Operations Support

Enclosure:

As stated CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-31

UNITED STATES NUCl. EAR REGULATORY COMMISSION In the Matter of Michael F. Dimun, M.D. Docket No. 030-19378 Carnegie, Pennsylvania License No. 37-13604-02(Expired) EA 89-52 ORDER TO CEASE AND DESIST AND ORDER RELATED TO DISPOSITION OF BYPRODUCT MATERIAL EFFECTIVE IMMEDIATELY I Michael F. Dimun, M.D. (Dr. Dimun) previously held NRC License No. 37-13604-02 issued by the Nuclear Regulatory Commission (NRC or Comission) on i february 24, 1982. This license expired without a request for timely renewal l on February 28, 1987. (Dr. Dimun had also held License No. 37-13604-01, which also had previously expired on March 31, 1980 without a request for timely renewal). When in effect, License No. 37-13604-02 authorized Dr. Dimun to possess sealed sources (containing 0.12 curies of strontium-90) at his office in Carnegie, Pennsylvania for use in the treatment of eye diseases. II During a telephone call with Dr. Dimun on August 5, 1988, the NRC, Region I, learned that even though the license had expired, Dr. Dimun still possessed a radioactive source containing strontium-90. During that telephone call, Dr. Dimun also informed Region I that he did not intend to submit an application for a new license, but rather planned to dispose of this regulated material by transferring it to an authorized recipieht. However, since the material

                                                                                                                                                               )

had not been disposed of at that time, even though the license expired in l NUREG-0940 II.A-32

l 4 February 1987, Region I sent Dr. Dimun a Notice of Vioittion (Natice) on September 21, 1988, citing him for possession of regulated material without a license. The Notice required Dr. Dimun to provide a response, within 30 days, describing the corrective action taken to transfer the source to an authorized recipient. As of February 16, 1989, the NRC Region I had not received a response to the Notice, and as a result, Region I again telephonically contacted l Dr. Dimun on thst date and was informed that he still possessed the strontium-90 sealed source. III NRC regul6tions, " Rules of General Applicability to Domestic Licensing of Byproduct itaterial," set forth in 10 CFR Part 30, require, in Section 30.3, tt6t except for persons exempt as provioed in 10 CFR Part 30 and 10 CFR 3 i Part 150, no person shall manufacture, produce, transfer, receive, acquire, own, possess, or use byproduct material except as authorized in a specific or general license issued pursuant to the regulations in Chapter I - Nuclear Regulatory Comission. Since Dr. Dimun no longer possesses a valid license to possess or use strontium-90 as a sealed scurce, and since he is not exempt from licensing requirements as provioed in 10 CFR Part 30 and 10 CFR Part 150, l possessien or use of this regulated byproduct material constitutes a violation i of 10 CFR 30.3. Dr. Dimun has indicated his intention not to seek another l license, and has not yet transferred the source to an authorized recipient l i despite being clearly put on notice to do so by the Notice of Violation issued by the NRC on September 21, 1988. Continued possession of this source without NUREG-0940 II.A-33 l

  - _ _ _ _       .___ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ .                                     __  _ _ _ _ _ _ _ _ _ _ _ _ _ ___ ______ ____}

being properly licensed could pose a threat to the health and safety of the public. Therefore, I have determined that immediate action shall be taken, in the interest of public health and safety, to ensure proper transfer of the source to an authorized recipient. IV Accordingly, in view of the foregoing, and pursuant to Sections 81, 161b, 1611, and 1610 of the Atomic Energy Act of 1954, as amended, and Part 30 of the NRC Regulations, IT IS HEREBY ORDERED, EFFECTIVE IMMEDIATELY, THAT-MICHAEL F. DIMUN, M.D. SHALL:

1. Cease and desist from any further use of byproduct material now in his possession;

2. Promptly store the material in a safe storage location, and', with respect to such storage, comply with the provisions of 10 CFR Part 20. " Standards for Protection Against Radiation;"

3. Within thirty days of the date of this Order, cause the byproduct material l

now in his possession to be leak tested in accordance with Condition 14 i of License No. 37-13604-02 (expired) and transfer the byproduct material l to a person authorized to receive it, and at least one working day prior to such transfer, notify the NRC of the name, address and location of the person to whom the material shall be transferred. The notification shall be made to Dr. Malcolm R. Knapp of the NRC Region I office (215)337-5000;and NUREG-0940 II.A-34

4 Within 10 cays af ter the actual transf er of the material, certify to the NRC, under oath or affirmation, that all byproduct material has been transferred to an authorized recipient and that no radioactive material (regulated by the NRC pursuant to a general or specific license) is still in his possession. That certification shall be sent to the Regional Administrator, USNRC Region I, 475 Allendale Road, l King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COPEISSION I Hu h L. Thompso J. D y Executive r tor for Nuclear Materials ety, Safeguards, and Operations Support Dated at Rockville, Maryland thisjydayofMarch1989 l l l l NUREG-0940 II.A-35

 **pm are 'o,                             UNITED STATES

[ j, NUCLEAR REGULATORY COMMISSION c e wAsmwarow.o.c. mmes g Docket No. 70-1113 License No. SNM-1097 EA 88-302 General Electric Company ATTN: Mr. Eugene A. Lees, General Manager Nuclear Fuel and Component Manufacturing Dep6rtment Post Office Box 780 Wilmington, North Carolina 28402 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Vera M. English, a former employee at General Electric Company's Wilmington facility, filed a complaint with the Department of Laoor on August 24, 1984, and an amended complaint on A6 gust 27, 1984, alleging discriminatory discharge under Section 210 of the Energy Reorganization Act of 1974 (ERA). Following-an investigation of her allegations, the Administrator of the Wage and Hour

    ' Division of the Department of Labor concluded that GE had discriminated against Ms. English in violation of the ERA. The case was referred to an Administrative Law Judge (ALJ) when both Ms. English and GE appealed the Administrator's decision.

Following a hearing, the ALJ issued a Decision and Order on August 1, 1985, (Case 85-ERA-002) finding, among other things, that GE discriminated against Ms. English for engaging in protected activities by dismissing her from the Chemet Lab. Subsequent reviews and decisions by the Secretary of Labor and the U.S. Court of Appeals have addresseo questions of timeliness of filing the complaint with D0L and of whether or not a continuing violation of the ERA has been established, but did not address the ALJ finding that discrimination occurred. Although the Court of Appeals remanded the case to the Secretary of Labor to consider Ms. English's claim of discrimination by retaliatory harassment while she was in the warenouse, there will now not be a final decision from the Secretary of Labor on the merits of the ALJ's decision concerning Ms. English's dismissal from the Chemet Lab. Therefore, the issue is now appropriate for NRC to consider. An Enforcement Conference is not being held in this matter in light of the opportunities General Electric has had to responc to a 1987 Petition submitted on behalf of Vera English pursuant to 10 CFR 2.206 and the information that Generaf Electric has provided to the Department of Labor. I 1 After reviewing the ALJ decision, the NRC staff has determined that a violation  ! of the Commission's regulations in 10 CFR 70.7 occurred in that Ms. English was l removed from the Chemet Lab as a result of her initiation of and participation in NRC proceedings under the Atomic Energy Act regarding Chemet Lab safety concerns. Beginning in 1982 and continuing into 1984, Ms. English reported NUREG-0940 11.A-36

General Electric Company l safety concerns to GE management and the NRC. On a number of occasions she raised with her management concerns relating to contamination that she was  ; finding in the Cheaet Lab. She reported that this contamination was being lef t by the workers on previous shifts and that she was having to clean it up for them. On March 15, 1984, Ms. English did not clean up contamination in l the lab but instead reported it to her supervisor. As a result of raising l concerns with her management and the HRC, Ms. English was removed from her job l in the Chemet Lab and barred from further work in controlled areas and subsequently terminated on July 30, 1984. The licensee failed to investigate why other employees had not cleaned up the contamination and no other employees I were disciplined for the failure to clean up spills reported by Ms. English. Acts of discrimination against an employee who raises safety concerns or who communicates with the NRC will not be tolerated. To emphasize this, I am l issuing the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Twenty Thousand Dollars ($20,000) 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, (1984) which was the Policy in effect at the time of the violation (Enforcement Policy}, the violation has been categorized as a Severity Level II violationi A civil penalty of $20,000, the base civil penalty for a Severity Level II violation at the time the discrimination occurred, is being proposed. The ; violation is categorized at a 3everity Level II because plant management was involved in the discrimination decision. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. This enforcement action does not consider whether Ms. English was subject to discrimination while working in a warehouse following her removal from the Chemet Lab. The DOL still has that issue before it. The staff will consider that matter following D0L's decision. You are required to respond to this letter and the enclosed Notice and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing i your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC 1 enforcement action is necessary to ensure compliance with NRC regulatory l I requirements. I In addition, a Director's Decision is being issued today concerning the 1987 l Petition submitted on behalf of Vera English. A copy is enclosed, t In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, l Title 10, Code of Federpl Regulations, a copy of this letter and its enclosures will be placed in the NHC Public Document Room. , t NUREG-0940 II.A-37 I

General Electric Cospany The responses directed by this letter and the enclosed liotice are not subject to the clearance procedures of the OTfice of Managenent and Budget as required by the Paperwork Reduction Act of 1980, FL 96-5611.

                                                                                                             ]

Sinceruly,

                                                                    /      /                   L             .

Hu h L. Thompso J r. De y Executive Dir r for Nuclear Materials Safety, Safeguards, and Operations Support

Enclosure:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Director's Decision i General Electric Company I

cc w/ encl: T. Preston Winslow, Manager Licensing and Nuclear Materials Management State of florth Carolina General Electric Compsi.y l Anthony 2. Roismar-  ! Suite 600 1401 New York Ave., NW  ! Washington. D.C. 20005

                                                                                                             )

i NUREG-0940 II.A-38

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY General Electric Company Docket No. 70-1113 Wilmington, North Carolina License No., SNM-1097 EA 88-302 Based on a Decision and Order issued by an Administrative Law Judge of the Department of Labor (DOL) dated August 1, 1985 (DCL case 85-ERA-002), the NRC , has determined that a violation of its regulations has occurred. In accordance I cith the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1984), which was the Enforcement Policy in effect at i the time of the violation, the Nuclear Regulatory Commission proposes to impose l a civil penalt  ! amended ("Act"y pursuant

                 ), 42 U.S.C. to PL 2282,  Section   234 96-295, andof10 the Atomic CFR   2.205.Energy  Act of 1954, as The particular 1

violation and the associated c1vil penalty are set forth below: 10 CFR 70.7 prohibits discrimination by a Commission licensee against an employee for engaging in certain protected activities. Discrimination ) includes discharge and other actions that relate to the compensation, terms,  ; conditions, and privileges of employment. The activities protected include j but are not limited to providing the NRC or the employee's management . information about possible violations of MRC requirements and requests to the NRC to take action against an employer for enforcement of NRC , requirements. j Contrary to the above, Vera M. English, a General Electric employee, was discriminated against for engaging in protected activities in reporting safety problems to her management and requesting assistance from the NRC. Beginning in 1982 and continuing into 1984, Ms. English reported safety concerns to GE management and the NRC. On a number of occasions she raised with her management concerns relating to contamination in the Chemet Lab.  ; On March 16, 1984, Ms. English oid not clean up contamination and instead l reported it to her supervisor. As a result of raising the concerns with httr management and the NRC, Ms. English was removed from her job in the Chemet Lab and barred from further work in controlled areas and subsequently terminateo on July 30, 1984. This is a Severity Level II violation (Supplement VII). Civil Penalty - $20,000 Pursuant to the provisions of 10 CFR 2.201, General Electric Company is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nufl ear Regulatory Cornission, within 30 cays of the date cf this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include: (1) admission or denial of the violation, (2) the reasons for the violation if admitted (3) the corrective steps that have been taken and the results achieved, (4),the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may NUREG-0940 II.A-39

Notice of Violation be proper should not be taken. Consideration may be given to extending the 4 response time for good cause shown. Under the authority of Section 182 of the Act, 42*U.S.C. 2232, this response shall be sebsitted under oath or affirmation. Within the same time as provided for the response required above under  ! 10 CFR 2.201, the licensee may pay the civil penalty by letter addressed to the i Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a l check, draf t, or money order payable to the Treasurer of the United States in l the amount of the civil penalty proposed above, or may protest imposition of j the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Cosutission. 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 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 flye factors addresse&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., citing page and paragraph nuesers) to avoid repetition. The attention of the licensee is directed to the other provisions of 10 CFR 2.205 regarding the procedure for { i imposing a civil penalty. l Upon failure to pay the penalty due, which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2262.  ; 1 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 Hotice 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 COP 9tISSION

                                                    /

H L. Thomp . Deputy Executive rector for Nuclear Materials Safety, Safeguards, and Operations Support Dated at Rockville, Maryland this fy/h day of March 1989 NUREG-0940 II.A-40

i a arc UNITED sT ATEs

                    ,,                        ]

y ,e i E, NUCLEAR REGULATORY COMMISSION 8 f REGION I 475 ALLENDALE ROAD

                           ' wa              j                                                                       :
                         '****                                                   KtNG OF PRUSSIA. PENNSYLVANIA 19406 MAR. 2 e 1989 t

Docket No. 030-01960 License No. 20-13391-01 EA 89-48 Anna Jaques Hospital ATTN: John Guidara Administrator 25 Highland Avenue Newburyport, Massachusetts 10950 Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection No. 89-001) This letter refers to the NRC inspection conducted on January 26 and 30, 1989 at Anna Jaques Hospital, Newburyport, Massachusetts of activities authorized by NRC License No. 20-13391-01. The report of this inspection was sent to you on February 17, 1989. During the inspection, ten violations of NRC requirements were identified. On March 1, 1989, an enforcement conference was conducted with you and a member of your staf f to discuss the violations, their causes and your corrective actions. The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty, include, but are not limited to:  ; (1) failure to promptly notify the NRC of a misadministration that occurred at your facility in December 1988; (2) failure to label certain syringes containing radiopharmaceuticals prior to administration of doses; (3) failure to perform required constancy, linearity and geometrical variation tests of the dose calibrator; (4) failure to perform certain required surveys; and (5) failure to maintain certain records of some of these activities. Although the violations, if considered individually, would be classified at a Severity Level IV, the violations collectively indicate a recent lack of manage-I ment oversight of, and attention to, your radiation safety program by the Radia-l tion Safety Officer. The NRC recognizes that the prior enforcement history at ) your facility.has been good, as evidenced by the fact that only one violation  ! was identified during the prior two NRC inspections in 1985 and 1982 and that a temporary technician was hired in December 1988 to replace another who left i l CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-41

MAR. 2 e 1989 Anna Jaques Hospital the facility on a disability. Nevertheless, the failure by the RSO to aggressively monitor the performance of the new technician represents a significant breakdown in oversight of the radiation safety program. To emphasize the importance of management, and in particular the RSO, continually maintaining adequate control over the radiation safety program, to assure that-licensed activities are conducted safely and in accordance with the terms of your license, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Materials Safety, Safeguards and Operations Support, to issue the_ enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Thousand Two Hundred Fifty

• Dollars ($1,250) for the violations described in that Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions,"

10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988) the 10 viola-tions described in the Notice have been classified in the aggregate as a Severity Level III problem to focus on their underlying cause as previously described. The base civil penalty amount for a Severity Level III. violation or problem is

             $2,500. Although a basis exists for 100 percent mitigation of the base civil penalty because of your prior good enforcement history, a basis also exists for 50 percent escalation because the violations were identified by the NRC, and the RSO should have reasonably identified them sooner. On balance, the base penalty was reduced by 50 percent. The other escalation and mitigation factors set forth in the policy were considered, and no further adjustment has been deemed appro-priate. You should note that if the violations had been promptly identified by your staff and promptly corrected, a civil penalty would not have been proposed in this case.

You are required to respond to this letter and the enclosed Notice, and should follow the instructions specified in the enclosed Notice when preparing your l response. In your response, you should document the specific actions taken i and any additional actions you plan to take to prevent recurrence. In your response, you should also describe the actions taken or planned to improve the R50's oversight of the radiation safety program. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further actions  ; are needed to ensure compliance with regulatory requirements. Furthermore, we ' emphasize that any recurrence of these violations may. result 1n more significant enforcement action. 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 ano its enclosure will be placed in the NRC Public Document Room. NUREG-0940 II.A-42

MAR. 2 81989 Anna Jaques Hospital 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, Sm4L.,M .

                                             " liam T. Russell Regional Administrator

Enclosure:

Notice of Violation and Proposed Impesition of Civil Penalty cc w/ encl: f j Public Document Room Local Public Document Room { Nuclear Safety Information Center (NSIC) t Commonwealth of Massachusetts { Document Control Desk I 1 l

                                                                                                             )

NUREG-0940 II.A-43

I NOTICE OF VIOLATION I AND PROPOSED IMPOSITION OF CIVIL PENALTY Anna Jaques Hospital Docket No. 030-01960 Newburyport, Massachusetts  ! License No. 20-13391-01 EA 89-48 l l During an inspection conducted on January 26 and 30,1989,10 violations of NRC j requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13,1988) the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular vio-lations and associated civil penalty are set forth below: A. 10 CFR 35.33(c) requires, in part, that when a misadministration involves a diagnostic procedure involving use of byproduct material, the licensee shall notify the appropriate NRC office in writing within 15 days if the patient is likely to receive an organ dose greater than 2 rem. Contrary to the above, on December 6,1988, a diagnostic misadministration involving byproduct material occurred that likely involved an organ dose to the bladder greater than 2 rem, and the NRC was not notified of this misadministration until receipt of a letter dated January 12, 1989 on January 20, 1989. The misadministration involved administration of 19.5 l millicuries of Tc-99m (MDP) to the wrong patient, which likely caused an organ dose to the bladder of greater than 2 rem. 1 B. l 10 CFR 35.60(b) requires that a licensee conspicuously label each syringe,  ! or syringe radiation shield that contains a syringe with a radiopharmaceu-tical, and the label shall show the radiopharmaceutical name or its abbre-viation, the clinical procedure to be performed, or the patient's name. Contrary to the above, on January 26, 1989, and on an indeterminate number of times prior to that date, syringes or syringe shields containing  ; radiopharmaceuticals routinely were not labelled as required. Specifically, ' technicians did not label the syringes or syringe shields but rather i prepared the dose and proceeded directly to inject the patient. l C. 10 CFR 35.51(a)(3) requires that at the time of survey meter calibration, the apparent exposure rate from a dedicated check source be oeterminea and recorded on the instrument. 10 CFR 35.51(c) requires that each survey instrument be checked with the dedicated check source each day of use. Contrary to the above, as of January 26, 1989, the apparent exposure rate from a dedicated check source had not been determined at the time of NUREG-0940 11.A-44

l NOTICE OF VIOLATION instrument calibration and recorded on the survey meters provided by Additionally, the Seabrook Nuclear Station and used at the hospital. same survey meters had never been checked for proper operation with a dedicated check source. D. 10 CFR 35.50(b)(3) requires that the linearity of the dose calibrator be 3 tested at installation and at least quarterly thereafter. Contrary to the above, as of January 26, 1989, the linearity of the dose calibrator had not been determined since August 24, 1988. E. 10 CFR 35.50(b)(1) requires, in part, that licensees check each dose calibrator for constancy with a dedicated check source at the beginning of each day of use and that the check be done on a frequently used setting. Contrary to the above, on several occasions in December 1988 and January 1989, including January 25 and January 26, 1989, a dose calibrator was used to measure patient doses of radiopharmaceuticals, and prior to use-on those days,' the calibrator was not checked for constancy. F. 10 CFR 35.50(e)(1) requires that records be maintained of daily constancy checks of dose calibrators for three years unless directed otherwise and that the records include, among other things, the model and serial number  ! of the dose calibrator and the initials of the individual who performed the check. Contrary to the above, records of daily constancy checks performed between September 1988 and January 30, 1989, did not contain the model and serial numbers of the dose calibrator nor the initials of the individual who l performed the check. G. 10 CFR 35.50(e)(2) requires that records be maintained of annual accuracy I tests'of dose calibrators for three years unless directed otherwise and that the records include, among other things, the signature of the Radiation Safety Officer. Contrary to the above, records kept of annual accuracy tests performed I J between April 1, 1987 and January 30, 1989 did not include the signature j of the Radiation Safety Officer. J H. 10 CFR 45.50(e)(3) requires that records be maintained of quarterly dose caliorator linearity tests for three years unless directed otherwise and that the records include, among other things, the signature of the , Radiation Safety _ Officer. Contrary to the above, records of quarterly linearity tests performed from April 1, 1987 to August 24, 1988 did not include the signature of the Radiation Safety Officer. i

                                                                                                      'I NUREG-0940                              II.A-45                                    ;

NOTICE OF VIOLATION I. 10 CFR 35.70(e) requires that licensees survey for removable contamination, at least once each week, all areas where radiopharmaceuticals are routinely

           . prepared for use, administered, or stored.

Contrary to the above,. between November 1,1988 and January 30, 1989, surveys for. removable contamination were not being performed once each week in and around the Hot Lab area where radiopharmaceuticals were routinely prepared for use and administered. 1 J. 10 CFR 35.70(a) requires that licensees survey with a radiation detection survey instrument at the end of each day of use all areas where radio-pharmaceuticals are routinely prepared for.use or administered. Contiary to the above, a survey with a radiation detection instrument was not performed at the end of each day of use in and around the Hot Lab Area where radiopharmaceuticals were routinely prepared for use and administered. Specifically, surveys were not performed on weekend days when radiopharma-ceuticals were prepared for use and administered, including December 10, 1988. These violations have been categorized in the aggregate as a Severity Level III problem (Supplements IV and VI). Civil Penalty - $1,250 (assessed equally among the violations). Pursuant to the provisions of 10 CrR 2.201, the Anna Jaques Hospital (Licensee) is hereby required to submit a wri +n 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) admis-sion 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 tnis 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 autho-rity 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 Ctai 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 i 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 NUREG-0940 II. A-46

NOTICE OF VIOLATION i I will be issued. Should the Licensee elect to file an answer in accordance with i 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) demon-strate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In additior, to protesting the civil penalty, such answer may request remission or mitigation of the l penalty. In requesting mitigation of the proposed penalty, the 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., 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 response to the Director, Officer of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTH: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COMMISSION j hl . l liam T. Russell pRegionalAdministrator Dated at King of Prussia, Pennsylvania this J F day or March 1989 4 J1 NUREG-0940 II.A-47

pa ass UNITED STATES

    /           \                   NUCLEAR REGULATORY COMMISSION

[ hg( } ' 7, i AEGloN lit s ,, 799 ROOSEVELT RO AD OLEN ELLYN. ILLINOIS 60137 May 31, 1989 , 1 Docket No. 99990003 General License (10 CFR 31.5) EA 89-065 Niagara of Wisconsin Paper Corporation ATTN: Mr. Elmer C. Beale President 1101 Mill Street Niagara, WI 54151 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY - $750 (NRC INSPECTION REPORT NO. 99990003/89002(DRSS)) This refers to the special safety inspection conducted on March 13, 1989, at your facility in Niagara, Wisconsin. The inspection was conducted in response to your January 18, 1989 telephone notification of a lost source that was in a device which was removed from service in October 1988. The findings of our inspection were forwarded to you on April 4,1989. An enforcement conference was conducted by telephone with.you and members of your staff on March 30, 1989 to discuss the violations, causes, and your corrective actions to prevent recurrence. The violations described in the enclosed Notice are significant because they resulted in the loss of radioactive material. Two violations were identified which involved: (1) failure to have licensed individuals perform the removal of a radioactive gauge from its installed location, and (2) transfer of a radioactive gauge to persons not authorized to receive such devices, specifically, an unlicensed metal salvage yard. To emphasize the importance of maintaining adequate control over gauges { containing radioactive material, I have been authorized, after consultation with the Director, Office of Enfo:coment, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Seven Hundred Fifty Dollars (5750) 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. 53 Fed. Reg. 40019 (October 13,1988) (Enforcement Policy), the violations described in the enclosed Notice have been categorized as a Severity Level III problem. l The base value of a civil penalty for a Severity Level III violation is 5500. The esc'alation and mitigation factors in the Enforcement Policy were considered and the base civil penalty amount has been increased by 50% because of the untimely corrective actions. Specifically, although the scope of your proposed NUREG-0940 II.A-48 1

Niagara of Wisconsin Paper Corporation 2 May 31, 1989 corrective actions appear adequate, such corrective actions should have been initiated in early December 1988, as opposed to waiting until January 19, 1989; and most of these actions were initiated based on discussions with NRC personnel. 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.

Although not required as part of your response, you should also review each

 . requirement in 10 CFR 31.5(c)(1) through (c)(10) and should., ensure that you have appropriate procedures in place to comply with each requirement on a continuing basis. It is important that you put adequate procedures into place now, since any future violations may result in more significant enforcement action, including escalated civil penalties as well as suspension or revocation ef your authority under the general license (10 CFR 31.5).

