ML20238A890
| ML20238A890 | |
| Person / Time | |
|---|---|
| Issue date: | 08/31/1987 |
| From: | NRC OFFICE OF ENFORCEMENT (OE) |
| To: | |
| References | |
| NUREG-0940, NUREG-0940-V06-N02, NUREG-940, NUREG-940-V6-N2, NUDOCS 8709090464 | |
| Download: ML20238A890 (399) | |
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NUREG-0940 Vol. 6, No. 2 Enforcement Actions: Significant Actions Resolved Quarterly Progress Report April - June 1987 I ___ Minuscript Completed: August 1987 Date Published: August 1987 Offico of Enforcement U.S. Nuclear Regulatory Commission < Wcshington, DC 20555 l l
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ABSTRACT This compilation sunnarizes' significant enforcement actions that have been resolved during one quarterly period (April - June 1987) and includes copies of letters, Notices, and Orders sent by the Nuclear Regulatory-Commission ~to licensees with respect to these enforcement actions. It is anticipated.that the information in this publication will be widely__ disseminated to managers and employees engaged in activities licensed by the NRC, so that actions can be taken to improve safety by avoiding future violations similar to those described in this publication. NUREG-0940 iii i
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1 CONTENTS l: 8 1 ABSTRACT............................................................... -111 INTRODUCTION................................ 4.. ....................... 1 SUMMARIES.............................................................. 3 I.. REACTOR LICENSEES A. Civil Penalties'and Orders American Electric Power Service Corporation, Columbus, Ohio Indiana and Michigan Electric Company (D. C. Cook Nuclear Plant, Unit 2) EA 87-13.....................................................I.A-1 Arkansas Power and Light Company, Little Rock, Arkansas (Arkansas Nuclear One, Unit 1) EA 86-151....................................................I.A-7 Commonwealth Edison Company, Chicago, Illinois (Byron Nuclear Power Station, Unit 1) , EA 86-48....................................................I.A-27 Commonwealth Edison Company, Chicago, Illinois (Byron Nuclear Power Station,. Units I and 2) EA 86-87....................................................I.A-45 Commonwealth Edison Company, Chicago, Illinois (Byron Nuclear Power Station, Unit 1) EA 87-16....................................................I.A-58 Commonwealth Edison Company, Chicago, Illinois
- (Dresden Nuclear Power Station, Units 2 and 3)
EA 87-26....................................................I.A-63 Commonwealth Edison Company, Chicago, Illinois (DresdenNuclearPowerStation, Unit 3) EA 87-49....................................................I.A-74 Commonwealth Edison Company, Chicago, Illinois (Dresden Nuclear Power Station, Units 1, 2, and 3) EA 87-53....................................................I.A-79 Duke Power Company, Charlotte, North Carolina (Catawba Nuclear Station, Unit 2) EA 86-147...................................................I.A-82 i Duke Power Company, Charlotte, North Carolina (McGuire Nuclear Station, Units 1 and 2) EA 87-08...................................................I.A-10S NUREG-0940 v i
CONTENTS (continued) Page REACTORLICENSEES(CONTINUED) Florida Power and Light Company, Juno Beach, Florida (Turkey Point, Units 3 and 4) EA 87-40...................................................I.A-111 Florida Power Corporation, St. Petersburg, Florida j (Crystal River) EA 87-47...................................................I.A-114 Georgia Power Company, Atlanta, Georgia ( (Hatch Nuclear Plant, Units 1 and 2) l EA 87-27...................................................I.A-116 Niagara Mohawk Power Corporation, Syracuse, New York (Nine Mile Point, Unit 1) i EA 87-45...................................................I.A-123 Portland General Electric Comp 0ny, Portland, Oregon ] (Trojan Nuclear Power Plant) 1 EA 87-60...................................................I.A-132 l Power Authority of the State of New York, White Plains, New York l (James A. FitzPatrick Nuclear Power Plant) EA 87-48...................................................I.A-139 The Detroit Edison Company, Newport, Michigan ) (Fermi, Unit 2) ] EA 87-50...................................................I.A-146 University of Utah, Salt Lake City, Utah { E A 8 6 - 13 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . A- 15 5 j l University of Wisconsin, Madison, Wisconsin l EA 86-179..................................................I.A-177 ) l B. Severity Level III Violations, No Civil Penalty J Duke Power Company, Charlotte, North Carolina (0conee Station, Units 1, 2, and 3) ! EA 87-43.....................................................I.B-1 j Duke Power Company, Charlotte, North Carolina (Catawba, Units 1 and 2) EA87-57.....................................................I.B-5 Duquesne Light Company, Shippingport, Pennsylvania (Beaver Valley Nuclear Power Station, Unit 2) E A 8 6 - 19 0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . B - 9 NUREG-0940 vi
I CONTENTS (continued) Page
'REACTORLICENSEES(CONTINUED)
Georgia Power Company, Atlanta, Georgia (Edwin I. Hatch Nuclear Plant, Units 1 and 2 EA87-111....................................)...............I.B-14 Pennsylvania Power and Light Company, Allentown, Pennsylvania (Susquehanna Steam Electric Station, Units'I and 2 EA 85-112..........................................).........I.B-17 Public Service Electric and Gas Company,'Hancock's Bridge New Jersey (Salem Nuclear Generating Station, Unit 1 EA84-36.................................)...................I.B-23 Tennessee Valley Authority, Chattanooga, Tennessee (Sequoyah Nuclear Plant, Unit 2) E A 8 5 - 4 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . B- 28 Vermont Yankee Nuclear Power Corporation Brattleboro, Yermont (Vermont Yankee Nuclear Power Station) EA84-7.....................................................I.B-35 II. MATERIALS LICENSEES A. Civil Penalties and Orders Babcock and Wilcox Company, Lynchburg, Virginia EA 87-24....................................................II.A-1 Cintichem, Inc., Tuxedo, New York EA 8 7- 3 0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A - 10 Cleveland Clinic Foundation, Cleveland, Ohio E A 8 7- 4 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A- 17 Comdustrial Roofing Contractors, Inc., Hatfield, Penns E A 87- 54. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....II.A-22 . . . . . . . . .yl v a n i a E. I. duPont.de Nemours and Company, Inc., Boston, Massachusetts EA 87-69...................................................II.A-27 l Grede Foundries, Inc., Milwaukee, Wisconsin 1 EA 8 6 - 2 01. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . A- 3 2 HCA Riverton Hospital, Riverton, Wyomin E A 8 6 - 18 5 . . . . . . . . . . . . . . . . . . . . . . . . . . ....................II.A-40
....g Hurley Medica. Center, Flint, Michigan EA 85-19...................................................II.A-53 NUREG-0940 vii
CONTENTS (continued)
. Page MATERIALSLICENSEES(CONTINUED)
Mercy Hospital, Port Huron, Michigan ! EA 87-21...................................................II.A-79 i Nurrie Construction Company, Muskogee, 0klahoma . j EA G6-152..................................................II.A-91 - PTL-Inspectorate, Inc., Pittsburgh, Pennsylvania EA 87-65..................................................II.A-108 1 Rappahannock General, Hospital, Kilmarnock, Virginia , EA 87-34..................................................II.A-114 i University of Missouri, Columbia,' Missouri EA 86-191.................................................II.A-119
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Yellowstone County Surveyor's Office, Billings, Montana EA 86-198.................................................II,A-137 B. Severity Level III Violations, No Civil Penalty Tracer Profiles, Inc., Oklahoma City, Oklahoma E A 8 7 - 91. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . B - 1 l l l NUREG-0940 viii
i i ENFORCEMENT ACTIONS: SIGNIFICANT ACTIONS RESOLVED f April - June 1987 ; INTRODUCTION This issue of NUREG-0940 is being published to inform NRC licensees about significant enforcement actions and their resolution for the first quarter of 1987. On April 12, 1987, the Office of Inspection and Enforcement was abolished as part of the NRC staff reorganization. Enforcement actions are issued by the Deputy Executive Director for Regional Operations (DEDRO) and the Regional Administrator. The Director, Office of Enforcement, may act for the DEDR0 in the absence of the DEDR0 or as directed. Primarily emphasized are those actions involving civil penalties and Orders that have been issued by the Director of the Office of Inspection and Enforcement (now DEDR0 or Director, Office of Enforcement) and the Regional Administrators. An objective of the NRC Enforcement Program is to encourage improvement of a licensee performance and, by example, the performance of the licensed industry. Therefore, it is anticipated that the information in this publication will be widely disseminated to managers and employees engaged in activities licensed by NRC, so all can learn from the errors of others, i thus improving performance in the nuclear industr.y and promoting the public i health and safety as well as common defense and srcurity. A brief summary of each significant enforcement action that has been resolved in the second quarter of 1987 can be found in the section of this report entitled, " Summaries." Each summary provides the enforcement action (EA) I norMr to identify the case for reference purposes. The supplement number refers to the activity area in which the violations are classified according to guidance furnished in the U.S. Nuclear Regulatory Commission's " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Ptrt 2 Appendix C (1987). 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 l copies of Notices of Violations that have been issued to reactor licensees for ! Severity Level III violations but for which no civil penalty was astessed. I Part II.A contains civil penalty or order actions involving materials licensees. j i I l NUREG-0NO 1 l _ _ - - - _ - - - - - - - - - - - - - - - - - - -- - - - - - - - 1
r -Part II.B includes copies of Notices of Violations that have been issued to materials licensees for Severity Level III violations but for which no civil 1 penalty was assessed. Actions still pending on June 30, 1987 will be included in future issues of j this publication when they have been resolved. 1 1 4 I NUREG-0940 2
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, m SUMMARIES j I. REACTOR LICENSEES 1
A. Civil Penalties and Orders American Electric Power Service Corporation, Columbus, Ohio Indiana er.d Michigan Electric Company j (D. C. Cook Nuclear Plant, Unit 2) EA 87-13, Supplement I ' A Notice of Violation and Proposed Imposition of C Nil Penalty in the amount of $50,000 was issued March 12, 1987 based on violations involving the licensee's operations staff rendering both Unit 2 independent emergency core cooling system subsystems not operable while operating in Mode 1, in violation of the Technical Specifica- i tion Limiting Condition for Operations. The licensee responded and paid the civil penalty on April 10, 1987. Arkansas Power and Light Company, Little Rock, Arkansas ; (Arkansas Nuclear One, Unit 1) EA 86-151, Supplement I i A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued November 12, 1986 based on violations ! identified during the NRC's Safety System Functional Inspection. The 1 most significant violation involved the modification of the steam ' supply lines to the turbine-driven emergency feedwater pump. The actual implementation of the modification deleted check valves without a proper design review and evaluation. The licensee responded on December 12, 1986 admitting the violation but citing certain factors mitigating the seriousness of the violation. After reviewing the licensee's resoonse, an Order Imposing a Civil Pensity was issued June 1, 1987. The licensee paid the civil penalty on June 25, 1987. Commonwealth Edisou Company, Chicago, Illinois (Byron Nuclear Power Station, Unit 1) EA 86-48, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $100,000 was issued May 6, 1986 based on violations i involving (1) the use of surveillance procedures that contained 1 l incorrect valve alignments for the residual heat removal system j l (RHRS) that resulted in neither train of the RHRS being able to 1 inject into the four legs of the reactor coolant system, and I l (2) several examples of the licensee's failure to understand j technical specifications, system operability, and associated action j statements. The licensee responded July 3, 1986 paying the civil ! penalty for the second violation and requesting mitigation of the ! civil penalty for the first violation. After reviewing the licensee's i response, an Order Imposing a Civil Penalty was issued February 26, 1987. The licensee paid the civil penalty on April 27, 1987. NUREG-0940 3
Commonwealth Edison Company, Chicago, Illinois (Byron Nuclear Power Station, Units 1 and 2) EA 86-87, Supplement VII A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,C00 was issued June 25, 1986 based on a violation of 10 CFR 50.7 in which Transco Products, Inc., a subcontractor of the licensee, discharged an employee for reporting to the NRC Transco's inadequate inspection procedures and the installation of non-radiation-proof seals at the licensee's Byron Nuclear Power Statien. The matter was investigated by DOL and an administrative law judge ruled in favor of the employee. The matter was settled prior to a decision by the Secretary of Labor. The base civil penalty was reduced by 50 percent because of the licensee's prior good l performance, the isolated nature of the incident, and the corrective i actions taken by the licensee. The licensee responded on July 29, I 1986 requesting total mitigation of the civil penalty. After reviewing the licensee's response, an Order Imposing a Civil Penalty , was issued April 2, 1987. The licensee paid the civil penalty on l April 27, 1987. ' Commonwealth Edison Company, Chicago, Illinois (Byron Nuclear Power Station, Unit 1) EA 87-16, Supplement I 1 A Notice of Violation and Proposed Imposition of Civil Fenalty in the amount of $50,000 was issued March 26, 1987 based on a violation involving the failure to obtain prior NRC approval of a change in acceptance criteria for a reactor coolant flow coastdown test from that described in the FSAR. The licensee responded and paid the civil penalty on April 24, 1987. Commonwealth Edison Company, Chicago, Illinois (Dresden Nuclear Power Station, Units 2 and 3) EA 87-26, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued April 23, 1987 based on violations, when evaluated collectively, identify a significant weakness in the control of plant modifications. Theseincluded(1)designchange control, (2) installation of equipment, (3) procedures and instruc-tions, (4) QA/QC overview of modification activities, (5) corrective action implementation, and (6) control of testing. The civil penalty was mitigated by 50 percent because of the unusually ptompt and extensive corrective actions taken to prevent recurrence and upgrade I the overall modification process and management controls. The licensee paid the civil penalty on May 22, 1987 with a partial response. The full response was made June 23, 1987. Commonwealth Edison Company, Chicago, Illinois (Dresden Nuclear Power Station, Unit 3) EA 87-49, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $25,000 was issued April 24, 1987 based on the failure to maintain primary containment integrity when the reactor water temperature went above 212*F. The civil penalty was reduced by 50 percent because of the licensee's unusually prompt and extensive corrective actions that included (1) disciplining individuals directly NUREG-0940 4
l 1 i involved in the event, (2) revising plant cooldown procedures, (3) relieving licensed operators from work activities not related to their primary function, and (4) implementing an Error Free Operation Program. The licensee responded and paid the civil penalty on May 22, 1987. Commonwealth Edison Company, Chicago, Illinois (Dresden Nuclear Power Station, Units 1, 2, and 3) EA 87-53, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued May 13, 1987 based on a violation involving the failure to ensure the integrity of the protected area barrier. The licensee responded and paid the civil penalty on June 12, 1987. Duke Power Company, Charlotte, North Carolina (Catawba Nuclear Station, Units 1 and 2) EA 86-147, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued November 12, 1987 based on violations of NRC requirements associated with the June 27, 1986 depressurization event during a loss of control room test. The violations involved the failure to change plant procedures when components were modified, inadequate human factors considerations for changes to control panels that resulted in the inadequate labeling and marking of components, and deficient procedures that lacked specific test termination criteria and caused incorrect valve settings. The licensee responded ' on December 12, 1986 admitting the first violation but denying the first two of three examples of the second violation. The licensee i requested reduction of the severity level of the violation and j remission of the civil penalty. After reviewing the licensee's l' response, an Order Imposing a Civil Penalty was issued April 14, 1987. The licensee paid the civil penalty on May 11, 1987. Duke Power Company, Charlotte, North Carolina l (McGuire Nuclear Station, Units 1 and 2) EA 87-08, Supplement I j A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued March 6, 1987 based on violations involving (1) failure to establish and maintain the operability l of the nuclear service water system, (2) performance of an l inadequate 10 CFR 50.59 evaluation used to justify cross-connecting the nuclear service water system, (3) inadequate test performance, i and (4) evaluation and failure to establish and implement adequate procedures associated with the nuclear service water system. The licensee responded and paid the civil penalty on April 3, 1987. Florida Power and light Compeny, Juno Beach, Florida (Turkey Point, Units 3 and 4) U 87-40, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $75,000 was issued April 21, 1987 based on two separate fmC-identified violations of the Physical Security Plan involving a security guard asleep on duty and an unescorted visitor NUREG-0940 5
in a. vital area. .The base civil penalty was increased by 50 percent because of the licensee's prior poor performance in the area of concern and prior notice of similar problems. The licensee responded and paid the civil penalty on May 14, 1987. Florida Pcwer Corporation ~, St. Petersburg, Florida (Crystal River) EA 87-47, Supplement III A Notice of Violation and Proposed Imposition of Civil Penalty in i the amount of $50,000 was issued April 22, 1987 based on two ' violations of the Physical Security Plan involving a security guard asleep on duty and failure of security guards to check security badge l authorizations against the access authorization list for facility j personnel entering several vital area portals. The licensee responded ) and paid the civil penalty on May 20, 1987. j 1 Georgia Power Company, Atlanta, Georgia (Hatch Nuclear Plant, Units 1 and 2) EA 87-27, Supplement I
. A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued April 8,1987 based on failure to follow procedures that resulted in the loss of approximately 141,000 gallons of water from the spent fuel pool transfer canal seals. These were (1) closing of the one valve supplying air to the fuel transfer canal' )
seals and (2) calibration of the. transfer canal leak detection switch. ' The licensee responded and paid the civil penalty on May 8, 1987. Niagara Mohawk Power Corporation Syracuse, New York (Nine Mile Point, Unit 1) EA 87-45, Supplements I and IV A Notice of Violation and Proposed Imposition of Civil Penalty in I the amount of $50,000 was issued April 29, 1987 based on violations involving (1) numerous examples of failure to follow station procedures, (2) failure to evaluate test results, and (3) failure to perform an adequate radiation survey and provide adequate radiation surveillance. The licensee responded and paid the civil penalty on May 19, 1987. Portland General Electric Company, Portland, Oregon I (Trojan Nuclear Power Plant) EA 87-60, Supplement IV i A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 was issued June 4,1987 based on violations involving failure to (1) establish and implement radiation protection procedures, (2) train workers, (3) perform radiation surveys, and (4) maintain records of radiation survey results. The licensee responded and paid the civil penalty on June 30, 1987. ' Power Authority of the State of New York, White Plains, New York (James A. FitzPatrick Nuc' ear Power Plant) EA 87-48, Supplement IV A Notice of Violation and Proposed In: position of Civil Penalty in the amount of $75,000 was issued April 22, 1987 based on violations associated with an unplanned radiation exposure on February 13, 1987 l NUREG-0940 6
i of 30.27 rem in one calendar quarter to the right hand of a , contractor employee. Although the penalty could have been increased 1 100 percent because of the licensee's repeated failure to assure I adherence to procedures and failure to implement adequate corrective action for the previously identified similar violations, the penalty was only escalated by 50 percent in recognition of the licensee's prompt and extensive corrective actions after the overexposure was identified. The licensee paid the civil penalty on May 21, 1987. The Detroit Edison Company, Newport, Michigan (Fermi, Unit 2) EA 87-50, Supplement I A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $100,000 was issued on May 14, 1987 based on violations involving (1) the lack of control of plant equipment availability during testing activities, (2) inadeouate scheduling of a surveillance test, and (3) deficiencies in test procedures and personnel errors in the performance of test activities. The civil penalty was increased i by 100 percent because of (1) the licensee's prior poor performance in the surveillance testing areas and (2) the licensee's incomplete corrective actions to prevent recurrence. The licensee responded and paid the civil penalty on June 12, 1987. University of Utah, Salt Lake City, Utah EA 86-136. Supplements I, III, IV, and V A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $3,000 was issued October 6, 1986 bated on violations involving (1) radioactive material being transported without shipping papers, proper labeling or radiological surveys to determine external radiation or contamination limits, (2) failure to perform adequate surveys and maintain control of TRIGA reacter core com-ponent. (3) the Physical Security Plan, and (4) the operation of the TRIGA reactor. The ifcensee responded in two letters dated October 29, 1986. After reviewing the licensee's response, an Order Imposing Civil Penalties was issued March 13, 1987. The licensee paid the civil penalties on March 30, 1987. University of Wisconsin, Madison, Wisconsin EA 86-179, Supplement IV A Notice of Violation and Proposed Imposition of Civil Penalty in the l amount of $1,250 was issued December 11, 1986 based on violations l involving failure to conduct appropriate radiological surveys during the course of an experiment and the loss of licensed material. The penalty was reduced by 50 percent because of the licensee's prompt l and extensive corrective actions. The licensee responded in a letter dated January 6, 1987 requesting further mitigation of the penalty. After reviewing the licensee's response, an Order Imposing a Civil Penalty was issued May 7, 1987. The licensee paid the penalty on May 14, 1987. NUREG-0940 7 l l 3 i
l l B. Severity Level III Violations, No Civil Penalty l Duke Power Company, Charlotte, North Carolina (0conee Station, Units 1, 2, and 3) EA 87-43, Supplement I A Notice of Violation war issued May 5,1987 based on violations involving a failure to. provide the alternate shutdown capability with the required independence of cabling for reactor coolant letdown valves. A civil penalty was not proposed because of the licensee's unusually prompt and extensive corrective actions to prevent recurrence and the licensee's prior performance in the area of fire protection. Duke Power Company, Charlotte, North Carolina f (Catawba, Units 1 and 2) EA 87-57, Supplement I A Notice of Violation was issued May 15, 1987 involving failures in ! the design control process. In the first example, because curbs had g not been specified on the design drawir,gs, the units have operated . since initial startup with containment air return fans that would be l susceptible to flooding and degraded operation under postulated loss- i of-coolant accident conditions. In the second example, due to unclear design drawings, one of two required pressurizer power operated relief ; valves was connected incorrectly to the backup nitrogen supply and would not have operated under certain postulated conditions. A civil 1 penalty was not proposed because the licensee's staff promptly reported ! the violations and prompt actions were taken to comply with appropriate Technical Specifications. l Duquesne Light Company, Shippingport, Pennsylvania J (Beaver Valley Nuclear Power Station, Unit 2) EA 86-190, Supplement II l A Notice of Violation was issued April 28, 1987 based on a violation l of NRC reporting requirement. An error was identified in the Westinghouse 7300 Process Protection System involving deficient Temperature Channel Test circuit cards in 1983 and the NRC was not notified until approximately 20 months later. After consultation with the Commission a civil penalty was not proposed because (1) written reports were made to the NRC, although untimely, (2) description of corrective actions was inadequate, the specific problems were promptly corrected when identified, and (3) this appeared to be an isolated occurrence based on the licensee's history of reporting. Georgia Power Company, Atlanta, Georgia (Edwin I. Hatch Nuclear Plant) EA 87-111 Supplement V A Notice of Violation was issued June 29, 1987 based on a violation i involving the shipment of two metal boxes of radioactive material I with radiation levels in excess of 1000 millirem per hour on the ! surface of the package. A civil penalty was not proposed because l a civil penalty had already been assessed by the State of South l Carolina, l l l NUREG-0940 0
Pennsylvania Power and Light Company, Allentown, Pennsylvania (Susquehanna Steam Electric Station, Units 1 and 2) EA 85-112, Supplement III . 1 A Notice of Violation was issued June 15, 1987 based on violations involving the failure to provide adequate fire protection features ! for systems necessary to achieve and maintein hot shutdown as required ! by the licensae's license. A civil penalty was not proposed because of the apparent lack of clarity regarding the fire protection require-ments, the-significant time that has elapsed since the inspection and the licensee's prompt action after the violations were identified. Public Service Electric and Gas Company, Hancock's Bridge, New Jersey (Salem Nuclear Genersting Station, Unit 1) EA 84-36, Supplement I A Notice of Violation was issued June 15, 1987 based on violations involving the failure to provide adequate fire protection features for systems necessary to achieve 'and maintain hot shutdown as required for redundant equipment located outside the primary containment. A civil penalty was not proposed Decau:e of the apparent lack of clarity regarding the fire protection requirements and the significant time that has elapsed since the inspection occurred. Tennessee Valley Authority, Chattanooga, Tennessee (Sequoyah Nuclear Plant, Unit 2) EA 85-48, Supplement I A Notice of Violation was issued June 8,1987 based on violations involving numerous examples in which both trains of redundant hot shutdown system could have been rendered inoperable in the event of a fire. A civil penalty was not proposed because of the apparent lack of clarity regarding the fire protection requirements and the significant time that has elapsed since the inspection occurred. Vermont Yankee Nuclear Power Corporation Brattleboro, Vermont (Vermont Yankee Nuclear Power Station) EA 84-7, Supplement I A Notice of Violation was issued June 15, 1987 based on violations involving several examples of the failure to provide adequate fire protection features for systems and electrical cabling necessary to achieve and maintain hot shutdown as required for redundant equipment located outside the primary containment. A civil penalty was not proposed because of the apparent lack of clarity regarding the fire protection requirements and the significant time that has elapsed since the inspection occurred. II. MATERIALS LICENSEES A. Civil Penalties and Orders Babcock and Wilcox Company, Lynchburg, Virginia EA 87-24, Supplements IV and VI A Notice of Violation and Proposed Imposition of Civil Penalty in the f amcunt of $6,250 was issued March 13, 1986 based on violations involving l NUREG-0940 9
l { l the failure to (1) perform adequate surveys. (2) meet license and procedural requirements for contamination surveys, (3) meet requirements for fixed air samples, (4) perform required audits, (5) calibrate instruments, (6) meet requirements for protective clothing, (7) post an airborne radioactivity area, (8) adequately train radiation workers, and (9) label radioactive material containers leaving the restricted area. The penalty was reduced by 50 percent because .of the licensee's unusually prompt and extensive corrective actions. The licensee responded and paid the civil penalty on April 8, 1987. Cintichem, Inc., Tuxedo, New York j EA 87-30, Supplements IV and VI . 1 A Notice of Violation and Proposed Imposition of Civil Penalty in the l amount $12,500 was issued March 26, 1937 based on violations involving ! the accumulated radiation exposure of 21.453 rem to the left hand of i a maintenance worker who was handling equipment contaminated with , radioactive material. The majority of the accumulated exposure was received by the worker while he performed maintenance on mechanical manipulator hands removed from the hot cells for repair. The licensee responded and paid the civil penalty on April 23, 1987. ' Cleveland Clinic Foundation, Cleveland Ohio EA 87-42, Supplement VI A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $2,500 was issued April 15, 1987 based on violations involving failure to (1) make a timely notification to the NRC regarding a - therapeutic misadministration, and (2) obtain approval of the Radio-isotope Committee for physicians to use licensed material. The licensee responded and paid the civil penalty on May 14, 1987. Comdustrial Roofing Contractors, Inc., Hatfield, Pennsylvania l EA 87-54, Supplement IV A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $500 was issued May 4, 1987 based en violations involving i the unauthorized storage of a moisture density gauge containino licensed l mater 41 and the failure to secure the gauge against unauthorized ' removal from the place of storage. The licensee responded and paid ) the civil peralty on May 21, 1987. I I E. I. duPont de Nemours and Company, Inc., Boston, Massachusetts l EA 87-69, Supplements IV and VI A Notice of Violation and Proposed Irrposition of Civil Penalty in the i amount of $12,500 was issued May 28, 1987 based on en incident in j l which an individual did not follow the licensee's procedures and as i a result received an overexposure to a small area of tnc left thurrb. ! The overexposure occurred when the technologist used his hand, rather j than a remote handling device, to remove the cap from a vial centeining 2 approximately 300 millicuries of molybdenum-99/ technetium-99m. The i licensee responded and paid the civil penalty on June 22, 1987. ) i l NUREG-0940 10 :
i Grede Foundries, Inc., Milwaukee, Wisconsin EA 86-201, Supplements VI and VII A Notice of Violation and Proposed Imposition of Civil Penalties and l Demand for Information in the amount of $7,500 was issued April 1, 1987 based on violations involving inaccurate statements in two letters to the NRC. The civil penalty was increased by 50 percent because of taultiple examples of an unauthorized individual performing radiographic exposures. The licensee responded and paid the civil penalty on j April 14, 1987. ! HCA Riverton Hospital, P.iverton, Wyoming EA 86-185, Supplement VI A Notice of Violation and Proposed Imposition of Civil Penalty in the l amount of $2,500 was issued January 21, 1987 based on violations involving the failure to (1) restrict use of licensed materials to qualified and authorized users, and (2) properly follow assay procedures for molybdenum-99/ technetium-99m generators. The licensee responded in letters dated February 12 and 13.1987. After reviewing the licensee's response an Orcer Imposi y a Civil Penalty was issued June 11, 1987. The licensee paid the civil penalty on June 19, 1987. Hurley Medical Center, Flint, Michigan EA 85-89, Supplements IV, V, and VI A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $2,500 was issued August 22, 1985 based on violations involving (1) using licensed material in an unauthorized location, (2) improper disposal of licensed materials, and (3) failure to perform surveys. The licensee responded on October 4, 1985 and after reviewing the response an Order Imposing Civil Penalties was issued February 24, 1986. The licensee requested a hearing on March 13, 1986. The decision from the hearing by the Administrative Law Judge upheld the civil penalties and the licensee paid the civil penalties on April 2, 1987. l Mercy Hospital Port Huron, Michigan j EA 87-21, Supplements IV and VI t A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $2,500 was issued March 9,1987 based on violations involving failure to (1) perform bioassays. (2) perform instrument calibration tests, (3) perform leak tests, and (4) maintain proper records. The licensee responded on April 6, 1967 and after reviewing l the response, an Order Imposing a Civil Penalty was issued June 1, 1987. The licensee paid the civil penalty on June 11, 1987. Nurrie Construction Company, Muskogee, Oklahoma EA 86-152 Supplements IV, V, and VI l A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $500 was issued October 31, 1986 based on violations NUREG-0940 . _ _ - ._ _ _ _ _ _ _ - _ -
i l l involving the failure to (1) leak test a sealed source, (2) conduct inventories of licensed material (3) maintain shipping package performance test records, (4) use shipping papers during trans- J portation of licensed material, (5) use an authorized Radiation ! Protection Officer, (6) use persnnnel dosimetry, (7) maintain i security of radioactive material, (8) maintain complete dosimetry records, and (9) maintain receipt records of licensed radioactive , materials. The licensee responded in a letter dated November 18, 1986. i After reviewing the response, it was determined that two of the nine I violations did not occur and the civil penalty was reduced by 25 percent. An Order Imposing a Civil Penalty in the amount of $388 i was issued May 7, 1987. The licensee paid the civil penalty on i June 10, 1987. PTL-Inspectorate Inc., Pittsburgh, Pennsylvania N 87-65, Supplement IV A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $5,000 was issued May 21, 1987 based on violations involving (1) the failure to maintain direct surveillance of a high radiation area at a temporary field site, resulting in an individual entering the area while a radiographic source was exposed. (2) allowing one individual at another field site to perform certain duties of a j radiographer's assistant without being certified, and (3) three ' individuals at yet another facility handling moisture-density gauges ! without either completing the training course before using the gauges. The licensee responded and paid the civil penalty on June 5, 1987. 1 Rappahannock General Hospital, Kilmarnock, Virginia EA 87-34, Supplement VI A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $750 was issued April 6, 1987 based on violations involving failure to (1) perform tests for contamination on external surfaces, (2) have quarterly Radiation Safety Committee meetings, and (3) to perform formal annual reviews of the Radiation Safety Program. The licensee respended and paid the civil penalty on April 15, 1987. ) University of Missouri, Columbia, Missouri EA 86-191, Supplement IV A Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $4,000 was issued January 15, 1987 based on violations involving an extremity overexposure and inadequate radiation hazard j evaluation during a pellet handling operation. The licensee responded ' by letters dated February 13, 1987 and after reviewing the response, an Order Imposing a Civil Penalty was issued May 22, 1987. The licensee paid the civil penalty on May 27, 1987. j Yellowstone County Surveyor's Office, Billings, Montana EA 86-198, Supplements IV, Y, and VI A Notice of Violation and Proposed Imposition of Civil Penalty in , the amount cf $500 was issued February 9,1987 based on violations NUREG-0940 12
involving the failure to (1) provide dosimetry to personnel using licensed material, (2) store licensed material properly, (3) maintain personnel exposure records, (4) maintain inventory records, (5) adhere to transportation requirements, and (6) perform leak tests. The-licensee responded. March 2, 1987.and after reviewing the response the civil penalty was mitigated by 50 percent because of the licensee's corrective actions taken to ensure compliance. An Order Imposing a Civil Penalty for $250 was issued May 12, 1987. The licensee paid the penalty.on May 26 -1987. B. Severity Level III Violations, No' Civil Penalty Tracer Profiles, Inc., Oklahoma City, Oklahoma EA 87-91, Supplements IV.and VI A Notice of Violation was issued June 8,1987 based on violations involving failure to (1) calibrate survey instruments at the required interval, (2) survey equipment for contamination and decontaminate as necessary, at the appropriate(3) time, return p(ersonnel monitoring
- 4) maintain records device for processing of bioassays, (5) maintain personnel exposure records, and (6). store licensed material at an authorized location. A civil penalty was not proposed because the-licensee agreed to implement extensive corrective actions that. included hiring a consultant and the licensee's past enforcement history has been good.
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NUREG-0940 _ _
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i' I.A. REACTOR LICENSEES, CIVIL PENALTIES AND ORDERS i 1 l
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.1 NUREG-0940
L pm arcg UNITED STATES q 0, NUCLEAR REGULATORY COMMISSION - g , 'r , , % REGloNlil )
$ , ,[ 799 ROOSEVELT RO AD g cLEN ELLvN stuNoss soin I
***** MAR 121987 1
Docket No. 50-316 Licente No. OPR-74 EA 87-13 American Electric Power Service Corporation , Indiana and Michigan Electric Company i ATTN: Mr. John E. Dolan ' Vice Chairman Engineering and Construction 1 Riverside Plaza , Columbus, OH 43216 4 Gentlemen:
SUBJECT:
NOTICE.0F VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY ' (NRC INSPECTION REPORTS.NO. 50-315/86042(DRP); NO. 50-316/86042(DRP)) This refers to the routine inspection conducted during.the period September 15 through November 13, 1986, of activities authorized by NRC Operating License No. DPR-74 for the D.C. Cook Nuclear Plant, Unit 2. As a result of this inspection, one violation of NRC requirements was identified. The results of the inspection were provided in the above referenced report sent to you by letter dated January 16, 1987. An enforcement conference was held in the Region III office on January 21, 1987, between you and other members of your staff, and myself and other members of the Region III and NRR staff to discuss the violation.
--The event described in the enclosed Notice of Violation and Proposed Imposition i of. Civil Penalty (Notice) involved your operations staff rendering both Unit 2 !
independent emergency core cooling system (ECCS) subsystems not operable while l Unit 2 was operating in Mode 1, in violation of the Technical Specification Limiting Condition for Operations. The north safety injection pump was not operable in that it had been isolated and de-energized, and the south safety injection pump was not operable in that two of its four injection flow paths l had been isolated. This condition existed for approximately twenty hours and l was identified several days later during a records review by the NRC Resident ; Inspection Staff. I CERTIFIED MAIL E R_ETURN RECEIPT REQUESTED NUREG-0940 I.A-1 1
Aserican Electric Power Service 2 W4R 121937 Corporation
.Your after-the-fact evaluation of this condition determined that a twenty-three (23) percent reduction in-the' design margin of the Final-Safety Analysis Report ECCS analysis had existed and that the ECCS would still have been capable of meeting its safety function. Ho' wever, the violation is of concern to the NRC. 'because several licensed operators or senior operators either reviewed this' condition. prior to its implementation or were later cognizant'of its existenc'e and were not aware that this condition was contrary to Technical Specifications, r This ceficiency demonstrates the'importance of a comprehensive knowledge of- ,
system operability requirements and the needed attention to detsil by operations - staff when removing equipment from' service.or operating with eqaipment out of service.- To emphasize the significance of this deficiency, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,001)'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 (1986)-(Enforcement Policy), the violation, as described in the ) enclosed Notice, has been categorized as a Severity Level III. The base civil penalty for a Severity Level III violation is $50,000; The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been' deemed appropriate. 1 You are required to respond to this letter and should follow the' instructions I specified in the enclosed Notice when preparing your response. 'In your I response,'you should document the specific actions taken and any additional action you plan to prevent recurrence. After reviewing your response to this Notice,-including your corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with regulatory requirements. l 1 In accordance with 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 y placed in the NRC Public Document Room. NUREG-0940- I.A-2
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'American Electric Power Service 3, k!
Corporation a MAR t 21987 The responses directed by this letter and the enklosed Notice are not subject I to the clearance procedures of the Office of Mariagement and Budget as required by the Paperwork Reductior, Act of 1980, PL 96-511. Sincerely, , n [ )O W A. Bert Davis Acting Regional Administrator
Enclosures:
3 Notice of Violation and Proposed Imposition of Civil' Penalty
- 2. Inspection Reports 1
No. 50-315/86042(DRP);.. No. 50-316/86042(DRF) cc w/ enclosures: W. G. Smith, Jr. , Plant Manager l DCS/RSB (RIDS) Licensing Fee Management Branch Resident Inspector, RIII Ronald Callen. Michigan Public Service Commission ~, E!S Coordinator, USEPA Region 5 Office y Nuclear Facilities and Environmental Monitoring I Section s i l
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l 1 NUREG-0940 , I.A-3 t
I g NOTICE OF VIOLATION AND PROPOSED IMPCSITION OF CIVIL PENALTY ! Indiana and Michigan Electric Company Docket No. 50-316 , D, C. Cook Nuclear Plant License No. DPR-74 i Unit 2 EA 87-13
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An NRC routine inspection conducted during the period September 15 through November 13, 1986, identified a violation of NRC requirements regardir.g operation of Ur.it 2 without the required emergency core cooling subsystems being operable. The violation involved the operability of the safety injection systems. In accordance with the " General Statement of Policy and Procedure for 3 l' NRC Enforcement Actions," 10 CFP. Part 2, Appendix C (1986), the Nuclear i Regulatary 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 l 10 CFR 2.205. The particular violation and associated civil penalty are set 3 forth below: > Technical Specification Limiting Condition for Operation (LCO) 3.5.2 requires that two independent emergency core coo 7tng system (ECCS) subsystems shall be , operable while the' unit is operated in Modes 1, 2 or 3 with each subsystem to { include one operable safety injection pump and an operable flow path. 1 l The safety analysis' for a small break loss of coolant accident at D. C. Cook i Unit 2 was based on one safety injection pump being capable of delivering flow to all four cold legs, as described in the Final Safety Analysis Report, dated , L October 1972. The basis of this analysis was not changed in the Updated Final 1 Safety Analysis Report, dated July 1982. Technical Specification LCO 3.0.3 requires that, when a Limiting Condition for Operation is not met, action shall be initiated within one hour to place the : unit in a Mode in which the specification does not apply by placing it in hot standby within the next 6 hours and hot shutdown within the following 6 hours. ; Contrary to the above, between 5:36 a.m. on September 4, 1986 and 1:39 a.m. on September S, 1986, while the unit was in Mode 1, neither of the Emergency Core Cooling Svstem subsystems included an operable safety injection pump with an i operable flow path and actions were not initiated to place the unit in a Mode in which Specification 3.5.2 did not apply. The north safety injection pump was isolated and deenergized and the south safety injection pump flow path was restricted to two cold legs. This is a Severity Level III violation (Supplement I). i Civil Penalty - $50,000.
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NUREG-0940 1.A-4
l Notice of Violation 2 MAR i 21987 Pursuant to the provisions of 10 CFR 2.201, Indiana and Michigan Electric I Company is hereby required to submit a written statement or explanation to the Director, Of fice of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, within 30 days of the date of this Notice. This reply should include for each alleged violation: (3) 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.
ff an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked, or why such other action as may be proper 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 subm +.ted under oath or affirmation. Within the same time as provided for the response required above under 20 CFR 2.201, Indiana and Michigan Electric Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draf t, or money order payable to the Treasurer of the United States in the amount of Fifty Thousand Dollars ($50,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Indiana and Michigan Electric Company fail to answer in the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Indiana and Michigan Electric Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violation listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or m Migation of the penalty. 2n requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1986) should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately frotr. 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 Indiana and Michigan Electric Company is directed to the other provisions of 10 CFR 2.205, ! regarding the procedure for imposing a civil penalty. l l i j NUREG-0940 I.A-5 i
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4 i Notice of: Violation
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W 1 2 1987 ! r l Upon failure to pay any civil penalties due yhich has been subsequently .
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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, 1 FOR THE NUCLEAR-REGULATORY COMMISSION a Nb A. Bert Davis' Acting Regional Administrator Dated af Glen Ellyn, Illinois i this 110 day of March 1987. i i NUREG-0940 I.A-6
[ UNITED STATES j / NUCLEAR REGULATORY COMMISSION 7i j- REGloN IV 611 RYAN PLAZA DRIVE. SUITE 1000 o,, , ARLIP8'iTON, TEXAS 78011 s NOV ? F W3 Docket No. 50-313 License No. DPR-51 ' EA d6-151 Arkansas Power & Light Company ATTN: Mr. Gene Campbell Vice President, Nuclear Operations First National Bank Bldg. Capitol & Broadway Little Rock, Arkansas 72201 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N0. 50-313/86-01) This refers to the Safety System Functional Inspection (SSFI) conducted on January 6-31,1986, at the Arkansas Nuclear One-Unit 1 facility. Violations of NRC. requirements were identified as a result of this inspection in the referenced inspection report sent to you by letter dated March 31, 1986. An enforcement conference was conducted in the Region IV office on July 11, 1986, with Messrs. .M. Pendergrass, T. Cogburn, ' Levine and others of your staff g and Messrs. J. Partlow, R. Hall, J. Gagliardo, and others of the NRC staff to discuss the apparent violations and other concerns identified during the SSFI.
.The most significant violation identified during the SSFI involved a modifi-L cation to the steam supply lines to the turbine driven Emergency Feedwater (EFW) pump and is described in Violation I of.the enclosed Notice of. Violation and Proposed Imposition of Cdvil Penalty (Notice). The fir,a1 design of the 1 EFW upgrade (a post-TMI modification) had been submitted to the NRC for- j i
approval by letter dated December 1, 1981. The change was implemented by
.' design change package DCP 82-D-1050 and installation was completed during the 1984 refueling outage. However, the modification deleted two check valves which had been included in the EFW upgrade presented in the December 1, 1981 submittal. The steam supply check valves are required to prevent blowdown of both steam generators during a nonisolable steam line break, assuming a single failure of one' AC power supply; specif ically, the " red" AC power supply which drives the motor-driven EFW pump and provides motive power to close the normally open isolation valve from the "A" steam generator. Although these check valves were deleted by the design change package because operating experience had NUREG-0940 1.A-7
L Arkansas ' Power & Light Company shown that these check valves did not: perforn reliably in service, the deletion
'of these check valves was.made without an adequate review for all possible design basis' accident scenarios.- 'This violation .is of significant concern because it reveals weaknesses in your program for~the review-of plant changes and of the administrative controls established to assure that design reviews are properly performed, including plant change reviews and licensee safety evaluations performed in accordance with 10 CFR 50.59. These plant change reviews are important to assure that-regulatory requirements continue to be satisfied and that changes to the plant do not. constitute a change to the technical specifications or an unreviewed safety ..i ssue.
To emphasize the importance of assuring that plant chcnges and modifications are properly reviewed for possible impacts on existing safety analyses and design bases, I have been authorized, after consultation with the Directnr,
,0ffice of Inspection and Entu rcea:ent, to issue the enclosed Notice of Violation and Proposed Imposition of Cis ^ Penalty in the amount of Fifty Thousand Dollars
($50,000) for Violation I 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 (1986) (Enforcement Policy), Violation I described in the enclosed Notice has been categorized at a So 'rity Level III. The escaletion'and mitigation' factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. Violation II in the enclosed Notice involves deficiencies identified in the areas of design centrol, equipment testing, maintenance procedure accuracy, and document control. These violations involve deficiencies of a less serious nature-than that in Violation I but are of more than minor concern and demonstrate the need for additional licensee management attention in the 1
-preparation and implementation of plant modifications to safety systems. ;
Therefore, these violation have been categorized as Severity Level IV , violations. a You are required to respond to this letter and should follow the instructions j specified in the enclosed Notice when preparing your response. In your J response,.you should document the specific actions taken and any additional : actions you plan to prevent recurrence. After reviewing your response to this .! Notice, including your proposed corrective actions, the NRC will determine ' whether further NRC enforcement action is necessary to ensure 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-8
f' Arkansas Power & Light Company ! The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office cf Management and Budget as required by the Paperwork Reduction Act of 1980, FL 96-511. Sincer .
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o . 4 N
- obert D. Martin Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty cc: Arkansas Radiation Control Program Director 4 , NUREG-0940 1.A-9 I I i
l NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Arkansas Power & Light Company Docket No. 50-313 Arkansas Nuclear One-Unit 1 License No. DPR-51 EA 86-151 During an NRC inspection conducted on January 6-31, 1986, violations of NRC requirements were identified. In accordance with the " General Statement of Polic
-(1986)yandProcedureforNRCEnforcementActions,"10CFRPart2,AppendixC
, the Nuclear Regulatory Commission proposes to impose a civil penalty j pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), i 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and )
associated civil penalty are set forth below l
- 1. Violation Assessed a Civil Penalty I 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires, in l part, that the design control measures shall provide for verifying or checking the adequacy of design, such as by the performance of design reviews, by the use of alternate or simplified calculational methods, or by the performance of a suitable testing program.
Contrary to the above, design control measures for design change package DCP 82-D-1050 failed to properly assess or verify the adecuacy of design regarding the potential for a single failure, loss of one power supply, to cause the simultaneous blowdown of both steam generators during a main steam line break accident, a situation outside the plant's design basis. This condition was caused when the design change package was implemented during the Unit 1 1984 refueling outage without certain check valves, the purpose of which was to prever.i. the simultaneous blowdown. This is a Severity Level 117 violation (Supplement I). Civil Penalty - $50,000. XI. Violations Not Assessed a , Civil Pensity A. 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires, in part, that measures shall be established to assure that applicable regulatory requirements and the design basis are correctly trans-lated into specifications, drawings, procedures, and instructions. The ANO Quality Assurance Manual - Operations, Section 3.0, Design Control, implements this requirement and comits the licensee to the provisions of Regulatory Guide 1.64 and ANSI N45.2.11-1974 Sections 4.0 and 6.0 of ANSI N45.2.11-1974 require, in part, that design activities are to be performed in a controlled, planned, end correct manner thet is traceable to the design basis. NUREG-0940 1.A-10
I Notice'of Violation Contrary to the above, as of January 6,1986, the licensee's program for design control did not assure that design and design reviews were properly performed.
- 1. The emergency feedwater (EFW) system design analysis was inadequate, in that:
- a. The consequences of certain high energy line. breaks in the area referred to as the " penthouse" on EFW system components coincident with a single failure and the consequences of a EFW high energy steam line break on other safety-related equipment in the area were not addressed.
- b. The determination as to whether safety-related room cooling was needed when both EFW pumps were operating was not performed.
- 2. Design calculations and verifications associated with certai-electrical equipment were inadequate in that:
- a. The correction factors for operation of the station battery at minimum temperature, specified as 60*F in Procedure 1307.006, D07 Quality Surveillance, were not included <
(CalculationGE-830-1032-01, January 25,1984).
- b. The station battery sizing calculation;; did not consider meter inaccuracy or increased loads during a design basis event (Calculation 83-1032-06, January 24,1986).
- c. The valve actuator sizing analysis for motor starting torque did not adequately consider the design requirements (Calculations 80-1083A-02, January 14, 1986; 80-1083A-04, January 24, 1986; and 830-1032-07, January 24,1986).
- d. The compatibility of the.DC distribution system components with the new, larger batteries was not determined (Calcula-tion 83D-1032-02, February 17,1984).
- e. The protective relay study for breaker A311 for the EFW pump motor failed to document the source of the critical parameters (Calculation 84E-0083-12, November 19,1985).
- 3. Vendor-supplied motor operated valve design data were not adequately translated into controlling documents, in that:
- a. Vaive maintenance procedures did not include certain vendor information for torque switch settings and as a result the torque switch open setting for valve j
CV 2627 was set below the manufacturer's tested setpoint. { l l NUREG-0940 I.A-11
h 1 i l Notice of Violation ; i
- b. .There were no-documented bases for the torque. switch j
. settings for valves CV 2870 and CV 3851. i i
This is a Severity Level IV. violation (Supplement I). )i B. 10 CFR Part 50, Appendix B, Criterion XI, Test Control, requires, in part, that a test program shall be established to demonstrate that structures, systems, and components will perform satisfactorily in service is identified and performed in accordance with written test procedures which incorporate the requirements and acceptance limits contained in applicable design documents. i The AND Quality Assurance Manual - Operations, Section 11.0, Test Control, implements this requirement and commits the licensee to Regulatory Guide 1.33 and ANSI N18.7-1976. ANSI N18.7-1976, Section 5.2.19, Test Control, requires, in part, that a test program oe established, including preoperational tests, surveillance tests, and maintenance / modification tests such that the safety of the plant is assured by demonstrating the satisfactory performance of a system or component following plant maintenance or modifications. Contrary to th? above, as of January 6,1986, the licensee's program for test control did not demonstrate that components would perform satisfactorily in service.
- 1. The modification acceptance tests for the station batteries did not demonstrate that the batteries would perform acceptably. 1
- a. The post-modification service test for battery 007 (ANO JO 05396) performed on March 24, 1984, in accordance with design change package DCP 83-1032 and calculation GE-83D-1032-01 did not include certain design requirements, including electrolyte temperatures, actual test current, battery minimum voltage limits, and discharge voltage profile calculations,
- b. The post-modification testing performed approximately 1983-1984 in accordance with Special Work Plan 1409.29, after the removal of two cells from each station battery 1 (DCP-83-119), used a battery temperature for which its basis could not be determined and the temperature correction i factor was incorrectly applied. l l
- 2. The EFW system discharge piping valves (CV-2620, CV-2626, CV-2627, CV-2670, CV-2869, and CV-2870), installed during the 1984 refueling outage as part of the EFW upgrade modification (DCP 80-1083), had not been tested or evaluated to demonstrate the capability to operate under system flow conditions.
NUREG-0940 1.A-17
l Notice of Violation <
- 3. Post-maintenance testing had not been performed in accordance with Procedure 1402.09, Emergency'Feedwater Pump Maintenance, following three separate maintenance activities performed during the 1984 refueling outage for EFW pump P7A. Procedure 1402.09 provides detailed guidance for taking post-maintenance vibration readirgs in the horizontal, vertical, and axial directions and requires that they be compared to a set of pre-maintenance vibration results,
- a. The testing documented for the December 23, 1984, mainte-nance on EFW Pump P7A under JO 76916 was conducted on January 17, 1985; however, the test records did not document that additional modifications to the pump had been made on January 7-11 end therefore, the testing did not reflect the work done under J0 76916.
- b. The testing documented on JO 81212 for replacement of a thrust bearing was missing some axial measurements and there was no pre-maintenance data for comparison.
- c. There was no post-maintenance test data or reference to test dsta recorded on JO 75648 for maintenance conducted on January 11, 1985.
- 4. The initial calibration and functional checkout of the Condensate j Storm e Tank (CST) level indication transmitter (LIT-4203) were !
not adequately performed and documented, and routine surveillance I procedures were not developed and performed following installation i of LIT-4203 during the 1984 refueling outage as part of the EFW upgrade modification (DCP 80-1083 and DCP 84-1045). 1
- 5. The required routine inservice testing of certain valves I i
associated with the EFW system was not adequately performed and documented. The operability and the full stroke response of valves CS-98, CS-99, CS-261, CS-262, FW-55A, FW-558, FW-56A, FW-56B, FW-10A/FW-61, and FW-10B/FW-62 had not been demonstrated and documented, although acceptable flow had been demonstrated l through the flowpaths in routine pump flow tests. i This is a Severity Level IV violation (Supplement I). C. Technical Specification 6.8.1 requires, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, November 1972. Section 1 of Appendix A to Regulatory Guide 1.33, November 1972, states, in part, that maintenance affecting safety-related equipment NUREG-0940 I.A-13
Notice of Violation should be properly preplanned and performed in accordance with written precedures, documented instructions, or drawings appropriate to the circumstances. ; 1 Contrery to the above, several discrepancies were identified regarding EFW motor operated valve (MOV) maintenance Procedures { 1402.160, Limitorque Motor Operated Valve SMB-000 Maintenance, 1 Revision 3; 1402.161, Limitorque Motor Operated Valve SMB-00 ) Maintenance, Revision 1; and 1402.71, EIM Motor Operated Valve Maintenance, Revision 2.
- 1. All three procedures referenced drawing E-195 for the description of the motor operated valve limit switch operation. However, this drawing did not show the l Limitorque limit switch cor. tact scheme and the EIN limit I switch scheme incorrectly showed contact "LSO/G" as being closed continuously throughout valve travel.
- 2. Valves CV-2663, CV-2620, CV-2870, CV-3850, CV-3851, CV-2627, CV-2626, and CV-2869 were not identified as de powered MOVs or as Q-listed valves.
- 3. The open and closed adjustments for torque switches were shown i as reversed in Procedures 1402.160 and 1402.161. I 4 Procedure 1402.161 incorrectly listed CV-3851 and CV-2620 as model SMB-00 operators, rather than as SMB-000 operators as installed.
- 5. The operation of the closed limit switches was incorrectly described in all three procedures.
- 6. Procedure 1402.71 incorrectly identified CV-3850 as a l
" modulating" valve rather that a " seal-in" type design.
- 7. Procedure 1402.71 did not provide for independent verification of the removal of a test jumper which could interfere with normal )
valve operations. l { This is a Severity Level IV violation (Supplement I). D. 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affectino cuality shall i be prescribed by documented instructions, procedures, or drawings ; appropriate to the circumstances. I NUREG-0940 I.A-14
l Notice of Violation i i The ANO Quality Assurance Manual - Operations, Section 5.0, Instructions, Procedures, and Drawings, implements the above l requirement onc' requires, in part, that instructions, procedures, i and drawings are provided for the control of activities which affect i cuality and safety at the nuclear plant, and include, as a minimum, administrative, general plant operation, modification, maintenance i and repair, and control cf activities related'to the ASME Code, Section III, Class 1, 2, or 3 components required to be operable. Contrary to the above, as of January 6,1986, the licensee's program failed to assure that instructions and. drawings were appropriate to the circumstances.
- 1. The following piping and instrumentation diagrams associated with systems important to safety were found to have incorrect ;
valve positions, incomplete locked valve positions indicated, or missing instrumentation bubbles: a. Drawing Emergency M-204, Sheet Feedwater, 3 of 4,2Pip Revision two(ing & Instrument Diagram, examples).
- b. -Drawing M-206, Sheet 1 of 2, Piping & Instrument Diagram, Steam Generator Secondary System, Revision 45 (three examples).
- c. Drawino M-202, Piping & Instrument Diagram, Main Steam, Revision 33(twoexamples),
- d. Drawing M-212, Sheet 1 of 2, Piping & Instrument Diagram, Plant Makeup Domestic Water Systems, Revision 29 (two examples),
i
- 2. The piping design specification for AN0-Unit 1, M-84, Piping )
Class Drawing, Revision 22, contained errors and was not o adequately controlled.
- a. DCP 80-1083B identified that a revision to the pipino design specification was required; however, evidence of this change was not apparent.
- b. Errors were identified between a controlled copy of specification M-84 and the one in Document Control.
1
- 3. There were 18 examples of drafting errors or incorrect '
information noted on controlled drawings. ThisisaSeverityLevelIVviolation(Supplements), i l NUREG-0940 1.A-15 J
{ Notice of Violation Pursuant to the provisions of'10 CFR 2.201, Arkansas Power & Light Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Comission, Region IV, 611 Ryan Plaza Drive, Suite 1000, Arlington, Texas 76011, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1)' admission or denial of the alleged violation, (2) the reasons
-for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified'in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration mey be given to extending the response time for good cause shown. Under the ruthority 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, Arkansas Power & Light Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Fifty Thousand Dollars ($50,000) or may protest imposition of the civil penalty in whole or in part by a written answer 1 addressed to the Director, Office of Inspection and Enforcement. Should Arkansas Power & Light Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Arkansas Power &. Light Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violation listed in this Notice in (2)demonstrateextenuatingcircumstances,(3)showerrorin whole or in part(4) this Notice, or show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written I answer in accordance with 10 CFR 2.205 should be set forth separately from the l i j 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 peragraph numbers) to avoid repetition. Arkansas Power & Light Company's attention is directed to the other provisions of 10 CFR 2.205, regarding the l l proceJure for imposing a civil penalty. ; NUREG-0940 1.A-16
L Notice of Violation - Upon failure to pay any civil penalty due which has been subsequently aetermined in accordance with the applicable previsions 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 Secticn 234c of the Act, 42 U.S.C. 2282. FOR THE CLEARREGUgTORYCOMMISSION obert D. Martin LY.~- ' Regional Administrator Dated at Arlington, Texas, this gN ay of November, 1986. L i NUREG-0940 I.A-37
l e o UNITED STATES g 8 n NUCLEAR REGULATORY COMMISSION
$ ep WASHINGTON, D. C. 20555
%*****/ l JUN 01 1987_
Docket No. 50-313 License No. DPR-51 EA No. 86-151 Arkansas Power and Light Company ATTN: Mr. T. Gene Campbell Vice President Nuclear Operations First National Bank Bldg. Capital and Broadway Little Rock, Arkansas 72201 Gentlemen:
SUBJECT:
ORDER IMPOSING A CIVIL MONETARY PENALTY i This refers to your letter dated December 12, 1986, in response to Violation I j of the Notice of Violation and Proposed Imposition of Civil Penalty (Notice) sent to you by our letter dated November 12, 1986. Our letter and Notice j described violations found during the NRC Safety System Functional Inspection (SSFI) conducted on January 6-31, 1986, of activities authorized by NRC license No. OPR-51 at Arkansas Nuclear One - Unit 1. , i' To emphasize the importance of assuring that plant changes and modifications are properly reviewed for possible impacts on existing safety analyses and i design bases, a civil penalty of Fifty Thousand Dollars ($50,000) was proposed. In your response to Violation I, for which a civil penalty was assessed, you admit that the violation occurred as stated in the Notice; however, you argue that certain factors mitigated the seriousness of the violation and, in addi-tion, you request mitigation of the proposed civil penalty. l After careful consideration of your response, we have concluded, for the l reasons given in the appendix to the enclosed Order Imposing Civil Monetary Penalty, that Violation I did occur as set forth in the Notice of Violation and Proposed Imposition of Civil Penalty, and that you did not provide in your response a sufficient basis for citigation of the proposed civil penalty. Accordingly, we hereby serve the enclosed Order on Arkansas Power and Light Company imposing a civil monetary penalty in the amount of Fifty Thousand Dollars ($50,000). We will review the effectiveness of your corrective actions during ' a subsequent inspection. CERTIFIED MAIL R_ETURN RECEIPT REQUESTED NUREG-0940 I.A-18
Arkansas Power and Light Company < In accordance with Section 2.790 of the NRC's " Rules of Pr[actice,' 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, mes M. Ta r, Deputy Executive Director for Regional Operations
Enclosures:
As stated cc: Arkansas Radiation. Control Program Director I l
\
i 1 I NUREG-0940 1.A-19 _t
)
l UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of i Arkansas Power and Light Company Docket No. 50-313 i Arkansas Nuclear One, Unit 1 License No. DPR-51 EA 86-151 ORDER IMPOSING CIVIL MONETARY PENALTY I Arkansas Power and Light Company (licensee) is the holder of Operating License No. DPR-51 (license) issued by the Nuclear Regulatory Comission (NRC/Comission) on May 21, 1974. The license authorizes the licensee to operate Arkansas Nuclear One in accordance with the conditions specified therein. I I II i A special inspection of the licensee's activities was conducted on January 6-31, 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 Penalty (Notice) l l' was served upon the licensee by letter dated November 12, 1986. The Notice stated the nature of the violation, the provision of the NRC's requirement that the licensee had violated, and the amount of the civil penalty proposed for Violation I. The licensee responded to Violation I of the Notice of Violation and Proposed Imposition of Civil Penalty by letter dated December 12, 1986. I NUREG-0940 I.A-20
i III 1 l J After consideration of the ~11censee's respense and the statements of fact, explanation, and argument for mitigation contained therein, the Deputy
' Executive Director for Regional Operations has detemined, as set forth in'the ' Appendix to this Order, that Violation I occurred as stated and that the penalty proposed for this violation in the Notice of Violation and Proposed Imposition of Civil Penalty should be imposeu.
i IV i In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act l of 1954, as amended (Act), 42 U.S.C.-2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT: r 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, Washir.gton, D.C. 20555. The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing should be clearly marked as a " Request for an Enforcement , L Hearing" and shall be addressed to the Director Office of Enforcement, U.S. NUREG-0940 I.A-21 ; I
Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. ! 20555,' with a copy to the Assistant General Counsel for Enforcement Office of i the General Counsel, U.S. Nuclear Regulatory Commission, Washingtor., D.C. 20555; the Regional Administrator, U.S. Nuclear Regulatory Comission, Region IV; and the NRC Resident Inspector. 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 shal'1 be effective without further proceedings. If payment has not been made by that i time, the matter may be referred to the Attorney General for collection. In the event the ifcensee 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 Violation I of the Notice of Violation and Proposed Imposition of Civil Penalty referenced in Section II above and (b) whether, on the basis of such violation. this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION
/
JaesM.Tayh
,JC puty Executive Director for Regional Operations Dated at Bethesda, Maryland, this \Fday of June 1987 NUREG-0940 I.A-22
1 l I t
]
APPENDIX' EVALUATIONS AND CONCLUSIONS f On November 12, 1986, a Notice of Violation and Proposed Imposition of Civil
. Penalty (Notice) was issued for violations identified during an NRC Safety System Functional Inspection (SSFI). A civil. penalty of $50,000 was proposed
. for Violation I' set out in the Notice. ' Arktnsas Power and Light Ccmpany responded to Violation I of the Notice by letter on December.12,1986. In its response the licensee admits that the violation occurred as stated, but argues.
that certain factors mitigated the seriousness of the violation, and requests mitigation of the proposed civil penalty. The NRC's evaluation and conclusion regarding the licensee's arguments are as follows:
' Restatement of Violation I
'10 CFR Part 50, Appendix B, Criterion III, Design Control, requires, in part, that the design control measures shall provide for verifying or checking the adequacy of design, such as by the performance of design reviews, by the use of alternate or simplified calculation methods, or by the performance of a suitable testing program.