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 l l will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the c1'earance procedures of the Office of Management and Budget, as required by the Paperwork Reduction Act of 1980, Pub. L., No. 96-511. Sincerely, f-A. Berf Davi s-i Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition l of Civil Penalty -

2. Inspection ~ Report No. 99990003/89002(DRSS)

See Attached Distribution 2 c NUREG-0940 II.A-49

NOTICE OF VIOLATION I AND PROPOSED IMPOSITION OF CIVIL PENALTY ' i Niagara of Wisconsin Dociet No. 999-90003 Paper Corporation Niagara, Wisconsin General License (10 CFR 31.5) EA 89-065 During an NRC special safety inspection conducted March 13, 1989, 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, 53 Fed. Reg. 40019 (October 13,1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. .The particular violations and associated civil penalty are set forth below: A. 10 CFR 31.5(c)(3) provides that persons who acquire, receive, possess, use or transfer byproduct material in measuring or gauging devices pursuant to a general license shall assure that removal of such devices from installation is performed in accordance with the instructions provided by the label or by a person holding a specific license pursuant to 10 CFR Parts 30 and 32 or from an Agreement State to perform such activities. t Contrary to the above, on October 25, 1988, a general contractor for the licensee, who did not possess a specific license pursuant to 10 CFR Parts 30 and 32 or from an Agreement State, removed from installation a generally-licensed device containing approximately 340 mil 11 curies of krypton-85; and this removal was contrary to the instructions provided by the label. B. 10 CFR 31.5(c)(8) provides, with exceptions not applicable here, that I persons who acquire, receive, possess, use, or' transfer byproduct material in measuring or gauging devices pursuant to a general license shall transfer or dispose of such devices only to persons who are authorized to i receive such devices in accordance with a specific license pursuant to Parts 30 and 32 or from an Agreement State. i Contrary to the above, on or about October 27, 1988, the licensee disposed i of a generally-licensed gauge containing approximately 340 m1111 curies of- ' krypton-85 by transferring the device to a metal salvage yard that was not i authorized to receive such gauge in accordance with a specific license

                      , pursuant to 10 CFR Parts 30 and 32 or from an Agreement State.

This is a Severity Level III problem (Supplement VI). Civil Penalty - $750 (assessed equally between the violations). NUREG-0940 II.A-50

l Notice of Violation 2 I Pursuant to the provisions' of 10 CFR 2.201, Niagara of Wisconsin Paper , Corporation (Licensee) is hereby required to submit a written statement or j explanation to the Director, Of fice of Enforcement, U.S. Nuclear Regulatory i Commission, within 30 days of the date of this Notice. This reply should be i clearly marked as a " Reply to a Notice of Violation" and should include for i each alleged violation: (1) admission or denial of the alleged violation; (2) the reasons for the violation if admitted; (3) the corrective actions that have been taken and the results achieved; (4) the corrective actions that will be taken to avoid further violations; and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an Order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. I Within the same time as provided for the response required under 10 CFR 2.201, i the Licensee may pay the civil penalty by letter to the Director, Office j of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, ' or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, 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 i accordance with 10 CFR 2.205 protesting the civil penalty in whole or in part, l 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 factors addressed in Section V.B of 10 CFR Part 2, Appendix C, should be addressed. Any written answer in acccrdance 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 penal.ty. Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provision of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c. l NUREG-0940 II.A-51

                         ' Notice of Violation                       3                                        l The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of..

Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region III, U.S.. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen.Ellyn, Illinois 60137. FOR THE NUCLEAR REGULATORY COMMISSION A. Ber Davir Regional Administrator { Dated at Glen Ellyn, Illinois - this 31st day of May 1989 4 i NUREG-0940 II.A-52

 /         %,                          UNITED STATES 8            o               NUCLEAR REGULATORY COMMISSION 5            I                       wAssmorow, o. c.aoses s.,...../

AIAY 11 1989  ; Docket No. 30-20317 ' License No. 35-23154-01 , EA No. 89-67 i P&L Trucks, Inc. ATTN: Don Riley, President 2018 North B Street McAlester, OK 74051 Gentlemen: I

SUBJECT:

ORDER TO SHOW CAUSE WHY LICENSE SHOULD NOT BE SUSPENDED AND REV0KED (EFFECTIVE Il#tEDIATELY) Enclosed is an issnediately effective Orcer regarding the suspension and revocation of your license. The Order requires you to take certain actions to transfer your licensed material to an authorized recipient and submit information to NRC Region IV within specified times. The reasons for this action are explained in the Order. In accordance with the terms of the Order, you may show cause why the Order should not have been issued and may request a hearing on whether the Order should be sustained. 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 I order will be placed in the NRC's Public Document Room. The responses directed by the enclosed Order 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, H L. Thompson ty Executive Dir r for Nuclear Materials Safety, Safeguards, and Operations Support

Enclosures:

As stated CERTIFIED MAIL R Tm F T ETTPT REQUESTED  ! NUREG-0940 II.A-53

UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of )

                                   )         Docket No. 30-20317 P&L Trucks                          )         License No. 35-23154-01 Wetumka, Oklahoma                   )         EA No. 89-67 ORDER TO SHOW CAUSE WHY LICENSE SHOULD NOT BE SUSPENDED AND REV0KED(EFFECTIVEIMMEDIATELY)

I P&L Trucks, Wetuska, Oklahoma (licensee) is the holder of Materials License No. 35-23154-01 issued by the Nuclear Regulatory Comission (NRC or Comission) on August 21, 1985, and due to expire on January 31, 1990. The license authorizes P&L Trucks to possess sealed radioactive sources containing americium-241 for use in well-logging of oil and gas wells and to possess i radioactive iodine-131 and iridium-192 for use in tracer studies of oil and gas wells. II NRC Region IV discovered in 1987 that P&L Trucks was no longer in business at l the location specified in its NRC license for the storage of its licensed radioactive material. Following extensive efforts to locate-the licensee. contact was made with Mr. Don Riley, the company's president, in January 1989 and Mr. Riley agreed to the following requests: 1) to maintain his licensed radioactive material in locked storage (in his well-logging truck) at its current location in Wetumka, Oklahoma, pending NRC authorization to move it; NUREG-0940 II.A-54

                                                                                                                           )

2) to request an amendment to P&L Trucks' license to correct the specified location for storage of material and to correct the mailing address; 3) to provide NRC with a list of the types of licensed radioactive material possessed at the former storage location in Pauls Valley, Oklahoma; and 4) to respond to a Notice of Violation that NRC sent to the licensee on August 21, 1907, and reissued on November 18, 1988, which was issued on the assumption that the l

licensee had discontinued licensed well-logging activities. Mr. Riley's commitments, which were to be completed by January 27, 1989, were restated in a Confirmation of Action Letter (CAL) issued to the licensee by NRC Region IV on January 27, 1989. The licensee responded to the CAL in a letter dated February 26, 1989, but did not make a formal request to amend the licent;e to reflect the current location for storage of licensed material and did not respond to the Notice of Violation. NRC Region IV conducted an announced inspection of this licensee on March 22, l 1989 and found the licensee in apparent violation of numerous NRC requirements. l These apparent violations are summarized here: 1) The licensee faileo to maintain acequate records of radiation exposures to individuals as required by 10 CFR 39.65(c). 2) The licensee failed to maintain records of radioactive I materialutilizationasrequiredby10CFR39.39(a). 3) The licensee failed to keep records of leak tests of sealed radioactive sources as required by 10 CFR 39.35(a) and there is no indication that leak tests were performed as required l by 10 CFR 39.35. 4) The licensee failed to keep records showing the receipt of radioactive material as required by 10 CFR 30.51. 5) The licensee failed to l conduct inventories of sealed radioactive sources as required by 10 CFR 39.37. 1

6) The licensee failed to maintain records of surveys performed prior to NUREG-0940 11.A-55

l transporting material as required by 10 CFR 39.67. 7) The licensee failed to calibrate its radiation survey instrument within 6 months as required by 10 CFR 39.33. 8) The licensee failed to store material at the storage location specified in the license. 9) The licensee failed to store material in a storage facility as described in the license application. The licensee was unable, in the absence of utilization records, to estimate when licensed material had last been used in well-logging activities. However, Mr. Riley stated that he had used the sealed americium-241 source to perform well-logging activities sometime between August 1985, when the license was issued, and the date of the inspection. The results of the NRC inspection are described in an Inspection Report sent to the licensee on May 5, 1989. III On April 13, 1989, NRC Region IV personnel again contacted Mr. Riley to offer him an opportunity to discuss NRC's concerns at an Enforcement Conference. The i stated purpose of the Enforcement Conference was to provide a further opportunity for the licensee to confirm or refute the apparent violations, produce any required records that might be located, and understand the enforce-ment actions that might be taken by NRC in this case. Mr. Riley declinen the offer to participate in an Enforcement Conference, stated that he had no additional records to offer, and indicated that he may wish to amend his license to provide for storage of material only. NUREG-0940 II.A-56

                                                                                      \
                                                                                      \

IV The foregoing events indicate that the licensee has made little or no effort to develop and maintain a program for ensuring compliance with the condttions of its NRC license and NRC regulations.- Based 'on the number of apparent-violations and the inability of the licensee to produce required records regarding the use of licensed material, the licensee is either unwilling or unable to meet Commission regulations. Therefore, I lack the requisite reasonable assurance that this licensee, if permitted to engage in licensed activities, will comply with Consnission requirements. Accordingly, I have determined that Materials License No. 35-23154-01 should be formally suspended,- that the licensee should be required to transfer all licensed material to an authorized recipient and, thereafter, that the license should be revoked. Because I find that the public health, safety, and interest so require, I have

                                                                                      ]

furtherdeterminedthat,pursuantto10CFR2.201(c),nopriornoticeof violatienisrequiredandthat,pursuantto10CFR2.202(f),thisOrdershould be effective inanediately. V 1 Accordingly, pursuant to Sections 81, 161b, 161c, 1611, 1610, 182 and 186 of the Atomic Energy Act of 1954, as amended, and the Commission's regulations in 10 CFR Section 2.202 and 10 CFR Parts 30 and 39, IT IS HEREBY ORDERED,  ; EFFECTIVE IMMEDIATELY, THAT: l NUREG-0940 II.A-57 i

l i

                                                                                .A. NRC Materik1s License No. 35-23154-01 is suspended except as provided in Sections V.B. and V.C. The licensee shall not receive any licensed material.

B. The licensee shall continue to maintain all licensed material in locked storage in accordance with the comitments stated in the January 27, 1989 Confirmation of Action Letter, and shall not transport said material , without prior authorization from NRC Region IV. C. Within 60 days of the date of this Order, the licensee shall cause the licensed material now in its possession to be leak tested in accordancer with Condition 13 of License No. 35-23154-01; and the licenses shall transfer all licensed material to an authorized recipient. At least one working day prior to such transfer, the licensee shall notify NRC of the name, address, and location of the person to whom the material will be transferred. The notification shall be nace to Dr. Dale Powers of the NRC RegionIVoffice(817-860-8195). D. Within 10 days after the actual transfer of the material, the licensee shall certify, in writing, under oath or affirmation, that all licensed material has been transferred to a licensed recipient and that no licensed , material is still in its possession. Tnat certification shall be accompanied by a completed form NRC-314 and shall be addressed to the Regional Administrator, NRC Region IV, 611 Ryan Plaza Drive, Suite 1000, Arlington, Texas 76011. NUREG-0940 II.A-58

E. Upon written approval by NRC Region IV of the information submitted under Section V.D., NRC Materials License No. 35-23154-01 is revoked. The Regional Administrator, NRC Region IV, may, in writing, relax or rescind any of these provisions for good cause shown. VI Pursuant to 10 CFR 2.202(b), the licensee ray show cause why this Order, in whole or in part, should not have been issued by filing a written answer under oath or affirmation within 20 days of the date of issuance of this Order, setting forth the matters of fact and law on which the licensee relies. The licensee may answer, as provided in 10 CFR 2.202(d), by consenting to the entry of this Order. IF THE LICENSEE FAILS TO FILE AN ANSWER WITHIN THE SPECIFIED TIME, CONSENTS TO THIS ORDER, OR FAILS TO REQUEST A HEARING IN ACCORDANCE WITH l l SECTION VII BELOW, THIS ORDER SHALL BE FINAL WITHOUT FURTHER PROCEEDINGS. VII The licensee or any other person adversely affected by this Order may request a hearing on all or any aspect of this Order within'20 days of the date of this Order. Any answer to this Order or request for hearing shall be submitted to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATIN: NUREG-0940 II.A-59

Document Control Desk, Washington, D.C. 20555. Copies also shall be sent to the Assistant General Counsel for Hearings and Enforcement, Office of the General Counsel, at the same address and to the Regional Administrator, NRC Region IV, 611 Ryan Plaza Drive, Suite 1000 Arlington, Texas 76011. If a person other than the licensee requests a hearing, that person shall set forth with particularity the manner in which the petitioner's interest is adversely affected by this Order and should address the criteria set forth in 10 CFR 2.714(d). AN ANSWER TO THIS ORDER OR A REQUEST FOR HEARING SHALL NOT STAY THE IPMEDIATE EFFECTIVENESS OF THIS ORDER. If a hearing is requested by the licensee or a person whose interest is adversely affected, the Comission will issue an Order designating the time and place of any hearing. If a hearing is held, the issue to be considered at such a hearing shall be whether this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION M1 / u . Thompson, Jr. De Executive it t for Nuclear Materials Saf , Safeguards, and Operations Support Dated at Roctville, Maryland, this lith day of May 1989. l NUREG-0940 I1.A-60

M O UNITED STATES i

                        !~

O (J"g% NUCLEAR REGULATORY COMMISSION REGION I E 475 ALLENDALE ROAD

                                                            *****                                                         KING OF PRUSSIA PENNSYLVANIA 19406 May 12, 1989 Docket No. 030-15058 License No. 37-18422-01 EA 88-291 Pesara Pushpamala Reddy, M.D.

Butler Ultra Nuclear Imaging Laboratory ) c/o Radiation Oncology Department Armstrong County Memorial Hospital Kittanning, Pennsylvania 16201

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection No. 88-001) This letter refers to the NRC special inspection conriucted on November 14, 1988, at the Butler Ultra Imaging Laboratory, Butler, Pennsylvania, and continued in the Region I office through February 10, 1989, of activities authorized under NRC License No. 37-18422-01. During the inspection, the report of which was sent to you on March 20, 1989, violations of NRC require-ments were identified. On March 29, 1989, an enforcement conference was held in the Region I office with you and Dr. Surendra K. Sethi to discuss the violations, their underlying causes and your corrective actions. The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty, include, but are not limited to: (1) failure to provide adequate training to persons working with licensed  ! material in restricted areas; (2) failure to perform required dose calibrator  ; constancy and linearity tests; and (3) failure to perform surveys of radio- ) active material packages, when received, as well as daily surveys of preparation- J and injection areas. l The violations are of particular concern to the NRC because they involve multiple examples (for example, failure to give training to more than one technologist, failures to perform dose calibrator testing at required frequencies on more than one occasion, and failure to survey radioactive packages on days they were received). In addition, the failure to perform dose calibrator constancy and linearity tests, as well as the daily surveys of the preparation and injection areas, are of additional concern to the NRC  : because similar violations were identified during previous NRC inspections conducted in 1984 and 1987. Furthermore, on August 1, 1988, your consultant i informed the owner of your facility that dose calibrator constancy was not CERTIFIED MAIL RETURN RECEIPT 4 4 NUREG-0940 II.A-61 1

Fesara Pushpamala Reddy, M.D. 2 j being evcluated. Notwithstanding this prior notice, actions taken to correct those deficiencies were not effective in preventing multiple recurrences of the violations.

                                                                                                                   ]

While the significance of the individual violations is low, the repetitive and multiple nature of certain of these violations, coupled with the failure to  ! implement effective corrective actions, demonstrate that you have not provided I adequate management attention to, and control of, activities authorized by your license to ensure that such activities are conducted safely and in accordance with the terms of the license. In addition, although the NRC issued a Confirmatory Action Letter No. 88-26 (CAL) on December 5,1988, confirming , your commitments to retain a qualified radiation safety consultant, develop  ! a training program, and submit a formal outline of that training to the NRC within thirty days of the issuance of the CAL, a response was not received until a Supplement to the CAL was issued on February 3, 1989. Furthermore, that response was inadequate since the submitted training outline was informal, i brief and did not describe-the individual responsible for providing the required j training. 1 While you subsequently provided sufficient information at the enforcement conference concerning your corrective actions, and also provided a firm commit-ment fer the submittal of an acceptable training outiine (which was sent to Region I in your letter dated April 8,1989), your prior lack of aggressive resolution of NRC concerns demonstrate the need for increasing and maintaining i adequate management oversight of licensed activities to ensure these activities are conducted safely and in accordance with the terms of your license. To l emphasize this need, I have been authorized, after consultation with the l Director, Office of Enforcement and the Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support, to issue the enclosed , Notice of Violation and Proposed Imposition of Civil Penalty in the amount l of One Thousand Five Hundred Dollars ($1,500) for the violations described in the enclosed Notice. In accordance with Section C.8 of Supplement VI of the 'Generd Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Dart 2,. 4 pendix C, 53 Fed Reg. 40019 (October 13, 1988) (Enforcement Policy), tht v'oiations described in the Notice have been classified in the aggregata as a Severity Level 111 problem to focus on the underlying concern, namely, a le k of proper attention to license responsibilities in the conduct of your activities at the facility. The base civil penalty amount for a Severity Level III violatinn or problem is $500. The escalation and mitigation factors set forth in the policy were considered and the base civil penalty amount has been increased by 200% because: (1) the violations were identified by the NRC and therefore provide a basis for 50% escalation of the penalty; (2) your corrective actions were neither prompt nor effective, as evidenced by your inadequate response to the CAL and, therefore, provides a basis for 50% escalation of the penalty; and (3) your past performance at this facility has not been good, as evidenced by the fact that your failure to perform constancy and linearity tests are repeti-tive violations, and the ineffectiveness of your prior corrective actions, and therefore, provides a basis for 100% escalation of the penalty. The NRC also considered further escalation of the civil penalty amount since the violations NUREG-0940 11 A-62

l Pesara Pushpamala Reddy, M.D. 3 involved multiple examples and you clearly had prior knowledge of tome of the problems via the consultant. However, since these factors were considered in classifying the violations in the aggregate at Severity Level III, further escalation of the penalty based on these factors was considered inappropriate. i I In addition to the violations, the NRC also has a concern regarding the poten-I tial falsification of a dose calibrator linearity test by a former technologist at your facility in February 1987. Although the NRC has not obtained suffi-cient evidence to establish that a willful violation of NRC requirements occurred, you acknowledged at the enforcement conference that, based on your review of the test data, it is likely that the former employee who performed the test manipulated the data. Therefore, you should recognize that any f falsification of records or willful violations of NRC requirements in the future by you or your staf f will be dealt with harshly whenever substantiated. You are required to respond to this letter and the enclosed Notice, and should follow the instructions specified in the 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, pursuant to , Section 182 of the Atomic Energy Act of 1954, as amended, please submit a statement under oath or affirmation indicating why, in view of the multiple and repetitive nature of the violations, the NRC should have confidence in your ability to assure that licensed activities in the future will be properly conducted. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further action is needed to ensure compliance with regulatory require-ments. Furthermore, we emphasize that a license to use byproduct material is a privilege granted by the NRC, and any recurrent violation of the terms of that license may result in more significant enforcement action, such as higher civil penalties, or modification, suspension or revocation of that license. 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,

                                                /[ - - _n     .

William T. Russell j Regional Administrator  ;

Enclosure:

Notice of Violation and Proposed  ! Imposition of Civil Penalty j l NUREG-0940 II.A-63 -

Pesara Pushpamala Reddy, M.D. 4 1 CC: i Public Document Room Commonwealth of Pennsylvania Dr. Sarendra K. Sethi 230 South Washington Street l Butler, Pennsylvania 16001 ' 1 1 1 1 NUREG-0940 II.A-64

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY 1 Pesara Pushpamala Reddy, M.D. Docket No. - 030-15058

     . Butler, Pennsylvania                                                          License No. 37-18422                                                                                       EA 88-291-t During an NRC inspection conducted between November 14, 1988, and February 10,                          '

1989, 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, 53 Fed. Reg. 40019 (October 13, 1989),.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. 10 CFR Part 19.12 requires, in part, that all individuals working in a restricted area shall be instructed in the precautions and procedures to minimize exposure to radioactive materials, in the purpose and function of protective devices employed, and in the applicable provisions of the Commission's regulations and licenses. Contrary to the above, as of November 14, 1988, technologists working in the nuclear medicine laboratory, a restricted area, had not been instructed in the proper procedures for using a radiation survey meter, in the procedures for safely ~ opening radioactive material packages, in the procedures for performing adequate daily and weekly radiation surveys, or in the procedures for performing required dose calibrator performance tests (linearity and constancy). B. Condition No. 13 of License No. 37-18422-01 requires that licensed radioactive material be possessed and used in accordance with the representations, statements, and procedures contained in the license app'lication dated March 25, 1984, and in the subsequent letters submitted in support of that application. I '. Item 14 of the application dated M ech 25, 1984, requires that radioactive material packages be opened in accordance with the . procedures contained in Appendix F of Regulatory Guide 10.8. Appendix F requires that radioactive material package receipt surveys include direct radiation measurements at three feet and on contact with the package and measurements of removable radioactive contamination. The measurements Eust be sensitive enough to detect 22,000 disintegrations per minute per 100 square centimeters. Contrary to the above, as of November 14, 1988, and for an indeterminate period prior thereto, radioactive material package receipt _ surveys and removable radioactive contamination .

    -NUREG-0940                                                    II.A-65

2 measurements were not performed in accordance with the procedures described in Regulatory Guide 10.8. Specifically, the surveys failed to include direct radiation survey measurements at three feet and on contact with the surface of the package, and the method used to analyze removable radioactive contamination was not sufficiently sensitive to detect 22,000 disintegrations per minute per 100 square centimeters.

2. Item 10 of the application dated March 25, 1984, requires that dose calibrator constancy be evaluated in accordance with the procedures described in Appendix 0 of Regulatory Guide 10.8. Appendix D, Item A.1, Section 2,_ requires that dose calibrator constancy be evaluated each day that the instrument is used to assay patient doses.

Contrary to the above, on August 11 and 25, September 15 and 16, October 13 and 27, and November 7,1988, the dose calibrator instrument was used to assay patient doses, and the dose calibrator constancy was not checked on those days.

3. Item 10 of the application dated March 25, 1984, requires that dose calibrator linearity be evaluated in accordance with the procedures described in Appendix D of Regulatory Guide 10.8. Appendix D, Item A.3, Section 2, requires that dose calibrator linearity be evaluated on a quarterly basis.

Contrary to the above, dose calibrator linearity was not evaluated during the first or second calendar quarters of 1988.

4. Item 17 of the application dated March 24, 1984, requires that area radiation surveys be performed in accordance with the procedures l described in Appendix I of Regulatory Guide 10.8. Appendix I i requires, preparation and injection areas to be surveyed on a daily basis and requires that analysis of area radiation survey contamination wipe samples to be sufficiently sensitive to detect 200 disintegrations per minute.