Contrary to the above, design control measures for design change package DCP 82-D-1050 failed to properly assess or verify the adequacy of design regarding the potential for a single failure, loss of one power supply, to cause the simultaneous blowdown of both steam generators during a main steam line break accident, a situation outside the plant's design basis. This condition was caused when the design change package was implemented during the Unit 1 1984 refueling outage without certain check valves, the purpose of which was to prevent the simultaneous blowdown. This is a Severity Level III violation (Supplement I). Civil Penalty - $50,000. Sumary of Licensee's Response The licensee admits that the Violation I did occur as stated, in that an : inadequate safet ;
- feedwater (EFW) y evaluation single was performed failure scenario for the to identify without situation the specific emergency certain check valves. The decision to delete the check valves was based on the desire to improve overall system reliability.
The licensee presents arguments related to the safety significance of the violation. The licensee asserts that, while the design basis of EFW system does consider the loss of offsite power, the design basis does not consider a Main Steam Line Break (MSLB) concurrent with a loss of offsite power. Therefore, it would be consistent with the plant's design basis for the scenario described not to consider the loss of offsite power and thus give credit for the operation of the EFW and main feedwater systems, b NUREG-0940 1.A-23
Appendix J l The licensee further states, that even without the check valves, the EFW system ' would have performed adequately during anticipated transients and accident scenarios and that a number of long-term measures were available to isolate i the steam generators, provide water to the steam generators, or use feed and bleed to achieve safe shutdown. In addition, the licensee asserts that the , calculated containment peak pressure would not be increased and the results j of the analysis are bounded by current FSAR analyses. Offsite dose consequences were calculated by the licensee to be less than 7% of the 10 CFR Part 100 thyroid limits, even assuming no mitigation of the accident for 48 hours. NRC Evaluation of Licu see's Response While it may be that the design basis of the EFW system does not consider a i MSLB concurrent with a loss of offsite power, the NRC staff believes that the I plant's design basis did consider a MSLB concurrent with a single failure, namely the loss of one power supply. This fonned the basis of the violation. Section 14.2.2.1 of the Arkansas Nuclear One, Unit 1 Final Safety /nalysis Report describes the accident analysis for a main steam line failure. Section 14.2.2.1.3.1 states that the Emergency Feedwater Instrumentation and Control l System is designed to protect against the consequences of a simultaneous blow- 1 down of both steam generators. Section 14.2.2.1.3.3 further states that
" Additional information regarding potential single failures in the emergency feedwater during recovery from a steam line break is included in Table 10-1."
Table 10-1 describes the capability of the EFW system to adequately perform its function under the single failure criteria and specifically the loss of Bus A3 which results in the loss of all AC " red" power. The design basis of i the EFW system was not met in the matter at hand in that, when the check valves were deleted from the design, the simultaneous blowdown of both steam generators was not prevented under the circumstances of a main steam line break and the loss of Bus A3, as it should have been as described in Section 14.2.2.1 and Table 10-1 of the FSAR. The design change package, DCP 82-D-1050, was Msued and implemented without evaluating the potential for the simultaneous bl;wdown of both steam generators, a violation of 10 CFR Part 50, Appendix B, Criterion III. The licensee asserts that the check valves were deleted to improve the overall EFW system reliability; however, in doing so this created the poter.tial for the simultaneous blowdown of both steam generators during a steam line break, l a situation which clearly was intended by design to be prevented. The design 1 change failed to properly evaluate a single failure scenario to ensure that the l EFW system would function as intended. j The licensee contends that, even without check valves installed, the consequences ! of the steam line break accident were within the capability of the plant's systems and structures, relying on manual operator actions. While it appears that these consequences were within the capability of the plant, the staff I' generally does not give credit for manual actions for systems which were designed to function automatically. In addition, at the time the design change package was issued and implemented, there had been no evaluation performed to ensure that the EFW system would function during postulated accident and single failure NUREG-0940 I.A-24
Appendix scenarios, specifically the steam line break accident with the failure of Bus A3. Without such evaluation and without the check valves instilled, the plant was placed in a condition outside its' design basis and one for which it was not knowri whether the EFW system could perform its intehded function under all postulated events. This was cause for significant regulatory concern. Based on the above discussion, the NRC staff considers that the violation did occur as stated in the Notice, that the single failure scenario described in the violation is a design basis event for a main steam line break, and the violation is appropriately categorized as a Severity Level III violation. Sunenary of Request for Mitigation of Civil Penalty The . licensee asserts that, after the.SSFI identification of concerns which in J part fonned the bases for Violation I, an immediate review was performed and notification to the-NRC was made. Further, inanediate actions were taken to install swing check valves in the steam supply lines and initiate procurement and design efforts to obtain lift check valves. The' licensee contends that, prior to and subsequent to the identification'of
. the deficiency, the licensee had recognized the need to improve the design modification process, the 10 CFR 50.,59 review program and the training of engineers, and had initiated piajor improvements in these areas.
The licensee 'also contends that it has demonstrated good performance in the general area of design control and that the violetion was somewhat isolated to the specific instance rather than indicative of an overall prograrrnatic . failure of the design change process. I NRC Evaluation of Licensee's Response The NRC views the licensee's actions in reporting the design discrepancy as prudent and appropriate. However, as the discrepancy was identified by the NRC, mitigation for prompt identification and reporting is not warranted. While the licensee installed check valves in the steam lines and took ether l corrective actions to address the programmatic concerns, these actions were not so unusually prompt and extensive as to warrant mitigation of the civil penalty.
-The NRC SSFI team did view the design of the emergency feedwater (EFW) system ,
to be sound in general; however, the SSFI team also identified significant ' concerns. The licensee's perfonnance in the design control area warrants neither mitigation nor escalation of the proposed civil penalty based on Category 2 and 3 SALP ratings in the areas of operations, maintenance, and
- , surveillance for the past rating periods with a single Category I rating in operttions in the latest SALP. Therefore, mitigation of the civil penalty was not considered appropriate.
NUREG-094G I.A-25 l
I t Appendix ~NRC Conclusion After careful consideration of the licen;ee's. response, the NRC staff concludes that.the violation is significant:in that the plant was placed in a condition ' outside its design basis and the violation is appropriately classified as a-Severity Level III violation. The staff. also concludes that .the licensee has Accordingly, not'provided a sufficient the proposed civil penalty inbasis for mitigation the amount of Fifty Thousand of the civil penalty Dollars (.
$50,000)- )
should be imposed. l l i l J u l l l i NUREG-0940 I.A-26
' *; ; # ; y REGloN til j
$ 199 moosEVELT RO AD cLEN cLLys. stuwois son st
, f l!.AY 6G Docket No. 50-454 License No. NPF-37 EA 86-48 Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 Chicago, IL 60690 Gentlemen:
SUBJECT:
N iTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY l (iRC INSPECTION REPORTS NO. 50-454/85042(DRP); 50-454/85043(DRP) l ai d 50-454/85056(DRP)) l This refers to inspections conducted during the periods August 12 through October 18, 1985 and October 2-31, 1985 of activities authorized by NRC Operating License NPF-37 for the Byron Nuclear Power Station, Unit 1. As a result of I l these inspections, certain of your activities appeared to be in violation of I NRC requirements. The violations were identified in the above referenced reports sent to you by letters dated November 14, 1985 and November 22, 1985, respectively. They were also the subject of an Enforcement Conference held l in the Region III office on November 27, 1985, between Mr. Bide L. Thomas and other members of your staff, and myself and other members of the NRC staff. Item I discussed in the enclosed Notice of Violation and Proposed Imposition of j Civil Penalties occurred on March 6, 7, April 20, 23, and May 30, 31, 1985 and on 3 different occasions on July 24, 1985. It involved the use of procedures containing instructions for incorrect valve alignments to conduct technical specification (TS) surveillance on the residual heat removal system (RHR). This rendered both trains of RHR, a subsystem of the emergency core cooling system (ECCS), inoperable in that neither train was capable of injecting into all four reactor coolant system (RCS) cold legs while the plant was in Mode 1. The Byron Unit 1 Final Safety Analysis Report (FSAR), Chapter 6, for a large Break Loss of Coolant Accident (LOCA) states that the ECCS fulfills its safety function by injecting into all 4 RCS cold legs. These events are significant because with both RHR trains only able to inject into 2 cold legs, the plants' ability to adequately respond to a large break LOCA was significantly degraded. l j On June 5, 1985, the NRC issued a Severity Level IV Notice of Violation because ! two safety injection pumps were isolated while the plant was in Mode 3 (Inspection Report No. 454/85002(ORP). Your corrective actions for that I l violation, as stated in your '.etter dated July 10, 1985, included reviewing and l revising all operating procedures involving ECCS systems that could affect ! l technical specification LCOs. Apparently, these corrective actions were i inadequate because RHR procedures still contained incorrect valve alignment ! instructions. CERT JIED MAIL i RE1URL RECEIPT REQUESTED NUREG-0940 1.A-27
l 1 Commonwealth Edison Company 2 MAY 6 1986 , Item II of the enclosed Notice involves several examples of your failure to ) understand technical specifications, system operability, and associated action ! statements. Specifically, Violation II. A involves your determination af ter
. completing a July 15, 1985 surveillance test that Train B of the solid state protection system was operable, even though the main steam line isolation and auxiliary feedwater functions had not been verified during the test. Violation II.B involves your application of the wrong action statement af ter engineered safety features actuation system (ESFAS) Train B was declared inoperable. It l also addresses the fact that ESFAS Train I was left in the test position in !
excess of the two hours allowed by plant technical specifications. Violations II.C and II.D involve the fact that action statement requirements were not met after plant personnel discovered potentially explosive gas mixtures in the waste gas holdup tank on July 6 and 11, 1985. Violation II.E involves-your failure to take TS required grab samples of the waste gas holdup tank while hydrogen and oxygen analysers were out of service. Violatior.11.F involves your 1 failure to perform adequcte post-maintenance inspections c.n the control room ! ventilation system which resulted in components not being able to maintain the l required negative pressure. We are concerned that it appears that the above violations occurred as a result 3 of inadequate management and supervision with regard to technical specification j req ui reme nt s, . We are further concerned that some of these events should not i have occurred if corrective actions to previous licensee event reports or
'NRC-identified violations had been effective.
To emphasize the need for you to ensure that: (1) the accident response capability for safety related systems is not adversely affected when performing surveillance procedure requirements; (2) system operability is evaluated by management personnel more effectively; (3) action statements are properly impleniented when applicable; and (4) corrective actions taken in response to violations of NRC requirements are effective, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of One Hundred Thousand Dollars (5100,000) for the Violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985) (Enforcement Policy), Item I described in the enclosed Notice has been categorized as a Severity Level III violation and Item II as a Severity Level III problem. The base value of a civil penalty for each Severity Level III violation or problem is Fifty Thousand Dollars (550,000). The escalation and mitigction factors in the enforcement policy were considered. While I recognize that you identified the violations and took prompt and extensive corrective actions, mitigation of the civil penalties would not be appropriate because o' vaur prior poor performance related to Item I and the multiple examples of violas is in Item II. 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 action you plan to prevent recurrence. After reviewing your response to this Notice, including your corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with regulatory requirements. NUREG-0940 1.A-28
I i i Commonwealth Edison Company 3 MAY 6 1986 h accordance with 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 0ffice of Management and Budget as required by the Paperwork Reduction Act of.1980, PL 96-5111. f.incerely, O[/ James wSd/[de G. Keppler Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalties
- 2. Inspection Reports No. 50-454/85042(DRP);
No. 50-454/85043(DRP); and No. 50-454/85056(DRP) cc w/ enclosures: D. L. Farrar, Director of Nuclear Licensing V2 I. Schlosser, Project Manager Gunner Sorensen, site Project Superintendent R. E. Querio, Plant Manager DCS/R5B (RIDS) Licensing Fee Management Branch Resident Inspector, RIII Byron Resident Inspector, RIII Braidwood Phyllis Dunton, Attorney I General's Office, Environmental Control Division D. W.- Cassel, Jr., Esq. Diane Chavez, DAARE/ SAFE Steve Lewis, ELD L. 01shan, NRR LPM H. 5. Taylor, Quality Assurance Division 1 NUREG-0940 I.A-29 ! l _ l
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES Commonwealth Edison Company ~ Docket No. 50-454 Byron Nuclear Power Station License No. NPF-37 Unit 1 EA 86-48 During NRC inspections conducted during the periods August 12 through October 18, 1985, and October 2 through October 31, 1985, vio1 Mions 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 (1985), the Nuclear Regulatory Commission proposes to impore civil penalties pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S.C. l 2282, PL 96-295, and 10 CFR 2.205. The particular violations and associated j civil penalties are set forth below:
- 1. Technical Specification (TS) 3.5.2 requires that two independent errere,ency core cooling system (ECCS) subsystems shall be operable with each subsystem comprised in part of one residual heat removal (RHR) pump and an operable flowpath when in Modes 1, 2, or 3.
Technical Specification 3.0.3, which applies when TS 3.5.2 is not met and if two '4HR pumps are inoperable, requires that within 1 hour, the licensee shall initiate action to place the unit in a mode in which the specification does not apply by placing it, as applicable, in at least hot standby within the next 6 hours, at least hot shutdown within the following 6 hours, and at least cold shutdown within the subsequent 24 hours.
'The definition of operability for the injection path for the ECCS is discussed in the Byron Unit 1 FSAR, Section 6.3 where it states that each RHR subsystem injects into all four cold legs of the reactor coolant-system.
Contrary to the above, on March 6, 1985 for approximately 13 hours, March 7, 1985 for approximately 13 hours, April 20, 1985 for approximately 31 hours, April 23, 1985 for approximately 6 hours, May 30, 1985 for approximately 30 hours, May 31, 1985 for approximately 5 hours and on July 24, 1985 for 3 separate periods of approximately 3 hours, 2 hours and 7 hours, while in Mode 1, both RHR subsystems of the ECCS were rendered inoperable during surveillance testing in that neither RHR pump was capable of injecting, as stated in the FSAR, into all four reactor coolant system cold legs due to the fact that valves IRH8716A and IS18809A for. RHR Pump A and valves IRH87168 and 1518809B for RHR Pump B were closed while F.ystem performance was being measured. This is a Severity Level III violation (Supplement I). Civil Penalty - 550,000 II.A. Procedure 1B053.1.1-21, " Train B SSPS Bimonthly Surveillance," requires l that whenever an operability surveillance test is performed on the , i subject system, certain functions including main steam isolation and ! auxiliary feedwater must be successfully tested before the train can be , declared operable. ! 1 ! NUREG-0940 1.A-30
.z, %
y , Notice of Violation 2 MAY 6 1986 s Contrary to the above, af ter perfcrming surveillance testing on July 15, 1985, the licensee improperly declared Train B of the solid state protection system operable even though the main steam isolation and auxiliary feedwater functions had not been verified during the surveillance as being operable, ,
<g B. Technical Specification 3.3.2 requires that for Modes 1, 2, and 3, the engineered safety features actuation system (ESFAS) instrumentation a channels and interlocks shown in Table 3.3-3 shall be operable. It also ,4 states that with an ESFAS instrument channel inoperable, apply the applicable action statement requirements of Table 3.3-3 until the '
channel is restored to operable status. I Table 3.3-3 requires, in part, that Functional Units 4.b, " Steam Line - Isolation, Automatic Actuation Logic and Actuation Relays" and 6.b,
" Auxiliary Feedwater, Isolation Automatic Logic and Actuation Relays," -
have a minimum of 2 operable channels when the plant is in Mode 1, 2, or
- 3. If the minimum channel requirement is not satisfied, then Action Statement 21 shall be followed.
Table 3.3-3, Action Statement 21 requires for Functional Units 4.b and 6 a that with less than 2 operable channels be in at least hot standby (Mod! 3) within 6 hours and in at least hot shutdown (Mode 4) within the follow ng 6 hours. However, one channel may be bypassed for up to 2 hours for surveillance testing per Specification 4.3.2.1 provided the other channel
- is operable.
Contrary to the above, on July 14-15, 1985, while in Mode 3, Train B of the ESFAS was declared inoperable, which rendered both required Train - . B Channels for Functional Units 4.b and 6.b inoperable and the plant was not placed in hot shutdown (Mode 4) within 6 hours. The plant was not put in Mode 4 until approximately 19 hours after the ESFAS train was declared inoperable. In addition, Train B of the ESFAS was placed in the bypass condition for 10.7 hours, which exceeded the 2 hour time limit allowed by technical specifications. C. Technical Specification 3.11.2.5, " Radioactive Effluents Explosive Gas Mixture," requires that the concentration of oxygen in the waste gas holdup system shall at all times be limited to less than or equal to 2% by volume whenever the hydrogen concentration exceeds 4% by volume. Technical Specification 3.11.2.5, Action Statement a., requires that with the concentration of oxygen in the waste gas holdup system greater than 2% by volume, but less than or equal to 4% by volume, the licensee shall reduce the oxygen concentration to the above limits within 48 hours. NUREG-J '10 1.A-31
Notice of Violation 3 MAY 6 1986 Contrary to the above, even though Special Chemistry Data Sheet, BCP-400-T.60, Revision 0, which was completed at 11:40 a.m. on July 6, 1985 stated that the waste gas holdup system had a hydrogen concentration of 5.5% by volume and an oxygen concentrator, of 3.9% by volume, the l- licensee failed to reduce the oxygen conce".tration to less than or equal to 2% by volume within 48 hours. This condttion existed for approximately 130 hours. D. Technical Specification 3.11.2.5, "Radioactiv'e Effluents Explosive Gas Mixture," requires that the concentration of oxygen in the waste gas holdup system shall at all times be limited to less than or equal to 2% by volume whenever the hydrogen concentration exceeds 4% by volume. Technical Specification 3.11.2.5 Action Statement b., requires that with the concentration of oxygen in the waste gas holdup system greater than 4% by volume, and the hydrogen concentration greater than 4% by = volume, the licensee shall immediately suspend all additions of waste gases to the system and reduce the concentration of oxygen to less than or equal to 4% by volume; then take Action a. above. __ _ _ Contrary to the above, even though Special Chemistry Data Sheet, BCp-400-T 60, Revision 0, which was completed at 9:20 p.m. en July 11, 1985, stated that the hydrogen concentration was 4.1% by volume and the oxygen concentration 10.8% by volume and the licensee did not immediately take action to reduce the concentration of oxygen to less than or equal to 4*. by volume. This conditien existed for approximately 53 hours. - E. Technical Specification 3.3.3.10 requires that the radioactive gaseous ef fluant monitoring instrumentation channels shown in Table 3.3-13 shall be operable as stated in the table.
' Technical Specification 3.3.3.10, Action Statement b. requires that with less than the minimum number of radioactive gaseous effluent monitoring instrumentation channels operable, the licensee shall take the action shown in Table 3.3-13.
Table 3.3-13, Instrument 3.a, Hydrogen Analyzer 0AT-GW8000, requires a minimum of one channel to be operable during waste gas holdup system operation or Action Statement 38 shall be applied. Table 3.3-13, Instrument 3.b, Oxygen Analyzers OAT-GW8003 and OAT-GW8004, requires a minimum of 2 channels to be operable during waste gas holdup system operation or Action Statement 38 shall be applied. Table 3.3-13, Action Stctement 38 requires that with the number of channels operable one less than required, operation of the waste gas holdup system may continue provided grab samples are taken from the system and analyzed at least once per 24 hours. Contrary to the above, from July 28 to August 4, 1985, with the waste gas holdup system operating and with all Hydrogen Analyzer 0AT-GW8000 and Oxygen Analy:er 0AT-GS8003 charnels inoperable, grab samples were not taken and analyzed at least once per 24 hours. NUREG-0940 1.A-32 l
je Notice of Violation 4 MY 6 1986 F. 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. Instructions, procedures or drawings shall include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished. Permanent Facility Modification (VM) #M6-0-84-242 was used by the licensee to install a blank-off plate in the control room ventilation Train OA makeup ductwork, Technical Specification (TS) 3.7.6 requires two independent control room ventilation systems to be operable for Modes 1, 2, 3, and 4. With one of two independent control room ventilation systems inoperable, the system must be restored in 7 days or the plant must be in hot standby with'n the next 6 six hours and in cold shutdown within the following 30 hours, i If two control room ventilation systems are inoperable, TS 3.0.3 applies, which requires that actions be initiated within I hour to place the unit in a mode in which.the specification does not apply by placing - it as applicable in at least hot standby within the next 6 hours and at least hot shutdown within the following 6 hours. Contrary to the above, on September 5,1985, PFM #M6-0-94-242 did not contain appropriate quantitative or qualitative acceptance criteria for determining that the installation of the blank-off plate was satisfactorily accomplished. As a result, the blank-off plate was installed in the wrong location. Plant personnel did not discover the error until September 13, 1985 when Train OA was used and it could not maintain the required differential pressure. Since one train had been inoperable from September 5-13, 1985, without the plant being put in the required mode, this was a violation of TS 3.7.6. Train OB was also rendered inoperable by the licensee on September 12, 1985, at 6:20 p.m. to perform maintenance. As a result, both control room ventilation trains = were simultaneously inoperable, in violation of TS 3.0.3, until Train OA was restored at 1:20 p.m. on September 13, 1986. Collectively the above violations have been evaluated as a Severity Level III problem (Supplement I). Cumulative Civil Penalty - 550,000 assessed equally among the violations. Pursuant to tne provisions of 10 CFR 2.201, Commonwealth Edison Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, within 30 days of the date of this Notice, a written statement or explanation, including for each alleged violation: (1) acmission or denial of the alleged violation, y NUREG-0940 1.A-33
i MAY 6 1986
' Notice of Violation' 5 (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 compliarce will be achieved. If an adequate reply is not received within the time ,pecified in this Notice, the Director, Office'of Inspection and Enforcement, may. issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken.
Consideration may b2 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 snall be submitted under oath or affirmation. Within the same. time as provided for the respon:e required above under 1 10 CFR 2.201,~ Commonwealth Edison Company may pay the civil penalties by letter ! addres ser: to the Director, Office of Inspection and Enforcers.t, with a check, draft, or .noney order payable to the Treasurer of the United States in the .] cumulative amount of One Hundred Thousand D,ollars (5100,000) or may protest ] imposition of the civil penalties in whole or in part by a writter, answer ! addressed to the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should l Commonwealth Edison Company elect to file an answer in accordance with ! 10 CFR 2.hj5 protesting the civil penalties, such answer may: (1) deny the ! violation circumstances, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civii penalties in whole or in part, such answer may request remission or mitigation of the penalties. < In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C dould be addressed. An.v 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 paragrap5 numbers) to avoid repetition. Commonwealth Edison's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalties. Upon failure to pay any civil penalties 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. FOR THE NUCLEAR REGULATORY COMMISSION I l' 0 ~ 0 g u k._ - ' hameTG.Kepp r Regional Administrator i Dated at Glen Ellyn, Illinois this 6 # tiay of May 1966. NUREG-0940 1.A-34 ,
# o
.....,.m.., '
~!' % NUCLEAR REGULATORY COMMISSION y, WASHINGTON, D. C. 20666
; ,E % e y
FEB 3 61981 Docket No. 50-454 l
' License No. NPF-37 !
EA 86-48 i Commonwealth Edison Company ATTN: Mr. Jdmes J. O'Connor President Post Office Box 767 Chicoco, IL 60690 Gentlemen: 1
SUBJECT:
ORDER IMPOSING A CIVIL MONETARY PENALTY This refers to your letter dated July 3,1986, in response to the Notice of Violation ano Proposed Imposition of Civil Penalties (Notice) sent to you by i our letter dated May 6, 1986. Our letter and Notice described violations documented in inspection reports conducted Auaust 12 throuah October 31, 1985 ct the Byron Nuclear Power Station, Unit 1. To emphasize the need for you to ensure that safety-related systems are not adversely affected when performina surveillance requirements, system operability < is evaluated more effectively, action statements are properly implemented, and - corrective actions are effective, a civil penalty of One Hundred ThousOnd Dollars ' (5100,000) was proposed. in your response dated July 3, 1986, with respect to Violation 1 you (1) cienied the violation occurred as stated in the Notice. (2) disaareed with the NRC's classification of the event as a Severity Level III violation, and (?) requested mitiaation of the civil penalty. With respect to the violations contailed in Section !! you admitted that Violations A throuch F had occurred, but disaareed with the NRC's conclusica that the events col?ectively demonstrated inadequate manaoement. However, you decided aaainst an appeal of that decision and submitted payment of 550,000. After careful consideration of your response, we have concluded for the reasons i aiven in the appendix attached to the enclosed Order imposina Civil Monetary Penalty that the violation contained in Section I of the Notice was appropriately classified as a Severity Level Ill violation. Because there were arounds for both mitiaation and escalation of the civil penalty, On balance, the base civil penalty was considered by the NRC staff to be appropriate. Since the violations contained in Section II were admitted by the licensee and full payment for the violations has been received, an evaluation and conclusion of these events by the NRC is not provided in the enclosed appendix. Accordingly, we hereby serve the enclosed Order on Commonwealth Edison Company imposino a civil monetary penalty in the amount of Fifty Thousand Dollars (550,000) for Violation 1. We will review the effectiveness of your corrective actions durina a subsequent inspection. CERT!FIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 1.A-35 l
1 Commonwealth Edison Company 2 In accordance with Section 2.790 of the NRC's " Rules of Practice," Pcrt 2, Title 10, Code of Fe:!eral Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Docume':t Room. i Sincerely,
, w. W Y
^
J s M. Tay1 , Director ffice of Inspection and Enforcement
Enclosure:
As stated cc w/ enclosure: C. Reed Vice President 4 D. L._ Farrar, Director of Nuclear Licensina V. 1. Schlosser, Project Manaaer . t Gunner Sorensen, Site Project l Superintendent R. E. Querio, Plant Manaaer DCS/RSB (RIDS) Licensino Fee Manaaement Branch 1 Resident Inspector, Rlll Byron ! Resident inspector, Rill ; Braidwood l Phyllis Dunton, Attorney General's Office, Environmental Control Division D. W. Ct rSel, Jr. , Esq. Diane Chavez, DAARE/ SAFE j Steve Lewis, OGC L. Olshan, NRR LPM ! H. S. Taylor, Quality Assurance Division i NUREG-0940 I.A-36
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of Docket No. 50-454 COMMONWEALTH EDISON COMPANY License No. NPF-37 (BYRON, U?!T 1) EA 86-48
)
ORDER IMPOSING CIVIL MONETARY PENALTY I Comnionwealth Edison Company (licensee) is the holder of Operatino License No. NPF-37 (license) issued by the Nuclear Reoulatory Commission (Commission / NRC) on October 31, 1984 The license authorizes the licensee to operate the Byron Nuclear Power Station, Unit 1 in accordance with the conditions specified therein. II NRC safety inspections of the licensee's activities were conducted Auaust 12 - October 18 and October 2 - 31, 1985. Durino these inspections, the NRC staff determined that the licensee had not conducted its activities in full compliance with NRC reyJirements. A written Notice of Violation and Proposed Impusition of Civil Penalties (Notice) was served upon the licensee by letter dated May 6, 1986. The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalties proposed for the violations. The licensee was oranted an extension and responded to the Notice by letter dated July 3,1986. l l 1 1 NUREG-0940 I.A-37
1 III After consideration of the licensee's response, which included payment of. Fifty Thousand Dollars ($50,000) for the violations in Section II of the' Notice, and the statements of fact, explanation, and araument for denial of the occurrence of Violation I, classification of the event as a Severity Level III violation, ana mitiaation of the proposed civil penalty contained therein, the Director, j i Office' of Inspection and Enforcement, has determined as set forth in the appendix
'to this Order, that the violation occurred as stated and that the penalty proposed !
for Violation I desianated in-the flotice should be imposed. l IV , l l In view of the- forecoina and pursuant to Section 234 of the Atomic Eneroy Act ] of 1954, as amended (Act), 42 U.S.C. 22A2, and 10 CFR 2.205, IT IS HEREBV ORDERED THAT: The licensee pay a civil penalty in the amount of Fifty Thousand Dollars (550,000) within 30 days of the date of this Order, by check, draft, I or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Inspection and Enforcement,-U.S. Nuclear Reaulatory Commission, Washinaton, D.C. 20555. l V The licensee may request a hearina within 30 days of the date of this Order. A request for a hearino shall be addressed to the Director, Office of Inspection NUREG-0940 I.A-38
\
i 1 and Enforcement, U.S. Nuclear Reculatory Commission, Washinoton, D.C. 20555. l l A'c'opy of the hearino request also shall be sent to the Assistant General Counsel for Enforcement, Office'of the General Coansel, U.S. Nuclear Reaulatory Commission, dashinoton, D.C. 20555 and to the Reaional Administrator, Reaion 111, l 799 Roosevelt Road, Glen Ellyn, Illinois 60137. j l If a hearina is requested, the Commission will issue an Order desianatina the time and place of the hearina, if the licensee fails to request a hearina within 30 days of the date of this Order, the provisions of this Order shall be effective without further proceedings, if payment has not been made by that time, the I matter may be referred to the Attorney General for collection. In the event the licensee requests a hearino as provided above, the ist,ues to be considered at such hearina shall be: h I (a) whether the licensee was in violation of the Commission's requirements as ] set forth in Section 1 of the Notice of Violation and Proposed Imposition of Civil Penalties referenced in Section 11 above and (b) whether, on the basis of such violation, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION
/'
\
, ,m < , ' 1 s M. Tavl ,,' Director
/fificeofIns'p'ectionandEnforcement
' Dated at Bethesda, Maryland, this d(0.. day of February 1987. NUREG-0940 I.A-39 1
APPENDIX EVALUATION AND CONCLUSION In 'a letter dated' July 3,1986, the licensee responded to the. Notice of Violation and Proposed Imposition of Civil Penalties (Notice) dated May 6, 1986. In its response the licensee (1) admitted the violations documented in Section II and (2) paid the Fifty Thousand Dollar ($50,000) civil penalty for these violations. However, with respect to the violation in Section I of the Notice, the licensee (1) denied that a violation occurred, (2) disaareed with the Severity Level III classification of the violation, and
'(3) requested mitication of the civil penalty if the violation is upheld. l Provided below are (1) a restatement o' the contested violation, (2) a sumary of the licensee's response renardina the violation, (3) the NRC's ,
ev61uation of the licensee's response to the violation, (4) a sumary of the licensee's arauments-in support of mitiaation of the proposed civil penalty, (5) the NRC's evaluation of the licensee's arauments in support of mitiaation of the proposed civil penalty, and (6) the NRC's conclusion. I. l Restatement of Violation 1 Technical Specification (TS) 3.5.2 requires that two independent emeraency ) core coolina system (ECCS) subsystems-shall be operable with each subsystem 1 comprised in part of one residual heat removal (RHR) pump and an operable !' flow path when in Modes 1, 2, or 3. Technical Specification 3.0.3, which applies when TS 3.5.2 is not met and if two RHR pumps are inoperable,' requires that within 1 hour, the licensee sha.ll initiate action to place the unit in a mode in which the specification aoes i not apply by placina it, as applicable, in et least hot standby within the next ! 6 hours, at least hot shutdown within the followino 6 hours, and at least cold shutdown within the subsequent 24 hours, l The definition of operability.for the injection path for the ECCS is discussed in the Byron Unit 1 FSAR, Section 6.3 where it states that each RHR subsystem injects into all four cold leas of the reactor coolant system. { Contrary to the above, on March 6,1985 for approximately 13 hours, March 7, 1985 for approximately 13 hours, April 20, 1985 for approximately 31 hours, April 23, 1985 for approximately six hours, May 20, 1985 for approximately 30 hours, May 21, 1985 for approximately five hours and on July 24, 1985 for three separate periods of approximately three hours, two hours and seven hours, while l in Mode 1, both RHR subsystems of the ECCS were rendered inoperable durina i surveillance testina in that neither RHR pump was capable of injectina, as stated ( in the FSAR, into all four reactor coolant system cold leas due to the fact that l and valves IRH8716A and ISIB809A for RHR Pump A and valves IRH8716B and 1518809B ! for RHR Pump B were closed while system performance was beino measured. This is a Severity Level III violation (Supplement I). Civil Penalty - 550,000. l Summary of Licensee Response ! In its July 3, 1986 respense to the Notice, the licensee contends that I the circumstances surrounding the violation neither constitute a Severity NUREG-0940 I.A-40
Appendix ~2-Level III violation nor warrant a $50,000 civil penalty. The licensee states that durina the event an emeraency core coolina system (ECCS) subsystem was capable of performina its intended temperature control function while a portion of the RHR injection flow path was isolated, and therefore, the event did not involve a situation in which a system desianed to prevent or mitiaate a serious safety event was not able to perform its intended function under certain conditions. The licensee further states that the event did not constitute a significant violation of a technical specification limitina condition for operation (LCO) in that the RHR system valve alianment durina the event did not result in.two inoperable subsystems of the ECCS and that an ECCS subsystem could still perform its intended function. Therefore, the licensee believes that there was no violation of a technical specification LC0 action statement durina the event. The licensee's denial of a violation of technica. specification requirements is based primarily on its disagreement with the NRC as to the definition of-operability for the injection flow pcth for the-ECCS. The licensee states that the specified function of the ECCC as documented in the FSAR shows that an ECCS subsystem is operable if it is capatie of limitina peak claddina temperature to within specified limits followina a losc-of-coolina-acciaent (LOCA). The licensee claims the operability-of the ECCS subsystem flow path was demonstrated throuch on analysis conducted by Westinghouse. The licensee states that the analysis shcwed adequate flow would have been available durina a desian-basis LOCA such that the increcse in peak claddino temperature was estimated to be less than 10"F and would remain well below the limit established in 10 CFR 50.46. The licensee disaarees with the NRC's interpretation that each RHR subsystem must inject into all four reactor coolant system (RCS) cold leas for the ECCS injection path to be considered operable. In addition, the licensee araues that Section 6.3 of the FSAR speaks only of injection "into" the RCS or deliverino flow "to" the cold leas and that FSAR Fiaure 6.3-2 only depicts the maximum safe-auards flow path available (not the minimum flow path necessary for operability). The licensee also contends that the times stated in the Notice indicatina when both RHR subsystems were inoperable are not accurate and were revised in a letter from the NRC to the licensee on November 22, 1985. The licensee provided a summary nf the approximate times that valves were closed; these times ranaed from 0.9 to 13.1 hours. NRC Evaluation While the NRC. staff neither aareas with nor disputes the Westinghouse analysis, it is significant to note that the analysis was not presented to the licensee until af ter the violation was identified. The LOCA analysis assumina minimum safeauards available, at the time the violation was identified, modeled the RHR flow from one RHR pump to all four cold leas. As described in the Licensee Event Report (LER 85-081-01) submitted to the NRC on September 23, 1985, the assumed flow path for the LOCA analysis was inconsistent with the actual RPR system alianment durina surveillance testina; only one RHR pump was available for injection into two RCS colu leas. The effect of this flow path chanae was described in the licenses's July 3, 1986 response to the Notice "With this configuration [ actual RHR system alianment NUREG-0940 I.A-41
Appendix- durina testina), the RHR pump can deliver.190 lbs/sec. durina the core reflood phase rather than the 390 lbs/sec. flow currently modeled." This is a reduction of approximately 50 percent in RHR flow rate and is considered by the NRC to be significant. It was not appropriate for the licensee to shut valves preventina RHR flow to two of four RCS cold leas. Althouah it was fortuitous that later analysis by the licensee appears to show t% licensee's action to have a lower safety- significance, it was not appropriate'to contradict the desian-basis accident analysis assumptions without a proper evaluation of the consequences. The NRC position continues to be that the licensee took actions which placed ' the RHR system in a configuration inconsistent with the assumptions of the LOCA dnalysis. The NRC believes that with the RHR subsystem in a configuration 1 inconsistent with the LOCA analysis and not knowina whether or n'ot the acceptance j criteria in 10 CFR 50.46 would be satisfied, the licensee should have declareu the subsystem inoperable. An analysis showina system or subsystem operability after the fact is not considered by the NRC staff to justify the licensee's , actions at the time the RHR injection valves were closed. l The event was significant because, with the RHR system only able to inject into two cold leas, the plant's known ability to adequately respond to a larae break LOCA was significantly dearaded. The NRC staff disaarees with the licensee in that the^ event did involve a situation in which a system desianed to prevent or mitiaate a serious safety question was not able (or was not known to be able) to perform its intended function under certain conditions and did I constitute a significant violation of technical specification requirements which were established to ensure the ECCS components were maintained in an operable condition. Since the licensee did not know whether system requirements could be met, the licensee should have declared the system inoperable. Therefore, ! the event is properly classified as b Severity Level III violation. If the l licensee's analysis had shown that 10 CFR 50.46 requirements were not met ! durina the event, the NRC staff would have considered the event a Severity ; Level 11 violation. The licensee contends that Section 6.3 of the FSAR does not state nor depict RHR subsystem flow beino injected into all four RCS cold leas. While the NRC stoff could dicoute the licensee's interpretation of the statements and fiaure of the FSAR, the event in which a portion of the RHR flow path was isolated contradicted the larae break LOCA analysis in existence at that time. This contradiction was described in a September 23, 1985 LER and in the licensee's July 3,1986 response to the Notice. it was for this contradiction of the ; LOCA analysis that the NRC staff believes that the RHR subsystems should have ' been declared inoperable and for which the vid ation of technical specification requirements was intended. The licensee also contends that the times stated in the Notice durina which the violation occurred were inaccurate. The NRC staff aarees with the licensee and had previously revised these times in Inspection Report 50-45a/85056. However, the revision of the times for which valves were closed does not affect the violation as written in that T'.chnical Specification 3.0.3 required certain actions within 1 hour, within the next 6 ncars, and within the followina 6 hours. A violation of Technical Specifications 3.5.2 and 3.0.3 occurred for those times lonaer than 1.0 hour that the valves were closed and the licensee did not initiate the required actions. NUREG-0940 I.A-42
Appendix Summary of Licensee Arauments for Mitiaation Even if the NRC believes the event is properly classified, the licensee believ2s there _is an adequate basis for full mitiaation of the proposed civil penalty. The licensee believes that full credit should be aiven for promptly identifying the event at the first available opportunity and reportina the event to the NRC. The licensee states that throuah its industry monitorina proaram it identified a potential concern reaardina an incident at the Callaway Station and pursued further investigation which led to the issuance of an LER. This LER resulted in the NRC review of this event and subsequent issuance of a violation in this area. The licensee believes that it was unusually prompt and responsive in its corrective actions. Procedures and surveillance were reviewed and revised to prevent closina of the valves. Statements were added to procedures to l address when the valves may be closed 2nd the operating medes that apply. , j Main control board switches were taaaed to advise reactor operators that certain ' ! valves were to remain open durina Modes 1, 2, 3, and 4. In addition, operational auidance documents were issued to operatina personnel to indicate the modes in which the valves were required to be open. Blso, an independent review of RCS and ECCS technical specification surveillance was conducted by the Westinghouse Site Enaineerina Team. For these reasont, the licensee contends that the civil penalty should be rr 3ced by 50 percent. Recardina past performance, the licensee views its prior performance in this a red to be acod and does not aaree that the events leadina to the June 5, 1985 Severity Level IV Notice of Violation were relevant. The corrective actions to that event, includina review and revision of all operatina procedures involvina ECCS systems which could affect technical specification LCO's, were taken to ensure that operators would follow procedures. In the current event, procedures were followed; therefore, the past corrective actions were not relevant to this event for which followina instructions led to an improper valve alianment. In addition, licensee personnel understood the particular RHR system valve alianment to be acceptable, consistent with other utilities, and as a recommended method by Westinchcuse for performina some RHR system surveillance. The licensee contends that a contributing factor to its belief that the surveillance l was acceptable was that previou; NRC review snd witnessina of the surveillance had verifled that the LC0 was beina mr.t. i The licensee also believes that the factors of prior notice and multiple occurrence l should not be considered fc. escalation of the civil penalty. NRC Evaluation The NRC staff considered the licensee's prompt identification and reportino of I the violation at the first available opportunity and its pron.pt and extensive l corrective actions. However, the NRC staff disaarees with the licensee's l assertion that.the corrective 6ctions for the previous Severity Level IV l violation, described in the June 5,1985 letter and involvina the safety injection pumps, would not have been expected to identify the concern witn the l RHR system valve alignment. The NRC staff recoanizes that the cause of the safety injection pump violation was the failure of personnel to follow procedures; however, the corrective actions for that violation included a review of ECCS I NUREG-0940 I.A-43
l 1 I l Appendix ! 1 i operatina procedures that could impact technical specification requirements. i This review was done by licensed personnel at the senior reactor operator level. l The NRC staff expects personnel at that level to be knowledgeable of, amona ' other thinas, a system's desian bases, the significant assumptions of applicable desian-bases accident analyses, and the appropriate system alianment for normal and test condttions. Therefore, the NRC staff expects that the previous ECCS procedure review would have identified the inconsistency between the j surveillance procedures and the desian-bases accident analyses for the RHR system. While the licensee's personnel felt that the RHR system alianment was I consistent with that of other utilities and Westinghouse system descriptions, this does not excuse plant personnel from their lack of understanding of the basis on which the RHR system was desioned and analyzed. Althouah the , licensee points out previous NRC reviews of the surveillance procedure found it J satisfactory and feels that this contributed to the belief that the surveillance j was acceptable, this does not imply that the NRC has performed a complete review of the procedure and that subsequent NRC or licensee reviews will not identify additional deficiencies and if the deficiencies are deemed to be significant, ' enforcement action could be taken. The NRC staff still believes that the civil penalty escalation factors for prior notice and multiple occurrences are not appropriate in this case; therefore these are not discussed. In summary, althouah the NRC staff still considert it appropriate to aive credit for the licensee's prompt identification and reportinc of the violation and its prompt and extensive corrective actions, the NRC staff believes, on balance, this is offset by the licensee's fsilure to correct the RHR surveillance procedure based on the corrective actions taken for a previous viola + ion. Conclusion The NRC staff concludes that the violation of technical specification LC0 3.5.2 and 3.0.3 did occur in that at the times the violation occurred, as revised, the RHR injection paths, as described in the FSAR and larae-break. LOCA analyses, were rendered inoperable curina surveillance testina. It was durina this surveillance testina that certain valves were closed which contradicted the assumed flow paths for a desian-basis accident. Operability proven after the fact cannot be used to justify the actions taken at the time the valves were closed. The NRC staff considers this violation cause for significant concern and appropriately classified as a Severity Level III violation. The mitiaation and escalation factors in the Enforcement policy were carefully considered. The NRC staff determined that althouah there were arounds for mitiaation of the civil penalty for prcmpt identification and reportina of the violation and for the licensee's prompt aad extensive corrective actions, there were also arounds for escalation of the civil penalty for prior poor performance } in that +he licensee failed to properly implement previous corrective actions for a similar problem which was cited as a Severity Level IV violation. Therefore, overall the NRC staff considers it appropriate to impose the base civil penalty. Accorcinoly, the civil penalty in the amount of Fif ty Thousand Dollars ($50,000) should be imposed. NUREG-0940 1.A-44
1 pM ac UNITED STATES
/
J
% NUCLEAR REGULATORY COMMISSION REGION lit h7',>c(/ $j i
7ee ROOSEVELT moAo
" k. a 4 GLEN ELLYN. ILUNOIS 60ln g%.+> f June 25, 1986 j I
i Docket Nos. 50-454; 50-455 j Licenses No.. NPF-37; CPPR-131 EA 86-87 l Commonwealth Edison Company ATTN: Mr. James J. O'Connor i President j Post Office Box 767 ) Chicago, IL 60690 l Gentlemen:
SUBJECT:
SEVERITY LEVEL III VIOLATION FOR EMPLOYMENT DISCRIMINATION IN VIOLATION OF 10 CFR 50.7 ; I 1 This refers to the results of an investigation and hearing conducted by the j Department of Labor (DOL) into a complaint filed on November 16, 1984 by i Mr. Jeffrey Johnson, an employee of Transco Products, Inc. (Transco) and a i quality control (QC) inspector at the Byron Nuclear Power Station. 00L Case { No. 85-ERA-7. In his complaint, Mr. Johnson alleged that he was transferred and subsequently discharged for reporting concerns to the NRC about Transco's inspection procedures and installation of non-radiation proof seals. A , December 3, 1984 decision by the DOL Area Director which was upheld by a DOL I Administrative Law Judge'(ALJ) on March 5, 1985 found merit in Mr. J P.nson's complaint. While the ALJ's recommended decisie s 'i order was pending before the Secretary of Labor, a settlement between b > on and Transco was reached and the Secretary of Labor issued an O_ o Approving Settlement on August 8, 1985. Af ter reviewing the record before the DOL, the NRC finds that i a violation of the Commission's regulations has occurred. This matter was i discussed with you during an Enforcement Conference on April 21, 1986. j The violation in the enclosed Notice of Violation describes an incident cf discrimination in violation of 10 CFR 50.7. Specifically, under 10 CFR 50.7, , discrimination by a Commission licensee, or its contractor, against an employce for engaging in certain protected activities is prohibited. The activities l which are protected include reporting of quality discrepancies and safety problems by an employee to his employer or the NRC. l 1 1 To emphasize that acts of discrimination against employees engaged in protected l activities will not be tolerated, and after consultation with the Director, l Office of Inspection and Enforcement, I am issuing the enclosed Notice of I Violation and Proposed Imposition of Civil Penalty in the amount of Twenty Five ! Thousand Dollars ($25,000) for the violation described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985) (Enforcement Policy), the discrimination against Mr. Johnson has been characterized as a Severity Level III violation. The base value of a civil penalty for a Severity Level III violation is $50,000. The NRC Enforcement Policy allows for reduction of CERTIFIED MAIL
'RlTURN RECEIPT REQUESTED NUREG-0940 I.A-45
Commonwealth Edison Company June 25, 1986 a civil penalty under certain circumstances. In this case, the base civil penalty is reduced by fifty percent because of your prior good performance in this area, the isclated nature of this incident, and the corrective actions that have been or will be taken to prevent further incidents of this type frei occurring in the future. You are required te respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additio'.a1 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 copv of this letter and its enclosure will be placed in the NRC Public Documen; Room. i The responses directed by this letter ano the enclosed Notice are not subject to the clearance procedures of the O Uice cf Management and Budget as required , by the Paperwork Reduction Act of 1980, PL 95-511. 1 Sincerely,
% h Nefudv vJames G. Keppler Regionel Administrator
! l
Enclosure:
f Notice of Violation and i Proposed Imposition of ' Civil Penalty See Attached Distribution i l l l l i l NUREG-0940 I.A-46 ! l
-)
-l l
Commonwealth Edison Company - 3'- ' June 25,~1986 i Distribution cc w/ enclosure: Mr. Cordell- Reed Vice President t D. L'. Farrar, Director of Nuclear Licensing V. 1. Schlosser, Project Manager , Gunner Sorensen, Site Project Superintendent R. E. Querto, Plant Manager-DCS/RSB (RIDS) Licensing Fee Management Branch Resident Inscector, RIII Byron. Resident Inspector, RIII Braidwood Phyllis Dunton, Attorney General's Office, Environmental Control Division D. W. Cassel, Jr. , Esq. Diane Chavez, DAARE/ SAFE Steve' Lewis, ELD
.L. 01shan, NRR LPM H. S. Taylor, Quality Assurance Division l
I L e i l l: j i l 1 NUREG-0940 I.A-47 l I
u NOTICE OF' VIOLATION i AND. PROPOSED IMPOSITION OF CIVIL PENALTY Commonwealth Edison Company . Docket Nos. 50-454; 50-455 Byron Nuclear Power Station, License Nos. NPF-37;.CPPR-131 Units l'and-2 EA 86-87 B'ased on 'the results cf .an , investigation and hearing consucted by the Department of Labor (D3L Case 85-ERA-7) and the resulting Order Approvirg Settlement'by the Secrttary'of Labor, dated August 8, 1985, in the case of j complainant Jeffrey Johnson, the NRC has determined that;a violation of its 4
. regulations has occurred. In accordance with the " General Statement of Policy and Procedure for-NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), f the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant !
to Section 234 of the Atomic EnergyEAct of 1954, as amended ("Act".), 42 U.S.C. 2282, PL196-295 and 10 CFR 2.205. The violation and associated civil. penalty is listed below: q 10 CFR 50.7 prohibits discrimination by a Commission licensee, or a contractor or subcontractor of a licensee, against an employee for engaging in certain protected activities. Discrimination includes discharge and other actions that relate to compensation, terms, conditions and privileges of employment. The L activities protected include but are not limited to providing the NRC information. { about possible violations of NRC requirements and requests to the NRC to take i action against.an employer for enforcement of NRC requirements.- Contrary to the'above, Jeffrey Johnson, an employee of Transco Products, Inc., a subcontractor of Commonwealth Edison Company and a quality control inspector at the Byron Nuclear Power Station, was discharged N November 2, 1984 by Transco j for engaging in protected' activities which involvec' reporting ~ to the NRC on ' October 16, 1984 the employer's inadequate inspeco son procedures and irsta11ation of non radiation proof seals. I' This is a Severity Level III violation (Supplemest VII). Civil Penalty - $25,000 i l Pursuant to-the provisions of 10 CFR 2.201, Commonwealth Edison Company is hereby l required to submit to the Director, Office of Inspection and Enforcement, j U.S. Nuclear Regulatory Commission, Washingtcn, D. C. 20555 with a copy to the ! Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, within 30 days.of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation, if admitted, (3) the corrective steps which Lwill be taken to avoid further violations, (4) tha corrective steps which will be:taken to avoid further violations, (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in f:, j NUREG-0940 I.A-48 l l
i i Notice of Violation June 25, 1986 I
)
I this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the 4 authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be t submitted under oath or airmation. Within the same time as provided for the response required above under 1C CFR 2.201, Commonwealth Edison Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Trwasurer of the United States in the cumulative amount of Twenty Five Thousand Dollars (525,000) or may protest imposition ! of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Commonwealth Edison Company fail to answer within the time specified, the Director, Office of Inspection and Enforc p ent, will issue an order imposing the civil penalty in the amount preposed above. Should Commonwealth Edison Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate j extenuating circumstances, (3) show error in this Notice, or (4) show other , reasons why the penalty should not be impesed. 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 cf the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Commonwealth Edison Company's attantion it, directed to the other provisior s of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to section 234c of the Act, 42 U.S.C. 2282 l FOR THE I,UCLEAR REGULATORY COMMISSION Q~b W-cWw UJemes G. Keppler i Regiona'i Mministrator i Dsted at Glen Ellyn, Illinois this 2.5%ay of , 1986. j NUREG-0940 1.A-49 b__ _ _ _ _
i [ *o
~g UNITEO sT ATEs 1 o NUCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20656 r,. j
%'m*/ APR 0 21be7 Docket Nos. 50-454; 50-455 Licenses No. NPF-37; NPF-66 EA 86-87 Commonwealth Edison Company ATTN: Mr. Jomes J. O'Connor President Post Office Box 767
' Chicago, IL 60690 Gentlemen:
SUBJECT:
ORDER IMPOSING CIVIL MONETARY PENALTY This refers to your letter of July 29, 1986, in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to.you by our letter dated June 25, 1986. The Notice of Violation described an incident of discrimination.in violation of 10 CFR 50.7 requirements. To emphasize the importance that the NRC places on ensuring that Comission licensees and their contractors do not engage in discriminatory acts against employees involved in certain protected activities, a civil penilty in the amount of Twenty Five Tho and Dollars ($25,000) was proposed. In your response, you did not take issue with the facts of the case, as described i in the Notice of Violation. However, you request total mitigation of the { proposed civil penalty because of your extensive corrective actions and your i prior, good enforcement history. You also request that the NRC reconsider 1 classification of the incident at Severity Level IV, and in support of your j position, reference two escalated enforcement actions that you believe are similar to this event. a After consideration of your response, we have concluded, for the reasons given I in the Appendix ettached to the enclosed Order Imposing Civil Penalty, that the violation was properly classified at Severity Level III and that further j mitigation of the civil penalty is not warranted. Accordingly, we hereby serve 1 the enclosed Order on Commonwealth Edison Company imposing a civil monetary J penalty in the amount of Twenty Five Thousand Dollars ($25,000). We will review j
- the effectiveness of your corrective actions during subsequent inspections.
In decordance with Sectior 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federai R29ulations, a copy of this letter and the enclosures ! will be placed in the NRL % Public Document Room. Sincerely, f z-owarc. L ordan, Acting Director 3 Offite Inspection and Enforcement i
Enclosures:
As stated NUREG-0940 I.A-50
I i Connonwealth- Edison Company - cc w/ enclosure': Mr. Cordell Reed ' i Vice President' D. ' L. .Farrar. Director of Nuclear Licensing V. I. Schlosser,' Project Manager ' R. E. Querio, Plant Manager. .. Licensing Fee Management Branch Resident Inspector,.RIII Byron
'Phyllis Dunton, Attorney General's-Office, Environment 61 Control Division D.' W. Cassel, Jr. . Esq. -
-Diane Chavez..DAARE/ SAFE Steve Lewis', OGC L. 01 shen, NRR LPM . .