Contrary to the above, as of November 14, 1988, and for an indeterminate period of time prior thereto, direct radiation survey  ! measurements were not made of radiopharmaceutical preparation and injection areas on a daily basis, and the method used for the analysis of area radiation survey contamination wipe samples was j not sufficiently sensitive to detect 200 disintegrations per minute. ' C. 10 CFR 35.14 requires that a licensee notify the Nuclear Regulatory Commission by letter within thirty days of any change in mailing address. Contrary to the above, as of February 16, 1989, the licensee had not notified the NRC of several changas of mailing addresses which occurred in the later half of 1988. NUREG-0940 11.A-66

3 l i l These violations have been categorized in the aggregate as a Severity Level III j problem. (Supplement VI) Civil Penalty - 51,500 (assessed equally among the six violations). Pursuant to the provisions of 10 CFR 2.201, Pesara Pushpamala Reddy, M.D., (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 1 reasons for the violation _if admitted, (3) the corrective steps that have been i 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, 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 , Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should I the Licensee fail to answer within the time specified, an Order imposing the civil penalty will be. issued. Should the License elect to file an answer in j 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 i 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 factors addressed in Section V.B. of 10 CFR Part 2, Appendix C , should be addressed. Any written answer in accordance with 10 CFR 2.201, 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. NUREG-0940 II.A-67

\ l 4 l l 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. The responses to the Director, Office of Enforcement, noted above (Reply to i a Notice of Violation, letter with payment of civil penalty,. and Answer to a j Notice of Violation) should be addressed to: Director, Office of Enforcement, i 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 I, 475 Allendale Road, King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COMMISSION W William T. Russell i Regional Administrator Dated at King of Prussia, Pennsylvania this X2# day of May 1989

                                                                                                     )

NUREG-0940 II.A-68

v

   /pa nto 'o                               UNITED STATES
              ~g
 !"             n               NUCLEAR REGULATORY COMMISSION
                $                        WASHINGTON, D. C. 20555 k*****/                                   JUN 0 2 29 I

License No. - Ceneral License (10 CFR 31.5) EA 89-62 James River Corporation ATTN: Mr. Benjamin Thorp Senior Vice President Treoegar Street Richmond, Virginia 23219 Gentlemen:

Subject:

1) NOTICE OF VIOLATION AND PROPOSED IliPOSITION OF CIVIL PENALTY - $1250

2) ORDER MODIFYING LICENSE NRC SPECIAL INSPECTION NO. 99990001/89-001)

This letter refers to the NRC inspection conoucted on January 30, 1989, at your factitty in South Hadley, Massachusetts, of activities authorized by an NRC general license unoer 10 CFR Part 31.5. The report of the inspection was for-warded to you on March 8,1989. The inspection was conducted to review the circumstances associated with a violation of NRC requirements, as described in the enclosed Notice of Viol 6 tion, involving the inadvertent cisposal of a static eliminator bar (containing 22.5 mil 11 curies cf americium-241) in an unlicensed landfill, The loss was identified by your staff on October 11, 1966,  ! l and reported to the NRC. On March 21, 1989, we held an enforcement conference with you and members of your staff, during which the viulation identified during I the inspection, its causes, and your corrective actions were discussed. The failure to control licensed material is a significant regu1 story concern, j i particularly in view of the fact that radioactive material from the South  ! I Hadley f acility, as well as frcm otner James River Corporation (JKC) facilities, I has been improperly disposed of in the past. Specifically, in February 1979, i the South Hadley facility lost another static eliminator bar containing radio-active materidl. Further, in October 1984 and again in May 1986,-the NRC issued civil penalties to JRC because of the improper cisposal and/or loss of  ; radioactive materials from your f acilities in Easton, Pennsylvania and Parch-  ; ment, Michigan. However, the corrective actions taken in response to those events were not effective in preventing the loss of the radioactive meterial from the South Hadley facility in October 1988. This loss occurred even though the JRC response, dated Septen.ber 5,1986, to the civil penalty issued as a result of the 1986 violation, stated that JRC was working on a corporate-wide radfation protection program. CERTIFIED FLAIL RElVRii RECEIPT REQUESTED NUREG-0940 II.A-69

i l James River Corporation Furthermore, in a letter dated October 26, 1988, the Safety Manager of the South Hadley, Massachusetts facility made corraitments to the NRC to take certain corrective actions to prevent recurrence of this violation. The actions described included, but were not limited to, proper labeling of all devices containing radioactive material, and improvement of the radiation device control system. However, at tne time of our inspection on January 30, 1969, implementation of several of these commitments had not been completed and the Safety Manager was not fully cognizant of the status of the devices containing radioactive material. l These incidents demonstrate the need for you to develop and implement a comprehensive corporate program for ensuring that adequate oversight and control of generally licensed material is maintained at all of your facilities throughout the country to prevent the loss or improper disposal of such materials in.the future. To emphasize this need, I have decided to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Thousand Two Hundred Fifty Dollars ($1.250) for the violation set forth in the enclosed hotice. This violation has been classified at Severity Level III in accordance with Section C.6 of Supplement IV of the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, , 53 Fed. Reg. 40019 (October 13, 1988) (Enforcement Policy). The base civil penalty for a Severity Level III violation or problem is $500. The escalation and mitigation factors were consioered and the base civil penalty  ! amount has been increased by 150% because: (1) you f611ed to promptly implement the corrective actions set forth in the October 26, 1968 letter to the NRC, which provides the basis for 50% escalation of this penalty; and (2) your corporate  ; enforcement history has not been good, as evidenced by the previous losses of ' licensed material and your continuing inability to prevent recurrence, which provides the basis for an additional 100% escalation of this penalty. While your initial identification and reporting of the improper disposal was prompt, your Safety Manager learned on October 12, 1988 that the device was most probably buried at the sanitary landfill; yet he did r.ot initiate a search of the lenofill until October 17, 1988. This delay lessened any chance of recovery. Therefore, on consideration of the Identification and Reporting factor, neither escalation nor mitigation is warranted. The other escalation and mitigation factors were considered, and no further adjustment is considered appropriate. In aodition to the civil penalty, I have also determined that, in the interest of the public health and safety, the enclosed Order Modifying License should be issued. The Order requires you to a) perform a compliance audit at each facility where NRC-licensed material is usec or stored, and b) develop and implement a corporate-based plan to ensure increased and improved oversight, control and accountability of radioactive material used at your various facilities throughout the country to prevent future loss of radioactive material. While the NRC has set forth in the Order certain minimal elements that shall be incorporated into the plan, it is your responsibility to develop a plan that contains not only these minimal elements, but whatever additional elements are necessary to effectively accomplish the objective of full control of your licensed material at all times. I NUREG-0940 II.A-70

l James River Corporation You are required to respond to the enclosed Order and Notice, and should follow the instructions specified therein when preparing your response to each docurrent. In your response to the Notice, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After review of your responses to the Order and Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further action is needed to ensure compliance with regulatory requirements. i I wish to emphasize that any further recurrence of these. Violations may result in more significant enforcement action, such as suspension or revocation of j your authority uncer the general license (10 CFR 31.5). In accoraance with Section 2.790 of the NRC's " Rules of Pr6ctice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placea in the NRC Public Document Room. The responses directeo by this letter and the enclosed Notice and Order are not subject to the clearance procecures of the Office of Hanogement and Booget as required by the Paperwork Reduction Act of 1980, PL No. 96-511. Sincerely, d , Hugh L. Thompson, , De ty Executive Direc or for { 1:uclear Materials Safe y, Safeguards and Operations Support

Enclosures:

1. Notice of Violation ano Proposed Imposition of Civil Penalty

2. Order Modifying License i

4 i NUREG-0940 11.A-71

l 140TICE OF VIOLATION AND PROPOSED It! POSITION OF CIVIL PENALTY James River Corporation General License Tredegar Street (10 CFR 31.5) Richmond, Virginia 23219 EA 89-62 On Januery 30, 1989, an NRC inspection was conducted at the James River Graphics Group facility in South Hadley, Massachusetts, to review the circumstances associated with the loss of radioactive material from this facility. The loss was reported to the NRC by the licensee. During the inspection, 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, 53 Fed. Reg. 40019 (October 13,1988), the Nuclear Regulatury 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. 2281, and 10 CFR 2.205. The particular violatiun and associated civil penalty is set forth below: 10 CFR 31.5(c)(8) requires that any person who acquires, receives, possesses, uses, or transfers byproduct material ln a device pursuant to a general license shall transfer or dispose of the device containing byproduct material only by transfer to persons holding a specific license pursuant to Parts 30 and 32 of , Title 10, Code of Federal Regulations or from an Agreement State to receive the device. Contrary to the above, between October 4 and October 11, 1988, the licensee disposed of a generally-licensed static eliminator bor containing 22.5 milli- l curies of americium-241, and this transfer or disposal was not made to a person  ! holding a specific license pursuant to Parts 30 and 32 of Title 10 Code of ' Federal regulations or from an Agreement State to receive the device. Specifically, the licensee improperly disposed of the device by transferring it to an unlicensed sanitary landfill. This is a Severity Level III violation. (Supplement IV) Civil Penalty - $1,250 Pursuant to the provisions cf 10 CFR 2.201, James River Corporation (licensee) is hereby required to submit a written statement or explanation to the Director, i 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 incluce for each violation: (1)aamissionordenial of the alleged violation; (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken eno the results achieved, (4) the corrective steps that will be taken to avoid further violation, 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, suspenced, 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-72

l Notice of Violation , i Within the same time as provided for the response required above under l 10 CFR 2.201, the Licensee may pay the civil penalty by letter tc the Director, l j 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 l amount of the civil penalty proposed above, or may protest imposition of the I 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 perialty will be issued. Shculd the Licensee elect to file an ariswer 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 shculd not be imposed. In accition to protesting the civil penalty, such answer may request remissiori or l mitigation of the penalty. ] In requesting mitigation of the proposed penalty, the factors addressed in Section V.B of 10 CFR Part 2, Appendix C, should be adcressed. 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., l citing page anc paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding l the procedure for imposing a civil penalty. I Upon failure to pay any civil penalty due which subsec,uently has been determined in occordance 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 response to the Director, Officer 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. Nucleer Regulatory Commission, ATTN: Document Centrol Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory  ; Commission, Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COWilSSION h Nd r-Hugh L. Thompson, Jr., De ty Executive Director for Nuclear Materials Safety, Safeguards and Operations Support Dated a Rockville, Maryldna thisj ay of June 1989 i NUREG-0940 II.A-73 l

l UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of James P.iver Corporation } General. License Tredegar Street J 10 CFR 31.5 Richmond, Virginia 23219 ) Docket No. 99990001 i

                                              ) EA 89-62 I

ORDER MODIFYING LICENSE I TheJamesRiverCorporation(thelicensee),TredegarStreet, Richmond, Virginia 23219 holds a Nuclear Regulatory Comission ("NRC" or " Commission") general- I license issued pursu6nt to 10 CFR Part 31.5. This general license authorizes possession and use of byproouct material containeo in devices designed and manufactured for the purpose of detecting, measuring, gauging or controlling thickness anc structural integrity of materials in an industrial environment. Under this general license, the licensee operates fifty-one facilities throughout the United States where generally-licensed gauges are used. II On January 30, 1989, the hRC conducted an inspection at the James River Graphics Group, South hadley, Massachusetts, a division of the licensee's corporation, to review the circumstances associated with the loss of a static eliminator bar (static bar) containing 22.5 millicuries of americium-241. The loss occurred on or of ter October 4,1988. The licensee discovered and reported the loss to the NRC on October 11, 1988. The loss occurred when NUREG-0940 II.A-74

                                                                                             )

contractor personnel, who were dismantling a paper-coating machine for disposal, failed to remove one of three static bars mounted on the machine. As a result, a static bar containing the radioactive material was inadvertently transferred with the coating machine to an unlicensed waste disposal firm and was subsequently buried at an unlicensed commercial landfill. This improper disposal constitutes a violation of NRC requirements as described in the Notice of Violation and Proposed Imposition of Civil Penalty issued on this date. In a letter dated October 26, 1988, the Safety Manager of the South Hadley facility made certain commitments regarding corrective actions to prevent future loss of licensed material from that facility. At the time of the January 30, 1989 inspection, several of these connitments had not been fully implemented. Specifically, not all raaivactive devices were properly labelled 4 to indicate they contained radioactive material; a new " altered equipment and process safety checklist" had not been estabitshed; and the monthly safety audit program did not contain the necessary elements designed to detect and correct improper control and disposition of radioactive material. Furthermore, during a plant tour at the time of the inspection, the Safety Manager was unaware of the status of an Ohmart gauge which was marked as containing radio-active material, but which was'not on the licensee's current inventory. It was later determined that the radioactive source had been removed from the Ohmart , i gauge and transferred to an authorized recipient in 1981. NUREG-0940 II.A-75

I 1 1

                                                                                      )

f J III NRC has serious concerns about the most recent improper disposal of radioactive material frcm the South Hacley, Massachusetts facility because this is the 1 i fourth incident since 1979 in which facilities owned by the licensee have improperly dispcsed of radioactive material. i j i 1 On May 27, 1986, the NRC Region III office conducted an inspection at the licensee's facility in Parchment, Michigan to review the circumstances sur-rounding the loss of an industrial gauge containing a 250 millicurie krypton-85 source. The inspection disclosed that the gauge was removed from service in July 1984, and was presumeo to have been placed in storage at the Parchment facility. However, when the licensce issued a purchase order to an authorized licensee in February 1986 in an effort to dispose of the gauge, the gauge was mis sir.g. Between July 1984, and May 27, 1986, the licensee had no bona fide inventory recora of the location of the gauge, since audit records reflecting that the gauge was in storage were based on oral statements from unidentified licensee representatives and not on visual inspection. The licensee has never located that source and presumes it has been improperly transferred and/or lost. I On October 15, 1984, NRC Region I conducted an inspection at the licensee's facility in Easton, Pennsylvania to review the circumstances surrounding the loss of an industrial gauge centaining 55 millicuries of strontium-90. The inspection. disclosed that sometime after April 27, 1984, the gauge was inadver-tently disposed of. Apparently, it was buried in an unlicensed sanitary landfill after the licensee failed to return the gauge to its proper storage NUREG-0940 II.A-76

1 location following the performance of a leak test. The licensee did not discover the gauge was missing until August 1984. ] Previcusly, on August 15, 1979, the licensee notified the NRC that a static eliminator bar containing radioactive material was lost from the South Hadley, I Massachusetts facility. All efforts to locate the static bar were unsuccessful ] and it was never recovered. Civil penalties of $250 and $500, respectively, were issued for the losses of 11censeo naterial in 1984 and 1986. In the licensee's September 5, 1986 response to the civil penalty issued 'for the 1986 loss o"f material from the Perchment, Michigan f acility, the licensee committed itself to develop a corporate radiation protection program to prevent the recurrence of loss of radioactive j material from its various facilities. However, the licensee's actions were not effective in preventing the loss of licensed material from the South Hadley, Massachusetts facility in October,1988. i IV The licensee's continued failure to naintain sufficient control of radioactive materials, resulting in the loss of generally-licensed material at the various licensee facilities, raises significant questions regarding the adequacy of oversight of these gauges by corporate management. Furthernere, although  ; i commitments were made to improve control of radioactive materials, the  ; commitments described in the licensee's October 26, 1980, and September 5, 1986 r letters in response to the losses at South Hadley and Parchment were not fully NUREG-0940 11.A-77 i

l implemented. Of particular concern to the NRC is the licensee's failure, following its Septenter 5,1986 comitment, to develop a corporate radiation protection program capable of preventing the October 1988 loss of licensed material. Accordingly, without additional requirements, there is a substantial question as to whether these materials will be adequately controlled. There-fore, I have determined that the public health and safety require that the licensee's general license (10 CFR 31.5) be modified by supplementing the license. V Accordingly, pursuant to Sections 81, 161b, 1611 and 161o of the Atomic Energy Act of 1954, as amended, and the Commission regulations in 10 CFR Part 2.204 and Part 31, IT 15 HEREBY ORDERED THAT: A. Upon approval of the Regional Administrator as specified in V.B. below, the licensee, supplemented as necessary by a outlified consultant, shall l conduct an on-site audit and prepare an audit report for each facility owned by the licensee where NRC-licensed material is used or stored. A written report of each audit shall:

1. Cover the previous 24 nonths of operation at each f acility.

2. Specifically address each requirement in 10 CFR 31.5(c)(1) through (c)(10), as well us each comitment made by the licensee in prior NUREG-0940 11.A-78

                                                                                       )

letters to NRC describing corrective action ,incluaing letters dated , March 25,1985 (Easton, PA facility), Septesber 5,1986 (Parchaent, MI facility), and October 26, 1988 (South Hadley, NA facility). 4

3. Describe a) the means or methoc that the facility is using to comply with each requirement in 10 CFR 31.5 and commitment referenced in 1

V.A.2. above; b) any deviation from,-or violation of, each requirement / consnitment; c) any other weaknesses identified during the audit; and d) reconsnendations to address past violations and weaknesses.

4. Be submitted to the Regional Adeninistrator, NRC Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406.

B. Within 60 days of the effective date of this Order, the licensee shall submit to the Regional Administrator, NRC Region I, for approval, 1) an j overall plan to conduct the required audits and 2) the qualifications, including the names and resuses, of the employees and any outside con-sultants who will perfor1n the audits. C. Within 120 days of the approval of the Regional Administrator as specified , in V.B. above, the licensee shall assure that all audits are completed l ano that all audit reports have been forwarded to the Regional-Administrator as specified abcVe. NUREG-0940 II.A-79

i i D. Within 30 days of the submission of all audit reports to the Regional  ! Administrator as specified in V.C. above, the licensee shall have developed and shall submic to the Regional Administrator, NRC Region I, for approval, a corporate plan to ensure that the licensee's facilities l meet all requirements of 10 CFR 31.5 as well as commitments made to NRC in letters describing corrective action, and to ensure that NRC-licensed materials are adequately controlled and disposed of only in an authorized manner. The plan shall be developed and managed at the corporate level and shall identify, by position, an individual at each facility with the appropriate level of authority who will implement the plan. The plan shall include, but not be limited to: I l

1. Establishment of a system to a) identify the locations of nuclear I gauges and the number of gauges present, b) distinguish these gauges from other plant equipment wherever they are used or stored, and c) provide the name and phone number (s) of a designated, knowledgeable employee (such as the Radiation Protection Officer) who will serve as a contact. The system of identification should be sufficient to alert workers to the presence of devices containing radioactive material and to prevent the inadvertent hanoling, servicing, dismantling, removal, or disposal of such devices.

2. Requirement for the physical presence and direct supervision of a cesignated, knowledgeable employee (such as the Radiation protection Officer)wheneveractivitiesspecifiedin10CFR31.5(c)(3)are carried out.

NUREG-0940 II.A-80

3. Establishment of a ~ systeniatic corporate-based inventory, compliance audit, and reporting system with methods and frequency appropriate for the scope of the licensee's nuclear materials program and history

                                            ~

of past problems involving these materials. 4 Establishment of a plan at each facility for securing nuclear

                                 ~

gauges that are not instelled in equipment and restricting access to such gauges to a designated, knowledgeable employee (such as the RadiationProtectionOfficer). 9

5. Establishment of a specific milestone schedule for initial implementation of the various aspects of the plan.

D. Within 7 days of the Regional Administrator's approval-of the plan, the licensee shall implement the plan in accordance with the established milestone schedule. The Regional Administrator, NRC Region I, may, in writing, relax or rescind  ; any of these provisions for good cause shown. I VI  ; l The licensee or any other person whose interest is adversely affected by this l Order may request a hearing within twenty days of its issuance. Any request  ; for a hearing shall be addressed to the Director, Of fice of Enforcement, U.S. , l Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington D.C. 20555, NUREG-0940 II.A-81 i i

with a copy to the Assistant General Counsel for Hearings and Enforcement. Office of the General Counsel, at the same address, and to the Regional Administrator, NRC Region I, 475 Allendale Rcad, King of Prussia, Pennsylvania, 19406. If a person other than the licensee requests a hearing, that person shall set forth with particularity the manner in which the petitioner's interest is adversely affected by this Order and should adcress the criteria set forth in 10 CFR 2.714(d). Upon failure of the licensee or any person adversely affected by this Order to request a hearing within the specified tirne, this Order shall be final without further proceedings. If a hearing is requested by the licensee or a person whose interest is edversely affected, the Commission will issue an Order designating the time ano place of any hearing. If a hearing is held, the issue to be considered at such a hearing shall be whether this Order should be sustainea. FOR THE NUCLEAR REGULATORY COMMISSION 4/I Hugh L. Thompso r De ty Executive 01 tor for Nuclear Materials Safety, Safeguaras, and Operations Support Dated g Rockville, Maryland thit,f day of June 1989 I l NUREG-0940 l II.A-82 ' i

James River Corporation cc w/ encl: John C. Cuthbertson, Director, Environinental Affairs Alfred DiLascia, Vice President and Executive General Manager, South Hadley facility Public Document Room (PDR) fluclear Safety Inforrnation Center (NSIC) State of Alabena State of California State of Delaware State of Georgia State of Illinois State of Indiena State of Iowa i State of Louisiana j State of Maine Commonwealth of Massachusetts State of Michigan State of Mississippi State of Missouri State of New Hampshire State of New Jersey State of New York State of Ohio State of Oregon State of Pennsylvania State of South Carolina State of Tennessee State of Texas Coninonwealth of Virginia State of Washington State of Wisconsin l 1 l l l NUREG-0940 II.A-83 l

                                          /                      %,                              UNs1[D sf ATE s j ,i ;, ;                                         NUCLEAR REGULATORY COMMISSION REGION I g
                                            % ' %.*        g/

t 475 ALLENDALE ROAD 1 KING OF PRUsslA, PENNSYLVANIA 19406 - February 2, 1989 Docket No. 030-03196 , License No. 37-13651-01 ' EA 88-298 St. Agnes Medical Center ATIN: Sister M. Clarence, O.S.F. President 1900 South Broad Street Philadelphia, Pennsylvania 19145

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY l (NRC Inspection No. 30-03196/88-01) i 1

This letter refers to the NRC inspection conducted on August 10 and November 2, j 1988 at St. Agnes Medical Center of activities authorized by NRC License No. l 37-13651-01. During the inspection, the report of which was sent to you on December 6,1988, violations of NRC requirements were identified. On December 13, 1988, an enforcement conference was held in the Region I office 3 with Mr. Thomas P. Callaghan and other members of your staff to discuss the l violations, their underlying causes and your corrective actions. 1 The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty, involved

(1) failure to perform ,

required constancy checks of the dose calibrator prior to its use on two  ! occasions; (2) failure to perform three different types of required surveys j at your facility; and (3) use of the dose calibrator to assay patient doses ' af ter a linearity test of the instrument indicated erroneous responses. The three examples of failure to perform required surveys, although initially i identified by your staf f, are of particular concern to the NRC because the ' failure to perform required surveys, or maintain records of such surveys, had been identified during previous NRC inspections in 1984 and 1987; however, actions taken to correct those violations were not effective in preventing i recurrence of the violations. l The NRC recognizes that the significance of the individual violations is low because they involved surveys and procedures which were routinely performed, but, at times, were not done at the required frequencies. Nonetheless, the NRC is concerned that three of these violations are repeats of violations identified during previous inspections, and that there have been, multiple occurrences of violations. Furthermore, the NRC is concerned regarding (1) the apparent loss or theft of four radioactive sources from'a secured area, (2) the discrepancies of certain records, and (3) the loss or theft of required records from a secured area, including those that contained discre-pancies. The NRC has not obtained sufficient evidence to substantiate that these occurrences represent violations of NRC requirements. These violations NUREG-0940 II.A-84

St. Agnes Medical Center 2 and concerns, however, demonstrate that the Radiation Safety Officer, the Radja, tion Safety Committee, and the Medical Center management have not provided appropriate management attention to, and control of, activities authorized by the license to ensure activities are conducted safely and in accordance with the terms of the license. The NRC recognizes that (1) you have made or planned organizational changes, including the hiring of both a new Medical Director and a new Administrator for the Radiology Department, as well as a proposal to change the Radiation Safety Officer; and (2) the individuals most likely responsible for the violations and the discrepancies of certain records are no longer employed by your facility. Nonetheless, to emphasize the importance of increased and improved management attention to activities authorized by your license, I have been authorized, after consultation with the Director of Enforcement and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Two Thousand Five Hundred Dollars (52,500) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) .(Enforcement Policy), the violations are classified in the aggregate as a Severity Level III problem to focus on the underlying cause, namely, a lack of adequate management control of the licensed program. The base civil penalty amount for a Severity Level III violation or problem is $2,500. The escalation and mitigation factors in the Enforcement Policy were considered and no adjust-ment has been deemed appropriate. { In addition to the civil penalty, the management of St. Agnes Medical Center, and its employees, should be aware that any inaccuracy in recordkeeping and violations of NRC requirements, in the future, may result in more significant enforcement actions. You are required to respond to this letter and the enclosed Notice and you should follow the instructions specified in the enclosed 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. Further, you should describe in detail the specific actions taken to improve control of licensed activities, in particular, the actions planned to ensure that (1) the Radiation Safety Officer, Radiation Safety Committee, and Medical Center management exercise increased and improved , control and oversight of licensed activities, and (2) personnel are properly and periodically instructed concerning license requirements, and are held , accountable whenever violations of NRC requirements occur. After reviewing your response. including your proposed corrective actions and the results of future inspections, the NRC will determine whether further enforcement action is necessary to ensure compliance with NRC regulatory  ; requirements. Furthermore, you should be aware that any additional recurrence .l of these violations may result in additional enforcement action.  ! 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 l Notice will be placed in the NRC's Public Document Room. NUREG-0940 II.A-85

St. Agnes Medical Center 3 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, William T. Russell I Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty l , cc w/ enc 1: Public Document Room (PDR) Nuclear Safety Information Center (NSIC) Commonwealth of Pennsylvania t, b 6 l l l NUREG-0940 II.A-86

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY St. Agnes Medical Center Docket No. 030-03196 Philadelphia, Pennsylvania License No. 37-13651-01 EA 88-298 During an NRC inspection conducted on August 10, 1988 and November 2, 1988, violations of NRC requirements were identified. In accordance with the

" General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:

A.10 CFR 35.50(b)(1) requires that licensees check each dose calibrator for contancy at the beginning of each day of use. Condition 15 of License No. 37-13651-01 requires that the licensee possess and use licensed radioactive naterial in accordance with the statements, representations, and procedures contained in the radioactive material license application dated December 31, 1985, and in letters dated September 19, 1986, October 31, 1986, and October 24, 1980. Item 10 of the application dated December 31, 1985, Section I, page 3 requires that the dose calibrator be tested for constancy on each day that the instrument is used for the assay of radiopharmaceuticais. Contrary to the above, on August 2 and 3,1988, the dose calibrator was used for the assay of radiopharmaceuticals which were subsequently administered to patients, and the dose calibrator was not tested for constancy at the beginning of each day. B.10 CFR 35.70(a) requires that licensees survey with a radiation detection survey instrument at the end of each day of use all areas where radiophar-maceuticals are routinely prepared for use or administered. Condition 15 of License No. 37-13651-01 requires that the licensee possess and use licensed radioactive material in accordance with the statements, representations, and procedures contained in the radioactive material license application dated December 31, 1985, and in letters dated September 19, 1986, October 31, 1986, and October 24, 1988. Item 17.A of the application dated December 31, 1985, requires that all radiopharmaceutical preparation and elution areas be surveyed daily. Contrary to the above, between July 18 and July 29, 1988, the radiopharma- ' ceutical preparation, use, and, administration areas were not surveyed. This is a repeat violation. NUREG-0940 II.A-87

k Appendix A 2 C. 10 CFR 35.70(b) requires that licensees survey with a radiation detection survey instrument at least once a week all areas where radiopharmaceuticals or radiopharmaceutical waste is stored. i 10 CFR 35.70(e) requires that licensees survey for removable contamination i once each week. all areas where radiopharmaceuticals are routinely prepared j for use, administered, or stored. Condition 15 of License No. 37-13651-01 requires that the licensee possess and use licensed radioactive material in accordance with the statements, representations, and procedures contained in the radioactive material license application dated December 31, 1985, and in letters dated , September 19, 1986, October 31, 1986, and October 24, 1988. " Item 17.C of the application dated December 31, 1985, requires that areas in which licensed radioactive material, other than where any quantities less than 200 mircrocuries are used, be surveyed weehly. Contrary to the above, between July 17 and July 30, 1988, areas in which licensed radioactive material, in quantities greater than 200 microcuries were used, were not surveyed. This is a repeat violation. . D. Condition 15 of License No. 37-13651-01 requires that the licensee possess and use licensed radioactive material in accordance with the statements, representettons, and procedures contained in the radioactive material license j appitcation dated December 31, 1985, and in letters dated September 19, 1986, ' October 31, 1986, and October 24, 1988. i 1

1. Item 14 of the application dated December 31, 1985, requires that each {

incoming package containing radioactive material be surveyed as soon as  ! practicable after receipt. Contrary to the above, between July 18 and July 29, 1988, incoming packages containing radioactive material were not surveyed as soon as practicable after receipt. This is a repeat violation. Item 10 of the application dated December 31, 1985, Section IV, 2. rcquires that a test for instrument linearity be performed quarterly. If a deviation of greater than 15 percent is found betwee'n the instru-ment reading and the decay corrected value at any point on the range of administered values, the instrument will be repaired. Contrary to the above, on August 8-10, 1988, the results of a linearity test of tne dose calibrator indicated a deviation of greater than i 5 percent between the instrument reading and the decay corrected value at NUREG-0940 11..A-88

l Appendix A 3 l certain points on the range of administered values. The instrument was ) not repaired and the licensee continued to use the instrument to assay 1 patient doses until mid-September, 1988. I These violations have been categorized in the aggregate as a Severity Level III problem. (Supplement VI) Cumulative Civil penalty - 52,500 (assessed equally among the violations) Pursuant to the provisions of 10 CFR 2.201, St. Agnes Medical Center (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 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 l 2.201, the Licensee may pay the civil penalty by letter to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draf t, or money order payable to the Treasurer of the United States in the amount of the l 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, Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the 1 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 shotid 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 l protesting the civil penalty, such answer may request remission or mitigation l of the penalty. In requesting mitigation of the proposed penalty, the six factors addressed in Section V.B of 10 CFR part 2, Appendix C (1988), should be addressed. Any  ! written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may  ; incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g. citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. l NUREG-0940 II.A-89

Appendix A 4 j l Upon failure to pay any civil penalty due which' subsequently has been deter- f mined in accordance with the appliceble provisions'of 10 CFR 2.205, this matter 1 may be referred to the Attorney General, and the penalty, unless compromised, ) remitted, or mitigated,' may be collected by civil action pursuar.t 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, J 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 I, 475 Allendale Road, King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COMMISSION hN William T. Russell. . Regional Administrator Dated at King of Prussia, Pennsylvania - tnis ghdday of February 1989 3 l 1 i NUREG-0940 II.A-90

I

                     'g                                                    UMTs0 STATES
            !          c                                         NUCLEAR REGULATORY COMMISSION 3           p                                               m e inerow.o.c.nemes g.....j                                                        APR 101989 Docket No. 030-03196 License No. 37-13651-01 W

St. Agnes Medical Center , I ATTN: Sister M. Clarence. 0.5.F. i President 1900 South Broad Street Philadelphia, Pennsylvania 19145 J

Subject:

ORDER IMPOSING A CIVIL MONETARY PENALTY This letter refers to your letter cated February 23, 1989, in response to the . Notice of Violation and Proposed Imposition of Civil Penalty (Notice) sent to . you with our letter cated February 2,1989. Our letter and Notice described l violationsidentifiedduringNRCInspectionNo.88-01,conductedonAugust1p and November 2, 1988. The violations were classified in the aggregate as a Severity Level III problem and a civil penalty in the amount of $2,500 was proposed to emphasize the need for increased management control of licensed activities. The base civil penalty amount for a Severity Level 111 violation i or problem is $2,500. The escalation and mitigation factors in the I Enforcement Policy were considereo and no adjustment was deemed appropriate. In your response to the Notice, you dio not deny the occurrence of the cited violations. However, you request that the civil penalty be mitigated or j waived in its entirety for reasons described in your response. After careful  ; consideration of your response, we have concluded, for the reasons given in i the Appendix attached to the enclosed Order Imposing Civil Monetary Penalty, that mitigation of the amount of the civil penalty is inappropriate. Accor- ' dingly, we hereby serve the enclosed Order on St. Agnes Medical Center imposing a civil monetary penalty in the amount of Two Thousand Five Hundred Dollars. You are required to respond to the enclosed Order, and you should follow the instructions specified therein when preparing your response. Furthermore, your letter, dated February 23, 1989, in reply to the Notice of Ytolation does not set forth the actions taken to correct the violations and to prevent recurrence nor does it describe the action you have taken to improve control of licensed activities, as requested in our letter dated February 2,1989. In order for the NRC to evaluate the adequacy of your corrective actions, you are required to submit, in response to this letter, the specific actions taken or planned to improve control of your licensed activities. As previously stated in our letter dated February 2,1989 ou should address with partic-ularity the actions planned to ensure that [1 the Radiation Safety Officer, and Medical Center mana ement exercise increased Radiation and improved Safety Committee oversight of $1 censed activities, and 2) personnel are properly and periodically instructed concerning license requirements, and are held I accountable whenever violations of NRC requirements occur. Failure to provide this response within thirty days of this letter may result in additional enforcement action. NUREG-0940 II.A-91

APR 101989 i St Agnes Medical Center ' The responses directed by this letter and the enclosed 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. 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 Document Room. Sincerely. O og Dt F L. Thompson J r. ty Executive Director for Material Safety, Safeguards v' and Operations Support

Enclosures:

1. Order Imposing Civil Monetary Penalty 1

2. Appendix - Evaluation and Conclusion cc w/encis:

PublicDocumentRoom(PDR) Nuclear Safety Information Center (NSIC) Commonwealth of Pennsylvania l l NUREG-0940 II.A-92

1 UNITED STATES NUCLEAR REGULATORY COPPISSION In the Matter of ST. AGNES MEDICAL CENTER Docket No. 030-03196 Philadelphia, Pennsylvania License No. 37-13651-01 EA 88-298 ORDER IMPOSING CIVIL MONETARY PENALTY I St. Agnes Medical Center, Philadelphia, Pennsylvania 19145 (the " licensee") is the holder of License No. 37-13651-01 (the " license") issued by the Nuclear Regulatory Commission (the "Comunission" or "NRC") which authorizes the medical use of byproduct material by the licensee. The license was issued on May 14, 1970, was most recently renewed on December 9,1986, and is due to expire on November 30, 1991. II An NRC safety inspection of the licensee's activities under the license was conducted on August 10 and November 2, 1988. During the inspection, the NRC i staff determined that the licensee had not conducted its activities in full j

 ,compliante with NRC requirements. A written Notice of Violation and Proposed Iniposition of Civil Penalty (Notice) was served upon the licensee by letter     l dated February 2,1989. The Notice states thc nature of the violations, the       ,

provisions of the Nuclear Regulatory Commission's requirements that the licensee had violated, and the civil penalty amount for each of the violations. A response, dated February 23, 1989, to the Notice was received from the licensee. In its response, the licensee did not deny the violations, but requested mitigation or waiver of the civil penalty. i NUREG-0940 II.A-93

III l Upon consideration of the answer received, the statement of facts, explanations, and argument for remission or mitigation of the proposed civil penalty contained therein, and as set forth in the Appendix to this Order, the Deputy Executive Director for Materials Safety, Safeguards and Operations Support has determined that the penalty proposed for the violations 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 1954, as amended (42 U.S.C. 2282, P1 96-295), and 10 CFR 2.205, IT IS HEREBY ORDERED THAT: The licensee pay a civil penalty in the amount of Two Thousand Five l Hundred Dollars ($2,500) within thirty cays of the cate of this Order, by check, draft, or money order, payable to the Treasurer of the United  ; i States and mailed to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washtngton, D.C. 20555. V The licensee may, within thirty days of the date of this order, request a hearing. A request for a hearing shall be clearly marked as a " Request for Hearing" and NUREG-0940 11.A-94

shall'ife addressed to the U.S. Nuclear Regulatory Commission, ATTN: Document i Control Desk, Washington, DC 20555, with a copy to the Assistant General Counsel for Enforcement, Office of the General Counsel, U.S. Nuclear Regulatory Cosmission, Washington, DC 20555 and the Regional Administrator, USNRC Region I, 471 Allendale Road, King of Prussia, Pennsylvania 19406. If a hearing is requested, the Cosmission will issue an Order designating the time and place of the hearing. If the licensee fails to request a hearing within thirty days 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. i In the event the licensee requests a hearing as provided above, the issue to be 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 II above, and l (b) whether, on the basis of the violations, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION Hu L. Thompson, Jr. , De ty Executive Dire or  ! for Material Safety, Safeguards _ and Operations Support l Dated at Rockville, Maryland  ; this 10 h day of April 1989 l I NUREG-0940 11.A-95 j

                                                   ._                                                        ~

APPENDIX . EVALUATION AND CONCLUSION On February 2,1989, a Notice of Violation and Proposed Imposition of Civil Penalty was issued for violations of a license issued to St. Agnes Medical Center. The licensee responded to the Notice on February 23, 1989, did not i deny the violations, but requested waiver or mitigation of the Civil Penalty. The NRC's evaluation and conclustion regarding the licensee's response are as follows: I. Restatement of Violations l l A. 10 CFR 35.50(b)(1) requires that licensees check each dose calibrator for constancy at the beginning of each day of use. Condition 15 of License No. 37-13651-01 requires that the licensee l possess and use licensed radioactive material in accordance with the statements, representations, and procedures contained in the radioactive material license application dated December 31, 1985, and in letters dated September 19, 1986, October 31, 1986, and October 24, 1988. a Item 10 of the application dated December 31, 1985, Section I, page 3 requires that the dose calibrator be tested for constancy on each day that the instrument is used for the assay of radiopharmaceuticals. Contrary to the above, on August 2 and 3,1988, the dose calibrator was used for the assay of radiopharmaceuticals which were subsequently administered to patients', ano the dose calibrator was not tested for constancy at the beginning of each day. B. 10 CFR 35.70(a) requires that licensees survey with a radiation detection survey instrument at the end of each day of use all areas ] where radiopharmaceuticals are routinely prep 5 red for use or  ! administered. Condition 15 of License No. 37-13651-01 requires that the licensee possess and use licensed radioactive material in accordance with the statements, representations, ano procedures contained in the radioac-l tive material license application dated December 31, 1985, and in letters dated September 19, 1986, October 31, 1986, and October 24, 1988. Item 17.A of the application dated December 31, 1985, requires that all radiopharmaceutical preparation and elution areas be surveyed daily. Contrary to the above, between July 18 and July 29, 1988, the radiopharmaceutical preparation, use, and administration areas were not surveyed. This is a repeat violation. NUREG-0940 II.A-96

1 Appendix  ! C. 10 CFR 35.70(b) requires that licensees survey with a radiation detection survey instrument at least once a week all areas where radiopharmaceuticals or radiopharmaceutical waste is stored. 10 CFR 35.70(e) requires that licensees survey for removable contamination once each week all areas where radiopharmaceuticals are routinely prepared for use, administered, or stored. Condition 15 of License No. 37-13651-01 requires that the licensee l possess and use licensed radioactive material in accordance with the l statements, representations, and procedures contained in the l radioactive material license application dated December 31, 1985, and in letters dated September 19, 1986, October 31, 1986, and October 24, 1988. Item 17.C of the application dated December 31, 1985, requires that areas in which licensed radioactive material, other than where any i quantities less than 200 aircrocuries are used, be surveyed weekly.

                                                                                                  ]

I Contrary to the above, between July 17 and July 30, 1988, areas in which licensed radioactive material, in quantities greater than 200 microcuries were used, were not surveyed. I This is a repeat violation. D. Condition 15 of License No. 37-13651-01 requires that the licensee possess and use licensed radioactive material in accordance with the statements, representations, and procedures contained in the radio-active material license application dated December 31, 1985, and in letters dated September 19, 1986, October 31, 1986, and October 24, 1988.

1. Item 14 of the application datec December 31, 1985, requires that each incoming package containing radioactive material be surveyed as soon as practicable after receipt.  !

Contrary to the above, between July 18 and July 29, 1968, incoming packages containing radioactive material were not surveyeo as soon ; as practicable after receipt. This is a repeat violation.

2. Item 10 of the application dated December 31, 1985, Section IV, requires that a test for instrument linearity be performed quarterly. If a deviation of greater than :t5 percent is found between the instrument reading and the decay corrected value at any point on the range of administered values, the instrument will be repaired.

Contrary to the above, on August 8-10, 1988, the results of a linearity test of the dose calibrator indicated a deviation of greater than i 5 percent between the instrument reading and the decay corrected value at certain points on the range of administered values. The instrument was not repaired and the NUREG-0940 II.A-97

Appendix licensee continued to use the instrument to assay patient doses until mid-September,1988. These violations have been categorized in the aggregate as a Severity Level III Problem. (SupplementVI) Cumulative Penalty - $2,500 (assessed equally among the violations) II. Summary of Licensee Response The licensee, in its response, did not deny the occurrence of the violations. However, the licensee requests that the NRC waive or mitigate the $2,500 civil penalty because the problems were first identified and corrected by them, were not willful, and current performance is consistent with license conditions. The licensee sets forth additional circumstances it feels are relevant to support mitigation of the civil penalty, including: .(1) the technolo involved'in the violations is no longer employed by the licensee; (2) gist there was a lack of connunication between the licensee and its consultant; and (3) the Radiology Administrator position was vacant at the time of the violations. III. NRC Evaluation of Licensee Response The licensee's identification and correction of a violation may provide' a basis for at least partial mitigation of the civil penalty. However, these considerations were offset by the fact that certain of the viola-tions were identified in previous NRC inspections in 1984.and again in 1987 and the corrective actions 'taken to prevent recurrence were not effective. In addition, the licensee submitted no information regarding the corrective actions taken or planned to permit an evaluation of their adequacy. Further, while the existence of a willful violation may result in an increase in the severity level ano consequent escalation of a civil penalty, the fact that a violation was not willful does not form a basis for mitigation. Finally, since compliance with all license conditions and regulatory requirements is expected at all- times, the licensee's current compliance with regulatory requirements is not a basis for mitigation of the civil penalty. The repetitive nature of certain of the violations, as identified above, is reflective of a programmatic problem in the licensee's management and control of its licensed' activities. Therefore, even though the technolo-gist involved in the violations is no longer employed by the licensee, that tact does not warrant mitigation'of the civil penalty. Furthermore, rather than providing a basis for mitigation, the communication problem between the l licensee and its consultant and the vacancy in the Radiology Administrator's ' position is merely additional' evidence that the licensee failed to maintain an adequate program to ensure that licensed activities were carried out in-conformance with license conditions and regulatory requirements. NUREG-0940 II.A-98

l l Appendix 1 j IV. NRC Conclusion J The licensee did not provide a sufficient oasis for mitigation of the amount of the civil penalty. Therefore, the NRC concludes the proposed civil penalty in the amount of $2,500 should be imposed. J

                                                                                                                                           \

I l NUREG-0940 II.A-99

i l 1 j a nse g UselTED STATES j k NUCLEAR REGULATORY COMMISSION j

 .[.

3 stoscas ses too moosavste moao i stam stovm. stumoes se:37

        .....                                March 16, 1989                          I I

l Docket No. 030-14027 l License No. 13-18677-01 l i EA 89-20 j l l St. Joseph's Hospital ATTN: Sister Jeanne Roach Leland Heights Huntingburg, Indiana 47542

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 030-14027/89001[0RSS]) l This refers to the NRC inspection conducted on January 19, 1989, at St. Joseph's Hospital of activities authorized by NRC License No. 13-18677-01. l The report of the inspection was sent to you February 1, 1989. During the inspection, violations of NRC requirements were identified by our inspector. On February 7, 1989, an enforcement conference was conducted in the NRC Region III office with you and other members of your staff to discuss the violations, their causes, and your corrective actions. The violations, which were identified during the January 19, 1989 inspection and are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), include: (1) use of licensed material by individuals who were not authorized, (2) failure of your Radiation Safety Committee to meet l and to review the radiation safety program as required, (3) failure to check  ! and test the dose calibrator for significant periods of time, (4) failure to i measure the ventilation rates in areas where radioactive gases are used, ' (5) failure to perform radiation surveys as required, (6) failure to: control licensed material in an unrestircted area, and (7) failure to calibrate i radiation survey instruments as required. l Although no violations were identified during the last previous inspection in l June 1984, six violations were identified during the June 1980 inspection and i it should be noted that three of those six violations were again identified during the January 19, 1989 inspection. In response to the violations . identified in June 1980, St. Joseph's Hospital employed a consultant who visited the hospital and conducted an audit on a regular basis until 1984, at which time the audits were discontinued. Subsequently, there was a significant breakdown in management oversight and control over the radiation safety program. By the time the January 19, 1989 inspection was conducted, numerous deficiencies existed in the nuclear medicine program. Based on an evaluation of those violations, the NRC has concluded that increased and effective involvement by the Radiation Safety Committee and the Administrator is needed to ensure that this licensed program is properly NUREG-0940 II.A-100

1 St. Joseph's Hospital 2 March 16. 1989 implemented. The Radiation Safety Committee needs to be more aggressive in its audit and review program and must ensure that deficiencies, when they exist, are promptly identified and effectively corrected. To emphasize the importance of ensuring that in the future you will exercise greater control over all HRC licensed activities, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Material Safety, Safeguards, and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Two Thousand Five Hundred Dollars ($2,500) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violations described in the enclosed Notice have been categorized as Severity Level III. The base value of a civil penalty for a Severity Level III violation is $2,500. 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. Further, you should describe in I detail your plans for performing an assessment of your radiation protection I program, particularly with regard to procedures, training, and improvements in supervisory oversight of radiological control activities. 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, 1 8 h a. d_c , S . N & h.BertDavis Regional Administrator

Enclosures:

1. Notice of Violation and Proposed Imposition of Civil Penalty

2. Inspection Report No. 030-14027/89001(DRSS)

NUREG-0940 1I.A-101

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY i l St. Joseph's Hospital ) Docket No. 030-14027 j Huntingburg, Indiana License No. 13-18677-01 J EA 89-20 During an inspection conducted on January 19, 1989, violations of NRC requirements were identified. In accordance with the

• General Statement of Policy and Proceoure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), 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 the associated civil penalty are set forth below: A. License Condition No.12 requires that licensed material be used by, or i under the supervision of, two specifically named physicians.  ! Contrary to the above, during the period December 19, 1988 through January 19, 1989, licensed material was routinely used~by an individual in the Nuclear Medicine Department who was not a specifically named physician or under the supervision of the two named physicians. B. 10 CFR 35.22(a)(2) requires that the Radiation Safety Committee meet at least quarterly. 10 CFR 35.22(b)(6) requires that the Committee review annually, with the assistance of the Radiation Safety Officer, the radiation safety program. t Contrary to the above, the licensee's Radiation Safety Committee did not meet between 6 approximately August 1986 and January 19, 1989 and did not review the radiation safety program in 1987 and 1988. C. 10 CFR 35.50(b) requires that a licensee: (1) check each dose calibrator for constancy at the beginning of each day of use; (2) test each dose calibrator for accuracy upon installation and at least annually thereafter; and (3) test each dose calibrator for linearity upon installation and at i least quarterly thereafter. Contrary to the above, a Capintec CRC-5 dose calibrator used by the j licensee to measure the amount of activity administered to each patient i was not checked and tested as required. Specifically: '

1. Constancy checks were not performed each day of use between approximately February 1988 and January 19, 1989.

2. Accuracy tests were not pecformed between approximately July 1983 and January 19, 1989.

3. Linearity tests were not performed between approximately September 1984 and January 19, 1989.

NUREG-0940 II.A-102

Notice of-Violation 2 I D. 10 CFR 35.205(e) requires that a licensee measure the ventilation rates available in areas of radioactive gas use each six n.onths. Contrary to the above, ventilation rates in the nuclear medicine hot laboratory and imaging room where xenon-133 gas is administered were not measured between approximately Octaber 1984 and January 19, 1989. E. 10 CFR 35.70(a) requires that a licensee survey with a radiation detection survey instrument, at the end of each day of use, all areas where radiopharmaceuticals are routinely prepared for use or administered. 1 10 CFR 35.70(b) requires that a licensee survey with a radiation detection survey instrument at least once each week all areas where radiopharma-ceuticals or radiopharmaceutical waste is stored. 10 CFR 35.70(e) requires that a licensee survey for removable contamination, once each week, all areas where radiopharmaceuticals are routinely prepared for use, administered, or stored. Contrary to the above, radiation surveys of areas where radiopharmaceuticals are routinely prepared for use or administered were not performed each day of use from approximately April 1988 to January 19, 1989. Radiation surveys of areas where radiopharmaceuticals or radiopharmaceutical waste is stored were not performed at least once each week from approximately April 1988 to January 19, 1989. Removable contamination surveys of areas where radiopharmaceuticals are routinely prepared for use, administered, and stored were not performed once each week from approximately October 1987 to January 19, 1989. F. 10 CFR 20.207(a) requires that licensed materials stored in an unrestricted area be secured from unauthorized removal from the place of storage. Contrary to the above, from 1984 until January 19, 1989, incoming packages of licensed material, including xenon-133 gas and molybdenum / technetium , generators, were temporarily stored, upon receipt, in an unrestricted l hallway area and were not secured from unauthorized removal.  ! 1 G. 10 CFR 35.51(a) requires, in part, that survey instruments used to show ] 1 compliance with 10 CFR Part 35 be calibrated annually. Contrary to the above, two survey instruments, Models No. CDV-700 and No. COV-715, used to show compliance with 10 CFR Part 35 were not  ! calibrated between approximately October 1987 and January 19, 1989. Collectively, these violations have been classified as a Severity Level III violation (Supplements IV and VI). Cumulative Civil Penalty - $2,500 - assessed equally among the violations. NUREG-0940 II.A-103 i

                                                                                    )

I i Notice of Violation 3 i Pursuant to the provisions of 10 CFR 2.201, St. Joseph's Hospital (Licensee) is hereby required to submit a written statement or explanation to the Director, ! Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of l 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) admis-sion or denial of the alleged violation, (2) the reasons for the violation if i admitted, (3) the corrective actions that have been taken and the results I achieved, (4) the corrective actions that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an  ! adequate reply is not received within the time specified in this Notice, an Order may be issued to show cause why the license should not be modified, suspended, or revoked or why such other 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 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 hotice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenua-ting 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 six factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., ' citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provision of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be. collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c. NUREG-0940 II.A-104

4 Notice of Violation 4 The responses to the Dire: tor, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Director, Office of Enforcement, Notice of Violation) should be addressed to:Document U.S. Nuclear Regulatory Commission, ATTN: Control Desk, Washington, l D.C. 20555, with a copy to the Regional Administrator, Region III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois 60137. FOR THE NUCLEAR REGULATORY COMMISSION f /t A d . 7 1 C

                                        'E Bert Davis Regional Administrator                                                                             ,

l Dated at Glen Ellyn, Illinois this 16th day of March 1989 1 i l NUREG-0940 II.A-105

                                                  /#       '*.
                                              /-               *
                                                                ;,                          UNITED STATES NUCLEAR REGULATORY COMMISSION y

wassiuorow, o c.20sss s....., e.,_ ] Docket No. 30-19244 License No. 35-19797-01 (expirec) l EA 89-007 1 Saturn Services, Inc. ATTN: Mr. John Condrin 6655 South Lewis, Suite 35C Tulsa, Oklahoma 74136 Gentlemen:

SUBJECT:

ORDER TO CONFIRM TRANSFER OF REGULATED PATERIAL (EFFECTIVE INNEDIATELY) Enclosed is an Order, effective immediately, requiring Saturn Services, Inc., to continu LLut til licerisable radioactive material which Saturn Services, i Irc., possessed has been transferred to an authorized recipient. This Order supersedes voluntary commitments to the PTC which were the subject of Confir-n.ation of Acticri letters (CALs) dated January 11 and 13,1989. If ycu have any questi ons regarding what is required of ycu, please coritact William L. Brown, NRC's Regional Counsel in Arlircton, Texas at telephone number (817)860-8271. I In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, i Title 10, Code of Federal Regulations, a cer3 of this letter and the enclosed Order will be placed in the NRC's Public Document Room. Sincerely, t ik. 11 'r

                                                                                                                                       )

Hu(FL. Thompson r, Deputy Executive Di ctor for Nuclear Materials Safety, Safeguards, and Operatiers Su;; port

Enclosure:

1.s stated cc: Mr. Harold Haught B&H Wireline Services Hominy, Oklahoma 74C35 Mr. O. C. LaMascus P.O. Box 650 Hominy, Oklahoma 74035 Oklahoma Radiation Control Frogram Directcr CERTIFIED MAIL MtluRN RtctIPT REQUESTED NUREG-0940 II.A-106

UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of Dor.ket No. 30-19244 Saturn Services Inc. License No. 35-19797-01 (expired) (formerly licensed as EA 89-007 Saturn Wireline Services. Inc.) Tulsa, Oklahoma ) ORDER TO CONFIRH TRANSFER OF REGULATED MATERIAL (EFFECTIVE IMMEDIATELY) I Saturn Wireline Services, Inc., (Saturn) previously held NRC License No. 35-19797-01 issued by the Nuclear Regulatory Commission (NRC or Comission) 1 on June 30, 1981 and amended on May 28, 1982. This license expired on June 30, 1986, Saturn having faileo to file a timely application for renewal. When in effect, the license authorized Saturn to possess sealed sources of radioactive f americium-241 and cesium-137 for use in gas and oil well logging and radioactive iodine-131 in any form for use in gas ar.o oil well tracer studies. During an inspection on January 10, 1989 the NRC learned that Mr. John Condrin of Tulsa, Oklahoma, had purchased Saturn Wireline Services,, Inc., sometime in January 1987 l and subsequently had renamed the company Saturn Services, Inc. (SSI). Neither Saturn Wireline Services, Inc. nor Saturn Services, Inc. currently has a valid l l NRC license. 1 1 II On August 29, 1986, two months following the expiration of NRC License No. 35-19797-01, a Notice of Violation (Notice) was issued to Saturn Wireline l Services, Inc., for possession of NRC-licensed material without a valia NRC license. This correspondence, which was mailed to Mr. O. C. LaMascus, then the president of Saturn, stated that Saturn was to keep licensed naterial in secure NUREG-0940 II.A-107

i l storage and that no additional byproduct material was to be purchased pending Saturn's obtaining a valid license. In an undated response received by hhc i Region IV on September 22, 1986, Mr. LaMascus, on behalf o' Saturn, replieo that Saturn's radioactive sources were in secure storage.  ; l In correspondence received by NRC Region IV on September 3, 1986, Saturn

                                                                                                                            )

llirtline Services, Inc., applied for a new NRC license to possess and use the same scaled sources possessed under the authority of the. company's expired NRC'  ! license. A September 30, 1986 letter from the NRC's Region IV office to Saturn i reiterated NRC's position that Saturn's radioactive material must remain in i secure storage until a valid license was obtained. On November 13, 1986, the NRC's Region IV Office wrote to Saturn and asked it to provide additional information in order for the NRC to continue processing the i license application. On February 20, 1987, NRC's License fee Management Branch l in Bethesda,f*aryland, unaware of the purchase of Seturn ty John Condrin and the change of the company name to Saturn Services, Inc., wrote to Saturn and informed it that until an outstanding Inspection fee cf $370 plus interest of

  $37.12 was paid, the NRC was discontinuing its consideration of the application for a new license.       This letter also informed Saturn that it was in violation of 10 CFR 30.36 for possessing byproduct materibl without a valid NRC license.