H. - S. Taylor, Quality Assurance Division i l i 1 hd l NUREG-0940 1.A-51 l L----_-_-_----_____=
r-UNITED STATES NUCLEAR REGULATORY COMMISSION l In the' Matter of~ COMMONWEALTH EDISON COMPANY Docket Nos'. 50-454 and 50-455 Byron Nuclear Station Licenses No. NPF-37 and NPF-66 Units 1 and ? EA 86-87 ORDER IMPOSING CIVIL MONETARY PENALTY I Commonwealth Edison Company is the holder of Operating Licenses No. NPF-37
-and NPF-66 issued by the Nuclear Regulatory Commission on October 3, 1984 ana January 30, 1987.- The licenses authorize the licensee to operate the i
Byron Plant,. Units 1 6nd 2, in accordance with the conditions specifiec '
.therein.
i II q 1 i A December 3,1984, cecision by the Department of Labor (DOL) Area. Director found that Transco. Pro'ucts. d Inc., hed discriminated against an employee engaged , 4 in protectea activities. That decision was upheld by a DOL Administrative Law Judge (ALJ) on March 5, 1985, and the case was settled prior to a decision by ) the Secretary. The NRC's review of this decision indicated that the licensee 2 haa not conducted its activities in full compliance with hRC requirements. A
. written Notice of Violation and Proposed Imposition of Civil Penalty was served upon the licensee by letter dated June 25, 1986. The Notice stated the nature of the violation, the provisions of the NRC's requirements that the licensee 1
had! violated, and the amount of the civil penalty proposed for the violation. ! The licensee responded to the Notice of Violation and Proposed Imposition of Civil Pendity by letter dated July 29, 1986. NUREG-0940 1.A-52
l 1 III' After consideration of the licensee's response and the statements of fact, explanation, and argument for mitigation contained therein, the Director, Office of Inspection end Enforcement, has determined, as set f'~th in the Appendix to this Oroer, that the violation occurred as stated and that the penalty proposed t%r the violation designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be imposed. IV In view of the foregoing *ad 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 1 HERE8Y ORDERED THAT: The licensee pay a cit il penalty in the amount of Twenty Five Thousand Dollars ($25,000) within 30 days of the date of this Order, by check, l draft, or money order, payable to the Treasurer of the United States l l and mailed to the U.S. Nuclear Regulatnry Commission, ATTN: Document l l Control Desk., Washington, D.C. 20555. ! l 77,e licensee may request a hearing within 30 days of the date of this Order. A request for a hearing shall be clearly marked as such and shall be addressed l to the U.S. Nuclear Reguldtory Commission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Regional Administrator, Region III, and a copy to the NRC Resident Inspector, Byron. l NUREG-0940 I.A-53
If-a hearing is requested, 'the Conunission 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 proceedir;;s. 'If payment has not been made by thdt' time, the matter may be referred to the Actorney General for collection, q In the event the licensee requests a hearing as_provided above, the issues !
to be. considered at such hearing shall be: l l (a) whether the licensee was in violation of the Commission's requirements as set forth in the-Notice of Violation and Proposeo Imposition of. Civil Pep ity referenced in Section II above and (b) whether, on the basis of such violation, this Order should be sustainea. FOR THE NUCLEAR REGULATORY COMMISSION Edward L ordan, Acting Director Office 01[ Inspection ano Enforcement Dated at Bethesda, Maryland this f' day of April 1987. l I' i
) .NUREG-0940 I.A-54
APPENDIX EVALUATIONS AND CONCLUSIONS On June 25, 1986, a Notice of Violation and Proposed Imposition of Civil Penalty (NOV) was issued for a violation of 10 CFR 5J 7 requirements. Commonwealth Edison Compeny responded to the Notice on July 29, 1986. In its response, the licensee did not take issue with the fdcts of the case, but stated that it believes that total mitigation of the proposed civil penalty is warranted because of its extensive corrective actions and its prior, good enforcement history. The licensee also requested NRC to reconsider classification of the violation ; to Severity Level IV. Provided below are (1) restatement of the violation; (2) a sumary of the licensee's response in support of this request; (3) the NRC's evoluation of the licensee's response, and (4) the NRC's conclusion. Restatement of Violation 10 CFR 50.7 prohibits discrimination by a Commission licensee, or a contractor or subcontractor of a licensee, ogainst an employee for engaging in certain protected activities. Discrimination includes discharge and other actions that relate to compensation, terms, conditions, and privileges of employment. The activities protected include but are not limited to providing the NRC information about possible violations of NRC requirements and requests to the NRC to take action dgainst an employer for enforcement of NRC requirements. Contrary to the above, Jeffrey Johnson, an employee of Transco Products, Inc., a subcontractor of Commonwealth Edison Company and a quality control inspector at the Byron Nuclear Power Station, was discharged on November 2, 1984, by Transco for engaging in protected activities which involved reporting to the NRC on October 16, 1984, the employer's inadequate inspection procedures and installation of non-radiation-proof seals. This is a Severity Level III violation (Supplement Vil). j Civil Penalty - $25,000 l Summary of Licensee's Response The licensee does not dispute the facts or findings of this event, but disagrees with the NRC's conclusion that the event is properly classified as a Severity j Level III violation. The licensee also requests that the NRC further review the positive and extensive corrective actions taken by the licensee. The licensee states that as soon as it learned of the incident, it began formulating and implementing the corrective actions which address the general area of worker protection to prevent a recurrence of similar events. In the area of past performances, the licensee believes that its performance over the past twelve years shows the effectiveness of Edison's commitment to worker j protection as demonstrated by the extremely low number of beportment of Labor [ (DOL) complaints at the LaSalle County, Byron, end Braidwood Stations. The licensee believes that 100% mitigation of the bose civil penalty is appropriate for the corrective actions taken and for past performance. In support of the licensee's arguments concerning reduction of the severity level and civil penalty, the licensee has provided two earlier NRC enforcement Cdses for Consideration. In EA S4-93, the NRC reevaluated a Severity Level 11 NUREG-0940 I.A-55 ! l
Appendix violation at Catawba Nuclear Station and reduced the vio12 tion to Severity Level III based on the isolated nature of the incident anc the licensee's generally good management of the quality assurance and control program. In EA 85-117, a civil penalty was not proposed for a violation at Vogtle Electric Generating Plant due to the licensee's corrective actions and good enforcement history. The licensee believes that the NRC should consider both of these cases in determining the appropriate sanction for this violation. NRC Evaluation of Licensee's Response In responding to the licensee's argument that the violation should be reclassified in light of EA 84-93, the violation in that case initially was properly classified as a Severity Level II violation because the incident involved " action by plant management above first-line supervision." That severity level classification Wds reduced, however, because of the particular facts in that incident and because the inc1 dent was a relatively isolated event and the licensee's manage-ment of the quality assurance and control program was generally good. (June 30, 1986 Order Imposing Civil Monetary Penalty, Appendix at 6.) The NRC believes that the violation in EA 86-87 was properly classified as a Severity Level III violation. Regarding the staff's mitigation of the civil penalty in EA 85-117, the correc-tive action taken was both very extensive and initiated immediately. A prompt thorough investigation was mode, and the cause of the problem was removed by replacement of the manager charged with the intimidation. EA 85-117 concerned remarks by a manager which were perceived by Quality Control (QC) personnel as intimidating regarding their freedom to perform their quality assurance functions. Investigation and subsequent inspections did not disclose that QC inspections were compromised. (November 15, 1985 Notice of Violation et 1.) The QC inspectors continued to perform their job and adverse action was not taken against them. In the instant case, odverse action was in fact taken against an employee who came forward and reported a sofety concern to the NRC. While the NRC will not tolerate either type of behavior, it finds especially serious those situations where actual discrimination, and not just the threat of discrimination, occurs in retaliation for an employee engaging in a protected activity. The facts of this event show that action was taken against an employee by first-line supervision in violation of Section 210 of the Energy Reorganization Act (ERA). This action is properly categorized as a Severity Level III violation in accordance with 10 CFR Part 2, Appendix C, Supplement VII.C.3. Any incident of discrimination is considered to be serious and not appropriate for reduction below Severity Level III. The hRC acknowledges that the licensee took corrective actions that were extensive in nature. The NRC also acknowledges the licensee's good enforcement history in this area as well as the apparent isolated nature of the event. For these reasons, partial mitigation of the base civil penalty was considered appropriate. Use of the same factors to also reduce the severity level classi-fication is not considered appropriate, as the significance of the violation determines the severity level, and previous good performance and subsequent corrective actions are factors that determine escalation /mitigotion of the civil penalty. NUREG-0940 I.A-56
l 1 Appendix Total mitigation of the civil penalty was not. considered. appropriate for several reasons. The NRC enforcement policy allows up to 50% reduction of the base civil penalty for unusually prompt and extensive corrective actions. While the licensee's actions were extensive, the NRC ~does not belicve that the actions w:re prompt in response to the discriminatory act by one of its contractors. - The initial complaint to DOL was filed on November 16, 1984. In December 1984 and March 1985, DOL officials found in favor of the complainant. A review of corrective actions taken by Consnoawealth Edison shows that these actions were only initiated in response to the NRC enforcement conference in April 1986. In its response, the licensee makes no mention of any corrective actions in response to this event prior .to April 1986. Although the NRC recognizes the licensee's good enforcement history in this area, full mitig6 tion is not considered appropriate. As a result of the f enforcement conference and the subsequent corrective actions tahn by the licensee, the NRC believes that contractors hao not been fully aware of their obligations in this area. Further, even though an event of this kind had occurred, approxi-mately one and one-half years elapsed before the licensee had a mechanism in l place to respond adequately and inform workers that such acts would not be tolerated. The absence of a program to inform contractors / employees of their responsibilities in this area as well as the failure of_ the licensed to respond promptly to prevent potential 1' intimidation of others resulting from this case indicates that the licensee's performance was not adequate to warrant full mitigation of the proposed ' civil penalty. NRC Conclusion The NRC stoff believes that the violation did occur as stated. The NRC has reviewed Commonwealth Edison Company's response to the proposed imposition of civil penalty and believes that the event was properly classified as a Severity Level III violation. The staff continues to believe that while partial miti-gation of the base civil penalty is appropriate, the. licensee's actions are not deserving of further mitigation. Consequently, the proposed Civil Penalty in . the amount of $25,000 should be imposed. I l NUREG-0940 1.A-57
E p*,*fCW UNITED STATES
*g ' NUCLE AR REGULATORY COMMISSION g rf S REGION til Y j 19e moosEvtLT mo AO' cLrN cLLYN, ILUNOl$ 60137 MAR 2 61987 .
I Docket No. 50-454 , License No. NPF-37 EA 87-16 , Commonwealth Edison Company 4
-ATTN: Mr. James J. O'Connor j President Post Office' Box 767 Chicago, IL. 60690 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT 50-454/84-87) This refers to the inspection conducted by the Nuclear Regulatory Commission (NRC) during the period December 31, 1984 - February 14, 1985, and to the investigation conducted by the NRC Office of Investigations, Region III Field Office during the perio'd March 15, 1985 - July 24, 1986 of activities at Byron Nuclear Power Station, Unit 1, authorized by NRC Operating License NPF-37. The report documenting the results of the inspection was provided to you by letter dated i March 5, 1985. The synopsis describing the results of the investigation was
.provided to you by ?etter dated November 7, 1986. The results of the inspection and investigation were discussed with Mr. Cordell Reed and members of your staff during an Enforcement Conference conducted in the NRC Region III office on December 15, 1986. Present at that conference representing the NRC were members of my staff, the Enforcement Staff from the Office of Inspection and Enforcement, the Offite of the General Counsel, and the Office of Nuclear Reactor Regulation.
The violation in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty occurred when your Project Engineering Section Manager approved the results of Startup Test 2.63.32 " Reactor Coolant flow Coastdown," by utilizinganacceptancecriteriondIfferentthanthatdescribedinChapter14 of'the Byron Final Safety Analysis Report (FSAR). Your license specifically required prior NRC approval for any change to test acceptance criteria. The Project Engineering Section Manager violated the Byron Unit I license when he approved the test results and did not request and obtain prior NRC approval for the change in the FSAR. TheProjectEngineeringSectionManagerstatedthathe CERTIFIED MAIL RjlVRN RECEIPT REQUESTED NUREG-0940 I.A-58
Commonwealth Edison Company 2 MAR ? 61997 i was aware of the requirement to obtain prior NRC approval of FSAR acceptance criteria changes and he was advised in a letter from Westinghouse Electric Corporation that the test acceptance criterion could be revised based on reanalysis of the Byron Unit 1 Complete Loss of Forced Reactor Coolant Flow accident. The Westinghouse letter further stated that a revised FSAR section would be provided after incorporation of the test results. Furthermore, the FSAR required the results of that test N be approved prior to Byron Unit 1 initial criticality. The Project Engineering Section Manager . approved those test results two days prior to initial criticality. The NRC staff considers that the circumstances surrounding this matter involve careless disregard of NRC requirements; specifically, the Byron (Init 1 license condition. The NRC has performed a technicci analysis of this event and has concluded that the violation would normally be categorized at Severity Level IV for a violation of the license condition requirement. However, after considering tne careless disregard toward regulatory compliance exhibited by your section manager who was vested with startup test approval authority, the violation described in the enclosed Notice has been categorized at Severity Level III, in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," Enforcement Policy 10 CFR Part 2, Appendix C (1986) (Enforcement Policy). .To emphasize the importance of ensuring that your managars ac'here to NRC requirements, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violation described in the enclosed Notice. The escalation and mitigation factors in the Enforcement Policy were considered andnoadjustmenthasbeendeemedappropriate. You are required to respond to this letter and should follow the instruction 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 requiremer.tr In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a co)y of this letter and its enclosure will be placed in the NRC Public )ocument Room. ; l i NUREG-0940 1.A-59
t Commonwealth Edison Company 3 MAR 2 61987
-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.
c Sincerely, a84 % A. Bert Davis Acting Regional Admini:tratcr
Enclosure:
Notice of Violation and Proposed Imposition of-Civil Penalty l cc w/ enclosure: O. L. Farrar, Director
- of Nuclear Licensing-V. I. Schlosser, Project Manager l Gunne* Sorensen, Site Project Superintendent R. E. Quer!o, Plant Manager i DCS/RSB(RIDS) !
Licensing Fee. Management Branch i
- Resident Inspector, RIII Byron Resident Inspector, RIII ,
Braidwood I Phyllis Dunton, Attorney I General's Office, Environmental l Control-Division
-D. W. "assel, Jr., Esq.
Diane chavez, DAARE/ SAFE Steve Lewis, OGC
.L. Olshan, NRR LPM H. 5. Taylor, Quality Assurance Division I
1 I tNUREG-0940 I.A-60
l l l NOTICE OF VIOLATION AND I PROPOSED IMPOSITIUR 0F CIVIL PENALTY ! Commonwealth Edison Company Docket No. 50-454 Byron Nuclear Power Station, Unit 1 l License No. NPf-37 EA 87-16 During an NRC inspection conducted on December 31, 1984 - February 14, 1985, and an NRC investigation conducted March 15, 1985 - July 24, 1986, a violation of the Byron Unit 1 license was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions " 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes,to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, PL 97-295, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below: Byron SectionNuclear Power Station, 2.C.(3), required Unit 1, conduct that the licensee Operating License No. NPF-37' loadin the post-fuel initial test Report (FSAR) program
, as as without amended, described in Chapter making 14 program any major of the Final Safety Analysis modification unless such modification had prior NRC approval. Major program modifications as defined in this license section included changes to the acceptance criteria for a safety-related test.
Coiltrary to the above, on January 31, 1985, thelicenseeimplementedamajor program modification to the post-fuel-loading initial test program without prior NRC approval. The Project Engineering Section Manager approved the results of Startup Test 2.63.32, "Reactot Coolant Flow Coastdown," a safety related test, based on an acceptance criterion different from that in FSAR Chapter 14 dated June 1984. The results of that test did not satisfy the approved acceptance criterion in FSAR Chapter 14. The licensee had not requested, nor had the NRC approved, a change of that acceptance criterion. This violation occurred because of careless disregard for the operating license requirements. This is a Severity Level III violation (Supplement 1). Civil Penalty - $50,000. Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company is hereby required to submit a written statement or explanation to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatury Commission, Region III, 799 Roosevelt Road, Glen Ellvn, IL 60137, within 30 days of the date of this Notice. This reply should i~nclude 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 i been taken and the results achieved, (4) the corrective steps which will be j taken to avoid further violations, and (5) the date when full compliance will > NUREG-0940 1.A-61 J
l l
. MAR 2 6 WB7 Notice of Violation 2
If an adequate reply is not received within the time specified be achieved. in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper 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. 4 l Within the same time as provided for the resporse required above under 10 CFR 2.201, Commonwealth Edison Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the amount of Fifty Thousand Dollars ($50,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Commonwealth Edison Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Commonwealth Edison Company elect to file l an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such ' answer may: (1) deny the violation listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. {; 1 In requesting l in Section V.B mitigation of 10 CFR of the2,proposed Part Appendix penalty,)the fivebefactors C (1986 should addressed 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. Commonwealth Edison Company's attention 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 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 j compromised, remitted, or mitigated, may be collected by civil action pursuant ) i to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATOR ( COMMISSION l hh A. Ber'. Davis W i Acting Regional Administrator i Dated at Glen Ellyn, Illinois i this 2 8 day of March 1987 ! NUREG-0940 1.A-62 1
ga8 466 UNITED STATES 6 , NUCLEAR REGULATORY- COMMi$$10N
~
f $ REGeoN ltl L j no moostvcLT noAo a clew cLLvw. stuNots sosu APR 2 31987 Docket Nos. 50-237; 50-249 j Licenses No. OPR-19; DPR-25 i
.EA 87-26 Commonwealth Edison Company ATTN: Mr. Jame: J. O'Connor President Post Office Box 767 Chicago, IL 60690 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY i (NRC INSPECTION REPORTS NO. 50-249/86009, 50-249/86012 AND 50-237/86015, AND 50-249/86017) j This refers to three NRC safety inspections that were conducted by personnel from the'0ffice of Inspection and Enforcement, Region III, and consultants, of activities at Dresden Nuclear Power Station authorized by NRC Licenses 1 I No. OPR-19 and No. DPR-25. During the inspections, numerous violations of NRC requirements were identified. The subject Inspection Reports'No. 50-249/ ; 86009, 50-249/86012, and 50-237/86015, and 50-249/86017 were sent to you on May 29, October 17, and June 30, 1986, respectively. An enforcement conference was held en February 26, 1987 with you and your staff to discuss the inspection findings and your corrective actions. The inspections were conducted between December 2,1985-July 16,1986, and took place at the Dresden Station, your corporate offices, and the offices of contractors responsible for engineering activities related to facility modifi-cations at Dresden. The inspections were part of a trial NRC program that was implemented to examine the adequacy of licensee management and control of modifications performed during scheduled major plant outages. The pu pose of the inspections was to examine, on a sampling basis, the detailed design and ; engineering that was required to support modifications as well as the installa- l tion and testing of plant modifications accomplished during the October 1985 I to July 1986 cutage at Dresden, Unit 3. The violations in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) are considered significant because, when evaluated collectively, they identify a major weakness in the modification area and include: (1) design change control, (2) installation of equipment, (3) proce- i dures and instructions, (4) 0A/0C overview of modification activities , (5) corrective action implemenution, and (6) control of testing. These violations demonstrate a need for licensee management involvement in the plant CERTIFIED MAIL j RETURN RECEIM REQUESTED NUREG-0940 I.A-63 I
Commonwealth Edison Company 2 APR 2 31987 modification area to ensure that ader~ te controls are available and being implemented. The violations listed ta the Notice are representative of the approximately 90 violations that were identified in the inspection reports. Although only selected examples of the violations were presented in the Notice in the interest of clarity, you are required to respond in the manner described in this letter and Notice tu each of the violations and deficiencies set forth in both the Notice and inspection reports. To emphasize the need for licensee management to remain actively involved in implementing effective modifications and corrective action programs, I have l been authorized, after consultation with the Director, Office of Enforcement I and Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Twenty-Five Ihousand Dollars (525,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Action," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), the violation has been categorized in the aggregate as a Severity Level III problem. The escalation and mitigation factors in the . Enforcement Policy were considered. The base value of a civil penalty for a i Severity Level III violation or problem is $50,000. The NRC Enforcement Policy allows for reduction of a civil penalty under certain circumstances. In this case, the base civil penalty is reduced by 50 percent because of the unusually i prompt and extensive corrective actions being taken to prevent reoccurrence and j upgrade the overall modification process and management controls. i You are required to respond to the enclosed Notice and should follow the instructions specified in the enclosed Notice when preparing your response. Your respome should be directed at the following three areas. First, you should confirm the completeness of the actions taken to correct the violations cited in the Notice as well as additional examples of similar violations described in the subject inspection reports. Second, you should address I how you have changed or strengthened the implementing procedures to preclude ' similar violations in these subject areas in the future. Third, you should ] describe the steps you have taken to ensure that continuing attention by J management will be provided to prevent recurrence of these kinds of failures. ! We note that you have, in some cases, already addressed these concerns in previous correspondence. Therefore, in your response you may reference previous submittals where appropriate. After reviewing your response to the j Notice, including your proposed corrective actions and the results of future 4 inspections, the NRC will determine whether further enforcement action is ) necessary to ensure compliance with NRC regulatory requirements. 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 enclosures will be placed in the NRC's Public Document Room.
)
i NUREG-0940 I.A-64
Commonwealth Edison Company .3 APR 2 31987 The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Ma.nagement and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, k D A. Bert Davis Regional Administrator
Enclosure:
Notice'of Violation and Proposed-Imposition of Civil Penalty cc w/ enclosure: D. L. Farrar, Director of Nuclear Licensing J. Eenigenburg, Plant Manager DCS/RSB (RIDS) Licensing Fee Management Branch Resident Inspector, RIII Richard Hubbard J. W. McCaffrey, Chief, Public Utilities Division-l NUREG-0940 1.A-65
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Commonwealth Edison Company Docket k 3. 50-237; 50-249 Dresden Nuclear Power Station Licenses No. DPR-19; DPR-25 Units 2 and 3 EA 87-26 i NRC inspections conducted curing the period December 2-6 and 16-20, 1985, January 6-11 and 13, 1986; May 19-23, 1986; and April 21 through May 7, June 9-13 and July 7-16, 1986, identified violations of NRC requiremero t. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the violations are listed below: A. 30 CFR Part 50, Appendix B, Cr,iterion XVI, requires measures to be established to assure that conditions adverse to quality and nonconfor-mances 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. Contrary to the above, measures did not assure that corrective action was taken to preclude repetition of a design error identified on Dresden Unit 2 from being implemented in Unit 3. For modifications M12-3-84-27 j' and M12-3-84-28 (Replacement of Solenoid Valves which Operate the Torus to Reactor Building Vacuum Breakers), procedures and drawings were in error and resulted in the air lines being reversed during the installation, This , error may have prevented the proper functioning of the valves. The error was identified and corrected during the modification on Unit 2. However, with regard to Unit 3, as of April 21 - May 7, 1986,, the dates of the inspection, the design docu.aents were not corrected and the air lines were , reversed. (50-249/86012 - Deficiencies 2.2-10 and 2.5-6). l B. 10 CFR Part 50, Appendix B, Criterion III, requires in part that measures be established to assure that appropriate quality standards are specified and included in design documents, and that deviations from such standards are controlled. Measures shall be established for the identification and control of design interfaces and coordination among participating design organizations. Design control measures shall provide for verifying and checking the adequacy of the design. Design changes, including field changes are subject to design control measures commensurate with those applied to the original design. Contrary to the above, measures were not established to assure that appropriate quality standards were specified and included in design documents, coordination was conducted between organization, adequacy of designs were properly verified, and design changes were subject to i cor. trol measures commensurate with those applied to the original design j in that: i I I 1 1 NUREG-0940 I.A-66 ! l
Notice of Violation 2 APR 2 31987 i I 1. For Modification M12-3-84-42 (High Pressure Coolant Injection Pipe ; I Whip Restraints), shims were added in the design to the bottom 180 l
~ degrees of the inside diameter of the restraint sleeve. This design i did not recognize the increased interference between the pipe and j restraint creating unanalyzed loads on each during thermal expansion.
(50-249/86012 - Deficiency 2.2.-2) i
- 2. For Modification M12-3-84-8 (HGA Relay Replacement), design changes were recorded on drawings rather than by processing the required design change documents. This resulted in the actual installation not conforming to the latest wiring diagrams. Handwritten notes on drawings caused changes to connection points, addition of jumpers, invoking of a different drawing revision, and provided options if an earlier modification had not yet been completed. (50-249/86012 -
Deficiency 2.2-4) ,
- 3. For Work Requests (WR) 39291 and 39292 (Replace Operator Mounting Bolts, Install Anti-Rotation Bars, Alter.0perating Times and Inspect Seats on Valves 3-1601-20A and 20B), unreviewed and undocumented design changes were made and lack of coordination between participating design organizations led to the following:
- a. Mechanical Maintenance Department (MMD) while attempting to add orifices in the exhaust ports of the solenoid operated valves which operate the vacuum breaker valves was not aware that Electrical Maintenance Department was replacing the solenoids operated valves. The addition of orifices would not work on the new valves and would not comply with vendor req'Jirements for placement of orifices.
- b. Stroke times for vacuum breaker valves was specified as 20 seconds maximum in the Dresden Operating Survei'11ance test procedure (DOS) 1600-1, " Quarterly Valve Timing." WRs 39291 and 39292 specified a stroke time of 10-25 seconds af ter the solenoid operated valves were fitted with orifices. There was no indication that the original design basis was reviewed for the modification.
- c. The Mechanical Maintenance Department determined that actuation failures experienced in the past (sheared bonnet bolts caused by slamming the valve closed) could be minimized in the future with the addition of " anti-rotation" stop blocks and stronger fasteners.
There were no drawing revisions or other formal engineering reviews or documentation of either the " anti-rotation" blocks or fastener modifications to assure that the modifications as i completed were acceptable and that future work on the valves would comply with the latest design and material requirements. I (50-249/86012 - Deficiency 2.2-H and 2.5-7) l NUREG-0940 I.A-67
J J Notice of Violation 3 N2 C ., 10 CFR 50.59. states that a. licensee may make changes in the facility as , described in the FSAR without prior Commission approval unless the proposed
~
i
~c hange' involves a change in the technical speci.fications or an unreviewed i
' safety question. Further, records shall be maintained which; include a ]
written safety evaluation which provides the bases for determining that the ] change does'not involve an unreviewed safety question, j
\
Contrary.to the above, .the licensee made the following changes in the i facility without prior Commission approval and did not perform a documented i review and safety evaluation which would provide the basis for determining
'that these changes did not involve unreviewed safety questions:
- 1. Lead Shielding was placed on safety-related piping without design controls or a safety evaluation. Had a seismic event occurred, i possible overstressing of piping or components could have occurred due to unanalyzed loading or possible damage to other safety-related equipment could have oct..rred because of shifting or falling shielding. !
(50-249/86012 -. Deficiency 2.2-1) ,
- 2. The as-built, accepted penetrations for Modification M12-2/3-85-34 l' (Reactor Building Hose Penetration) did not conform to the original Sargent and Lundy design requirements thereby negating the original l 10 CFR 50.59 safety evaluation and a new safety evaluation was not !
performed. (50-249/86012 - Deficiency 2.2-8)
- 3. 10 CFR Part 50, Appendix B, Criterion V, requires activities affecting quality to be prescribed by and accomplished in accordance with documented instructions, procedures, or drawings, and that these instructions, proce-dures, and drawings shall include appropriate acceptance criteria.
Contrary to the above, activities affecting quality were not prescribed or conducted in accordance with documented instructions, procedures, or drawings, and appropriate acceptance criteria was not included in that:
- 1. The licensee did not have an approved procedure for selecting over-lord protection fur motor operated valves (MOV). Although the Station Electrical Engineering Department did use a draft procedure for setting A.C. overloads it was used only to review MOVs when requested by Station Nuclear. There was no procedure for selecting overload pro-tection for D.C. motor operated valves. (50-249/86009 - Deficiency D5.3-1)
- 2. Work packages, including seven different modification packages, a special procedure, a work request and an AE specification, contained inadequate acceptance criteria for inspection and testing modifications for running current, insulation resistance and rotation tests; recorder calibration linearity; turns to back seat valves; seismic requirements; as-found location, inspection requirements or clearances for pipe whip restraints; slopes of instrument lines and drain lines; repair manual requirements and material selection for replacement parts.
(50-249/86012 - Deficiency 2.4-1) NUREG-0940 1.A-68
I i Notice of Violation 4 APR 2 31987 l
- 3. .QA or QC hold points were not specified for Modification M12-3-83-37 I which reletc3 to calibration and hydrostatic testing; Modification j M12-3-83-40 which relates to splices made in environmentally qualified :
equipment; and Modifications M12-3-84-49 and 50 for repairs made to power leads on environmentally qualified Low Pressure Coolant Injection room cooler motors. Dresden Administrative Procedure (DAP) 15-) requires hold points for each of these activities. (50-249/86012 - Deficiency 2,4-6)
- 4. Dresden Administrative Procedure 15-1, " Work Requests." did not adequately address revisions of work requests for work in progress in the areas of management review, 10 CFR 50.59 review, QA/QC involvement and work scope changes. Further, the Total Job Management (TJM) manual (referenced in DAP 15-1) referenced out of date work request forms.
(50-249/86012 - Deficiency 2.4-10)
- 5. For Modification M12-3-83-40 (IEB 79-01 Instrumentation Replacement),
safety-related cables were bundled with non safety-related cables in Panels 2203-73A and 2203-73B. Note 2 on Drawings 12E7860, Revision E and Drawing 12E7861, Revision E required non safety wiring to be in conduit or have six inches of separation from safety-related wiring. (50-249/86012 - Deficiency 2.5-1)
- 6. Modification Packages M12-3-84-27 and 28, M12-3-83-40, M12-3-84-49 and 50, and M12-3-84-9 contained examples of cable splices that were ,
not made in accordance with documented instructions including severe bend radius, braided jacket extending under the splice insulation, damage to splice sleeve including exposed bare conductors, sleeves l shorter than required length, kinked wires and damaged insulation. (50-249/86012 - Deficiency 2.5-3) i l
- 7. For Modification M12-3-84-8 (HGA Relay Replacement) the Low Pressure Coolant Injection (LPCI)/ Core Spray (CS) relay wiring was not con- I nected strictly in accordance with the wiring diagram. The wiring, as installed, was electrically equivalent due to a jumper.
(50-249/86012 - Deficiency 2.5-4)
- 8. For Modification M12-2-84-14 (CCSW Pump Room Cooler Piping Modification Unit 2) installation was not in accordance with as-built or design documentation in that fiber gaskett were installed instead of specified i Flexitallic gaskets, 150 psi flanges were installed instead of specified 300 psi flanges, dimensions did not match as-built drawing, and piping, valve and cooler designators were incorrectly intermixed. In addition, l work instructions were not followed in that work was accomplished which !
replaced CCSW piping and components and which was outside the scope of I j the modification. (50-249/86012 - Deficiency 2.4-11 and 2.5-8) E. 10 CFR Part 50, Appendix B, Criterion VI, requires that measures be established to control the issuance of documents, such as instructions, . procedures, and drawings, including changes which prescribe all activities NUREG-0940 1.A-69 ,
APR 2 31987 Notice of Violation 5 i affecting quality and that these measures assure that documents including changes are reviewed for adequacy and approved for release by authorized personnel. Contrary to the above, the licensee's document control measures for activities affecting quality were not adequately implemented in that numerous documents did not reflect proper control or assurance that documents, including changes, were not sufficiently reviewed for adequacy and consequently did not reflect the condition of the plant. , 1 For example: ) 1
- 1. Drawings and other work package documents for Modification Packages l M12-3-84-14 (Unit 3) and M12-2-84-14 (Unit 2) were inaccurate regarding l Containment Cooling Service Water (CCSW) Pump Room Cooler piping modi- I fications in that design drawings specified 150 psi reversing valves !
and adjacent flanges; hwever, the architect engineer specification specified 300 psi valves and flanges. Piping and Instrumentation l Diagram (P&ID), M-360, showed flow elements and temperature indicators as actually installed, however, the piping drawings and field instal- j lation did not contein these elements. Also, line and cooler designa-I tors were in error the drawings did not specify an orientation for the reversing vah es, and there was no documentation of source and QA ; acceptance of the eight installed 300 psi flanges. (50-249/86012 - 1 Deficiency 2.3-4) i
- 2. On May 21, 1986, several individual discrepancies existed between the configuration shown on the designated electrical drawing and what actually existed in the field. These discrepancies included several examples of wires shown on drawings, but not found installed in the field, two conductors attached to a terminal where the drawing showed only one, a wire connected to a terminal point which was different than that shown on the drawing, use of a " Critical Drawing" revision ;
in the Control Room dif ferent than the designated as-built revision, and an incorrect status for drawings in the Records Retention Vault. (50-237/86015; 50-249/86017 Paragraph 4.a.(11 and 4.a.(2)-(8)) F. 30 CFR Part 50, Appendix B, Criterion XI, requires in part that a test program be established to assure that all testing required to demonstrate that structures, systems, and components wil? perform satisfactorily in service is identified and performed in accordance with written test proce-dures. Test results shall be documented and evaluated to assure that test requirements have been satitfied. Contrary to the above, the licensee's test program failed to identify and document all testing necessary to demonstrate that systems and components will perform satisfactorily in-service or to assure that tests were performed in accordance with written test procedures in that: NUREG-0940 1.A-70
1 1 Notice of Violation 6 .. APR 2 31987 l In several instances there were no requirements for documentation of 1. test completion, test acceptability, or temporary changes to test requirements. As a result, test failures or deviations were not I properly documented. This included: two relay failures during j Core Spray Logic and LPC1/CCSW logic testing, failure of LPCI pump i discharge pressure to meet acceptance criteria, use of equipment 1 other than that required by the procedure, failure of a computer point position indication for a Reactor Water Cleanup Valve and performance of testing with initial conditions other than those required by the test. (50-249/86012 - Deficiency 2.7-3; 2.8-1; 2.8-2; 2.8-4; and 2.8-5)
- 2. Undervoltage and ECCS integrated functional tests were inadequate in the areas of performance and test changes in that changes were made to procedures without the appropriate test change request (TCR) and its associated documentation of review and approval. Procedures did not specify the restoration position for switches and breakers for the reactor cleanup recirculation Pump 3B. Breakers were found out of position despite signed verification to the contrary. In addition, test steps were repeatedly missed without reviewing the test and at-tempting to re-establish conditions. (50-249/86012 - Deficiency 2.8-7 and 2.8-8)
G. 10 CFR Part 50, Appendix B, Criterion 11 requires that the licensee carry out a quality assurance program and shall identify the structures, systems, and components to be covered by the quality assurance program and the major organizations participating in the program. The quality assurance program shall provide control over activities affecting the quality of the identified structures, systems, and components, to an extent consistent with their , importance to safety. ) i Contrary to the above, the licensee and its contractors did not provide I adequate control over activities affecting quality of identified structures, l systems, and components with their importance to safety in that the Master Equipment List for Dresden Unit 3, dated September 1, 1985, incorrectly classified (as non safety-related) the actuator motors for the steam supply j valve to the High Pressure Coolant Injection (HPCI) turbine, two HPCI pump i suction valves, the HPCI pump cooling leakage water return line valves, and the motors for the pumps which provide service water to the corttinment cooling heat exchanger in the Low Pressure Coolant Injection (LPCI) System. l (50-249/86009 - Deficiency D4.3-2) ) l Collectively, these violations have been evaluated as a Severity Level 111 problem (Supplement 1). Cumulative Civil Penalty - $25,000 (assessed equally amoung the violations). NUREG-0940 I.A-71
Notice of Violation. 7 APR 2 31987 i Pursuart to the provisims of 10 CFR 2 201, Commonwealth Edison Company is hereby required to submii a written statement or explanation to the U.S Nuclear Regulatory Commission, N:TN: Document Control Desk, Washington, D.C. 20555 J with a copy to the Regioial Administrator, U.S. Nuclear Regulatory Commission, Region III, and a copy to the NRC Resident Inspector, Dresden Nuclear power Station, 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 1 cach alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective step 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 i specified in this Notice, an order to show cause why the license should not j be modified, suspended, or revoked or why such other action as may be proper i should not be taken may be issued. Consideration may be given to extending i the response time for good cause sho.in. Under the authority of Section 182 ' of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or af fi rmation. Within the same time as provided for the response required above under 10 CFR 2.201 Commonwealth Edison Company may pay the civil penalty by letter I addressed to the U.S. Nuclear Regulatory Commission, ATTN: Document Control = Desk, Washington, D.C. 20555 with a check, draf t, or money order payable to the Treasurer of the United States in the amount of Twenty-Five Thousand Dollars (525,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555. Should Commonwealth 4 Edison Company fail to answer within the same time specified, an order imposing the civil Nnalty in the amount proposed above will be issued. Should Common-wealth Edison Company elect to file an answer in accordance with 10 CFR 2.205 ; protesting the civil penalty, such answer should be clea'rly marked as an !
" Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty !
should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Sectior V.B of 10 CFR Part 2, Appendix C (1987) should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in ieply 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. Commonwealth Edison Company's attention is directed to the other provisions of 10 CFR 2.250, regarding the procedure for imposing a civil penalty. NUREG-0940 1.A-72
Notice of Violation 8 APR 2 31987
'Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.
FOR THE NUCLEAR REGULATORY COMMISSION b aQ w A. Bert Davis Regional Administrator Dated At Glen Ellyn, Illinois this i3d day of April 1987. 1
)
I I NUREG-0940 1.A-73
UNITED . STdTES e M stacg\ NUCl.E A R REGULATORY COMMISSION
; e( $ REGION lli 7n j 799 moostvtLT aOAD 'l 1
'ib , y cLEN ELLYN, ILLtNOIS 601 M o.....
APR 2 41997 ; Docket Nos. 50-237; 50-249 Licenses Nos. DPR-19; DPR-25 EA 87-49 Commonwealth Edison Company ;
. ATTN: Mr. James J. O'Connor l President Post Office Box 767 Chicago, IL 60690-0767 Gentlemen: i
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT N05. 50-237/87011(DRP) and N0. 50-249/87010(DRP)) This refers to the NRC inspection conducted on February 28 - March 4, 1987, of activities authorized by NRC Operating Licenses No..DPR-19 and No. DPR-25 and the circumstances associated with Unit 3 exceeding a reactor water J temperature technical specification limit of 212 F without having primary- I containment. The event, which resulted in a violation of NRC regulatory requirements, was identified by your plant staff and reported to the NRC. The details are provided in the subject inspection report which was sent to you by letter' dated March 20, 1987. An enforcement conference is usually held with licensee management to discuss significant violations. In this instance, a management meeting had already been held on March 4, 1987 to discuss this event as well as other issues at Dresden and Mr. D. Farrar of your staff agreed that an enforcement conference was unnecessary. This i' understanding and additional information related to the event were described in the letter to the NRC dated March 31, 1987. The violation described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) occurred when licensed operators failed to monitor the reactor water temperature for more than four hours. During that period, reactor water temperature rose from 170 F and exceeded the 212 F technical specification limit for approximately 50 minutes, reached 223 F, and containment was not isolated as required by plant technical specifications. Although there were at least three correct reactor water temperature indicators in the control room, four licensed operators or senior operators failed to observe any of these indicators. Two principle factors contributed to this event: 1) your plant management and operators allowed multiple activities to distract control room personnel from monitoring important plant parameters and 2) your procedures did not adequately address how to establish, maintain, and monitor a plant cooldown. These extraneous activities included back-shift telephone operator activities, I NUREG-0940 I.A-74 j _ 1
Commonwealth Edison Company 2 i ADR P 41987 numerous requests for high radiation area access, excessive surveillance and < outage workload, and shif t management meetings away from the control room. Although we are concerned that licensed operators did not fully satisfy their i responsibility for ensuring that the plant is operating safely, the NRC is i equally concerned that the management system at Dresden permitted work activities j to be conducted without adequate controls. This violation indicates the need j for increased management attention to ensure that all control room personnel l perform acceptably in an environment where they are aware of the operational { status of plant equipment at all times. To emphasize the importance of licensed operators fulfilling their responsibi-lities and continuous and effective management control to ensure that plant personnel are provided with an environment free from distractions, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Twenty-Five Thousand Dollars ($25,000) for the violation described in the enclosed } Notice. In accordance with the " General Statement of Policy and Procedure for t NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), f the violation described in the enclosed Notice has been categorized at a Severity I Level III. The base value of a civil penalty for a Severity Level III violation is S-50,000. The NRC Enforcement Policy allows for reduction of a civil penalty under certain circumstances. In this case, the base civil penalty has been reduced by 50 percent because of your unusually, prompt and extensive corrective actions. These actions included: (1) disciplining individuals directly involved in the event, (2) revising plant cooldown procedures, (3) relieving licensed operators from distracting work activities not related to their primary function, and (4) implementing an Error Free Operation Program. Further mitigation was not applied because, although you promptly reported the event after it was discovered, numerous opportunities existed during the four-hour period for detecting the increasing reactor water temperature and therefore we have concluded that identification of the problem was not prompt. 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 j 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 enclosures will be placed in the NRC Public Document Room. I l NUREG-0940 1.A-75
t ,
.i
'l Commonwealth Edison Company. 3 APR 2 41997 The responses directed by this letter and.the~ enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget'as required' by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
l Sincerely,- .]
.h & "
~l A. Bert Davis i Regional Administrator
Enclosures:
- 1. Notice of Violation and '
Proposed Imposition of. Civil Penalty
- 2. Inspection Report ..
i l No. 50-237/87011(DRP); No. 50-249/87010(DRP) cc w/ enclosures: D. L.'Farrar, Director - of Nuclear Licensing- ; J. Eenigenburg, Plant Manager-.
- DCS/RSB (RIDS)
Licensing fee Management Branch ;
' Resident Inspector, RIII Richard Hubbard J. W. McCaffrey, Chief, Public Utilities Division i
NUREG-0940 1.A-76
L NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Commonwealth Edison Company- Docket No. 50-249 Dresden Nuclear Power Station License No. DPR-25 Unit 3 EA 87-49 During an inspection conducted during the period February 28-March 4, 1987 a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violation and associated civil penalty are set forth below: Technical Specification 3.7.A.2 requires that primary containment integrity be maintained at all times when the reactor water temperature is above 212 F and fuel is in the reactor vessel except while performing low power physics tests. Contrary to the above, on February 27, 1987 from 7:15-8:05 p.m., primary containment integrity was not maintained although the reactor water temperature'was abcVe 212 F, fuel was in the reactor vessel, and low power physics tests were not in progress. The maximum temperature reached was 223 F. This is a Severity Level III violation (Supplement I). Civil Penalty - $25,000. 1 Pursuant to the provisions of 10 CFR 2.201, Commonwealth Edison Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice. This reply should be clearly marked as a
<" Reply to a Notice of Violation" and should include for each alleged violation:
(1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in the Notice, an order may be issued to show cause why the_ license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be give to extending he response time for nood cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 223), this response shall be submitted under oath of 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 NURFG-0940 I.A-77
3 l Notice of Violation 2 APR 2 41987 civil penalty in whole or in part by a written answer addressed to the Director, j 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 { with10CFR2.205protestingthecivilpenalty,suchanswershouldbeclearly 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 l the penalty should not be imposed. In addition to protesting the civil j penalty in whole or in part, such answer may request remission or mitigation of the penalty. 4 In requesting mitigation of the proposed penalty, the five factors addressed
'in Section V.B of 10 CFR Part 2, Appendix C (1987) should be addressed. Any !
written answer in accordance with 10 CFR 2.205 should be set forth separately j from the statement or explanation in reply pursuant to 10 CFR 2.201, but may i incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., l citing page and paragraph number) 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 Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may l be referred to the Attorney General, and the penalty, unless compromised, j remitted, or mitigated, may be collected by civil action pursuant to i Section 234c of the Act, 42 U.S.C. 2282. 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 j 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, for the appropriate Region, and, if applicable, a copy to the ) NRC Resident Inspector, at the facility which is the subject of this Notice. ( FOR THE NUCLEAR REGULATORY COMMISSION
~
4O h /d A vg f) s l A. Bert Davis ' Regional Administrator Dat?d at Glen Ellyn, Illinois this'1* day of April 1987 l NUREG-0940 I.A-78
l p aso UNITED STATES l 8 % NUCLEAR REGULATORY COMMisslON [' )e k FIEGloN lit O* V -E 799 ROOSEVELT ROAD l 0 GLEN ELLYN, ILLINot$ 60137 4 ,y. MAY 131987 Docket Nos. 50-10, 50-237, and 50-249 l License Nos. DRP-2, DRP-19, and DRP-25 ; EA 87-53 l Commonwealth Edison Company ATTN: Mr. James J. O'Connor President Post Office Box 767 i Chicago, IL 60690 l l Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS NO. 50-10/87003(DRSS); NO. 50-237/87012(DRSS); AND NO. 50-249/87012(DRSS)) This refers to the NRC special physical protection inspection conducted during j the period March 26-31, 1987 at the Dresden Nuclear Power Station, Morris, Illinois. The inspection was in response to a licensee identified event regarding degradation of the protected area physical barrier. An enforcement conference to discuss this matter was held on April 10, 1987 between Mr. L. DelGeorge and other members of your staff and Mr. C. Paperiello and other members of the NRC Region III staff. The violations involved a pathway that potentially provided uncontrolled access from the owner controlled area (OCA) to the protected area (PA). This failure to control access resulted in two of the three elements of access control for the'affected portion of the protected area perimeter being inadequate such that an individual could have gained unauthorized, undetected access. The violations were identified by a radiation / chemistry technician on March 20, 1987 while obtaining water samples in the area. However, the security event was not identified to the security organization so that compensatory measures could be taken until March 23, 1987 nor was NRC contacted until that date. Although a radiation / chemistry foreman attempted to contact security, he did not follow through to assure that Security was aware of the potential breach in the PA barrier prior to going home for the weekend. These actions at least indicate the need for improved awareness of security matters by your non guard force employees. In addition to the above, the NRC is particularly concerned about the duration , of the violation and the opportunities to discover the violation. The i relocation of the PA fence in 1980 created the violations, but a review of the l l modification and subsequent walkdowns failed to identify the problem. ) l Subsequently, Information Notice No. 86-83, " Underground Pathways Into Protected Areas, Vital Areas Material Access Areas, and Controlled Access Areas" dated September 19, 1986, was issued to inform licensees of identified vulnerabilities a 1 Enclosure contains j NUREG-0940 1.A-79 5AFEGUARDS INFORMATION ! Upon separation this page is Decontrolled
Commonwealth Edison Company 2 MAY 131987 at NRC licensed facilities. Although you documented your actions taken on ' October 10, 1986 in response to that Notice, which included walkdowns of the PA/VA barriers, the degraded portion of the PA barrier again was not identified. We have not included a citation for the failure to make a report of the event ] in this case. However, in the future a citation may be issued where a supervisor ! or foreman is aware of a reportable security issue which is not reported to ! the NRC. I 1 To emphasize the importance of ensuring the integrity of the PA barrier and that degradations are promptly identified and corrected, 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 i Fifty Thousand Dollars (550,000) for the violations described in the enclosed , Notice. In accordance with the " General Statement of Policy and Procedure for I NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), ! the violations described in the enclosed Notice have been categorized as a l Severity Level III problem. The base value of a Civil Penalty for a Severity. Level III violation is $50,000. , While it is commendable that a technician was Lu'fficiently sensitive to security l matters to identify this weakness in your protected area barrier while ; performing routine duties, this is offset by the failure of his supervisor to I address those concerns for three days. The escalation and mitigation factors l in the Enforcement Policy were considered and no adjustment has been deemed appropriate. Although the NRC recognizes your corrective actions, any mitigation that may be warranted for this is balanced against your prior notice of the problem and the multiple opportunities for its discovery and correction. . l You are required to respond to this letter and should follow the instructions j 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 provide an analysis of why the degraded barrier was not discovered earlier and what steps will be i taken to improve prompt identification and correction of similar problems in the I future. After reviewing your response to this Notice, including your proposed l l l 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. Enclosure contains SAFEGUARDS IfiFORMATION Upon separation this NUREG-0940 1.A-80 page is Decontrolled
Commonwealth Edison Company 3 MAY 131987 I The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of, Management and Budget as required : by the. Paperwork Reduction Action.of 1980, Pub. L. No. 96-511. Sincerely, l ac d9r== A. Bert Davis , Regional Administrator-
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty (UNCLASSIFIED SAFEGUARDS INFORMATION) ; cc w/ enclosure: !
-D. L. Farrar, Diiector of Nucl_ ear Licensing J.~Eenigenburg, Plant Manager cc w/ enclosure, w/o j
UNCLASSIFIED SAFEGUARDS INFORMATION: DCS/RSB (RIDS) Licensing Fee Management Branch Resident Inspector, RIII Richard Hubbard J. W.'McCaffrey, Chief, Public Utilities Division Enclosure contains SAFEGU/.RDS INFORMATION Upon separation this page is Decontrolled NUREG-0940 I.A-81
I l UNITED STATES l [pa arcq*%, NUCLEAR REGULATORY COMMISSION l 0s f ', REGION il j !
.1 I j 101 M ARlET T A ST RE ET. N W.
g (- t ATLANTA. GEORGI A 30323 N . .~. . . / NOV 12 $86 Docket Nos. 50-413 and 50-414 License Nos. NPF-35 and NPF-52 EA 86-147 Duke Power Company ATTN: Mr. H. B. Tucker, Vice President Nuclear Production Department 422 South Church Street Charlotte, NC 28242 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION 0F CIVIL PENALTY (NRC INSPECTION REPORT N05. 50-413/86-25 AND 50-414/86-27) This refers to the NRC inspection conducted on June 28 - July 2, 1986, of activities authorized by NRC Licenses NPF-35 and NPF-52 for your Catawba facility. This inspection was conducted as followup to the Catawba Unit 2 depressurization event of June 27, 1986, which occurred during a loss of control room test. During this inspection, violations of NRC requirements were identified,.and the report docu-menting the results of the inspection was sent to you by letter dated July 25, 1986. These matters were also discussed by Dr. J. N. Grace, Regional Administrator, with Mr. G. E. Vaughn, General Manager, Nuclear Stations, in an Enforcement Conference held in the Region II Office on August 11, 1986. Violation A in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involves a significant failure in your design control program. The violation indicates that you had not exercised adequate control to ensure that a design change, Design Change Authorization (DCA) CN-2-M-1527, which changed the design bases of a system, was reviewed for its effect on established procedures and for human factors considerations. The DCA which changedthemodeofcontrolofthesteamgeneratorpoweroperateareliefvalves, was not reviewed for its effect on an operating procedure used to establish initial controller settings in preparation for the Loss of Control Room Test. As a result, during the test, on the transfer of control from the control room to the Auxiliary Shutdown Panels and the Unit 2 Auxiliary Feedwater Pump Turbine Control Panel, the steam generator power operated relief valves opened to approximately 75 percent of the full open position rather than remaining closed as intended, causing a rapid decrease in both pressure and level in the reactor coolant system. In addition, inadequate labeling of the controllers prevented the plant operators at the remote shutdown panel from diagnosing the problem i and regaining control of the plant. It is significant that for six minutes after the steam generator power operated relief valves opened, no operator action was taken to transfer control to the control room. It is fortuitous that there were no adverse thermal-hydraulic or nuclear effects on the plant I because of this design control failure. NUREG-0940 I.A-82
a e
]
.Du'ke Power Company NOV 12 $66 Violation B in the enclosed Notice involves the failure to establish adequate procedures for the Loss of Control Room Test. Procedures used in the Loss of Control Room Test were inadequate in that they specified improper initial settings such that, upon transfer of control to the Auxiliary Feedwater Pump Turbine Control Panel from the control room, the charging flow and seal injection i flow control valves went to positions not as intended. The test procedures were also inadequate in that neither the limitations of the remote shutdown panels nor consideration of safety system parameters were taken into account in guidance i provided to the plant operators for termination of the Loss Control Room Test.
One such limitation was the fact that safety injection could not be initiated
~ from actions at the remote shutdown panels. Actions would have to be performed ;
at other locations in the plant in order to start and align the required components. Significant reactor coolant system parameters of pressurizer level and pressure were not.available to the plant operators at the Auxiliary Shutdown Panels when I these parameters went below the range of the instruments. Violation B also in- '
' volves the failure of plant personnel to follow a procedure which provided guidance for changes to the remote shutdown panels involving human factors considerations. The labeling of valve controllers indicated the opposite of that intended and resulted in plant operators manipulating the valves improperly.
demonstrate the need for more These thoroughviolations reviews of are test significant because procedures and r;esig they'n changes and their effects on i plant procedures. The difficulties encountered during the loss of Control Room Test indicate that at the time of the test, existing plant hardware and l I procedures were incapable of assuring that when the reactor was shutdown from outside the control room it could be maintained in a stable condition. While we recognize that this test was intended to demonstrate this capability, there 3 were opportunities during the design, installation, and testing of the steam i generator power operated relief valve controllers to identify the types of problems which occurred during the Loss of Control Room Test. Therefore, to emphasize the impcatance of complete and thorough reviews of design changes, the necessity of adequate procedures and procedural adherence, I have been authorized, after consultation with the Director, Office of I Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars ($50,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy), the violations described in the enclosed Notice have been categorized as a Severity Level III problem. The base civil penalty for a Severity Level III violation or problem is $50,000. ' The escalation and mitigation factors in the Enforcement Policy were considered. Although we acknowledge your prompt and extensive corrective actions, including 4 the review of all design changes, we also note the occurrence of previous ; testing deficiencies during Unit 2 cold hydrostatic tests that resulted in overpressurization of residual heat removal system piping and the volume control i tank. Therefore, neither mitigation nor escalation of the base civil penalty is deemed appropriate in this case. l NUREG-0940 I.A-83
Duke Power Compa'ny NOV 12 SB6 During this. inspection, an unresolved item was also identified. This item concerns the adequacy of training of licensed personnel on' facility design changes. In accordance with the current NRC policy statement on training Land qualification of nuclear power plant personnel, this violation is not cited. However, the promptness and adequacy of your corrective actions will be reviewed at a future date to assure compliance with 10 CFR Part 50, Appendix B, Criterion XVI. You are required to respond'to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document _the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further 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. Theresponsedirectedbythisletteranditsenclosuresarenotsubjecttothe clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, J. Nelson Grace Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalty
- 2. Enforcement Conference Summary cc w/encis:
J. W Hampton, Station Manager, Cathwba NUREG-0940 I.A-84
NOTICE OF VIOLATION AND PROPOSED IMPOSITI F 0F CIVIL' PENALTY Duke Power Company Docket Nos. 50-413 and 50-414 Cata'wba Units 1 and 2 License Nos. NPF-35 and NPF-48 EA 86-147 During the Nuclear' Regulatory Commission (NRC) inspection conducted on June 28 - July 2, 1986, violations of NRC requirements were identified. The violations involved the failure of design control measures and the failure to establish and implement procedures. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954,-as amended, ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and associated civ_il penalty are set forth below: A. 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires that measures be established to assure that applicable regulatory requirements and the design basis are correctly translated into specifications, drawings, procedures, and instructions. Contrary to the above, as of June 27, 1986, the licensee's program for design control did not assure that Design Change Authorization (DCA) CN-2-M-1527, which changed the design basis for the mode of control for the steam generator power operated relief valves (S/G PORVs), was correctly translated into specifications, drawings, procedures, and instructions. Specifically:
- 1. DCA CN-2-M-1527 was not properly reviewed by plant personnel as required by Station Directive 3.0.3, Management of Shutdown Requests, for the effects on Operating Procedure OP/2/A/6100/04, Shutdown j to Cold Shutdown. As a . q Dutside the Control result, Enclosure Room 4.5 from Hot OP/2/A of Procedure Standby /6100/04 was not modified and incorrectly specified the setpoint of the S/G PORVs. Instead of remaining closed the S/G PORVs opened to approximately 75 percent of full open.
- 2. DCA CN-2-M-1527 was not properly reviewed by design personnel as required by Design Engineering Procedure EDP 3.17, Control Room Changes - Handling, in that there was no evaluation done for human factors considerations. The DCA was implemented and changed the control mode of the S/G PORVs without any visible change to I the S/G PORV controllers or labeling at the Auxiliary Feedwater 4 Pump Turbine Control Panel.
l 1 l l NUREG-0940 1.A-85
)
Notice of Violation B. 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and I Drawings, requires that activities affecting quality shall be prescribed l 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. Contrary to the above, as of June 27, 1986, certain procedures affecting j quality were inadequate or not properly implemented and contributed to . the depressurization event of June 27, 1986. Specifically: 1
- 1. Operating Procedure OP/1/A/6100/04, Shutdown Outside the Control Room from Hot Standby to Cold Shutdown, was inadequate in that )
Enclosure 4.5 to the procedure specified initial settings.for ) valves 2NV-309 and 2NV-2S4 which resulted in these valves going to incorrect positions when control was transferred to the remote shutdown panels (Auxiliary Shutdown Panels A and B and the Auxiliary Feedwater Pump Turbine Control Panel).
- 2. Test Procedure TP/2/A/2650/03, Loss of Control Room Functional Test, was inadequate in that the procedure lacked specific criteria for termination ,of the test if the plant was determined to be in an 3 uncontrolled or uncontrollable condition with control transferred i to the remote shutdown panels.
- 3. Operations Management Procedure OMP 1-6, Control Panel Information Changes, dated May 10, 1982, was not followed by plant operations 1 personnel in the labeling of valves 2NV-294 and 2NV-309 at the j remote shutdown panels. OMP 1-6 states that changes to the control l panel will conform to human factor guidelines and conventions.
l However, the labels placed on the controllers for valves 2NV-294 and j 2NV-309 were reversed and indicated opposite of the intended and anticipated meaning. Collectively, these violations have been categorized as a Severity Level III problem (Supplement I). (Cumulative Civil Penalty - $50,000 assessed equally between the violations.) Pursuant to the provisions of 10 CFR 2.201, Duke Power Company is hereby r m ired to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Region II, within 30 days of the date of this Notice a written statement or explanation including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avcid further violations, and (5) the date when full compliance will be achieved. If an l adequate reply is not received within the time specified in this Notice, the l Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper 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 1.A-86
Notice of Violation Within the same time as provided for the response requirad above under 10 CFR 2.201, Duke Power Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative arount of Fifty Thousand Dollars ($50,00C) or may protest imposition of the civil penalty in whole or in part by a written answer iddressed to the Director, Office of Inspection and Enforcement. Should Duke Power Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount propcsed above. Should Duke Power Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the viol 6tions 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, cuch 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, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explar + ion in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFk 2.201 reply by specific reference (e.g.g citing page and paragraph numbers) to avoid repetition. Duke Power Company s attention is directed to the other provisions of 10 CFR 2.205 regarding the procedure for , imposing a civil penalty. ( Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR' REGULATORY COMMISSION
~
. ,. L~
/ J. Nelson Grace Regional Administrator i
Dattd at Atlanta, Georgia, this /4> day of November 1986 l l 1 l l NUREG-0940 I.A-87 1 1
"1 8(p* *tooq'o
~ g o
UNITED STATES NUCLEAR REGULATORY COMMISSION
$ rE. WASHINGTON, D. C. 20065 ,
APR 141987 9 Pocket No.-50-414 2 -)
.Licente No. NPF-52 ., !
EA-86-147- , i
. Duke Power Company 1
. ATTN: Mr. H.;B. Tucker, Vice President j Nuclear. Production Department ;
422 South Church Street- : Charlotte, NC 28242
~
j i Gentlemen: i
SUBJECT:
' ORDER IMPOSING A CIVIL MONETARY PENALTY This refers to your letter dated December 12, 1986, in response to the Notice )
of Violation and Proposed Imposition of Civil Penalty (Notice) sent to you by ! our letter dated November 12, 1986. Our letter and Notice described violations u involving a significant failure in your design control program and the failure I to establish adequate procedures for the Loss of Control Room Test. These ) violations were identified during an inspection conducted as followup to the-Catawba Unit 2 depressurization event of June 27, 1986.. ; To emphasize the importance of complete and thorough reviews of design changes, i the necessity.of adequate procedures and procedural adherence, a civil penalty ! of.FiftyThousandDollars($50,000)wasproposed. 'l
. In your response dated December 12, 1986, you admitted the first violation, but !
denied that the deficiencies related to the modification of the steam generator i power operated relief valves constituted programmatic deficiencies. In addition, , you denied the first two of three examples of the second violation, and you !
~ admitted the third example but denied that the mislabeling was a result of a '
failure to' follow Operations Management Procedure OMP-1-6. You a?so requested I reduction of the severity level and remission of the proposed civil penalty. '
-After careful-consideration of your response, we have concluded, for the reat.ons I given in the Appendix attached to the enclosed Order Imposing Civil Monetary i Penalty, that the violations occurred as stated in the Notice as amended in the l Appendix to this Order with respect to Violation B.2 ar.d that sufficient basis .
does not exist for reduction of the severity level or the proposed civil penalty, i Accordingly, we hereby serve the enclosed Order on Duke Power Company (DPC) imposing a civil penalty in the amount of Fifty Thousand Dollan ($50,000). In addition, we note your denial of Violation B.1 and B.2 concerning inadequate test procedures. We have concluded the Violation B.1 is correct as stated and that Violation B,'d should be amended to reflect a failure to properly implement i procedures. Furti#er corrective actions to prevent recurrence are required. An edditional example of an inadequate test procedure was cited as a violation in Inspection Report Nos. 50-413/86-43 and 50-414/86-46 issued on November 7, 1986 dnd resulted in the draining of 12,000 gallons of reactor coolant water from the NUREG-0940 I.A-88
i i l Duke Power Company l 4 reactor vesse'l flange / head gap while Unit I was in the refueling mode. We r: quest that you respond within 30 days of the date of this letter describing y:ur plans to assure test procedures and test programs do not result in further undue component or system damage or challenges, especially with regard to procedures which are infrequently used. We will review the effectiveness of your corrective actions during a subsequent inspection. l 1 Additionally, you noted that while the Notice was issued for Catawba Units 1 and 2, Unit I was not involved in the subject events. The NRC inspection covered examination of both units and the NRC acknowledges that the violations cited in the Notice were intended only for Unit 2. Our records will be adjusted accordingly. In accordance with Section 2.790 of the NRC's Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in'the NRC's Public Document Room. The responses directed by this letter and the accompanying Order are not subject to the clearance procedures of the Office of Management and Budget as required by the Faperwork Reduction Act of 1980, PL 96-511. Sincerely,
,- Y J es M. Ta r eputy Exec tive Director for j Regional Operations l
Enclosure:
Order Imposing Civil Monetary Peralty with Appendix i NUREG-0940 I.A-89
i i j UNITED STATES l NUCLEAR REGULATORY COMMISSION l i In the Matter of ) DUKE POWER COMPANY Docket No. 50-414 4 (Catawba Nuclear Station, ) License No.,NPF-52 Unit 2) ) EA 86-147 ORDER IMPOSING CIVIL MONETARY PENALTY I ; 1 Duke Power Company (DPC/ licensee) is the holder of Operating License No. NPF-52 (license) issued by the Nuclear Regulatory Commission (NRC/ Commission). j on February 24, 1986. The license authorizes the licensee to operate the Catawba Nuclear Station, Unit 2, in accordance with the conditions specified therein. II An NRC inspection was conducted June 28 - July 2, 1986, as followup to the Catawba Unit 2 depressurization event, which occurred on June 27, 1986, during a Loss of Control Room Test. During the inspection, the NRC staff detennined 1 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 November 12, 1986. The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of civil penalty proposed for the violations. The licensee respcnded to the Notice by letter dated December 12, 1986. NUREG-0940 1.A-90
l
~III After consideration of the licensee's response and the statements of fact, explanations, and arguments for reduction of the severity level and remission or mitigation of the proposed civil penalty contained therein, the Deputy ' Executive Director for Regional Operations has determined as set forth in the Appendix to this Order, that the penalty proposed for the violations. designated in the Notice of Violation and Proposed Imposition of Civil Penalty as amended in the Appendix to this Order should be imposed.