Neither Saturn nor SSI responded to the February 20, 1987 letter. Based on a telephone conversation with Mr. LaMascus on August 4,1987, NRC Region IV issued a Confirr.ation of Action Letter (CAL) on the same date to Saturn (addressed to Mr. LaMascus) which confirmed Saturn's commitments to (1) pay the outstanding NUREG-0940 II.A-108 l

l l 1 frispection fee and submit a revised license application within 10 days of his receipt of the letter, and (2) maintain radioactive materials dr Saturn's possession in locked stortte until Saturn ebtainea a valid license. Neither Saturn nor SSI responded. Nu information as to Saturn's purchase by fir. John Condrin was provided to NPC at that time. i Ill { On January 10, 1989, an NRC Region IV inspector visited Saturn's facility at 220 East liain Street in Hominy, Oklahona, and determined that (3) one of Saturn's i radioactive sources was not in locked storage and in fact was in use on that date, (2) Saturn had been using its radioactive sources regularly in the j conduct of gas and oil well logging without a valid NRC license to possess anc use such materials and in violation of Saturn's previous commitments made by j Mr. LaMascus, and (3) Saturn had been purchased t,y Mr. John Concrin and renamed 551. The inspection also disclosed several opher apparent violations of NRC requirements associated with Saturn's sate use of these sources. On January 11, l 1989, Mr. LaMascus acknowledged that Saturn hao been using these materials without a license and agreed to transfer to an authorized recipient all licensable material that was in his possession. This comitment was confirmed in a CAL issued on that date. The transfer of three sealeo sources from Saturn to B&H Wireline Services, 300 E. Main Street, Hominy, Oklahoma, an f5C licensee authorized to possess these materials, was carried out on the same date. On 4 January 13, 1989, Mr. John Condrin, President of SSI, acknowledged that SSI, Saturn's successor, would continue to not use t edioactive material until notified  ! otherwise by the NRC. This comitment was confirmed in a CAL issued on the same date. NUREG-0940 II.A-109 i

I { IV The foregoing events indicate a disregard for NRC requirements on the part of f Saturn and Mr. LaMascus. In particular, the possession and use of byproduct materials without a license is prohibited by Section 81 of the Atomic Energy Act of 1954, as amended, and by 10 CFP, 30.3 of the Commission's regulations. In light of Saturn's apparent deliberate violation of the Atomic Energy Act of 1954, as amended, and NRC's regulations and Saturn's apparent violation of radiation safety-related requirements associated with the safe use of licensed ~ materials, I have determined that it 1s necessary to issue this Order to ensure

                                                                                                                       )

that no licensed material remains in the possession of Saturn Services, Inc., a company that does not pcssess a valid NRC license. Further, because of the willful nature of the violation, I have determined that this Order be immediately effective. V l 1 Accordingly, pursuant to Sections 81, 161b, 161c, 1611, and 1610 of the Atomic  ! Energy Act of 1954, as amended, and 10 CFR Part 30, IT IS HEREBY ORDERED, EFFECTIVE IMMEDIATELY, THAT: i Saturn Services, Inc., shall certify under oath or affirmation within 10 days of the effective date of this order that all regulated radioactive material has been transferred to an authorizea recipient and that no such material remains in Saturn Service's possession. The certification NUREG-0940 II.A-110

i shall be sent to the Regional Administrator, USNRC Region IV, 611 Ryan Plaza Drive, Suite 1000, Arlington, Texas 76011. FOR THE NUCLEAR REGULATORY COMi1ISSION lt 19 Hug L. Thompso J. De ty Executive Di ctor for Nuclear Materials Safety, Safeguards, and Operations Support Dated at Rockville, Maryland thisptJLday of February 1989 l i i l i NUREG-0940 II.A-111 l 1 o

i

     #          o,                              UNIT ED. STAT E s

[ 'l\ ;,. , h NUCLEAR REGULATORY COMMISSION E

                    !                                REGION I
         'v      o[                           478 ALLENDALE ACAD
       '****                          KING OF PRUSSIA. PENNSYLVANIA 19406 April 5, 1989 Docket Nos.      30-02464 30-00347 License Nos. 29-03038-01 l                           29-03038-02

! EA 89-51 The Hospital Center at Orange l ATTN: Francis X. Mcginn, M.D., F.A.C.P., F.A.C.C. { Administrator, Medical Affairs 188 South Essex Avenue Orange, New Jersey 07051 Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection No. 89-001) This letter refers to the Nuclear Regulatory Commission (NRC) inspection conducted on February 2,1989 at the Hospital Center at Orange, New Jersey of activities authorized by NRC License Nos. 29-03038-01 and 29-03038-02. The report of this inspection was sent to you on February 23, 1989. During the inspection, apparent violations of NRC requirements were identified, On March 1, 1989, an enforcement conference was conducted with you and members of your staff to discuss the violations, their causes and your corrective actions. ) As a result of information supplied at the enforcement conference, three of the apparent violations in the inspection report are not cited in the enclosed Notice of Violation. ~ The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty, include, but are not limited to: (1) failure to perform certain required surveys at your facility; (2) failure i to maintain proper control and surveillance of certain unsecured materials- 1 (3) failure to perform the required constancy, linearity and geometrical ) variation tests of a replacement dose calibrator; and (4) failure by a  : technologist to wear appropriate protective clothing and devices while handling radioactive material. Based on our evaluation of these violations, the NRC has found that nuclear medicine technologists did not always follow your procedures during the performance of licensed activities, both during the week and on Saturdays. CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-112

The Hospital Center at Orange 2 In addition, the Radiation Safety Officer has not been aggressive in monitoring and evaluating the licensed activities of the technologists to assure activities were properly performed. Furthermore, although periodic audits of these activities were conducted by an outside consultant, the majority of these violations went undetected, and when detected were not promptly reported to management and immediately corrected, which raises significant questions con:erning the adequacy of those audits. These deficiencies demonstrate the need for increased and improved management l attention to the radiation safety program to assure that licensed activities are conducted safely and in accordance with the terms of the license. To emphasize this reed, I have been authorized, after cor.sultation with the Director, Office of Enforcernent, and the Deputy Executive Director for Mater'.'s Safety, Safeguards and Operations Support, to issue the enclosed Notice of Violation and proposed Imposition of Civil Pef.alty in the amount of Three Thousand Seven Hundred Fif ty Dollars (53,750) for the violations described in that Notice. In accorcance with the " General Statement of Policy and Proceoure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40029 (October 13,1988), the eight violations described in the Notice have been classified in the aggregate as a Severity Level III problem to focus on the lack of adequate oversight of licensed activities which resulted in a number of violations representing a breakdoon in control of licensed activities. The base civil penalty amount for a Severity Level 111 violation or problem is $2,500. The escalation ar.d mitigation factors in the Enforcement Policy were considered. In this case, the base civil. penalty amount has been increased by 50*, because the violations were identified by the NRC, and you should have been aware of the violations sooner if the R50 had appropriately monitored the program, or if the audits by the consultant had been effective in detecting and correcting problems. You are required to respond to this letter and the enclosed Notice, and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to take to prevent recurrence. Furthermore, you should describe the act-ions taken or planned to improve the oversight of the program by the Radiation Safety Officer. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further action is needed to  ! ensure compliance with regulatory requirements. Furthermore, we emphasize that any recurrence of these violations may result in more significant enforcement action. 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 II.A-113 ) i

The Hospital Center at Orange 3 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, l William T. Russell Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc w/ encl: Public Document Room Nuclear Safety Information Center (NSIC) State of New Jersey I NUREG-0940 II.A-114

l NOTICE OF VIOLATION i AND PR0p0 SED IMPOSITION OF CIVIL PENALTY The Hospital Center at Orange Docket Nos. 30-02464 Orange, New Jersey 07051- 30-00347 License Nos. 29-03038-01 ) 29-03038-02 EA 89-51 l During an inspection conducted on February 2,1989, violations of Nuclear Regulatory Commission (NRC) requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13,1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: A. 10 CFR 20.207(a) requires that licensed materials stored in an unrestricted area be secured against unauthorized removal from the place of storage. 10 CFR 20.207(b) requires that licensed materials in an unrestricted ares not in storage be under constant surveillance and immediate control of the licensee. As defined in 10 CFR 20.3(a)(17), I an unrestricted area is any area access to which is not controlled by the licensee for purposes of protection of individuals from exposure to radiation and radioactive materials. Contrary to the above, on February 2,1989, millicurie quantities of licensed material were stored in an unlocked nuclear medicine hot lab and an unlocked storage area for radioactive waste (unrestricted areas), , and were not secured against unauthorized removal nor were they under  ! the constant surveillance'and immediate control of the licensee. These areas were unrestricted since they were accessible to visitors, employees and ambulatory patients on that date. B. Condition 18 of License No. 29-03038-01 requires, in part, that licensed material be possessed and used in accordance with statements, representa-tions and procedures contained in the application dated September 24, 1979, ) and letter dated June 25, 1985.

1. The letter dated June 25, 1985 requires that dose calibrators be . ';

calibrated in accordance with procedures contained in Appendix D, Section 2, of Regulatory Guide 10.8 (October 1980).

a. Item C of Appendix D, Section 2, recuires the licensee to assay at least one reference source before each day's use of the instrument. 4 l

l NUREG-0940 II.A-115

Notice of Violation 2 Contrary to the above, on certain days, the licensee did not assay at least one reference source before use of the instrument, as evidenced by the follcwing examples:

1. fron December 3, 1938 to January 28, 1989, the dose calibrator was used to assay patient doses on-Saturdays without the required constancy check of the calibrator being performed; and I

ii. from June 17' to July 8,1938, a dose calibrator was used l by the licensee to assay patient doses and during that l' time, the dose calibrator was not tested for constancy. before each day's use. (This dose calibrator was a

                                                                              " loaner" obtained for use,while the licensee's dose calibrator was out for servicing.)

b. Items A.3 and A.4,of Appendix D, Section 2, require that the dose calibrator linearity be determined at installation and quarterly thereafter, and.the geometrical variation be determined at installation.

Contrary to the above, although a " loaner" dose calibrator was installed on June 17, 1983, the linearity and geometrical variation were not determined at that time.

2. Item No. 14 of the application requires that packages containing radioactive material be opened in accordance with the procedures in Appendix F of Regulatory Guide 10.8 (January 1979). i Appendix F requires, in part, that when opening packages in which licensed material has been received, gloves are to be worn; the 3

                                                             ' exposure rate at the surface of the package and at three feet from the surface shall be measured and recorded; and a wipe' test be taken of the external surface of the final source container.

Contrary to the above, on February 2,1989 while opening packages in j which licensed material was contained, a licer.see employee did not wear gloves; did not measure and record the. exposure rate at the surface of the package and at three feet from the surface; and did not take a wipe test from the external surface of the final source l

                                 .                            container until after the container was opened and a number of patient doses were withdrawn from it.

3. Item No. 15 of the application requires that radioactive materials be used in accordance with Appendix G of Regulatory Guide 10.8 (January 1979).

Appendix G requires, in part, tr.at laboratory coats or other protective clothing be worn at all times ir, areas where radioactive materials are used; that disposable. gloves be worn at all times while handling radioactive materials; that personnel monitorirg devices (film badges) NUREG-0940 II.A-116

Notice of Violation 3 be worn at all times while in areas where radioactive materials are used or stored; and that a TLD finger badge be worn during preparation and assay of radiopharmaceuticals. Contrary to the above, on February 2,1989, a technologist was observed in an area in which radioactive materials are used, without wearing the required clothing and personnel monitoring device, and without wearing disposable gloves or the required TLD finger badge while handling radioactive materials and preparing and assaying radiopharmaceuticals. 4 Item No. 17 of the application requires that surveys be performed in accordance with Appendix I of Regulatory Guide 10.8, January 1979.

a. Step 1 of Appendix I requires daily surveys of all elution, preparation and injection areas.

Contrary to the above, from December 3, 1988 to January 28, 1989, preparation and injection areas were not surveyed on Saturdays when patient studies were performed.

b. Step 5 of Appendix ! requires, in part, that records of survey results include corrective action taken in the case of contamination. Step 6 of Appendix I requires that areas be J cleaned if the contamination level exceeds 200 dpm/100 cm2, i

Contrary to the above, as of February 2, 1989, although area wipe test survey records indicate that wipe tests of all areas routinely exceeded 200 dpm/100 cm2, in some cases corrective action was not taken nor was the cause of the high readings determined.

5. Item No. 21 of the application requires that radioactive gases be used in accordance with the procedures and precautions attached to the application.

The procedures and precautions attached to the application require, I in part, that, in order to assure that the xenon trap is working i efficiently, the trap will be checked after the last xenon-133 study  ! of the week.  ; Contrary to the above, as of February 2,1989, xenon-133 was used  ; weekiy; however, the xenon-133 trap was checked on a monthly frequency j rather than after the last xenon-133 study of the week. These violations have been categorized in the aggregate as a Severity Level  ! III problem (Supplements IV and VI). Cumulative Civil Penalty - 53,750 (assessed equally among the eight violations). NUREG-0940 II.A-117

Notice of Violation 4' Pursuant to the provisions of 10 CFR 2.201, The Hospital Center at Orange (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 that will be taken to i avoid further violations, and (5) the date when full compliance will be achieved. i 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, Cffice of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draf t, or money order payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (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 wbf 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 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., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarcing 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. 22E2c. NUREG-0940 II.A-118

l Notice of Violation 5 The response to the Director, Officer 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 I, 475 Allendale Road, King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COMMISSION 1 h 1 d n ator Datedagtsir.g of Prussia, Pennsylvania this I day of April 1989 I l l l l NUREG-0940 II.A-119

p# 'o UNITED STATES

 !              n               NUCLEAR REGULATORY COMMISSION i

j neosow v f 1400 MARIA LANE, SUITE 210

   %,        /                     WALNUT CREEK, CAUFORNIA 940064300 Docket No. 030-13550 License No. 04-17862-01 l       EA 88-39 V.A. Medical Center Jerry L. Pettis Memorial Veterans Hospital ATTN:     Mr. John F. Hickman Hospital Director 11201 Benton Street Loma Linda, California 92357 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NOS. 87-01 and 88-02) This letter refers to the Nuclear Regulatory Commission (NRC) inspection conducted by J.F. Pang on December 16-17, 1987, and a followup NRC inspection by Messrs. D. Skov, J. Montgomery, and R. Pate on December 19-21, 1988, at the V. A. Medical Center, Loma Linda, California. The followup NRC inspection at your facility was completed on January 11, 1989 by D. Skov, who was accompanied by R. Marsh, NRC Region V Office of Investigations (01). The inspections examined the activities authorized by License No. 04-17862-01 as they relate to radiation safety and to compliance with NRC regulations and the conditions of your license. These inspections identified numerous failures to comply with NRC regulatory and license requirements. The December 1987 inspection identified several apparent violations, of which four were repeats of prior violations identified by the NRC during inspections performed in November 1985 and October 1986. On February 24, 1988, we sent to you our report documenting the results of our inspection in 1987. We discussed the inspection findings with you at an Enforcement Conference on March 1, 1988. The letter summarizing this Conference was sent to you on April 4, 1988. From December 19, 1988 to January 11, 1989, we conducted an inspection of your licensed activities. This inspection identified several additional apparent violations, two of which were repeats of prior violations identified by the NRC during the December 1987 inspection. These inspection results were contained in a report sent to you by letter dated January 27, 1989. Based on these inspection findings, we conducted another Enforcement Conference with you on February 7, 1989. During that Conference, we discussed the violations, their causes, and your corrective actions. The letter summarizing this latest Conference was sent to you on February 16, 1989. The NRC is concerned about the repetitive nature of the violations identified. They demonstrate a lack of effective corrective action to prevent recurrence and thus a lack of management oversight of your radiation safety program. Violatinns first identified in the inspection of November 18-19, and 27,1985, CER11.FIED MAIL - RETURN RECEIPT REQUESTED NUREG-0940 II.A-120

MAY 101989 V.A. Medical Center were repeated in the October 22-23, 1986, inspection and identified for the thi.r.d time during the December 16-17, 1987, inspection. In essence, these vio-lations have existed for at least 36 months without effective corrective action to prevent recurrence. Such lack of effective corrective action is unacceptable to the NRC. This enforcement action has been delayed pending completion of the Region V Office of Investigations inquiry of whether certain of the violations discussed below were, willful. The inquiry has concluded that there was "no direct evidence of wrongdoing." The following violations, described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties, were identified during the inspections conducted in December 1987 and December 1988 - January 1989: (1) several radiation workers and ancillary personnel exposed to radioactive use areas had not received required annual refresher training, (2) weekly radiation level and wipe surveys were not conducted in various laboratories and rooms containing radioactive material, (3) calculations and evaluation of T.he dose calibrator accuracy test were not completed, (4) evaluations of radiation exposure for lost and missing film badges worn by hospital personnel had not been conducted, (5) project authorizations for use of licensed material had not been reviewed annually for approval, (6) results of weekly wipe surveys were not recorded in proper units of measurement, (7) records of disposal of phosphorus-32 to the sanitary sewer system, and of surveysiof technetium-99m generators released for unrestricted use, were not maintained, and (8) instructions to personnel describing emergency responses for spills and other incidents involving radioactive material were not posted. The violations represent h significant lack of adequate oversight and control of licensed activities at your facility. To emphasize the importance of complying with license and regulatory requirements and ensuring management oversight of licensed programs, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of Six ! Thousand Five Hundred Dollars ($6,500) for the violations described in the enclosed Notice. The violations described in Section I of the enclosed Notice were identified  ! during the inspection of December 16-17, 1987. In accordance with the

  " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988) (Enforcement Policy),

the violations described in Section I of the enclosed Notice have been classified in the aggregate as a Severity Level III problem. The base civil penalty for a Severity Level III violation or problem is $2,500. Based on consideration of the escalation and mitigation factors set forth in the enforcement policy, the base civil penalty amount was increased by 100 percent because of your poor past performance. The violations described in Section II of the enclosed Notice were identified as repetitive violations during the inspection of December 19, 1988 - January 11, 1989. In accordance with the Enforcement Policy, 53 Fed. Reg. 40019 (October 13, NUREG-0940 II.A-121

MAY 101989 V.A. Medical Center 1903), each violation has been classified as a Severity Level IV violation. The base civil penalty for a Severity Level IV violation is $750. The escalation and mitigation factors set forth in the enforcement policy were considered, and no adjustment has been deemed appropriate. Violations identified in Section III of the enclosed Notice were not assessed a civil penalty. These three new violations were also identified during our December 19, 1988-January 11, 1989 inspection. In accordance with the Enforcement Policy, the violations in Section III of the Notice have been categorized as Severity Level V violations. Although the safety significance of these new violations is relatively low, they provide additional evidence that your internal audit and management control system has not been effective in identifying and correcting potential violations of NRC requirements in all areas of your radiation safety program. You are required to respond to this letter and the enclosed Hotice, 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 your re!,ponse, you should address why several of the corrective actions described in your January 26, 1986 letter were ineffective and why the current actions will be effective. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further action, including possible modification of your license, is needed to ensure compliance with regulatory requirements. Furthermore, we emphasize that a license to use byproduct material is a privilege granted oy the NRC and future significant failures to control licensed activities may result in suspension of your license. 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, P.L. No. 96-511. Sinc rely, h/?d John B. Martin Regional Administrator

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc. Dr. James W. Fletcher Director, Nyclear Medicine Service (115) Veteran's Administration 810 Vermont Ave. NW Washington, D.C. 20420 NUREG-0940 II.A-122

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES V.A. Medical Center Docket No. 030-13550 Jerry L. Pettis Memorial Veterans Hospital License No. 04-17862-01 11201 Benton Street EA 88-39 Loma Linda, California During NRC inspections conducted on December 16-17, 1987 and December 19, 1988 to January,.11, 1989, violations of NRC requirements were identified. % accordance with the " General Statement of Policy and Procedure for NRC Enforce- j ment Actions," 10 CFR Part 2, Appendix C, the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy  ; Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular I violations and associated civil penalties are set forth below: l l I. Violations Assessed Civil Penalty (NRC Inspection December 16-17, 1987) l A. 10 CFR 20.201(b) requires each licensee make such surveys as may be necessary to comply with the requirements in Part 20 and which are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present. As defined in 10 CFR 20.201(a), " survey" means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presence of radioactive materials or other sources of radiation under a specific set of conditions.  ; l Contrary to the above requirement, at the time of the inspection, j radiological evaluations of the estimated exposure doses received ' by badged personnel had not been made for film badges lost or i missing since October 24, 1986. (The licensee averaged about seven i to eight lost / missing film badges per month). l This is a repeat violation from the inspections of November 18-19, and 27, 1985 and October 22-23, 1986. B. License Condition 18 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in a letter and attachments dated February 25, 1983, and in an application dated August 24, 1983.

1. Item 12 of the application dated August 24, 1983 requires, in part, annual refresher training of radiation workers and ancillary workers who come into contact with radioactive material work areas.

Contrary to the above requirement, at the time of the inspection, the technician working in the radioimmunoassays (RIA) laboratory had not received annual refresher training i since October 1984. This is a repeat violation from the inspection of October 22-23, 1986. NUREG-0940 II.A-123

Notice of Violation 2. Item 17 of the application dated August 24, 1983 requires, in part, that radiation surveys be conducted in accordance with Appendix I of NRC Regulatory Guide 10.8, Revision 1, October, 1980. Appendix I of the Regulatory Guide requires that radioactive waste storage areas be surveyed weekly with a survey meter to measure radiation levels, and with a series of wipe tests to measure radioactive contamination levels. Contrary to the above requirements, radiation surveys of the radioactive waste storage rooms (1B-43 and IB-45) were not performed during five weekly periods between February 1987 and December 1987. This violation is repetitive from the inspections of November 18-19, and 27,1985 and October 22-23, 1986.