IV fn 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 penalty in the amount of Fifty Thousand Dollars ($50,000) within 30 days of the date of this Order, by efeck, 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, Washington, D.C. 20555. l i L l NUREG-0940 I.A-91
1 V The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing shall be addressed to the Director, Office'of Enforcement. U.S. Nuclear Regulatory Comission, Washington, D.C. 20555. A copy of the hearing request also shall be sent to the Assistant General Counsel for Enforce-ment, Office of the General Counsel, U.S. Nuclear Regulatory Comission, Washington, D.C. 20555 and to the Regional Administrator, Region II,101 Marietta
-St. NW, Atlanta, Georgia 30323.
ff a hearing is requested, the Commission will issue an Order designating the time and place of the hearing.- If the licensee fails to request a hearing within 30 days of the date of this Order, the provisions of this Order shall be effective without further proceedings. If payment bes not been made by that time, the matter may be referred to the Attorney General for collection. < l In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be: (a) whether the licensee was in violatier of the Comission's requirements as set forth in the Notice of Violation and Proposed Imposition of Civil i Penalty referenced in Section II above as amended in the Appendix to this ! Order, and l I 1 NUREG-0940 I.A-92 i
1 d I
. (b). whether, on the basis of such violation, this Order should be sustained.
FOR THE NUCLEAR REGULATORY COMMISSION
/
J es M. Tay1 , eputy Executive Director for ! Regional Operations Dated at Bethesda, Maryland this f.// May of April 1987 5 NUREG 0940 i I.A-93
APPENDIX EVALUATIONS AND CONCLUSIONS i 1 In a letter dated December 12,g1986, Duke Power Company.(DPC) responded to the Notice of Violation and Proposed Imposition of Civil Penalty (Notice) issued by the NRC on November 12, 1986. DPC denied some of.the violations set forth in the Notice, requested reduction of the severity level, and requested remission _ of the proposed civil penalty. Provided below are (1) a restatement of the : violations,.(2) a summary of.the licensee's response regarding the violations. and classification' of the violations as a Severity Level III and arguments for mitigation of the proposed civil penalty. (3) NRC's evaluation of the licensee's response regarding each area,~and (4) the NRC's conclusion. Restatement of Vio1a' tion A A. '10 CFR Part 50,. Appendix B, Criterion III Design Control, requires that
. measures be established to assure that applicable regulatory requirements and the design basis are correctly translated into specifications, drawings; procedures, and instructions.
Contrary to the above, as of June 27, 1986, the. licensee's program for l design control did not assure that-Design Change Authorization (DCA) . CN-2-M-1527, which changed the design basis for the mode of control for the < steam generator power operated relief valves (S/G PORVs), was correctly translated into specifications, drawings, procedures, and instructions. Specifically:
- 1. DCA CN-2-M-1527 was not properly reviewed by plant personnel as required by Station Directive 3.0.3, Management of Shutdown Requests for the effects on Operating Procedure OP/2/A/6100/04 Shutdown Outside the Control Room from Hot Standby to Cold Shutdown. As a result, Enclosure 4.5 of Procedure OP/2/A/6100/04 was not modified and incorrectly specified the setpoint of the S/G PORVs. Instead of remaining closed, the S/G PORVs opened to approximately 75 percent of full open.
- 2. DCA CN-2-M-1527 was not properly reviewed by design personnel as required by Design Engineering Procedure EDP 3.17, Control Room Changes - Handling, in that there was no evaluation done for human factors considerations. The DCA was implemented and changed the control mode of the S/G PORVs without any visible change to the S/G PORV controllers or labeling at the Auxiliary Feedwater Pump Turbine Control Panel.
Sunnary of Licensee Response to Violation A
- In its December 12, 1986 response to the Notice, DPC admits the violation as stated, but denies that the deficiencies related to the modification of the steam generator power operated relief valves constituted programmatic deficiencies.
DPC believes instead that the violation reflects an isolated failure in the design review of an atypical riodification and the subsequent failure to recognize the impact on station procedures. Additionally, DPC does not believe that examples A,1 and A.2 accurately reflect events related to the modification. NUREG-0940 1.A-94 J
Appendix- ) l NRC Evaluation of Licensee Response Even if this violation reflects an isolatsd failure in design review and the subsequent failure to recognize the impact on station procedures, the violation involved a significant failure in DPC's design control program. This violation indicates that DPC had not exercised adequate control to ensure that a design change, Design Change Authorization CN-2-M-1527, which changed the design basis of a system, was_ reviewed for. its effect on established operating procedures and was ~ correctly translated into the appropriate procedure. Th;s situation was further aggravated by human engineering deficiencies introduced by the modifi-cations. As .a consequence, the DPC plant staff assigned to perform the test did not understand the function and interaction of controls on the' shutdown-panels. This lack of understanding led to a pretest setup of the panels that ensured that the power operated relief valves would open on transfer and that attempts to shut them would,be futile. For these reasons, the NRC staff believes that the violations do reflect circumstances associated with DCA CN-2-M-1527. Restatement of Violation B.1 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 and shall be accomplished in accordance with these instructions, procedures, or drawings. Contrary to the above, as of June 27, 1986, certain procedures affecting quality were inadequate or not properly implemented and contributed to the depressurization event of June 27, 1986. Specifically:
- 1. Operating Procedure OP/1/A/6100/04, Shutdown Outside the Control Room from Hot Standby to Cold Shutdown, was inadequate in that Enclosure 4.5 to the procedure specified initial settings for valves 2NV-309 and 2NV-294 which resulted in these valves going to incorrect positions when control was transferred to the remote shutdown panels (Auxiliary Shutdown Panels A and B and the Auxiliary Feedwater Pump Turbine Control Panel).
i Sunnary of Licensee's Respon,se to Violation B.1 j 1 DPC dentes Violation B.1 and asserts that the settings for valves 2NV-309 and 2NV-294 were esteb11shed based on the predicted flow requirements and the controller test data. The Catawba Nuclear Station FSAR Summary of Test Program I Objectives (Section 14.2.1) stetes in part that the general objectives of the l Initial Test Program at Catawba Nuclear are to provide assurance that operating and emergency procedures are appropriate to the extent practicable. DPC asserts that the Test Procedure TP/2/A/2650/03 was being conducted to meet this objective for the use of Operating Procedure OP/1/A/6100/04 and that the initial positions of valves 2NV-309 and 2NV-294 had been specified on the basis of the best available information. DPC believes that deficiencies identified as a result of this testing are not significant contributors to the transient and are not in i I themselves violations unless some other regulatory requirement had been violated. NUREG-0940 I.A-95
Appendix NRC Evaluation of Licenst.e's Response
'The NRC staff maintains its position that Operating Procedure OP/1/A/6100/04 was inadequate in that it specified improper initial settings such that upon transfer of control from the control room to the Auxiliary Shutdown Panels, the charging I flow and seal injection flow control valves went to positions which were not )
intended. This was caused by a temporary change to the procedure which had l been made to ensure that valve 2NY-309 would be in the closed position, but j actually resulted in the valve going to the fully open position. Also, valve 2NV-294 was supposed to be set for 32 gpm. This procedure did not i acknowledge that the valve controller is reverse-acting and that there are no i units on the 2 ASP-A controller scale. Valve 2NV-294 was therefore set for 32 percent closed which happened to correspond to about 40 gpm flow rate. Additionally, several Catawba personnel were questioned on the operation of seal water injection flow control valve 2NV-309. This valve is capable of being controlled from either 2 ASP-A or 2 ASP-B. The controlling signal is the highest , signal from either controller. Not all personnel questioned were aware of this fact, nor were any aware that the valve is reverse-acting and the controller on Unit 2 was labeled backwards. Indeed, the balance of plant (B0P) operator on ' 2 ASP-A, during the event, thought that 2NV-309 was initially closed. When he saw, no response on charging flow after attempting to "open" the valve, he reset it to 4 its original position and disregarded it, believing it to be malfunctioning. The settings on 2NV-309 and 2NV-294 resulted in a degree of operator confusion ; during the initial phase of the test. The parameters that behaved unexpectedly ' were letdown flow (flashing), seal injection, and pressurizer level. Although the failure of 2NV-148 was the apparent direct cause of the letdown flashing, the incorrect labeling of 2NV-294 was also a contributor. Even before the steam generator power operated relief valves opened, the shutdown panel crew was otherwise concerned and occupied with the unanticipated behavior of the above three parameters. Had the power operated relief valves not opened, the NRC staff believes it is unlitely that the misoperation of these valves would have been discovered because this was not discovered during previous similar testing on Units 1 and 2. Therefore, the NRC staff believes that the deficiencies caused an unnecessary burden on the operators and the objectives of the initial test program were not met in that the deficiencies went previously undetected. Restatement of Violation B.2 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 and shall be accomplished in accordance with these instructions, procedures, or drawings. i Contrary to the above, as of June 27, 1986, certain procedures affecting l quality were inadequate or not properly implemented and contributed to the depressurization event of June 27, 1986. Specifically: NUREG-0940 I.A-96
Appendix 2. Test Procedure TP/2/A/2650/03, Loss of Control Room Functional Test, was inadequate in that the procedure lacked specific criteria for termination of the test if the plant was determined to be in an uncontrolled or uncontrollable condition with control transferred to the remote shutdown panels. Summary of Licensee's Response to Violation B.2 The licensee denies that this example is a violation of regulatory requirements j because there are no specific requirements for termination criteria in test ' procedures. DPC also asserts that the essentially identical Unit 1 Loss of f Control Room Test procedure was reviewed and approved by the NP,C with no mention i of termination criteria. Step 6.10 of the test procedure states, "if any situation arises that cannot be adequately controlled from the auxiliary shutdown panels, transfer back to the Control Room." In DPC's opinion, this action was adequate and appropriate. Additionally, DPC states that an attempt to cover every possible contingency would add unnecessary volume without any assurance of covering all occurrences and that instead reliance is appropriately placed on the training and judgment of the licensed operators who are conducting the test. NRC Evalue < n of Licensee's Response The NRC staff agrees with the DPC statement that it is not practical for a procedure to cover every possible contingency and there is necessarily some reliance on the operators' training and judgment while conducting a test. However, as described in Inspection Report 50-413/86-28 and 50-414/86-27, all personnel involved in the test were interviewed by the NRC and there was insufficient guidance given to establish under what conditions or situations the test should be terminated if a successful test was not achieved. While it can be argued that the procedural statement in Step 6.10 was necessarily general in nature, the lack of detail in this step was not compensated for in the training given to the test personnel. During the event while the parameters of pressurizer level and Reactor Coolant System pressure went below the lowest range of the shutdown panel instruments, the operators tried to control the transient from the Auxiliary Shutdown Panels without indication of significant reactor coolant system parameters and without knowing whether they were correcting or contributing to the problem. In addition, most of the operators in the main control room were unaware of the limitation of the reactors coolant system pressure instrument of the Auxiliery Shutdown Panels and therefore, were unable to recognize the situation faced by the operntors outside the main control room. DPC failed to properly implement the procedure in not transferring i control back to the control room as required because test personnel were not adequately prepered to recognize situations which could not be controlled from the Auxiliary Shutdown Panels. Therefore, Violation B.2 is modified to read as q follows: ! 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and I Drawings, reovires that activities effccting quality shall be prescribed { by documented instructions, procedures, or drawings, cf a type appropriate i to the circumstr.nces arid shall be accomplished in accordance with these l instructions, procedures, or drawings. ' NUREG-0940 1.A-97 b
j I Appendix 1'
-Contrary to the above, as of June 27, 1986, certain procedures affecting quality were inadequate or not properly implemented and contributed to the :
depressurization event of June 27, 1986. Specifically:
- 2. Test Procedure TP/2/A/2650/03, Loss of Control Room Functional. Test, w6s not properly implemented in that control was not transfered back to the control room when a situation arose that could not be adequately !
controlled from the auxiliary shutdown panels. The violation, as rewritten, focuses on the licensee's failure to implement the procedure to assure that-personnel adequately understood the steps of the procedure and would be able to promptly transfer control back to the control room should the situation warrant it, as opposed to the inadequacy of the procedure to provide test termination criteria. The NRC staff has concluded l that this violation, as rewritten, occurred. Restatement of Violation B.3 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 and shall be accomplished in accordance with these instructions, procedures, or drawings. Cnntrary to the above, as of June 27, 1986, certain procedures affecting quality were inadequate or not properly implemented and contributed to the depressurization event of June 27, 1986. Specifically:
- 3. Operations Management Procedure OMP 1-6, Control Panel Information, Changes, dated May 10, 1982, was not followed by plant operations <
personnel in the labeling of valves 2NV-294 and 2NV-309 at the remoto shutdown panels. OMP 1-6 states that changes to the control panel will conform to human factor guidelines and conventions. However, the labels placed on the controllers for valves 2NV-294 end 2NV-309 were reversed and indicated opposite of the intended and anticipated , meaning. Summary of Licensee's Response to Violation B.3 , DPC admits that the labels placed on the controllers for valves 2NV-294 and 2NV-309 were reversed and indicated the opposite of the intended and anticipated meanings. However, DPC denies that the mislabeling was a result of a failure to follow Procedure OMP 1-6. The licensee asserts that the mislabeling of the subject valves occurred due to the lack of a formal mechanism for labeling the valves. As a result of the Control Room Design Review, the station had been requested to add "0" and "C" tags to the appropriate controller, and it was left up to the station to determine the correct placement of the tags. The licensee contends that the labels should have been placed in accordance with a formal change, either a Nuclear Station Modification or a work request. The licensee asserts that OMP 1-6 was not intended for implementing labels such as NUREG-0940 1.A-98
i
. Appendix the "0" and "C" tags, but rather provides a mechanism for review and approval f of amplifying information to be provided on control board components. DPC j also does not consider the effect of the valve mislabeling to be significant '
to the transient. NRC Evaluation of Licensee Response Procedure OMP 1-6, Control Panel Information Changes, is the procedure which defires the method by which information may be added, changed, and or deleted on control panels under Operations Group responsibility, either as a permanent or temporary change. OMP 1-6 states "any informational change shall conform to i human factor guidelines used in the design of the station and agree with set-f points, limits, and precautions established in approved operating procedures." ! Labeling valve controllers is considered to be an informational change. Tw NRC l staff maintains its position that the licensee failed to implement OMP 1-6 to l ensure that valves 2NV-294 and 2NV-309 were properly labeled on the shutdown panels and that this contributed to the event. The staff considers the effect of the valve mislabeling to be significant to the transient because of the distraction caused by the unanticipated changes in system parameters, as given in our evaluation of Violation B.I. Even if OMP 1-6 was not intended to be used for these types of labels and a formal change mechanism was required, as DPC asserts, a violation of 10 CFR Part 50, Appendix B did occur in that procedures were not followed in the labeling of these valves. Summary of Request for Reduction of Severity Level , The licensee believes that the categorization of the event as a Severity Level III problem is inappropriate because no risk to the public health and safety was present, thus there was not "cause for significant concern." DPC presented the following three reasons to support this assertion:
- 1. DPC was conducting a pre-planned startup test when the event occurred. In OPC's view, it is the nature of testing to detect errors and identify any deficiencies in the design, construction, or operating procedures before ,
the unit going into routine service. Therefore, the licensee asserts that l l matters detected and corrected in a normal pre-planned startup test made should not be viewed as significant concerns, and to penalize DPC for i detecting errors is inconsistent with the concept of testing. l 1
- 2. DPC asserts that because the pre-planned startup test was under way, control I room personnel were alert to the fact that anomalies might exist in design, l construction, or operating procedures; were aware of plant conditions at all J times throughout the test; were in a position to take action; and did in l fact take appropriate corrective actions in a timely manner. DPC further asserts that while the NRC staff highlighted the significance of 6 minutes i elapsing from the tine the steam generator power operated relief valves opened until operator actien was taken to transfer control to the control room, control room cperators and supervision were fully aware of plant conditiens throughout the 6 minute period. Consistent with NRC guidance, control room personnel were determined to give the operators at the auxiliary panels an opportunity to ascertain the problem and to take corrective action. When it became apparent that the operators at the auxiliary panels l NUREG-0940 I.A-99
l Appendix l I i could not correct the situation and well before any situation would jeopardize l the public health and safety, the control room personnel took corrective actions. The Shift Technical /dvisor (STA) and Operator at the Controls (0ATC) confirmed that the reactor vessel remained full and the reactor coolant pumps continued to operate without indications of problems. The status of the vessel's water level and reactor coolant pump's operation are prime : indicators for potential thermal-hydraulic and nuclear effects. Since these parameters were under control at all times, it does not appear that the absence of adverse effects was " fortuitous."
- 3. DPC asserts that no Technical Specification Liniting Conditions for Operation were violated.
NRC Evaluation The NRC staff agrees that tests are conducted to detect errors; that as e result-of testing, errors can be corrected; and that it is better to find an error during a test than during plant operation. However, the function of testing is not a substitute for good engineering and human factors review. Testing is intended to confirm that tasks were performed correctly in the first place. While the NRC staff recognizes that this test did in fact indicate that existing plant hardware and procedures were incapable of assuring that the reactor could be maintained in a stable condition when it was shut down from outside the control room, there were opportunities during the design, installation, and testing of the steam generator power operated relief valve controllers to identify the types of problems which occurred during the Loss of Control Room Test. The categorization of the violations as a Severity Level III problem was to focus attention on the root cause of the violations, namely the lack of adequate design review, inadequate procedures, and the failure to follow procedures. The NRC staff considers this, i coupled with the fact that the deficiencies involved functions which were important to plant safety, to be cause for significant concern. Neither the limitations of the remote shutdown panels nor consideration of safety l system parameters were taken into account in guidance provi6ed to the plant operators for termination of the Loss of Control Room Test. When significant reactor coolant parameters of pressurizer level and pressure went below the range of the instruments on the Auxiliary Shutdown Panels and plant operators at the Auxiliary Shutdown Panels no longer had indication of these parameters, they should have known or had guidance to terminate the test imediately and switch control back to the control room. Instead the operators continued to try to control the transient from the Auxiliary Shutdown panels without indication of reactor coolant system inventory and, therefore, without knowing whether they were correcting or contributing to the problem. Therefore, the 6 minute period from the time the steam generator power operated relief valves opened until operator action was taken to transfer control back to the control room is considered to be significant. Although the transient did not result in a violation of Technical Specification cooldown rate or shutdown margin, the NRC maintains its position that it is fortuitous that there were no adverse thermal-hydraulic or nuclear effects on the plant because of this design control failure. If the transfer of control had occurred a short period of tine after the actual 6 minute transfer, the NPC believes that much more serious ccnditions wculd have resulted. NUREG-0940 1.A-100
, ~
( , 1 J Appendix Sumary of Request for Mitigation of Civil Penalty
.DPC. contends that even if a Severity Level III categorization were appropriate for this case, there are sufficient mitigation' factors to completely eliminate any associated civil penalty. In support of this position DPC presented the following arguments:
L Licensee Coment-In the licensee's view, a 50 percent reduction in the proposed civil penalty is warranted based.on prompt identification and reporting of the event. Because the test was witnessed by NRC/ Region II personnel DPC contends that the NRC was immediately made. aware of the event and that notification of. the NRC Operations Center was promptly made. I NRC Evaluation The purpose of this factor is to encourage licensees to identify and report infonnation to the NRC. In this case, due to the nature of the event and the NRC presence during the actual test, the NRC was aware of the situation which arose at the same time as DPC. Therefore, mitigation of the proposed civil penalty for prompt identification and reporting of the event is'not warranted.
- 2. Licensee Comment
'DPC asserts that the November 12, 1986, Notice of Violation and Proposed Imposition of Civil Penalty acknowledges the prompt and extensive corrective .
actions taken by the licensee; therefore, DPC believes a 50 percent reduc- / tion of the' proposed civil penalty is warranted. NRC Evaluation The November 12, 1986, transmittal' letter did acknowledge that prompt and extensive corrective actions were taken, but it also referred to the occur-rence of previous testing deficiencies. Any mitigation that might have resulted from the licensee's-prompt and extensive corrective actions was offset by past performance considerations. The NRC staff maintains its original position on this matter.
- 3. Licensee Comment In the November 12, 1986, transmittal letter, the NRC stated that deficien-cies in Catawba's past performance were justification for not mitigating the ,
proposed civil penalty and cited a Catawba. Unit 2 cold hydrostatic test that resulted in the overpressurization of the residual heat removal system piping and the volume control tank. DPC contends that these events were of minimal safety significance as reflected by a Severity Level IV citation. DPC also centends that the root cause of both cold hydrostatic overpressure-zation events was personnel error and that the root cause of the Loss of Centrol Room Test transient was design deficiency and defective procedures l caused by inadequate communications between plant and design personnel. DPC 1 NUREG-0940 I.A-101
Appendix. 9 believes that the two occurrences did.not,have similar root causes and that' the previous overpressurization events are unrelated to this event.. There-fore, in DPC's view, this is not a justifiable basis for not mitigating the proposed civil penalty and 100 percent mitigation of the civil penalty based on this factor is warranted. NRC Evaluation The NRC staff contends that the two occurrences did have the same root cause in the management control. of testing activities.and demonstrated a lack of effective communications and. inadequate procedures to perfom the testing.. Therefore, the testing deficiencies in Catawba's past performance were adequate justification for not mitigating the proposed civil penalty.
- 4. Licensee Comment DPC contends _ that the factors of prior notice and multiple occurrences are not appropriate in this case.
NRC Evaluation The NRC staff agrees that these factors should not be applied in this case. Additional Comments The licensee requested that additional comments on the November 12, 1986, transmittal letter be considered.
- 1. Licensee Comment DPC states that Violation A involved the Design Change Authorization (DCA) program under which the trodification to the steam generator power operated rogram. This program was relief replaced by the Nuclear Station Modification p(NSM) program which provide valves was done was a pre-operational for greater involvement of station personnel in the modification process and would tend to preclude the type of problem that occurred. Therefore, the emphasis on design' changes that is intended by imposition of a civil penalty is lost on a design change program that is no longer in use.
NRC Evaluation' ) I The NRC staff considers DPC's NSM program which provides for greater involve-i ment of station personnel in the modification process, to be a potential ! improvement, and recognizes that the deficiencies occurred under the DCA ) program which is no longer in effect. However, this does not preclude the fact that significant design deficiencies which resulted in a severe plant transient renained undetected under the DCA program. The NRC staff expects' > that similer deficiencies would not recur in the hSM program. NUREG-0940 1.A-102
L
.LAppendix - 10'- i n 2. Licensee Comment DPC contends that the identified-deficiencies in th'e procedures used for the Loss of Control Room Test were either insignificant to the transient and are criticisms that.go beyond the design basis of the plant or are beyond the secpe of the test.
- a. Licensee Comment' ,
DPC does not consider the improper settings of charging flow-and seal injection flow control valves to be significant contributors to the- q transient. NRC Evaluation The NRC staff believes that the deficiencies caused an unnecessary
. burden on the operators and that'the operating procedure was inadequate.
This is also discussed in the NRC response to Violation B.I.
- b. Licensee Comment-DPC contends that there are no specific requirements for termination-criteria in test procedures. DPC also asserts that the essentially identical Unit 1 Loss of Control Room Test procedure was reviewed and approved by the NRC with no mention of termination criteria. In DPC's opinion, the procedural caution in Step 6.10 was adequate and appropriate.
Additionally, DPC states that an attempt to cover every possible contingency would add unnecessary volume without any assurance of covering all occurrences and that, instead, reliance is appropriately placed on the training and judgment of the licensed operators who are conducting the test. NRC Evaluation This is discussed in the NRC response to Violation B.2.
- c. Licensee Comment DPC contends that the design of Catawba's auxiliary shutdown panels R was reviewed and approved by the NRC and as noted in the SER, no accident is assumed to have occurred. Therefore, inclusion of proce-dures for actuation of safety injection systens in the test procedure
.wes beyond the design basis of the plant.
IIRC Evaluation The inability to initiate safety injection frem the remote shutdown panels was not cited as part of Violation B.2. It ns intended to be an example of a limitation of the remote shutdown panels that was not taken into account in procedural guidance provided to the plant operators for termination of the Loss of Control Room Test.
'HUREG-0940 I.A-103
i l Appendix d. Licensee Conrient DPC asserts that the limitation of narrow range pressurizer pressure (1700 to 2500 psig) had been previously recognized as Human Engineering Design (HED) No. C-1-0102 and is documented in DPC's Response to Supplement I to.NUREG-0737. This HED was scheduled for correction during the first refueling outage in accordance with Licensee Condi-tion 7. The test procedure was adequate for its intended purpose since the Reactor Coolant System temperature was to be reduced by 50 F in accordance with FSAR Table 14.2.12-2. At that temperature, the pressurizer level and pressure would have been on-scale. NRC Evaluation This is discussed in the NRC response to Violation B.2.
- e. Licensee Comment-4 DPC contends that the mislabelling of the valve controllers is not considered to be a significant contributor to the transient.
NRC Evaluation The is discussed in the NRC response to Violation B.3. Conclusion The NRC staff concludes that the violations as amended herein with respect to 1 Violation B.2 occurred and that these violations are significant because they demonstrate the need for more attention to test procedures, procedure implemen- l tation, and design changes and their effects on plant procedures. The difficulties " encountered during the Loss of Control Room Test indicate that at the time of the test, existing plant hardware and procedures were incapable of assuring that the reactor could be maintained.in a stable condition when it was shutdown from outsido the control room. While the NRC staff recognizes that this test was I intended to demonstrate this capability, there were opportunities during the design, installation, and testing of the steam generator power operated relief valve controllers to identify the types of problems which occurred during the Loss of Control Room Test. ; i Therefore, after careful consideration of your response, the NRC concludes that 4 the violations are appropriately classified as a Severity Level III problem and that sufficient basis does not exist for the reduction of the severity level or mitict. tion the proposed civil penalty. Accordingly, the civil penalty in the amount ot' Fifty Thousand Dollars ($50,000) civil penalty should be imposed. NUREG-0940 1.A-104
ma stic UNITED STATES v/ oSo NUCLEAR REGULATORY COMMISSION [' ", REGION ll y ?
,j 101 M ARIET".h STREET, N.W.
]
t ATLANTA. GEORGI A 30323 '
'Ql'../ MAR 061987 Docket Nos. 50-369, 50-370 License Nos. NPF-9, NPF-17 EA 87-08 Duke. Power Company . l ATTN:' Mr.'H. B. Tucker, Vice President Nuclear Production Departmant 422 South Church Street Charlotte, NC 28242 I
Gentlemen:
]
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 50-369/85-38 AND 50-370/85-39) This refers to the Nuclear Regulatory Commission (NRC) inspections conducted at the McGuire Nuclear Station on October 15-17, 1985, and January 27-31, 1986. The subject report documenting these inspections was sent to you on June 27, 1986. These inspections included a review of the overall operability of the station's nuclear service water (RN) system for Units 1 and 2. Significant violations of NRC regulatory requirements were identified. These concerns, as well as the generic implications involving the McGuire Nuclaar Station RN system, were discussed by Dr. J. N. Grace, Regional Administrator, NRC, Region 11, with Mr. G. Vaughn, General Manager, Nuclear Stations, Duke Power Company, in a management meeting held on March 14, 1986. An Enforcement Conference was held on December 8,1986, where these issues were discussed by Mr. M. L. Ernst, Deputy Regional Administrator, and Mr. H. B. Tucker, Vica President Nuclear Production Department. Meeting summaries regarding the rieeting and the conference are documented in Inspection Reports Nns. 50-369/85-38, 50-370/85-39 ; and 50-369/86-39, 50-370/86-39, respectively. l Violation A in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) involves the failure to adequately establish and maintain the operability of the station's RN system, a system requirad to be operable by Technical Specifications. This condition existed for a period i of approximately three years. Violation B involves the performance of an ! inadequate 10 CFR 50.59 evaluation which Duke Power Company used to justify the RN system in a cross-connected configuration not specifically allowed by lechnical Specifications.- Violations C.and D in the enclosed Notice address inadequate test performance and evaluation and the failure to establish and implement adequate procedures associated with the nuclear service water system.
. s.
These violations indicate serious deficiencies in Duke Power Comoany management's diligence to control the operability of the McGuire Nuclear Station's RN system. It further indicates that the McGuire Nuclear Station was operated for an extended , period of time without the necessary assurance that the RN system would function properly if called upon. The NRC is further concerned that withnut NPC attention to the area,.your efforts to resolve the heat exchanger problem would have taken a significantly longer time. l NUREG-0940 1.A-105
Duke Power Company MAR 0 61987 j To emphasize the need to maintain the overall operability and quality of i safety-related systems at the McGuire Nuclear Station, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to ] issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty d in the amount of Fifty Thousand Dollars ($50,000), for the violations described j in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for' NRC Enforcement Action," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy), the violations have been categorized in the aggregate 1 as a Severity Level III problem. The base value of a civil penalty for a j Severity level III problem is $50,000. The escalation and mitigation factors were considered, and no adjustment was deemed appropriate. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions ye1 3 clan to prevent recurrence. After reviewing your response to this Notice, l including your proposed corrective actions, the NRC will determine whether ! further NPC enforcement action is necessary to ensure compliance with NRC ) j regulatory requirements. I In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, J 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. PL 96-511. Should you have any ouestions concerning this letter, please contact us. Sincerely, l I d vW
,e
- m. F
/ J. Nelson Grace Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty j cc w/ encl: T. L. McConnell, Station Manager NUREG-0940 I.A-106
NOTICE OF VIOLATION- , PND PROPOSED IMPOSITI6R~0F CIVIL-PENALTY DukG Power Company Docket Nos. 50-369 and 50-370 McGuire Units 1 and ? License Nos. NPF-9 and NPF-7 EA 87-08 During the Nuclear Regulatory Commission (NPC) inspection conducted on October 15-17, 1985 and January 27-31, 1986, violations of NRC requirements were identified. In accordance with the " General Statement of Poliev and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear. Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 c' the Atomic Energy Act of 1954, as amended ("the Act", A2 U.S.C. 228?.. et 76-295, and 10 CFR 2.205. The particuler violations and Lssociatad civil penalty are i
. set forth below:
A. Technical Specification (TS) 3.7.4 requires that two independent nuclear service water loops be operable for modes 1, 2, 3, and 4. With only one ' i loop operable, both loops must be' restored to an operable status within 72 hours or the unit be in hot standby within the next six hours and cold i shutdown within the following 30 hours. Contrary to the above, as of January 27, 1986, the RN system was not-operable in that the system was not capable of providing the McGuire Final Safety Analysis Report (FSAR) specified flow rates to certain heat exchangers under design basis accident conditions of a seismic event causing loss of Lake Norman. This condition had existed from March 1983 to January 1986. During this period the units were operated in modes requiring the RN system to be operable. B. 10 CFR 50.59 requires in part that the holder of a license authorizing I operation of a production or utilization facility may make changes in the facility as described in the safety analysis report without rior Commission approval, unless the proposed change involves a change in the Technical Specifications incorporated in the license or an unreviewed safety question. Shared systems are designated in the Technical Specifications by an asterick (*) in the margin adjacent to the associated Technical Specifications requirement. Contrary to the above, on October 7, 1985, the licensee prepared a 10 CFR 50.59 evaluation and performed actions which were intended to cross-connect the 1A and 2A nuclear service water system trains. The conclusion of the 10 CFR 50.59 evaluation was in error in that the cross-connection would have placed the RN system in a configuration which would involvi a change to the Technical Specifications. Because Technical Specification 3.7.4 was not designated by an asterick to indicate a shared system, cross-connecting the 1A and 2A trains was not appropriate. NUREG-0940 I.A-107
l Notice of Violation C. 10 CFD 50, Appendix B, Criterion XI, requires that a test program shall be ) established to assure that all testing recuired to demonstrate that I structures, systems, and components will perform satisfactorily in service is identified and performed in accordance with written test procedures which incorporate the requirements and acceptance limits contained in applicable design documents. The test program shall include, as appropriate, proof tests prior _ to installation, preoperationti tests, and operational tests during nuclear power plant operation, of structures, systems, and components. Test results shall be documented and evaluated to assure that test requirements have been satisfied.