3. Item 10 of the application dated August 24, 1983 provides, in part, that all calibrations of dose calibrators shall be performed in accordance with Appendix D, Section 2 of Regulatory Guide 10.8, Revision 1, October, 1980.

Appendix D, Section 2 of the Regulatory Guide requires, in part, annual accuracy tests of the dose calibrator. Contrary to the above requirement, at the time of the inspection, the licensee had not completed the calculations necessary to evaluate the accuracy of the dose calibrator (Capintech Model CRC-20) from test measurements conducted in December 1986. This violation is repetitive from the inspection conducted on November 18-19, and 27, 1985.

4. Items 22 and 23 of an application included as part of the letter dated February 25, 1983, indicate the attachment of

                " Procedures and Precautions for Use of Radioactive Material in Animals and Specified in Item 6.b. (Research and Development Radionuclides). The attachment entitled " Approval for Radio-isotope Use" contains the statement that "This approval will expire one year from the date approved unless renewed." Point 1 of the attachment entitled " Comments" states that " Projects are usually approved for a one year duration subject to review and renewal at the end of that time." It also describes the procedures for submittal of an application to the Radiation Safety Committee.

Contrary to the above, at the time of the inspection, the licensee's Radiation Safety Committee had not performed a review and renewal of several ongoing projects. Specifically, the following projects continued beyond the one year expiration date: Project No. 860108 was neither reviewed ner renewed in 1987 when it expired; Project No. 850219, which expired in 1986, NUREG-0940 II.A-124

1 l Notice of Violation  ! was neither reviewed nor renewed in 1986 and 1987; and Project No. 840620, which expired in 1985, was not reviewed or renewed in 1985, 1986 and 1987. These violations are categorized in the aggregate as a Severity Level III problem (Supplements IV and VI). Cumulative Civil Penalty - $5000 (assessed equally among the five violations). II. Violations Assessed Civil Penalty (NRC Inspection December 19, 1988-January 11, 1989) A. License Condition 18 requires that licensed material be possessed I and used in accordance with statements, representations, and j procedures contained in a letter and attachments dated February 25, 1983, and in an application dated August 24, 1983.

1. Item 12 of the application dated August 24, 1983 requires, in part, annual refresher training of radiation workers and ancillary workers who come into contact with radioactive material work areas.

l

a. Contrary to the above requirement, three radiation workers using licensed material in two research laboratories had not received annual refresher. training during 1988.

b. Contrary to the above requirement, three individuals working in the Animal Research Facility, where animals i containing licensed material were housed, had not received annual refresher training in 1987 or 1988.

The above examples constitute a Severity Level IV Violation i (Supplement VI) and are repetitive from the inspection of  ! December 16-17, 1987.  ; Civil Penalty - $750.

2. Item 17 of the application dated August 24, 1983 provides, in j part, that radiation surveys are to be conducted in accordance i with Appendix I of NRC Regulatory Guide 10.8, Revision 1, October, 1980.

Appendix I of the Regulatory Guide provides that laboratory  ! areas using more than 200 microcuries of licensed material are  ; to be surveyed weekly with a survey meter to measure radiation i levels, and with wipe tests to measure radioactive contamination levels.

a. Contrary to the above requirements, between Septamber 16, 1988 and December 17, 1988, there were no weekly wipe surveys of the Connective Tissue Research Laboratory following the use of greater than 200 microcuries of

                                                                                                     ""~ '

NUREG-0940 II.A-125

Notice of Violation b. Contrary to the above requirements, between October 25, 1988 and December 19, 1988, there were no weekly wipe surveys in the Animal Research facility (Room 18-27) i following the use of up to 15 millicuries of phosphorus-32 l on October 25, 1988. Also, radiation level surveys had l not been conducted in Room 18-27 between November 23, 1988 j and December 13, 1988. The above examples constitute a Severity Level IV Violation I (Supplement VI) and are repetitive from the inspection of December 16-17, 1987. l Civil Penalty - $750. III. Violations Not Assessed Civil Penalty These violations are from the inspection of December 19, 1988 - January 11, 1989 A. 10 CFR 30.51.provides that each person who receives byproduct material pursuant to a license issued pursuant to the regulations in Parts 30 and 31-35, shall keep records showing the receipt, transfer, and disposal of such byproduct material. Contrary to the above requirement, at the time of the inspection, the licensee had no records documenting the disposal to the sanitary sewer system of phosphorus-32 in animal waste in Room 18-27 between October 26, 1988 and December 19, 1988. This is a Severity Level V violation (Supplement VI). 4 B. 10 CFR 20.401(b) provides, in part, that each licensee shall maintain records in the same units used in Part 20, showing the results of surveys required by 10 CFR 20.201(b), and disposals made under 10 CFR 20.302 and 20.303. 10 CFR 20.5 provides that radioactivity levels evaluated as a result of surveys completed by licensees are to be measured in units of disintegrations per unit time or in curies (millicuries, microcuries).

1. Contrary to the above requirements, at the time of the inspection on December 19-21, 1988, the licensee had no records of the surveys of up to 15 spent molybdenum-99/ technetium-99m generators prior to their disposal to unrestricted use during February, 1988.

2. Contrary to the above requirements, at the time of the inspection on December 19-21, 1988, the results of wipe tests conducted since January,1988 to measure contamination levels in several laboratory rooms using licensed material (e.g. ,

Rooms 1B-43,1B-45, 4E-28, and Nuclear Medicine Laboratory / Radiopharmacy), had been recorded in epm rather than in disintegrations per unit time or curies (microcuries). I NUREG-0940 II.A-126 I

Notice of Violation The above examples constitute a Severity Level V Violation (Supplement IV). C. License Condition 18 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in a letter and attachments dated February 25, 1983, and in an application dated August 24, 1983.

• Item 16 of the application dated August 24, 1983 commits the

          ' licensee, in part, to post the procedure. " Emergency Instructions,"

in Academic (Research) Laboratories. Contrary to the above requirement, at the time of the inspection on December 20, 1988, the " Emergency Instructions" procedure was not posted in the Research Laboratories designated as Rooms 4C-22, 3C-06 and 4C-02. This is a Severity Level V violation (Supplement VI). Pursuant to the provisions of 10 CFR 2.201, the V. A. Medical Center, Loma Linda (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 will be 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 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 the civil penalties proposed above, or may protest imposition of the civil penalties in whole or in part or by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the licensee fail to answer within the time specified, an order imposing the civil penalties will be issued. Should the licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil 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 penalties, such answer may request remission or mitigation of the penalties. NUREG-0940 II.A-127

Notice of Violation -G-In requesting mitigation of the proposed penalty, the 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. , 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 penalties 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 U.S.C. 2282c. l ' 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 Control Desk, Washington, DC 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region V, 1450 Maria Lane, Walnut Creek, California, 94596. FOR T NUCLEAR REGULATORY COMMISSION l 4

                                               /YA Y n B. Martin Regional Administrator Dated at Walnut Creek, California this jp day of May 1989 NUREG-0940 II.A-128

4 [pa ascghg UNITED STATES j i i (  % NUCLEAR REGULATORY COMMISSION E E REGION I o 476 ALLENDALE ROAD

     *****                      KING OF PRUSSIA, PENNSYLVANIA 19408 March 13, 1989 Docket No. 30-30856 License No. 37-28291-01 EA 89-23 Jeffrey Weisman, M.D.

7718 Caster Avenue i 1 Philadelphia, Pennsylvania 19111 Gentlemen:

Subject:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection No. 89-001) This letter refers to the NRC inspection conducted on January 24, 1989 at your f acility (Wilmington Imaging Lab) in Wilmington, Delaware of activities author-ized by NRC License No. 37-28291-01. This was the first inspection conducted of this license which was issued on December 6,1988. The inspection report was sent to you on February 3, 1989. During the inspection, several violations of NRC requirements were identified. On February 6, 1989, an enforcement i conference was conducted with you, V. Sagar, M.D. (the Radiation Safety Officer i at your Wilmington facility) and two of your consultants, to discuss the viola- l tions, their causes and your corrective actions. l The violations, which are described in the enclosed Notice of Violation and i Proposed Imposition of Civil Penalty, include, but are not limited to: (1) failure by the Radiation Safety Officer to ensure that the radiation safety , activities were being performed in accordance with approved procedures and ' regulatory requirements, (2) failure to provide adequate training to indi-viduals performing litensed activities at your facility, and (3) the failure to perform several instrument calibration checks as required by the terms of your license.

                                                                       ~

The NRC is particularly concerned that this license was just recently issued on December 6, 1988, and therefore, the requirements of the license should have been clearly understood and properly implemented by your staff (including the Radiation Safety Officer). Nonetheless, use of licensed materials for treat-ment of patients commenced on December 28, 1988 without all conditions of the license being implemented, and without possession of all required instruments-  ! tion (survey meters, check sources, etc.) necessary to implement these require-l ments. These actions are especially disturbing in view of the fact that you own two other NRC licensed facilities and should have been aware of the license requirements that needed to be fulfilled and the equipment that needed to _be operable prior to the use of licensed material for diagnostic imaging studies. NUREG-0940 II.A-129

Jeffrey Weisman, M.D. 1 Furthermore, although one of your consultants performed an audit of your facility in December 1988 prior to operations, and apparently identified certain deficiencies, management did not assure that they were promptly informed of the audit findings to ensure prompt correction of any identified deficiencies. In a Confirmatory Action Letter (CAL) issued on January 26, 1989, you agreed to suspend possession and use of licensed material until the NRC was satisfied that the facility, equipment, and testing requirements specified in your license application were implemented. Your corrective actions taken to implement these requirements were described in your written response dated February _6, 1989. Although the NRC concurred that the corrective actions were satisfactory and withdrew the CAL on February 7, 1989, the violations identified during the inspection demonstrate the need for maintaining continued management attention and oversight of the radiation safety program to ensure that activities are conducted safely and in accordance with the terms of the license. To emphasize this, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Saf ety, Safeguards, and Operations Support, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Thousand Two Hundred Fifty Dollars (51,250) for the violations described in that Notice. In accordance with Section C.8 of Supplement VI of the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988) (Enforcement Policy), the violations described in the Notice have been classified in the aggregate as a Severity Level III problem. The base civil penalty amount for a Severity Level III violation or problem is $500. The escalation and mitigation factors in the Enforcement Policy were considered,. and the base civil penalty amount has been increased by 150% because (1) the violations were identified by the NRC, and (2) management should have had prior notice of deficiencies via the consultant's audit in December 1988, yet operations began without correction of the deficiencies. You are required to respond to this letter and the enclosed Notice,.and should follow the instructions specified in the enclosed Notice when preparing , your response. In your response, you should document the specific actions ' taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further action is needed to ensure compliance with regulatory requirements. Furthermore, we emphasize that a license to use byproduct material is a privilege granted by the NRC, and any recurrent violation of the terms of that license may result in more significant enforcement action, such as higher civil penalties, or modification, suspension or revocation of that license. 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. NUREG-0940 II.A-130

Jeffrey Weisman, M.D. 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

Enclosure:

Notice of Violation and Proposed Imposition of Civil Penalty cc: State of Delaware Commonwealth of Pennsylvania Vidya Sagar, M.D. Radiation Safety Officer Wilmington Imaging Lab 1411 North Van Burn Avenue Wilmington, Delaware NUREG-0940 II.A-131

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Jeffrey Weisman, M.D. Docket No. 30-30856 Wilmington, Delaware License No. 37-28291-01 EA 89-23 During an NRC inspection conducted on January 24, 1989, violations of NRC requirements were identified. In accordance with the " General Statement of i Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (Enforcement Policy) (1988), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: A. 10 CFR 35.21(a) states that the Radiation Safety Officer (R50) is responsible for implementing the radiation safety program and for ensuring that radiation safety activities are being performed in accordance with approved procedures and regulatory requirements in the daily coeration of the licensee's program. 10 CFR 35.21(b)(2), in part, specif;es that the R50 shall establish and implement written policy and procedures for: performing checks of survey instruments and other safety equipment; receiving and opening packages of byproduct material; performing periodic radiation surveys; and using byproduct material safely. Condition 13 of License No. 37-28291-01 lists the licensee's statements and representations in the application dated July 19, 1988 and letters dated October 21, 1988 and November 17, 1988 as the basis for issuing the license. Contrary to the above, as of January 24, 1989, the Radiation Safety Officer did not implement the radiation safety program and did not ensure that radiation safety activities were being performed in accordance with the licensee's approved procedures and regulatory requirements in the daily operation of the licensee's program, as evidenced by the following examples:

1. The RSO did not establish action limits for performing safety checks with the cesium-137 source in the licensee's possession as required by step 5 of Attachment A to the letter dated November 17, 1988, which is listed as a basis of the license by License Condition 13.

2. The RSO did not ensure that the technologists took action when values for the check source obtained during the daily dose calibrator constancy test exceeded 10% of the predicted value, as required by step 6 of Attachment A to the letter dated November 17, 1988, which is listed as a basis of the license by License Condition 13.

NUREG-0940 II.A-132

                                                                                                                                                         /

NOTICE OF VIOLATION 3. The RSO did not ensure that wipe tests of the external surfaces of the shipping container and final source container were performed, as required by step 5 of Attachment 10.7 to the licensee letter dated August 29, 1988, which is incorporated as a basis of the license by License Condition 13.

4. The RSO did not ensure implementation of the procedure for per-forming weekly wipe tests, as required by steps 3 and 4 of Attach-ment 10.12 of the licensee's letter dated August 29, 1988, which is incorporated as a basis of the license by License Condition 13.

5. The RSO did not ensure the use of remote handling devices (tongs) during handling of licensed material, as required by Attachment 9.1.1 of the licensee's letter dated August 29, 1988, which is incorporated as a basis of the license by License Condition 13; and

6. The RSO did not ensure that the licensee possessed two survey meters, as required by Paragraph 3 of the licensee's letter dated November 17, 1988, which is incorporated as a basis of the license by License Condition 13.

B. 10 CFR 19.12 requires that all individuals working in a restricted area be instructed in the precautions and procedures to minimize exposure to radioactive materials, in the purposes and functions of protective devices employed, and in the applicable provisions of the Commissions' regulations and licenses. Contrary to the above, as of January 24, 1989, a nuclear medicine technologist performing licensed activities in a restricted area had not been in'structed in the precautions and procedures to minimize exposure to radioactive materials, in the purposes and functions of protective devices employed, or in the applicable provisions of the Commissions' regulations and licenses. C. 10 CFR 35.50(b)(3) requires that each dose calibrator be tested for linearity upon installation and at least quarterly thereafter. 10 CFR 35.50(b)(4) requires that each dose calibrator be tested for geometry. dependence upon installation over the range of volume configurations for which it will be used. Contrary to the above, as of January 24, 1989, the dose calibrator installed prior to December 23,1988, had not yet been tested for linearity or geometry dependence. D. 10 CFR 35.50(e) requires that the licensee retain a record of each check and test required by 10 CFR 35.50. 10 CFR 35.50(b)(1) requires that each dose calibrator be checked for constancy with a dedicated check source at the beginning of each day of use. NUREG-0940 II.A-133

NOTICE OF VIOLATION l Contrary to the above, as of January 24, 1989, records were not maintained of dose calibrator constancy checks that were performed on December 28, 1988, and January 4, 9, 11 and 16, 1989. E. 10 CFR Part 35.51(a)(3) requires that a licensee conspicuously note on survey instruments the apparent exposure rate from a dedicated check source as determined at the time of calibration, and the date of calibration. Contrary to the above, as of January 24, 1989, neither the apparent exposure rate nor the date of calibration were noted on the Ludium Model 14C survey instrument. l F. 10 CFR 35.51(c) requires the licensee to check each survey instrument for ] proper operation with a dedicated check source each day of use. Contrary to the above, from December 6,1988, to January, 24, 1989, the survey meter was not checked for operation with a dedicated check source on any day of use. G. 10 CFR 71.5(a) requires that each licensee who transports licensed material outside the confines of its plant, or delivers licensed material to a carrier for transport, comply with applicable requirements of the regulations appropriate to the mode of transport of the Department of  ; Transportation (DOT) in 49 CFR Parts 170-189. 49 CFR 173.475(1) requires that prior to each shipment of any radioactive materials package, the shipper ensure by examination or appropriate tests that the external radiation and contamination levels are within allowable limits specified in subchapter C. Contrary to the above, from December 28,1988, to January 24, 1989, packages containing technetium-99m were shipped from the licensee's facility to a licensee, and prior to shipment, examinations or tests were not performed to ensure that package external contamination levels were within allowable limits. 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, Jeffrey Weisman, M.D. (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 violaticn 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 NUREG-0940 II.A-134

l NOTICE OF VIOLATION ) I i l violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an i order may be issued to show cause why the license should not be modified, l 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 l cause shown. Under the authority of Section 182 of the Act, U.S.C. 2232, this  ! response shall be submitted under oath or affirmation, l i 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 cf 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 i civil penalty will be issued. Should the Licensee elect to file an answer in I accordance with 10 CFR 2.205 protesting the civil penalty, in wLsle 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 i protesting the civil penalty, such answer may request remission or mitigation of the penalty. l In requesting mitigation of the proposed penalty, the six factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1988), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the f 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, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, NUREG-0940 II.A-135

NOTICE OF VIOLATION > DC 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory i Commission, Region I, 475 Allendale Road, King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COMMISSION hl William T. Russell Regional Administrator Dated atjKing of Prussia, Pennsylvania this /87/l day of March 1989 l I I NUREG-0940 II.A-136

1 i i i l

                                                                     )

1 l l l l i

                                                                    \

II.B. MATERIAL LICENSEES, SEVERITY LEVEL III VIOLATION, NO CIVIL PENALTY l 1 NUREG-0940

 /pm Mc      'o
            ~,                               UNITED STATES E      ,t    '$                   NUCLEAR REGULATORY COMMISSION 3                j                                REGION 4 475 ALLENDALE ROAD
   *.,e*                         KING OF PRUS$1A. PENNSYLVANIA 19406 May 25, 1989 Docket No. 030-02981 License No. 37-01317-01 EA 89-89 Allegheny General Hospital ATTN:     Sean Haag Vice President 320 East North Avenue Pittsburgh, Pennsylvania      15212 Gentlemen:

Subject:

NOTICE OF VIOLATION (NRC Inspection No. 89-001) This letter refers to the NRC inspection conducted on February 22, 1989 at Allegheny General Hospital, Pittsburgh, Pennsylvania of activities authorized by NRC License No. 37-01317-01. The report of this inspection was sent to you on April 21, 1989. During the inspection, the NRC inspectors reviewed the circumstances associated with diagnostic misadministration identified by your staff and reported to the NRC. During the inspection, four violations of NRC requirements were identified. On May 4, 1989, an enforcement conference was conducted with Mr. Louis Shapiro and other members of your staff to discuss the violations, their causes and your corrective actions. The violations, which are described in the enclosed Notice of Violation, involve: (1) f ailure to properly label radiopharmaceuticals on two occasions, contrary to 10 CFR Part 35.60(b), resulting in a diagnostic misadministration in July 1987, and two additional diagnostic misadministration in October 1988; (2) f ailure to properly secure licensed material stored in an unrestricted area; (3) use of licensed material by a physician on a number of occasions without wearing the required ring dosimeter; and (4) use of material by an individual prior to being authorized for such use by the Radiation Safety Committee. The first violation, involving the failure to properly label radiopharmaceu-ticals, is of particular concern to the NRC because these f ailures resulted in three patients receiving unnecessary exposure to radiation. In addition, another diagnostic misadministration which occurred in March 1987, prior to the ef fective date of 10 CFR Part 35.60, was also caused by a labeling error. Furthermore, a diagnostic misadministration also occurred in October 1987 because a technologist used the wrong syringe. These misadministration, in particular, those caused by violations of NRC requirements, demonstrate the importance of appropriate management oversight of these activities to ensure that radiopharmaceuticals are properly administered. In accordance with the guidance set forth in Section C.7 of Supplement VI of the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13,1988) (Enforcement NUREG-0940 II.B-1

Allegheny General Hospital 2 Policy), Violation A in the enclosed Notice has been classified at Severity Level III. Although a civil penalty is normally issued for a Severity Level III violation, I have decided, after consultation with the Director of Enforce-ment and the Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support, not to issue a civil penalty in this case, because full mitigation was considered warranted, in that (1) the violations which caused the misadministration were identified by your staff and the misaaministrations reported to the NRC, and (2) your corrective actions, after each event and subsequent to the inspection, were prompt and extensive. The other escalation and mitigation factors were considered and no further adjustment is deemed appropriate. You are required to respond to this letter and the enclosed Notice, and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to take 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 actions are needed to ensure compliance with regulatory requirements. Furthermore, we emphasize that any recurrence of these violations may result in more significant enforcement action. 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, AU William T. Russell Regional Administrator

Enclosure:

Notice of Violation cc w/ encl: Public Document Room Nuclear Safety Information Center (NSIC) Commonwealth of Pennsylvania NUREG-0940 II.B-2

NOTICE OF VIOLATION Allegheny General Hospital Docket No. 030-02981 Pittsburgh, Pennsylvania License No. 37-01317-01 EA 89-89 During an inspection conducted on February 21, 1989, violations of NRC require-ments were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13,1988) the particular violations are set forth below: A. 10 CFR 35.60(b) requires that licensees conspicuously label each syringe, or syringe radiation shield that contains a syringe with a radiopharma-ceutical, and that the label show the radiopharmaceutical name or its abbreviation, the clinical procedure to be performed, or the patient's name. Contrary to the above, on July 30, 1987, and October 13, 1988, syringes containing a radiopharmaceutical were not labeled in accordance with 10 CFR Part 35.60(b). Specifically, these syringes were labeled to show a clinical procedure which was not correct for the radiopharmaceutical contained in the syringes. Consequently, one patient in July 1987 and two patients in October 1988 were given radiopharmaceuticals different from the ones which had been prescribed, resulting in a diagnostic misadministration in each case. This is a Severity Level III violation. (Supplement VI) B. 10 CFR 20.207(a) requires that licensed materials stored in an unrestricted area be secured against unauthorized removal from the place of storage. 10 CFR Part 20.207(b) requires that materials not in storage be under constant surveillance and immediate control of the licensee. As defined in 10 CFR 20.3(a)(17), an unrestricted area is any area access to which is i not controlled by the licensee for purposes of protection of individuals from exposure to radiation and radioactive materials. Contrary to the above, for an indeterminate period of time prior to 1 l February 21, 1989, millicuries quantities of strontium-90 in the form of sealed sources were located in an office in the Calibration Laboratory,  ; an unrestricted area, and at the time, the office was unlocked and the l licensed material located therein was not under constant surveillance and immedirte control of the licensee. This is a Severity Level IV violation. (Supplement IV) 1 C. License Condition 20 requires, in part, that the licensee conducts its program in accordance with the procedures contained in the application dated October 25, 1983. Item 20 of the application includes the procedure entitled, " Therapeutic Use of Sealed Sources." Paragraph C 1 NUREG-0940 II.B-3

1 Notice of Vi lation 2 of this procedure requires that all individuals who handle sealed sources  ; be equipped with a TLD ring badge. j Contrary to the above, as of February 21, 1989, an individual physician who implanted brachytherapy sealed sources in patients routinely did not wear a TLD ring. badge while handling these sealed sources. This is a Severity Level IV violation. (Supplement VI) D. Condition 11.A of License No. 37-01317-01 limits the use, or supervision ' of use, of licensed material to individuals designated by the licensee's Radiation Safety Committee. ' Contrary to the above, as of February 21, 1989, licensed material in the' form of millicurie quantities of strontium-90 in sealed sources was used by an individual (for checking the response of ionization chambers), i and at the tiene, the individual was not designated by the licensee's ] Radiation Safety Committee for use of licensed material.  ! This is a Severity Level IV violation. Pursuant to the provisions of 10 CFR 2.201, Allegheny General Hospital (Licensee) is hereby required to submit a written statement or explanation to  ! the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within l 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 1 results achieved, (4) the corrective steps that will be taken to avoid further  ! violations,. and (5) the date when full compliance will be achieved. Considera-tion may be given to extending the response time for good cause shown. FOR THE NUCLEAR REGULATORY COMMISSION i William.T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania this M" day of May 1989 i NUREG-0940 II.B-4

UNITED STATES . [p* *80gk NUCLEAR REGULATORY COMMisslON i 7, nEciou n 5 f 799 MOOSEVELT RO AD GLEN ELLYN. ILUNOIS 401 M

'g
   .....                                   June 28, 1989 Docket No. 030-13274 License No. 21-17754-01 EA 89-97 Alpena General Hospital ATTN:     Mr. John A. McVeety Administrator 1501 W. Chisholm Street Alpena, MI 49707 Gentlemen:

SUBJECT:

NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 030-13274/89001(DRSS)) This refers to the inspection conducted on April 19, 1989, at Alpena General Hospital of activities authorized by NRC License No. 21-17754-01. The report of this inspection was sent to you on May 5, 1989. During the inspection, violations of NRC requirements were identified. On May 8, 1989, an enforcement conference was conducted by telephone with Mr. Al Moe, Assistant Administrator for Operations and other members of your staff and Mr. J. W. N. Hickey and other members of the NRC Region III staff. During the conference we discussed the violations, their causes, and your corrective actions. The violations which are described in the enclosed Notice of Violation include: (1) ordering a therapy dosage of iodine-131 without a written request from the physician who was going to perform the procedure, (2) failure of the Radiation Safety Committee to consistently meet at required intervals during 1984 through 1987, (3) failure to include a representative of the nursing service on the Radiation Safety Committee, (4) failure to consistently test a Capintec CRC-12 dose calibrator for instrument linearity at required intervals during 1984 and 1987, and (5) failure to measure the thyroid burden of an individual who helped prepare and administer a therapy dosage of iodine-131. An incident resulted from the violation that involved ordering a therapy dosage of iodine-131 without a written request (Violation A). On December 12, 1988, a patient was given a therapy dosage of 15.2 millicuries of iodine-131 although the patient's referring physician requested that a therapy dosage of 6 millicuries of iodine-131 be administered to the patient. We realize that a physician named as authorized user on your NRC license examined the patient and administered a dosage that he considered appropriate based on his evalustion of the patient. We are not questioning the medical evaluations and judgements made by the authorized user and the referring physician. However, the authorized user agreed that, had he known of the referring physician's request, he would likely have administered a dosage of 6 millicuries after discussing i the matter with the referring physician. As noted in the enclosed inspection i report, this problem was precipitated by the failure of a technologist to follow the procedures specified in your NRC license for ordering radioactive CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.B-5

Alpena General Hospital June 28, 1989 material. For therapeutic uses, these procedures require a written request from the physician who will perform the procedure. The written request must indicate the isotope, compound, and activity. The person who orders the therapeutic radioactive material must reference the physician's written request when placing the order. The incident described above demonstrates the seriousness of this breakdown in procedures required by your NRC license for ordering therapeutic quantities of radioactive material. Therefore, in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988) (Enforcement Policy), Violation A as described in the enclosed Notice is considered to be of significant regulatory concern and has been categorized at Severity Level III. Normally, a civil penalty is issued for a Severity Level III violation. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, I have decided that a civil penalty will not be issued in this case for the reasons below. The base civil penalty for a Severity Level III violation or problem is $2,500. The Enforcement Policy allows for mitigation of up to 100% of the base civil penalty on the basis of prior good performance. Your performance was good at the time of the last inspection in 1984 and appears to have improved in the recent past as evidenced by your identification and correction of some of the violations in the Notice. However, your performance declined between these times as indicated by these violations. Thus a reduction of only 50% has been applied on the basis of prior performance. The Enforcement Policy also allows a reduction of 50% based on your prompt identification and reporting of the event. The remaining escalation and mitigation factors in the Enforcement Policy were considered and no further adjustment is deemed appropriate. The NRC acknowledges that you promptly reported this event as a potential therapy misadministration even though you believed the event did not compromise the safety or well-being of the patient. We encourage you to continue reporting actual or suspected therapy misadministration, if any should occur in the future. This information is used by the NRC to identify the cause of the misadministration, ensure timely corrective action, ensure timely and proper followup medical care of the patient, if needed, and prevent recurrence. The NRC also uses this information to identify generic problems that may be attendant with misadministration cases. When such problems are identified, the NRC notifies all appropriate licensees so that prompt actions may be taken by them to avoid the same or a similar problem. 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 of the violations described in the NUREG-0940 II.B-6

Alpena General Hospital June 28, 1989 Notice. In addition, during the April 19, 1989 inspection, it was noted ) that your institution has experienced nine misadministration of diagnostic radiopharmaceuticals during the period May 16, 1981 through April 19, 1989. Although this is an average of only one diagnostic misadministration per year, you should review these events to determine whether there are common root causes and develop measures to improve performance. Therefore, in your response, describe what you have done or plan to do to improve performance in the quality assurance and quality control of administering radiopharmaceuticals 4 to patients. 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 enclosures will be placed in the NRC Public Document Room. The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. i Sincerely, h V A. Bert Dav s Regional Administrator [

Enclosures:

1. Notice of Violation

2. Inspection Report No. 030-13274/89001(DRSS)

NUREG-0940 II.B-7

J NOTICE OF VIOLATION i Alpena General Hospital Docket No. 030-13274 Alpena, Michigan License No. 21-17754-01 EA 89-97 During an NRC inspection conducted on April 19, 1989, violations of NRC requirements were identified. In accordance with the " General Statement of i 1 Folicy and Procedure for NRC Enforcement Actions, "10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13, 1988)," the violations are listed below: A. License Condition No. 17 requires that licensed material be possessed  ! and used in accordance with statements, representations, and procedures contained in an application dated April 13, 1983. The application requires that radioactive material be ordered in accordance with Appendix E of Regulatory Guide 10.8, October 1980. Item 2.b. of Appendix E requires that, when ordering materials for therapeutic uses, a written request indicating the isotope, compound, and activity be obtained from the physician who will perform the procedure; and that persons ordering materials for therapeutic uses reference the physician's written request when placing the order. Contrary to the above, on December 11, 1988, a technologist employed by the licensee ordered a dose of iodine-131 for therapeutic use without obtaining a written request from the physician who was going to perform the procedure. This is a Severity Level III violation (Supplement VI).  ; B. License Condition No. 17 requires that licensed material be possessed and'ased in accordance with statements, representations, and procedures contained in an application dated April 13, 1983. Item 7 of the application requires the licensee to follow the procedures'in Appendix B of Regulatory Guide 10.8, October 1980. Appendix B requires the Medical Isotopes Committee (Radiation Safety Committee) to meet as often as necessary to conduct its business, but not less than once in each calendar quarter. Contrary to the above, the Medical Isotopes Committee failed to meet during the third quarter of 1984, the first and second quarters of 1985, the third quarter of 1986, and the first and third quarters of 1987. 1 This is a Severity Level IV violation (Supplement VI). I NUREG-0940 II.B-8

Notice of Violation C. 10 CFR 35.22(a)(1) requires that the membership of the Radiation Safety Committee (RSC) include, among other individuals, a representative of the nursing service. Contrary to the above, as of April 19, 1989, the licensee's RSC membership did not include a representative of its nursing service. This is a Severity Level IV violation (Supplement VI). D. License Condition No. 17 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in an application dated April 13, 1983. Item 10 of the application requires the licensee to follow the procedures in Appendix D of Regulatory Guide 10.8, October 1980. Appendix D, Section 2, requires the licensee to test dose calibrators for linearity at installation and quarterly thereafter. Contrary to the above, the licensee's Capintec CRC-12 dose calibrator was not tested for linearity during the first, second, and third quarters of 1985 and during the first and fourth quarters of 1987. This is a Severity Level IV violation (Supplement VI). E. 10 CFR 35.315(a)(8) requires the licensee to measure the thyroid burden of each individual who helped prepare or administer a dosage of iodine-131 within three days after administering the dosage to a patient hospitalized for compliance with 10 CFR 35.75. Contrary to the above, the licensee failed to measure the thyroid burden of an individual who helped prepare and administer a dosage of iodine-131 on March 11, 1988, to a patient who was hospitalized for compliance with 10 CFR 35.75. This is a Severity Level IV violation (Supplement VI). Pursuant to the provisions of 10 CFR 2.201, Alpena General Hospital 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 III, U.S. Nuclear Regulatory Commission, 799 Roosevelt Road, Glen Ellyn, Illinois, 60137, within 30 days of the date of the letter transmitting this Notice. This reply should be clearly narked 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 NUREG-0940 11.B-9

l Notice of Violation . actions that have been taken and the results achieved; (3) the corrective actions that will be taken to avoid further violations, and (4) the date when full compliance will be achieved. Where good cause is shown, consideration will be given to extending the response time. If an adequate reply is not

          'aceived 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.

FOR THE NUCLEAR REGULATORY COMMISSION

                                                                                      .4 A. Bert D vis                                                                  J Regional Administrator                                                         !

Dated at Glen Ellyn, Illinois this' 2 5 day of June 1989. l l l l 1 l l l NUREG-0940 II.B-10 w-__-.__ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ - - - _ _ _ _ _ - _ _ _

   .*         o g                           NUCLEAR REGULATORY COMMISSION
              ,g                                        accion in

[ g E 799 ROOSEVELT RO AD 0, s. GLEN ELLYN ILLINOIS 60937

   "% ,,,,.

• May 24, 1989 Docket No. 030-02153 License No. 21-13367-01 EA 89-24 Zacharia Mikros, 0.0.

30730 Ford Road Garden City, MI 48135

SUBJECT:

NOTICE OF VIOLATION AND TERMINATION OF LICENSE (NRC INSPECTION REPORT NO. 030-02153/89001(DRSS)) Enclosed is a Notice of Violation and a Notice of Termination of your Byproduct Material License No. 21-13367-01. Since you requested to surrender your license,.no further response to the enclosed Notice of Violation is required. The violations described in the enclosed Notice of Violation demonstrate a significant breakdown in control of licensed activities warranting escalated enforcement action. If you had not requested termination of your license, NRC would have taken action to suspend and revoke it. 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 Document Room. Should you have any questions regarding this matter, please contact Dr. Bruce S. Mallett of the NRC Region III' office (312-790-5612). Sincerely, A A. Bert Davis Regional Administrator

Enclosures:

1. Notice of Violation

2. Notice of Termination of License

3. Inspection Report No. 030-02153/89001(DRSS)

4. License Amendment No. 08 dated 5/23/89 CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.B-11

l NOTICE OF VIOLATION Zacharia Mikros, 0.0. Docket No. 030-02153 30730 Ford Road License No. 21-13367-01 Garden City, MI 48135 EA 89-24 During an NRC inspection conducted during the period January 10-31, 1989, violations of NRC requirements were identified. In accordance with the 3

   " General Statement of Policy and Procedure for NRC Enforcement Actions,"

10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13,1988) (Enforcement Policy), the violations are listed below: A. License Condition No. 14 requires that the licensee conduct its program in accordance with statements, representations, and procedures contained in certain referenced documents, including the application dated May 30, 1985.

1. Item 15 of the application requires that radioactive materials be used in accordance with Appendix G of Regulatory Guide 10.8 (October 1980). Appendix G, Item 6.a. requires that each patient dose be assayed in the dose calibrator prior to administration.

Contrary to the above, the licensee has not, in all cases, assayed patient doses in the dose calibrator prior to administration. For example: six patient doses were administered on January 4,1989 and two patient doses were administered on January 10, 1989; however, none of these doses were assayed in the dose calibrator prior to administration.

2. Item 25 of the application requires that whole body as well

! as finger badges be used to monitor exposure to individuals handling radioactive material. In addition, Item 15 of the application requires that radioactive materials be used in accordance with Appendix G of Regulatory Guide 10.8 (October 1980). Appendix G, Item 7, requires that film badge or TLD personnel monitoring devices be worn at all times in areas where radioactive materials are used or stored. Appendix G, Item 8, requirc:s that TLD finger badges be worn during elution of generators and preparation, assay, and I injection of radiopharmaceuticals. Contrary to the above, as of January 10, 1989, four nurses employed by the licensee who routinely handle and inject radioactive material have not worn any whole body or finger personnel monitoring devices. NUREG-0940 II.E-12

Notice of Violation 3. Item 10 of the application requires that dose calibrators be calibrated in accordance with Appendix D of Regulatory Guide 10.8 (October 1980). Appendix D, Section 2.A, requires that dose calibrators be tested daily for instrument constancy, annually for instrument accuracy, and quarterly for instrument linearity. Appendix 0, Section 2.C48, requires that variations greater than t 5 percent from the predicted activity require instrument rapair or adjustment. Contrary to the above: (a) The licensee's Victoreen Rad / Cal dose calibrator was not tested for accuracy from May 1985 through January 1989 and was not tested for linearity from August 1984 through January 1989. This is a repeat violation. (b) Constancy tests performed on the dose calibrator on 13 occasions between November 2, 1988 and January 10, 1989 showed variations from predicted activity of greater than i 5 percent and repairs or adjustments were not made. For example: on January 4,1989, a test with a nominal 210 microcurie cesium-137 calibration source showed 276 microcuries and on January 10, 1989, a test with the same source showed 295 microcuries. Both test results represent variations of greater than 5 percent from the predicted activity of 210 microcuries and repairs or adjustments were not made.

4. Item 10 of the application requires that survey meters be calibrated in accordance with Appendix D of Regulatory Guide 10.8 (October 1980). Appendix D, Section A.3, requires that calibration of survey meters be performed et least annually and after servicing.

Contrary to the above, the licensee's Eon Corporation Survey meter was not calibrated from May 1985 through January 1989 and the Eberline Model E-120 survey meter was not calibrated from December 1986 through January 1989. This is a repeat violation. l S. Item 15 of the application requires that radioactive materials i be used in accordance with Appendix G of Regulatory Guide 10.8 (October 1980). Appendix G, Item 4, requires that syringe shields be used for administration of radioactive material to patients. NUREG-0940 II.B-13

i Notice of Violation Contrary to the above, nurses employed by the lict.nsee did not use syringe shields while administering radioactive material to , at least 25 patients during the period November 23, 1988 through  ! January 10, 1989. i

6. Item 15 of the application requires that radioactive materials  !

be used in accordance with Appendix G of Regulatory Guide 10.8 (October 1980). Appendix G, Item 3, requires that hands and l clothing be monitored for contamination after each procedure or before leaving the area. l Contrary to the above, individuals employed by the licensee failed to monitor their hands and clothing for contamination  ! after each procedure on at least 25 occasions during the period November 23, 1988 through January 10, 1989.

7. Item 17 of application requires that surveys be performed in accordance with Appendix I of Regulatory Guide 10.8 (October  :

1980). Appendix I, Item 1, requires that all elution, ' preparation, and injection areas be surveyed daily. Contrary to the above,'the licensee failed to survey injection i areas on December 21 and 28, 1988, and on January 10 and 11, 1989; and injections were performed by the licensee on those days. , This is a repeat violation.  ! B. 10 CFR 19.12 requires, in part, that all individuals working in or frequenting any portion of a restricted area be kept informed of l the storage, transfer, or use of radioactive materials and be instructed in the health protection problems associated with exposure to such radioactive materials or radiation, in precautions er procedures to minimize exposure, and in the purposes and functions of protective devices employed. Contrary to the above, as of January 10, 1989, four nurses employed by the licensee who routinely wor k in a restricted area and administer radioactive material to patients were not instructed in the health protection problems associated with exposure to such radioactive material or radiation, in precautions or procedures to minimize exposure, and in the purposes and functions of protective devices. C. 10 CFR 35.59(b)(2) requires, in part, that each sealed source be tested for leakage at intervals not to exceed six months. NUREG-0940 II.B-14

Notice of Violation Contrary to the above, a nominal 210 microcurie cesium-137 sealed source possessed by the licensee was not leak tested from September 1984 through January 1989. This is a repeat violation. D. 10 CFR 35.59(g) requires, in part, that the licensee conduct a quarterly physical inventory of all sealed sources in its possession. Contrary to the above, the licensee did not perform a physical inventory of sealed sources in its possession from September 1984 through January 1989. This is a repeat violation. Collectively, these violations have been classified as a Severity Level III prob 1cm (Supplement VI). FOR THE NUCLEAR REGULATORY COMMISSION A. Bert" Davis Regional Administrator Dated at 31en Ellyn, Illinois this g f day of May 1989~ l l NURE's 0940 II.B-15

UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION

                       ~

In the Matter of. )

                                             )

Zacharia Mikros, 0.0. ) Docket No 030-02153 30730 Ford Road ) License No. 21-13367-01 Garden City, Michigan ) EA 89-24 NOTICE OF TERMINATION OF LICENSE I Zacharia Mikros, 0.0. (the licensee) is the holder of Byproduct Material License No. 21-13367-01 issued by the Nuclear Regulatory Commission ("NRC" or " Commission") pursuant to 10 CFR Part 35. The license authorizes the licensee to conduct any diagnostic procedure listed in Groups I and II of Schedule A, Section 35.100 of 10 CFR Part 35 and in vitro studies at the licensee's facility located at 30730 Ford Road, Garden City, Michigan. The license was originally issued on August 7, 1969, was amended in its entirety on August 27, 1985, and is due to expire on August 31, 1990. II As a result of a routine safety inspection which was conducted by the NRC during the period January 10-31, 1989, the NRC identified apparent violations of regulatory requirements. These violations, more fully described in the i Notice of Violation istued this date, demonstrate a significant breakdown of. management control over licensed activities and include the'following: (1) failure to assay patient doses prior.to administration; (2) failure to provide personnel monitoring devices for nurses who injected radioactive NUREG-0940 II.B-3F,

material into patients;-(3) failure to perform accuracy and linearity tests ) on the dose calibrator and failure to make appropriate repairs'or adjustments when dose calibrator test results showed a variation of. greater than five. 4 I percent from the predicted activity; (4) failure to calibrate survey meters at required intervals; (5) failure to use syringe shields while administering radioactive material; (6) failure to monitor hands and clothing for contamination on at least 25 occasions in a 7 week period; (7) failure to perform area surveys as required; (8) failure to evaluate occupational doses to four individuals who routinely injected patients with radioactive material; (9) failure to instruct four 1r.dividuals who routinely work in a restricted O area in the health protection problems associated with exposure to radioactive material; (10) failure to leak test sealed sources at required intervals; and (11)failuretoperformaninventoryofsealedsourcesatrequiredint$ervals. The three violations that were identified during the last previous inspection on August 8, 1984 were also identified during the January 10-31, 1989 inspection and constitute repeat violations. These violations included: (1) failure to leak test sealed sources at required intervals; (2) failure to perform accuracy tests on the dose calibrator; and (3) failure to perform inventories of sealed sources at required intervals. During a January 25, 1989 telephone contact with the NRC Region III office, Dr. Mikros stated he had ceased performing nuclear medicine procedures and I would not resume, except for emergency procedures, until he had: (1) performed NUREG-0940 II . B-17

a linearity test, accuracy test, and geometrical variation test on the dose calibrator; (2) trained individuals who administer radioactive material to - patients; (3) obtained personnel monitoring devices for individuals who administer radioactive material to patients; (4) assured that all patient doses are assayed in a dose calibrator; (5) calibrated survey instruments; and (6) performed a leak test on sealed sources. These commitments by Dr. Mikros were documented in an NRC Confirmatory Action Letter, dated January 25, 1989. Dr. Mikros has not performed nuclear medicine procedures since January 25, 1989. An enforcement conference was scheduled to be held in the NRC Region III , 1 office on February 23, 1989, between Dr. Mikros and members of the NRC staff to discuss the January 10-31, 1989, inspection findings. On February 21, 1989 Dr. Mikros contacted the Region III office by telephone, stated that he was going ' i to retire soon, and requested that the enforcement conference be cancelled. This was followed by a letter dated February 23, 1989, in which Dr. Mikros stated he would surrender his license as of that date. The NRC Region III Licensing Section, in a letter dated March 21, 1989, informed Dr. Mikros that License No. 21-13367-01 could not be terminated until he had completed form NRC-314, had performed a close-out radiation survey of the facilities which he formerly used for nuclear medicine procedures, and had submitted this information to the NRC for approval. In NUREG-0940 11.B-18

                                      - 4'-

a telephone conversation with the NRC Region III licensing staff on April 28, 1989, Dr. Mikros stated that these activities would be completed within one week. This commitment was confirmed in a May 3, 1989 letter from NRC Region III to the licensee. On May 18, 1989 NRC Region III received the required information. III Accordingly, License No. 21-13367-01 is terminated in accordance with Amendment No. 08, dated May 23, 1989. FOR THE ' NUCLEAR REGULATORY COMMISSION A. Bert Davis Regional Administrator Dated gt. len Ellyn Illinois this A day of May 1989. NUREG-0940 II.B-19

c# "*% UNITED STATES ys '

                                                                   ,            NUCLEAR REGULATORY COMMISSION h..                 1 REGloN IV k ,.               [                 611 RYAN PLAZA DRIVE, SUITE 1000
                                                             ,,,                        ARUNGToN. TEXAS 76011 J.N I 41989 Docket No. 30-06388 License No. 41-00090-03 EA No. 89-84 i

Schlumberger Technology Corporation Schlumberger Limited ATTN: Mr. C. E. Racster Radiation Safety Officer 5000 Gulf Freeway P.O. Box 2175 Houston, Texas 77001 l Gentlemen:

SUBJECT:

NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 89-01) This is in reference to the NRC inspection conducted on January 10, 1989 at Schlumberger's Houston offices, to our, discussions with you on February 22 at the Nuclear Regulatory Commission (NRC) office in Arlington, Texas and to the enforcement conference conducted at the NRC office on April 28. The enforcement conference was conducted to discuss apparent violations of NRC requirements regarding Schlumberger's control of licensed radioactive material used in oil and gas well-logging tools. These apparent violations were based on information provided by Schlumberger to NRC in February 1989 regarding the company's failure to have included certain sealed radioactive sources in its inventory control system and the apparent loss and improper disposal of sealed sources. The material that your company cannot account for today includes three minitrons containing up to one curie of tritium and as many as 62 stabilization sources containing up to 50 microcuries of americium-241.. The vast majority of these sealed sources contained only small quantities of radioactive material (50microcuriesorless). Nonetheless, the NRC considers Schlumberger's inability to account for this material a significant regulatory concern in CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II . B-20

Schlumberger Technology Corporation that, as you suggested, it is likely that this material was improperly disposed of as normal trash. Therefore, in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, 53 Fed. Reg. 40019 (October 13,1988)(EnforcementPolicy),theviolationsin the enclosed Notice of Violation (Notice) involving material inventory and control hate been classified as a Severity Level III problem. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support, I have decided that a civil penalty will not be imposed in this case. In concluding that a civil penalty is not warranted, the following factors were weighed: The extended duration of these violations permits escalation of the base civil penalty by 100%; however, your identification and prompt reporting of the problem permits mitigation by 50%, your prompt and extensive corrective actions permit mitigation by 50%, and your prior good compliance record permits , mitigation by 100%. ) i The remaining violations in the Notice, involving a failure to conduct leak 1 tests and a failure to post required documents, have been classified at Severity Levels IV and V, respectively. We acknowledge that the loss of these sources occurred over nearly a decade and therefore amounts to only a small percentage of the sealed sources possessed by Schlumberger during this period. We also recognize the overall comprehensive-ness of your system for accounting for the licensed radioactive material in your possession and the extensive steps you took following the discovery of the violations referred to in this Notice to correct your errors and enhance your accountability system. 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 ycu plan to prevent recurrence. Af ter reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. 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. NUREG-0940 II.B-21

Schlumberger Technology Corporation 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. Sincerelf, , . .

                                                                                  \               .

L' t Robert D. Martin ht '7 Regional Administrator

Enclosure:

Notice of Violation cc: Texas Radiation Control Program Director NRC Public Document Room 2' l l NUREG-0940 II.B-22

NOTICE OF VIOLATION Schlumberger Technology Corporation Docket No. 30-06388/89-01 Houston, Texas License No. 42-00090-03 EA 89-84 During an NRC inspection conducted on January 10 and February 22, 1989, 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, 53 Fed. Reg. 40019 (October 13,1989),the violations are listed below: A. Violations Involving Inventory and Control of Material

1. Condition 16 of License No. 42-00090-03 required the licensee to conduct a physical inventory every 6 months to account for all sealed sources received and possessed under the license.

10 CFR 39.37 (effective July 14,1987), which supersedes Condition 16, requires each licensee to conduct a semiannual physical inventory to account for all licensed material received and possessed under the license.

a. Contrary to the above, since 1980 the licensee received approximately 300 logging tools containing americium-241 sealed sources and failed to inventory these sealed sources from the time they were received until the licensee recognized this problem in February 1989.

b. Contrary to the above, as of January 10, 1989, the licensee did not conduct a semiannual physical inventory to account fer certain sealed sources received and possessed under the license and relied instead on inventories performed by reviewing records.

For example, the licensee failed to conduct a physical inventory to account for a 0.5 curie tritium neutron generator from 1986 until the licensee discovered that the source was missing in January 1989.

2. 10 CFR 20.207(a) requires that licensed materials stored in an unrestricted area be secured against unauthorized removal from the place of storage. 10 CFR 20.207(b) requires that licensed materials in an unrestricted area and not in storage be tended under constant surveillance and immediate control of the licensee. As defined in 10 CFR 20.3(a)(17), an unrestricted area is any area access to which is not controlled by the licensee for purposes of protection of individuals from exposure to radiation and radioactive materials.

Contrary to the above, from 1980 to 1986 the licensee lost three tritium neutron generators to unrestricted areas such that they were not secured against unauthorized removal nor under the constant surveillance and immediate control of the licensee. These violations are considered collectively as a Severity Level III problem (Supplements IV and VI). NUREG-0940 II. B-23

Notice of Violation ) B. Other Violations

1. Condition 13 of License No. 42-00090-03 required, with exceptions not applicable here, that each sealed source containing licensed material be tested for leakage at intervals not to exceed six months.

Condition 13 was superseded by 10 CFR Part 39 (effective July 14, 1987). Specifically, 10 CFR 39.35(a) requires each licensee who uses a sealed source to have the source tested for leakage periodically and 10 CFR 39.35(c) specifies that each sealed source shall be tested at intervals not to exceed 6 months. Contrary to the above, since 1980 the licensee received approximately 260 logging tools containing 50-microcurie americium-241 sealed sources and did not leak test these sources until the licensee recognized the problem in February 1989. The licensee reported that the tools containing these sources had been in use during this period. This is a Severity Level IV violation (Supplement VI).

2. 10 CFR 19.11(a) reouires each licensee to post current copies of the license, license conditions, documents incorporated into the license by reference, and amendments thereto.

Contrary to the above, as of January 10, 1989, the licensee had not b posted or maintained a copy of a letter dated July 21, 1978, , incorporated by reference to License Condition 15 of Amendment No. 51 l dated December 13, 1988. This is a Severity Level V violation (Supplement VI). Pursuant to the provisions of 10 CFR 2.201, Schlumberger Technology Corporation 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, NRC Region IV, 611 Ryan Plaza Drive, Suite 1000, Arlington, Texas 76011, 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:

(2) the corrective steps that (1)thereasonfortheviolationifadmitted}thecorrectivestepsthatwillbe have been taken and the results achieved (3 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 c6use why the license should not be

 \
         *s
            } NUREG-0940                             II.B-24

Notice of Violation 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. 1 FOR THE FUCLEAR REGULATORY COMMISSION f-, T////,/i :/

                                                                  ).  '
                                                                            /

L/ n'll L.d { . v / L 7( H L- '" Robert D. Martin Regional Administrator Dated at Arlington, Texas, this m day oft 1989

                    , llw s

l NUREG-0940 II. B-25

NR f oxu 336 U.S. NUCLE AR fit GUL ATORY COMMISSION 1. EP R1 N ER

                                        "                                                                                                                                                                        ~

I2 ODE 2 BIBLIOGRAPHIC DATA SHEET ~~ ~"N " ISee irutructoons ort the reversel y [g_Q94g

2. TITLE AND SUBTITLE Vol . 8, No. 2 Enforcement Actions: Significant Actions Resolved Quarterly Progress Report 3. DATE REPORT PUBUSHED (April - June 1989) *~~ ma 1 l

September 1989 )

4. FIN OR GR ANT NUMBE R

5. AUTHOR (S) 6. TYPE OF REPORT Office of Enforcement Technical

1. PE R IOD COV E Rl D oncluswa corest 8P F RMI RG MZ AT ION - N AME AND ADDR ESS tir kRC. provm Dmsoon, Ortoce er Reeron. V.$ Nucker neguistorv Commuunon. and mennp ocorest or centractor. prove Office of Enforcement U.S. Nuclear Regulatory Commission Washington, DC 20555

9. O R NG ORG AN12 ATSON - N AME AND ADDR ESS too nRc. type "ume es usour". ir contractor. prove Nec Daism. orrece or Ree,on, v 5 wcuar Rogusatory commosuon.

Same as item 8.

10. SUPPLEMENT ARY NOTES

11. ABST R ACT (200 worm or hul This compilation summarizes significant enforcement actions that have been resolved during one quarterly period (April - June 1989) and includes copies of letters, Notices, and Orders sent by the Nuclear Regulatory l Commission to licensees with respect to these enforcement actions. Al so 1 included are a number of enforcement actions that had been previously resolved but not published in this NUREG. It is anticipated that the information in this publication will be widely disseminated to managers and employees engaged in activities licensed by the NRC, so that actions can be taken to improve safety by avoiding future violations similar to those described in this publication.

12. KE Y WORDS/DESCR :PT OR S /tdar woras or pnesses rner wm essier rewareners m socerins rne report.s is. avattAsets1 v s1 At tut =1 Technical Specifications, Radiographer, Quality Assurance, Ited Radiation Safety Program, Safety Evaluation ,,,,,,,,,,

Unclassified 1rr.,, Repo,o Unclassified

65. NUMBER OF PAGEb

16. PRICE NIC 708tM 33S O49) o u, $, GCgEnhmt hf PR1hijkG prr ICL 81969 241 590:00264

w W$h&h &g M M w@n$$ $ W & W?$% $w$ n%z&n$w$ h. - &h?k Mw Me';,? nA um w -w-%QQ. - K? 4 ggfWQLEApMGOLATORYCOMMISS10N3@R ~s Oph

                                                                                  --                                                                                                  .                               -                                                                              n                                                                      -

M, . p; V P M g gSP N g

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          ' g JMM                                                                ,

4W MMWASHWGTON$. 9,;A M S5.9 h, W, Wa ,ig 4Ws u > e;g

                                                                                                                                                 -m+                                                                                                                                  w                                                                                                           ,7M %~cp                                                          ,*                                                                                                                     w                                                           mmw, es                                                                                                                                                                                                             m ye                                                             mu v

.&yJA.p. t. g s N. aw b 4wg M p g m . sq m% .. o<MT$  % gh, e , s

                                                                                                                                                                                                                                                                                            /:..me,+ pn.,,A
                                                                                                                                                                                                                                                                                                                                                    -,4 mV 4

Wf t c.y

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         %v a, p d cp < r
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ~

1

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     ~

0 yf y mm s m?;.@w NI ~w c+ au &w{!W ..a p- il dwwwaw, pG kff Ol$y $hCthl&$WWN,lN w ..a m.. m. yltllxhW' ' -lk,;;m r

                                                                                                                                                                                                                                                                                                                                                                                                -N?~g.e        -
                                                                                                                                                                                                                                                                                                                                                                                                                             , <r J 'i                                                        .                          r aL ,1 h's                                     j

w. fjf.<

4:Q

gwy

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             .e w.t  l'
                                                                                                  .^. . fy,w Q                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         $d - m"*%m s
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  , ' , , fs ' t,;.s1 g.w%.                                              ff , yw((

h> ; @~ n < jA m vb@.q' r,snyg , y ~Of a ', Qh,q [s -%y$gQQ e - 7mge . 3

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  ,h, c     -

6 ~.w. m , , , s n p, f '. y

                 ..-.Que : g.- MJ y                                                                                                            eMo'                                     "'

a s . k(hI  % :mM + 1235S5139531 1 1AN1CJ1CYlAB1 t gg&;p @J DWm% M gh,%C,.K@g$ L,.- CE @ M JS NaC-CADM $[p; - j Q c a N w z.Jq.4N~ , h [4,CQ h, W, M@ w 4x m7- ho a .~ r sm, w ay w 31 v port. s e m :.:tal m. an_d 1 * % , g, 9 t

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          " #'y'                                        g
                                                                                                                            % if i t g. %                                                                        gs +*! TP3 P14-Nu9ta 7g:                                                                            e y

4

                                                                                                                                          %                  i                '                    4                 Lap                                               >

_33a y"9~ f' _4 i R"AF' b 44 M' u~.m. A@g g?@V , e#%

                                                                                                                                                   , .                 ~e ~h,                        - .~ >

iMECu"s 3 f ~e wmi%T% @ g, ot 20 m " ' m

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          ; gHpWMgghg q?

e w> #_9: g, ,. x,e 1-7 ec. de.,p a_.>

                                                           < &Ih$                 % g-, . v.,+y                                            g;',n., g,q.            . , $hn                          ggg ' .                                                             . q,
                                                                                                                                                                                                                                                                                                                                                                                                                                                              &.jg                         QX                                               ,~

• a v v .N f hN s< '

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    .m                                             g. l ,

ry. _; p. q g. sL. p .,1g([ .w seq d y(g

                                                                                                                                                                                                                                                                  ,                                   ,1                                    gp. .                   , ;                                            ,

sc f: y 1 s

                                                                                                                                                                                        .u,.                                                     , ,
                                                                                                                                                                                                                                                          %             ^.                        , ;

l I E ,l Qi L 1,M: ,'=c m&y . . . z, .  %.k.w , mtf A,a..._n, g,.,:y, . ; n 9 \ .

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          , p3              1

.A.. ;,f t ,v.4 mn,.,i a ,. ,. g .,

                                                                                                                                                                                                                                                                                                                                                                                                                                                              ,p_,,y,                                                        a                                                         g-                                                   , . , . ..                       ,-.m..                                        % ^)> >

c&. 4 >lJ .~.u.e. ,,

7. ,f

                                                                                                                                                                                                                                                                                                                   .,, jsp-.                                                                                                                                    . ..p m s Ep                                     e,,

m.. c

                                                                                                                                                                 -g f                   ...
                                                                                                                                                                                                                                                                                                                                                     ,                                                                                                                                                                                                               .r .                     y                                                                                       g.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     ",1..

s s.

                                                                                                                                                                                                                                                                                                                    -., p'                                                                                                                                                                                           !
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     , . ,;g>_                                                                                                                                                                                        f k
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         /5g h' v! g ;t                                                                                     ,y
                                                                                                                                                                                         ' 'g     ]f' q'                                                                                                                                                                                                 }i                                                                                                                                                                                                                          [

f , f g f,. .. r_ g. e'Yio t p* :, . 3

                                                                                                                                                                                                                                                                                                                                                                                                     .w                                                                                                                                                                                                                                              k i            ,;y,w                     (                                  ,.j,                   3                                Gc,1s.,;                                                                                          3             };,' ' g), '-                          s                                                                                                                                                                           1                                                                             j pgp.S.

4 S :.16,, g E;m q>,u_ t;#' , ,' '#' f M 4m G s[ 'a ,A q? s 1N i M'y.

                                                                                                                                                                                                             -A                 , 2,/ , A (yb. Md                                   gs v                          t 9,I 7                  i w,,:;       ... ~C.W
                                                                                                                                                                                                                                                                                                                                                                                                  . m'I                                 ,                             s
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 'W                           .-e; -@ ,

mn 4 a m.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   ' Q , M, W',       n.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             ,s 4.tl" gq y M [W '

r m'% a< ,- e

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             ] o
                                                                                                                                                                                                                                                                                                                                                                                                                                                               ' , , _w' l ", N;'                                                                                              ~,
                                                                                                                       ,{lf f~ l. )                                                                                      Nj'                                                                                                                                                                                                                                                                                                                                                                                                                 j, _                             ,

h $l h  % _ erb

                                                                      ;                                                                                                                                                                                              ,y Q av                   y
                                                                                                                                                                                                                                                                                                                                                                                   . . . ' I 'l1 m,                     w
                                                                                                                                                                                                                                                                                                                                                                                                                               ,,                                                                                            f!,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     ,                                        . . f. t   . y'                                                                            <m                                                     . 4 V-         -y p$lf j+wf                                                                                          UY. -                             N'.l.,wYhff ' Y                                                                           .m,              f, ,"                                (' ,                                    x.f k t 19 k

• Y k.. # u;_< ff khNa.,..$ hh: mul gu w f N '~ @j f>[w'f.Y .{sau$ w, v;.,$a~ #fp @s),.% w

                                                                                                             <                                                                                                                                 r wn                   i, ( 39id,:( s i
 ' %g"
.t.          g y

i .. ,w@M. . as, ,g n.W 1,6 . , .

                                                                                                                                                               .s 4,'p - 4 i < p r. s. - -y,                                                      g v:

s w eq m.. a

                                                                                                                                                                                                                                                                                                                  ,J w' em%.zp ,

NY.,y,s,gng@ )...'.p ts . A t 3,

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           '        e.m
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  ,M=.,

mij y m WE

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ,.e-%,.,%..ss     u                                                                                                          -
                                                                                                                                                                                                                                                                                                                                                                                                                                                                     . ; .3 , > ~:g w: i' , . , ,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           . s x m ,'

4.. 4, 'p g is 3 s e .

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                '. .agg; e&                                                                                                              qf                                          y x:ow o ,i gyg' vg &sO, V i
                                                                   @wtn                                                    ..,>                        syn                      +v                  - :n.                                    a                                                                                                                                                v                                                                                                                                                                                                                                                                        3 m                         g* wpykp i. w.. ap:;d(e r
- <                      w c%mg, v,

nmmm y t" hr ., 3., & gm w

                                                                                                                                                                                                                                             >qw m  g; %g,y , u s p ;p s y.".-   , p, m           m,g ,' <                                                                                                              m <w;                ;-g,y                                    eg n+

n em)na w +vi . mA ny ys o a.c s g;g wa a.p v p >g g a

                                                                                                                                                                                                                                                                                                                                   , - > ap_ :
                                                                                                                                                                                                              +

g  ; ;m%(s cqw.w.- s

s. n wm r .m -: . +

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           \

m e.m &. . a.n. ,- 6,i t w " '

    , y%y(s...ws                                                   W W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ;y%
                                                                                                                                                                                                                                                      < %?p'1                                                                                    a, J P.vW y %-cpm s                                                              4:/             .r
                                                                                                                                                                                                                                                                                                                      <                                                                                          }U n, =,ja yf.j,.                                                               ,"'sem                    3s ";p:b .                                                                                           W+4 .@. , .,s.                                                                    y',,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         ._;W .,,r yf                                                                                                                                                                                                                                                                                                                                                                                                                                             r
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ,o

$$m.,y..Q,5 Ra , .

                                                                        ,< ~' a wa-                                   gqq ,i                                                       tr                  N'S                0
                                                                                                                                                                                                                              ,f;@             ,
                                                                                                                                                                                                                                                                             "(                       !

wm g, .j a C,p . *, y s

                                                                                                                                                                                                                                                                                                                                                                                                                                                                $9               M
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          -d h
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               ,,, e
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ,1~-                        , ,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ,a AQ ,;g..,.(t ;p.                      .            '

s l(Q. d ..u y +f ' m i,s

m. , s. p' y,1 2N.it gc gu. . q ,.p a.,}. .y; a

                                                       ..                                                                                                              , , ,                                     s'                                                                                                                                                                                                                                                                                                                 3                                                          351 h[l/ i<&.A f 1,j %'                                                                                                j j 1
                                                                                                                                                     ~')                                                                j                         ,j,                          j              T.                                                                                        ..                                                                    / ,                                             , g y ..                                   ,y y;            gg,9u / {t_                            '
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           -                                                   'f                                    -y, g{k ,                                                                                                                                                   s Y &py

[ jp A.i. ; s ((M ' [{ SN [-G b ch,q  : , ,. , , ,} M ,

p nd.....,.-

h

                                                                                       ~H . < ,
                                                                                          "l'
                                                                                                                                                           ,ry
                                                                                                                                                                      ,i                ,q" u. ;. "~> N s l ';        .
                                                                                                                                                                                                                                8=

i H t . .' ,-

                                                                                                                                                                                                                                                                                                                                                                                                         >,' e.( ; g a a r]*,'j7 e'        I ts
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            ,                                   4 J. x . -     o y                          ce                                                                             e g.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               .O f,,,

_-), u S d,p) 30*,- , , ,

' - i j w3 b                                                                       'L,                                                                                                                                                                                                                                      -                                                                             -

t'h .l..','r.y ',: . n <e

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ,, [ 7,

• E ..a . .q g? " ,' ' ' , ' "- < ,

t.p-. e

o. 2 i 3.g- s ,. s 91 4,a

r , y.

                                                              ..'.k 9

i c

                                                                                                                                                         ' "       ,-                                                                                                                                                                                                                                        r v%i i           .e, c

si ,a.- yu. - k e

• t .yi .,<.w~ -

                          ,.Q _f, , , ~ r'
                                                                                                                      *a                                                                                                                                                                                                                                '

j[ }%,, [+ [' f A}_~ Q~ ) h, !m .u &m ,. ,.l , p

                                                                                                                                                                                                                                        '                                                                                                                                                                                    c l oG,                                   ,                                                                                                                            ,'
                                                                                                                                                                                                                                                                                                                    ,                ,                                                                                                                               , .j _:.                          r Qs , ,

w~ t

                                                                                                                                                                                                                                                                                                                                                                                        .n:                                                                                                                                                                                                 ~.,t vt                                                                                                                                                                                                                                                             ,

e , rp . . , r s in , s  ;, b

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       -Q"                                                     Opk                                < ,-j e t                                                       g     n            x                t
                                                                                                                                                                                                                                                                     ..b i .,                                                                                                                                                                                                                                                                                                                                                                              1
                                       )                        ,g t                . ,                                                                                                                                         ;r                                                      +                                                                   ,

s i ,

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               -9
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             , 4
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          . ;         s.g                                                        y .hs@I.:           "

3 W ,, 4 f , 6' ' s n ee :tc_. ..,on u .v .s .m . .q , , 1 7 6 14 i  ; ,

                                                                           , g.                                                       y                                                          Qf                                                                                >                                                                                                           >
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  ,r                ,                    s s                      y. , . . , , ,, m                                                                                                                 4,
                                                                 .. . -                                                                  .c                                                             .
                                                                                                                                                                                                                                                                                                                                             ,                    ,p                                                                                                                                                                                                                                                                      '

e t ,, c f,,

                                                                                                                                                                                                                                                                                                                                                                    .~3..

ik E

                                                                                                                                                                                                                                                                                                                                                                                                                                                                      ,                                                                                     [
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               ,q,                   ,.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   ,f.                                    y' t.7             t I;               #

[ i',

                                                                                '                                                                                                                                                                                                                                                                                                                                                                                                                                                                              i
                                                                           .(.,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        -

7,. ( .y

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       ,,i                                                              8i#                   s                                4            I
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       ; .                                                                           j
3-{.'
                                                                                                                                                                                        'I-                                                                                     g                                                                                                                                                  e'l,,                                                                          gl-(' .' k                                                   ,3        F                                ,--

I4 4

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 - ,(A 9st                                         :                                                                                                                                                                                                                                                                                                         p                                                                       (<                                                                                                       <.;g                                                                                                                                       y
                                                                                                                             ,./,,                                                                                          ,

3

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               >                                      s;h -                                 t                         ;
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   'r
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    .-                  s        .,s p' , 6v             y
         '                                                                                                                                                                                                         ;                                                                                                                                              P                t                     i                                                                                                                                                                                                                                                        i t
                                                                                                                                                                                .,': c                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          #

L i , <.w

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ' ,                                         ,I      1
           \           4                                                                                                        '                                                -

A 1 yk I -

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             %                   1 s                     a 1                                                   w, w
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     @y '
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         ,.                             f
                                                                                                                                                                                                                                                                                                                                                                                                                                      ,.:) i-                                                                                                                                                                                                                                                                                                                        ;

jpu

                                                                                                                                                                                     <                     ;p
                                                                                                                                                                                                                                                                                                                                     'L,                                                             ,

o. e q ., y e_ _ g 3

yyy wo,

                                             /                                                                                                                                                                                                          i                                                                                                                           i                                                                                                                                                                                                                                                          N, 'l , '                 I                                                                    -

J, i 4 { r .- c' ):o 'm. . t , '

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         ,,                                                                                                                                                                        a                                                              .
                            '(

n t j, t , .fs' - 5, %

                                             '_{l'q
                                                                           'y)                                                                                                                                    }                I                                                   -
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               \
         @' r,-                                                                                                                                                                                                                                                                 -f.
                                                                                                                                                                                                                                                                                                                                                            )                                          !             ,

w

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              .i.14                          Oy 3 u "
                                              .,i,i                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           4                                    -

r5 } t

                                           .'.c             'f-                                                                                                                                                                                                                                                                                                                                                      l                                                                                                   )                                                  yI             ,-.I                                                 "'

y,"- g

                                               .' ,                                                                           i s\.

t , ..;,

d: -, y '; . 4

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  ,.,d i g i ', #
                                                                                                                              .I ,                                                                                                                                                                                                                                                                                                                                                                       #t                                                                                                                                                    i n<                                                                                                                                                                                                                                                                                                                                        +
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         ..1             , < >                                                                                        , yn , c                                                                                                                                                     . ;

WD. 4

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ',js                         i                                                                                          4 .N 6
                                                                                                                                                                                                                                                                                                                                  .('
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           ;                        7                           ,

M, t ,ipr a, i 1

                                              ,                           ,i,                                                                                                                                                      ,.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                      .                                                                                                     i           y                <                                        a i; '                                   W ..                                               +               4 M.1
                                                                           \>                                                                                                                                             ,.3                      ,,.                                                                                                                                ..

p, , /- a s,[ y .. l 'j .-

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   ';-            ,.}                                                                             y - ' . , ,                                                                                     k I'
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   -'                                                                                                                                                         Q' [j' ' _

30 ,.. , i ' 4 w a I

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    *-, m,    b, - i s, a,                                                       .7,                               ss+ m.w-q                                                                                                                                                                                               p                                                                                                                                       i                                s
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         .9 :                   ,,                                               - e r                                                                                                                                                                                                                                                                                                                                                                                                                                                                            4
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        . ;4                       m y

n:} - .. .q,.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   , .s v >                                        ..

we, o,, 1:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ,tj; 4-                                   ,se...
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ,y                                 .L;. Or                    1 4 (                                                            r
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           . '- {-

m t Qs

                                                                                            ~'

dj " \ q.T f, - : ) :,  ! 1 I

• c f e, . . ks .',- t 4

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  -                                                                                4 Mi.:.                   5 9                    ,

w?...,t

                                                                                                                                                                          *'      g-I 1,
                                                                                                                                                                                                                                                                                                                                         ,,,+ .
                                                                                                                                                                                                                                                                                                                                             '],
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ,(             i                   )

c-,s 40 j.; ' n' .j.l ;gy

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         .';g. .

N'. N'[ t,j,'  ;  ; J j 'f, '/ M .L')g- ' ,g $ .-i Iff f-'r tr 5 , .

                                                                                                                                                                                                                 ,4 _,                                                                                                      ,,f                                                            4                                                     ,                                                                                                                                                                                                        " j'~'        n r.s
':Q                                                                                                                          J                           (
                                                                                                                                                             ,                                            { { ,h                                                                                                                                                                                               . , .'             >       b                                        j.                                                                                                                                                                                                                                           L, 9 .3- r< 'y" . q g ma s

yy  :, q __ , ' Q < 4- y ', , e

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ;. 4                                        g.q4 ty. m                        m m i                                                                                                                                                                                                                                  "

4 ,.B $v ; j y

,y,                              v n:y,
                                               ;7 s         u                                                                          ,                                    yJ.;. s          ,
                                                                                                                                                                                                                                      ,                                               s e                                                                                                                                                 , 'e i >                                         2' e                                                                        s Ta                                                                                                                                                                                                                                                                                                 i V-                                                               s                                                                                                                                                                                                                                      0 W,J 1                                     ' s '.
, ,                                                                       x
                                                                                    'f y                                              ,                                                                                                                                                                                                                                                                                                                                                                                                                         .,                                                                                                        y.7 4;
                 2                              4       l                      }ll'                                                                                    -.                                                                                                                                     '
                                                                                                                                                                                                                                                                                                                                                                                                                          '                                                                                                                                                                       <y                                                                                (3                                    s.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     ., f , "                                W j             y 1                                                                                                                                                                                                                                                                                                                                                                                                              1 4                               i           J.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       -'jy h                         ,IQ.
                                                                                                                                                                                                                                                                                                                                                                                                                                . o
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       ,        'f"h                 i
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         '\

p 4 i, s

s. e- i Y

                                                    ^         .i.,-
                                                                ?j                 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          t-             y                              ,i- .

y. 8 6 si y i.

                                                                                                                                                    ..,4,'

2 p t , 1 , j? k5 . M p ) / s > i > i k. . , c

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   .s
                     ^

g Y . g ,J._

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     );'

f k a7 i 4 rL'.

                   , w'
                      'I -4g j'!.,'                                                                                                                            sg   ,

g :.. -

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 ~r
                                                                                                                                                                                                                                                                                                                                                                                                                       - 3 ..i tc, g @

i!' yt I 4 ,.. b, s,

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             ..)'
         +                               s                                                        i
                                                                                                                             .,. 0j                                                                                                                                                                 11                                                                                                                                                                           }                                s
                                                                                                                                     ..                                       ..                                                                                                                                                                                                                                                                                                                                                  \
                                                                                                                                                                                                                                                                                                                                                                                                                                                   '                'b-                                                                                                                                                                                                                                                                      '

3 c

                                                                           \                                               .,[                               .' /4                   hi                                                                                                                                                                                                                                                                   t                                                                                                                                                                                                                                              ,[. I                                                                  k;
             %. s V.,;                 , L, Nt; 4                                                 ', i V.  .
                                                                                                                                                                 ,, i d.
                                                                                                                                                                                        - . e.'+;;.,i 4
                                                                                                                                                                                                                         .,a                                                                     <2

n. ,

                                                                                                                                                                                                                                                                                                                                                                                                                                          .s ,y. ;                                       1 9

a. , ' .:4-V .'

           ,0;.+                  i_                           :.                                                                              3                           y                                                                                                                                                                                                                                                                           ,'                                                                                         '

t'. . .J'lY',y i i( jg-t-'d 6.{'wL. - A' y / , f =' -

                                                                                                                                                                                                       '. } N .,"'f p                                                                                                                                                   5
                                                                                                                                                                                                                                                                                                                                                                                           < ,!%, tj..                                                                             ' u bi ( (                                                                                                                                .t.                                          .-                                 O                          i s           -

e 4 s - < nwg . gm a c' t,a ' y h, ? S}}