- 1. Contrary to the above, preoperational testing of_the RN system did.
not include simultaneous alignment of both RN trains to the standby nuclear service water pond, a design basis accident configuration described in the FSAR.
- 2. Contrary to the above, test results indicated that systems or components, as shown below, were not able to perform as intended, and the results were not properly documented and evaluated,
- a. On December 17, 1985, testing indicated that the Unit 1 "A" train _ containment sprav heat exchanger, control room chiller heat exchanger, charging pump oil cooler, spent fuel pool pump room air handling unit, and ' containment spray pump room air handling unit flows were less than their requisite FSAR flow values. It was not until January 1986, that the licensee formally prepared a " written"_ evaluation to detennine the acceptability of the test data when reauested by the NRC.
- b. While performing a quarterly performance test of the 1A containment spray heat exchanger on October 7, 1985, the as-found RN flow rate of 800 gallons per minute.(gpm) for that heat exchanger was identified, a value significantly below previous as-found test data. This condition was not evaluated by the licensee until requested by_ the NRC on March 24, 1986. Additionally, during the test, an RN flow of 4600 gpm for the 1A containment spray heat exchanger was achieved rather than the 5000 gpm as specified by the procedure. The inability to perform the test at 5000 gpm was not formally evaluated by the licensee until reouested by the NRC on October 15, 1985.
D. 10 CFR 50, Appendix B, Criterion V, states that activities affecting quality shall be prescribed by documented instructions, procedures, or drawinps, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. Instructions, procedures,- or drawings shall include appropriate quantitative or Qualita-tive acceptance criteria for detennining that important activities have been satisfactorily accomplished.
,NUREG-0940 I.A-108
1 Notice of Vin 1ation Contrary to the above: 1.. Throttle valve positions associated with RN components set during preoperational testing were not incorporated into the appropriate operating and surveillance procedures. As a result, the actual valve throttle positions differed from the pra-operational tast positions and operating procedures. This condition existed from February 1981 through January 1986. 2.- The licensee's quarterly performance test of the 1A containment spray heat exchanger, PT/1/A/4403/04, conducted periodically between June 1983 and October 1985, lacked qualitative and quantitative a:ceptance criteria which resulted in.significant, undetected fouling and degradation of thr.t heat exchangers. ;
- 3. Licensee's procedure TT/1/A/9100/105 requires that valve IRN73A, IA train service water diesel generator heat exchanger outlet isolation valve, be returned to its normal position at the completion of that test. On January 28, 1986, the NRC discovered that the procedure j was not followed in that valve IRN73A had not been returned to its normal condition at the completion of the test earlier that day.
- 4. Licensee emergency operating procedures for safety injection (EP/1/A/5000/01,EP/2/A/5000/01) and for transfer to cold leg recir-culation (EP/1/A/5000/2.3, EP/2/A/5000/2.3) did not provide specific operator actions to assure proper nuclear service water flow through the diesel generator cooling water heat exchanger and containment spray heat exchanger during accident conditions in that reouired flow rates were not specified.
Collectively, these violations have been evaluated as e Severity Level III problem. (Supplement I). Cumulative civil penalty - $50,000 (assessed equally among the violations) Parsuant to the provisions of 10 CFR 2.201, Duke power Company is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555, with a copy to the Regional Administrator, U. S. Nuclear Regulatory Commission, Region II, 101 Marietta Street, N.W. , Suite 2900, Atlanta, Georgia 30323, within 30 days of the date of this notice a written statement or explanation including for each violation: (1) admission or denial of the violation, (2) the reason for the violation if
- 3) the corrective steps which have been taken and the results admitted,{4)thecorrectivestepswhichwillbetakentoavoidfurtherviola-achieved, t l tions, and (5) the date when full compiiance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 162 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. j NUREG-0940 1.A-109
l Notice of Violation ) Within the same time as provided for the response required above under 10 CFR 2.201, Duke Power Cnmpany may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the amount of Fifty Thousand Dollars ($50,000) or may protest imposition of the civil penalty in l whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Duke Power Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Duke Power l Company elect to file an answer in accordance with 10 CFR 2.200 protesting the I civil penalty, such answer 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 nr mitigation of the penalty. l In requestino mitigation of the proposed penalty, the five factors addressed in l 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. Duke Power Company's attention is directed to the other provisions of 10 CFR 2.205 regarding the procedure for
]
)
impesing 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, i or mitigated, may be collected by civil action pursuant to Section 234c of the { Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION u t. J. Nelsnn Grace Regional Administrator Dated at Atlanta, Georgia this 6 day of March 1987 l l NUREG-0940 1.A-110
g . UPetTED ST/.Tt$ l4p 8 *' * #88g% NUCLEAR REGULATORY COMMIS$10N f 'n- MEG 60N li g ,3 ios uAniaTTA Sf acti,ww. 1
~$ ATL ANTA. GEOnG( A 30323
\* */ ***
APR 211987 i i Docket Nos. 50-250 and 50-251 I License Nos. OPR-31 and DPR-41
.EA 87 Florida Power and Light Company ATTN: . Mr. C. O. Woody Group Vice President Nuclear Energy Department P.O. Box 14000-Juno Beach, FL 33408 i
Gentlemen:
'SU8 JECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL' PENALTY ,
(NRC INSPECTION REPORT N05. 50-250/87-05, 50-251/87-05, 50-250/87-11 l AND50-251/87-11) l\ This refers to the Nuclear Regulatory Commission (NRC) inspections conducted l by Mr. A. Tillman at Turkey Point on January 20-21 and March 3-4, 1987. The : inspections included a review of the circumstances surrounding a security gJard being found asleep on post by the NRC Resident Inspector and an NRC Regional Inspector discovering a visitor without an escort in a vital area. The reports
' documenting these inspections .were sent to you by letters dated February 10, 1987 and March 20, 1987. The inspection findings were discussed by Mr. M. L. Ernst,
- Deputy Regional Administrator, NRC, Region II, with Mr. J. W. Dickey, Vice President, Fuclear Operations, during an Enforcement Conf.trence held on February 23, 1987.
The violations described in the enclosed Notice of Violation are of particular concern because a review of Licensee Irregularity Reports during subsequent inspections confirmed the occurreace of six additional instances of security personnel being found asleep and identified eight additional instances where visitors were discovered without an escort. These violations demonstrate a lack of management oversight and involvement in response to the continued occurrence of similar or identical problems. .The repetitious nature of the violations also indicates an apparent weakness in your employee training for the security area. To emphasize the importance of ensuring that physical security cwunitments are fully implemented and the integrity of the protected and vital areas is main-tained I have been authorized, after consultation with the Director, Office of Enforcement and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the , amount of. Seventy-Five Thousand Dollars ($75,000) for the violations described i in the enclosed Notice.. In accordance with the " General Statement of Policy and 1 Procedure for NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1987), the l ! violations have been categorized in the aggregate as a Severity Level !!! problem. i NUREG-0940 I.A-111
1 Florida Power and Light Company The base civil penalty for a Severity 1.evel III violation or problem is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered; ; and although prompt and exteWsive corrective actions were taken after the events' ! were identified by NRC inspectors, the base civil penalty amount has been l increased by 50 percent becauce of your prior poor performance in the area of concern and your prior notice based on Licensee Irregularity Reports which identified similar problems. You are required to respond to thisI 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. Your response to the Notice should also address 1 the actions you plan to take to improve your security program to assure that positive access control to the protected and vital areas is maintained and that continuous escort for visitors is provided within the protected and vital areas. In addition, you should specifically address the issue of work hours as they impact on the alertness of security personnel. 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 l compliance with NRC regulatory requireme,nts. { fn 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, with the exception of the report cover page which represents a nonexempt sumary, will not be placed in the NRC Public Document Room. The responses directed by this letter and its enclosures are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, FL 96-511. , Sincerely, m . N , w DA J. Nelson Grace [ Regional Administrator
Enclosure:
(See page 3) l l l l zMcLo8URE CONTAINS
!d.Fi:CUARbs INFORMATION 4 UPON SEPARAT!0M THIS NUREG-0940 I.A-112
i nr n 4 & RfO/ Florida Power and Light Company
Enclosure:
Notice of Violation and Proposed Imposition of Civil, Penalty (Safeguards Information) cc w/cnc1: C. M. Wethy, Vice President Turkey Point Nuclear Plant .
'C. J. Baker, Plant Manager Turkey Point Nuclear Plant L. W. Bladow, Plant QA Superintendent J. Arias, Jr., Regulatory and Compliance Supervisor i
l l l
'""LoSURE CONTAINS
^
- 'EGUARDS ZWFoRMATIoW
' $C14 SEPARAT2oN TNIS NUREG-0940 I.A-113 PAGE Is orcournou.tc.
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\..../ APR 2 2 887.
Docket No. 50-302 License No. DPR-72 EA 87-47 Florida Power Corporation l ATTH: Mr. W. S. Wilgus ) Vice President Nuclear Operations j Post Office Box 14042, M.A.C. C-2-M i St. Petersburg, Florida 33733 ! I Gentleman: ) 1
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-302/87-02) 1
.This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by G. F. Gibson at the Crystal River facility on January 12-16, 1987. The inspection included a review of the circumstances surrounding failures to control access to vital areas. The report documenting this inspection was sent to you with a letter dated February 10, 1987. As a result of this l
inspection, failures to comply with NRC regulatory requirements were identified. The inspection findings were discussed by M. L. Ernst, Deputy Regional Admini-strator, NRC, Region II, with you and members of your staf f in an Enforcement Conference held on February 25, 1987. A summary of the Enforcement Conference was included in Inspection Report No. 50-302/87-06 which was sent to you with a letter dated March 23, 1987. Violations I.A and I.B which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty have been collectively assessed a civil penalty. The first violation I.A. involved the failure of a security guard to remain alert in that he was found asleep at his post. The second violation, I.8, involved the failure of security guards to maintain positive access control over several vital area portals in that the guards did not check security badge authorizations against the access authorization list for facility personnel entering these vital areas. To emphasize the need for positive access control to vital areas, 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 l of Violatien and Proposed Imposition of Civil Penalty in the amount of Fifty l Thousand Dollars (550,000) for the violations described in the enclosed Notice. l In accordance with the " General Statement of Policy and Procedure for NRC I Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), violations I.A and I.B which are described in the enclosed Notice have been categorized as a Severity Level III problem. We have considered the corrective actions taken, your prior poor performance in the general area of concern and the multiple occurrences of one of the violations and have decided that neither escalation nor mitigation of this penalty is appropriate. N OM E CONTA!Ng
$ M u;0A; m g y g g ,
WGN EDAn4trog gggg NUREG-0940 I.A-114 PAR 18 DE00Nrnor.r.m i __
Flcrida Power Corporation 2' D 31ddle l Violatich II, which is not assessed a civil penalty, involved the failure to ! suty.dt a change t6 the Physical Security Plan. This violation has been ! categorized as a Severity LeveleIV violation. 1 O u are required to respond to,this letter and should follow the instructions , s;d.:1fied th the enclosed Notir.e tfien preparing your response. In your rSponse, you tshould document'the specifir.' actions taken and any additional cctions you'glan to prevent recurre xe. Mter reviewing your response to this
~
. otice, inclMing yeer proposed corrective actions, the NRC will determine wnther further-NRC enforcement act{cn is necessary to ensure compliance with' l
KC regulatory nquirescots. *
.t and 10 CFR.7L 21, 53 f eguards activities and In accordance with?10 CFR 2.790(d)x sic sity measures are exempt from public disclosure; thsrefore, the enclosure' to:this. letter, with the exception of the report cover page which presents a
-nchexempt. summary,'wi'l not be placed in the NRC Public Document Room.
1 2 The responses directed by this letter and its"enciosure are not subject to the clearance procidures of the Offica of Management and Budget as required by the Paperwork Reduction Act of 1980,'Pi. 96-511. s 4
.Should you have ar,y fdsti6Us cyncerning ihis letter, please contact us.
' Si nce rel'y ,- .
- ;. 1 , s .
1 y_n- '
). Nelson Grace
',tj stegional
' Adr.inistrator L A E ,losure:
L :N M ' otter of Violation and Proposed i ,, lirposition of Civil Penalty
.f l(Eafeguards InformatiM)
- . cc w/ encl: 1 4 P. F. McKeg, Director. i A Ndles.hPt. tnt 0/eratians !
R. C. Widell,dianager, Nuclear j s Operations Licea:ing and fuel Management ,
- l t: m.,,
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- ATL ANTA, GEORGI A 30323
%, ..../ APR 0 81987 Docket Nos. 50-321 and 50466 License Nos'. DPR-57 and NPF-5 EA 87-27 Georgia Power Company ATTN: Mr. James P. O'Reilly Senior Vice President-Nuclear Operations P. O. Box 4545 Atlanta, GA 30302 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS NOS. 50-321/86-41 AND 50-366/86-41, 50-321/86-43 AND 50-366/86-43) This refers to the Nuclear Regulatory
- Commission (NRC) inspections conducted {
at the Hatch Nuclear Plant on December 4-7, 1986, and December 20, 1986 - January 23, 1987. The inspections included a review of the circumstances surrounding isolation of the air supply to the inflatable seals in the fuel j transfer canal, the subsequent loss of fuel pool water on December 2-3,19BE, and the inoperability of one train of the standby gas treatment system due to the wetting of the charcoal filter bed. The reports documenting these inspec-tions were sent to you by letters dated January 8,1987, and March 11, 1987. On January 22, 1987, an E0forcement Conference was conducted with you and members < of your staff to ciscuss the inspection findings related to the fuel pool leak ' and your corrective actions. Violation I described in the enclosed Notice of Violation and Proposed Imposi-tior. of Civil Peralty INotice) involves failures to follow plent procedures which resulted in the loss of approximately 141,000 gallons of water from the spent fuel pools through the fuel transfer canal seals. Violation I.A and I.B involve the events associated with the closing of the air supply valve to the fuel transfer canal seals for which personnel failed to properly document a defective air regulator and to properly identify by a' tag a valve which was used to throttle the air supply when the air regulator was found to be defective. Violation I.C and I.0 involve errors made during the calibration of the transfer canal leak detection level switch. Personnel failed to follow procedures in that they left valves in incorrect positions after the calibration was performed and the calibration procedure was used although it was inappf0priate to do so becau'.,e it did not have instructions for the instrument's removal from service. To emphasize the importance of management insistence on procedural adherence and attention to detail and the complete evaluation and resolution of plant deficiencies, i have been authorized, after consultation with the Director, CERTIFIED Mall hETURN RECEIPT REQUESTED NUREG-0940 I.A-116
Giorgia Power Company 2 APR 0 81987 Office of Inspection and Enforcement, to issue the enclosed Notice of Violation
.and Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars
($$0,000) for violation I described in the enclosed Notice. In a-ccordance with j the " General Statement of Policy and Procedure for NRC Enforcement Actions," ' 10 CFR Part 2 Appendix C (1986) (Enforcement Policy), violation I described in the enclosed Notice has been categorized as a Severity 1.evel III violation. The ; escalation and mitigation factors in the Enforcement Policy were considered, and
~
no adjustment of the base civil penalty amount has been deemed appropriate. j While the corrective actions to reduce the radiological consequences of the event were excellent, violation I demonstrates a lack of management insistence on procedural adherence and attention to detail which could lead to other more serious incidents. The violations are indicative of inattention to detail in several actions and inactions by plant personnel. Several opportunities existed to prevent isolation of the air supply to the inflatable seals and to mitigate the resultant loss of fuel pool water. These opportunities existed but were not taken advantage of when your plant personnel failed to: (a) write a Deviation Pe ort or Maintenance Work Order when the defective air regulator was found, (b notify appropriate plant personnel when the partially open valve was closed, (c regularly monitor the pressure to the transfer canal seals, (d) aggressively pursue the cause of repetitive low-level alanns from the fuel pool skimer surge l tank, and (e) log the low-level alanas or comunicate at shift change the fact that the alarms had been received. Violation 11 involves the inoperability of one train of the standby gas treet-ment system when a fire protection valve leaked water and saturated a charcoal filter bed. Although the leaking valve was identified by your plant staff l and the water supply isolated on November 24, 1985, it was not until March 11, . 1986 that the charcoal filter bed of the 1A train was recognized to have been inoperable because of the previously leaking water. The NRC was then notified of the violation of technical specification requirements. Because this violation involves a less significant violation of technical specification requirements, this violation has been categorized as a Severity Level IV violation. oarticular concern in the events associated with violations I and 11 is the failure cf personnel to recognize the effects of component failures and personne' actions on related systems and overall plant components. These events demonstrate that plant personnel f ailed to properly evaluate and document deficient plant equipment and this resulted in systems becoming inoperable and not being recognized as being inoperable for an extended period of time. Because these violations have similar root :auses, you should assure that your corrective actions are implemented which will prevent further recurrence of these types of violations. You are required to respond to this letter and should foHow the instructions specified in the enclosed Notice when preparing your response. in your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. , NUREG-0940 I.A-117
Georgia Power Company 3 APR O 81987 We are continuing to pursue evaluation of a possible violation of NRC require-ments regarding the design of the transfer canal seals and the seal leak detection system. This is identified as an Unresolved Item (50-321, 366/86-41 02) pending review by the Office of Nuclear Reactor Regulation.
~
In accordance with Section 2.790 of the NRC's " Rules of Pr'actice," Part 2 Title 10, Code of Federal Regulations, a copy of this 1c-tter and its enclosure I will be placed in the NRC Public Document Room. l 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 i Paperwork Reduction Act of 1980, PL 96-511. ! Sincerely, l
- n. A s !
J. Nelson Grace Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enc 1: J. T. Beckham, Vice President, Plant Hatch H. C. Nix, Site Operations General Manager A. Fraser, Acting Site QA Supervisor L. Gucwa, Manager, Nuclear Safety ] and Licensing NUREG-0940 I.A-118
1 NOTICE OF VIOLAT 0N AND - PROPOSED IMPOSITIUK 0F CIVIL PENALTY Georgia Fower Company Docket Nos. 50-321 and 50-366 Hatch Units 1 and 2 L1 ense Nos. DPR-57 and NPF-6 EA 87-27 During an augmented Nuclear Regulatory Comission (NRC) Frispecticn of a loss of fuel pool water due to isolation of the air supply to inflatable seals in the fuel transfer canal, conducted on December 4-7, 1986, and an inspection conducted on December 20,~1986 - January 23, 1987, concerning the inoperability of the standby gas treatment system, violations of NRC requirements were ideritified. In accor(ance with the " General Statement of Policy and Precedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Comp'ssion proposes to impose a civil penalty pursuant to Section 234 of the Ateuc 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. Violation Assessed a Civil Penalty Technical Specification 6.8.1.a requires that written procedures be estab-lished, implemented, and maintained covering the activities recomended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33 specifies that procedures are required for equipment control and the operation of the instrument air system, i Technical Specification 6.8.1.b requires that written procedures be estab-lished, implemented, and maintained covering activities for refueling operations.
Contrary to the above, written procedures for equipment control and the instrument air system were not implemented. Specifically, l A. Section 8.1.2.1 of Procedure 10AC-MGR-004-05, Pevision 1 Deficiency Control System, requires that a Maintenance Work Order (MWO) be used to control the correction cf defects in plant equipment. However, prior to the loss of spent fuel pool water on December 2-3, 1986, no MWO was written to document a defect in plant equipment when the air regulator supplying air to the transfer canal seals was found to be defcctive and a valve in the same line was throttled to control air , to the seals. l B. Operations Department Interoffice Correspondence LR-0PS-002-0286, dated February 3,1986, requires hose station valves to be tagged open on a clearance. However, prior to the loss of spent fuel pool water on December 2-3, 1986, the hose station lever valve that supplied air to the transfer canal seals was not tagged open on a j clearance. C. Calibration Procedure 57CP-CAL-094-2, Revision 1, requires at the end of the calibration that the drain valve to the level switch be closed and the isolation valve be opened. However, on October 10, 1986, the drain valve to level switch 2G41-N019, a safety-related instrument NUREG-0940 1.A-119 l 1
i Notice of Violation. on the transfer canal leak detection system, was incorrectly left open and the isolation valve was incorrectly closed after the perfomance of Procedure 57CP-CAL-094-2. This rendered the transfer canal seal - 1 leak detection system inoperable and defeated the system's ability to - detect a leak. _ 1 D. Section 5.3.1.3 of Procedure 10AC-MGR-003-05, Revision 5, Preparation and Control of Procedures, requires personnel to stop, notify their ! supervisor, and back out of a procedure if it is wrong. However, j the transfer canal seal leak detection system was calibrated on i October 10, 1986, using Calibration Procedure 57CP-CAL-094-2, Revision 1 ! even though this procedure was wrong in that it did not provide instructions for the removal from service for level switch 2G41-N019. This is a Severity Level III violation (Supplement I). (Civil Penalty - $50,000.)
- 11. Violation Not Assessed a Civil Penalty Unit 1 Technical Specifications 3.7.B.1.a requires a minimum of three-(two in Unit 1 and one in Unit 2) of the four independent standby gas treatment system trains to be operable at all times when Unit I secondary containment integrity is required. With one of the Unit I standby-gas treatment systems inoperable Unit I reactor operation and fuel handling
. is. permitted for seven days provided that all active components in the
- ' remaining operable standby gas treatment systems in each unit be demonstrated '
to be operable within four hours and daily thereafter. Further, if the i inoperable Unit 1 standby gas treatment system is not made fully operable l within the seven-day period, the Unit i reactor shall be shutdown and placed in the cold shutdown condition within the next 36 hours and Unit 1 fuel handling operations 5, hall be terminated within four hours. Unit 2 Technical Specifications 3.6.6.1 requires two Unit 1 and two Unit 2 independent standby gas treatment subsystems be operable in Conditions 1, 2, and 3. With one subsystem inoperable, the inoperable subsystem must be restored to the operable status within seven days or Unit 2 must be in at least hot shutdown within the next 12 hours and in cold shutdown within the ' following 24 hours. Contrary to the above, from November 25, 1985 to March 11, 1986 during various times when Unit I secondary containment integrity was required or when Unit 2 was in Condition 1, 2, or 3, the 1A standby gas treat-ment subsystem (train) was inoperable for greater than seven days and actions were not taken to: (1) demonstrate all active components in the remaining operable standby gas treatment systems in Units 1 and 2 were operable within four hours and daily thereafter, (2) for Unit 1, shutdown the reactor and be in the cold shutdown condition within the next 36 hours, (3) terminate Unit 1 fuel handling operations within four hours, or (4) for Unit 2, be in hot shutdown within the next 12 hours and in cold shutdown within the NUREG-0940 I.A-120
Notice of Violation following 24 hours. The 1A train was inoperable because the associated charcoal filter bed had become wet and unable to perform its intended safety function for the removal of methyl iodine. This is a Severity Level IV violation (Supplement Q.. Pursuant to the provisions of 10 CFR 2.201, Georgia Powar Company is hereby required to submit a written statement or explanation to the Director Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Comission, Region II,101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, within 30 days of the date of this Notice. This reply should include for each alleged violation: (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the 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, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper 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, Georgia Power Company may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Fifty Thousand Dollars ($50,000) or may protest imposition of the civil penalty l in whole or in part by a written answer addressed to the Director, Office of l Inspection and Enforcement. Should Georgia Power Company fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Georgia Power Company elect to file an answer in accordance with 10 CFR 2.205 l prttesting the civil penalty, such answer may: (1) deny the violation listed in , this Notice in whole or in part, (2) demonstrate extenuating circumstances, j (3) show error in this Notice, or (4) show other reasons why the penalty should I not be imposed. in addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2 Appendix C (1986), 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 2.20P but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Georgia Power Company's attention is directed to the other provisions of 10 CFR 2.205 regarding the procedure for imposing a civil penalty. NUREG-0940 1.A-121
\
Notice of Violation 4 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 Gereral, 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. FOR THE Nt! CLEAR REGULATORY COMMISSION J. Nelson Grace
# * * **0" Dated at Atlanta, Georgia this KJAday of April 1987 NUREG-0940 I.A-122
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'op ' UNITED STATES
![. n NUCLEAR REGULATORY COMMISSION
$ ,E REGION I 4 - $, 631 PARK AVENUE
$'.ING oF PRUS$1A, PENNSYLVANIA 19406
% a . . . + ,o#a April 29,1987 Docket No. 50-220 License No. OPR-63 EA 87-45 Niagara Mohawk Power Corporati n .
ATTN: Mr. C. V. Mangan Senior Vice President 301 Plainfield Road Syracuse, New York 13212 Gentlemen:
Subject:
NOTICE OF VIOLATION AND . PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection Report Nos. 50-220/86-13; 50-220/86-16; 50-220/86-17)
.This refers to three NRC inspections conducted between August 4 and September 19, 1986 at Nine Mile Point, Unit 1, Scriba, New York. The inspection reports were sent to you on September 30, 1986, December 18, 1986, and January 20, 1987, respectively. Two of the inspections, including a special team inspection conducted on August 25-29, were conducted in response to several allegations made to this office by one of your employees concerning the areas of maintenance, surveillance, operations, quality assurance and radia-tion protection at Unit 1. During the inspection, many of the allegations were substantiated and several violations of NRC requirements were identified by the NRC, including violations unrelated to the allegations. On February 19, 1987, an enforcement conference was conducted with you and members of your staff to
; discuss the violations, their causes and your corrective actions.
.The violations are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) and, when evaluated collectively, indicate underlying weaknesses in the control of licensed activities at Unit 1. In particular, (1) problems identified by your staff are not always brought to the attention of management for resolution; (2) probiems are not adequately analyzed to determine their underlying caisses; (3) corrective actions taken for identified problems lack thoroughness and depth; and (4) the Quality Assurance Department has not been effective in assisting the line organizations in identifying and correcting problems. The specific violations include: numerous examples of the failure to follow station procedures when performing maintenance and surveil-lance testing, and when controlling measurement.'and test equipment; failure to properly evaluate test results; the failure to perform adequate radiation surveys; failure to follow procedures for personnel radiation protection; and failure to provide adequate radiation surveillance in the work area.
l These weaknesses further demonstrate an apparent complacent attitude among certain members of your staff which may have contributed to declining performance and an increase in the number of operational problems at Unit 1, as indicated in the Systematic Assessment of Licensee Performance Board Report sent to you on february 27, 1987. Additionally, the violations also indicate NUREG-0940 1.A-123
Niagara Mohawk Power Corporation 2 that your system for resolving employee concerns was inadequate in that the alleger had discussed his concerns with supervision prior to contacting the NRC, but timely and effective action was not taken to analyze and resolve these concerns. To emphasize the need for (1) strict adherence to procedures, (2) the timely and effective resolution of problems raised by employees, and (3) complete and thorough actions to correct underlying causes, I have been authorized, af ter consultation'with the Director, Office of Enforcement, and the Deputy Executive . Direscor for Regional Operations to issue the enclosed Notice of Violation and l Proposed Imposition of Civil Penalty in the amount of Fifty Thousand Dollars 1 ($50,000) fo the violations described in the enclosed Notice. Individually the violatior s might not be categorized at a Severity Level III. However, collectively, they raise a significant concern for the reasons stated above. l Therefore, in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), the violations have been categorized in the aggregate as a Severity i Level III problem to focus on the underlying weaknesses. The escalation and I 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 j plan to prevent recurrence. After reviewing your response to this Notice, j including your proposed corrective actions, the NRC will dete miner whether " further enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of the NRC's " Rules of Practice" Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will . be placed in the NRC Public Document Room. l The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork fleduction Act of 1980, Pub. L. No. 96-511. Sincerely, a
&h: T. Ak ,
William T. Russell Regional Administrator i
Enclosure:
Notice of Violation and Proposed , Imposition of Civil Penalty I cc: See Next Page , l l 1 NUREG-0940 I.A-124
l 1 Niagara Mohawk Power Corporation 3 l cc w/ encl: T. E. Lempges, Vice President, Nuclear Generation J. A. Perry, Vice President, Quality Assurance ! T. Perkins, General Superintendent, Nuclear Generation i W. Hansen, Manager of Quality Assurance l T. Roman, Station Superintendent J. Aldrich, Supervisor, Operations W. Drews, Technical Superintendent ! Troy B. Conner, Jr. Esquire ; John W. Keib, Esquire i
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Director, Power Division Public Document Room (PDR) local Public Document Room (LPDR) Nuclear Safety Information Center (NSIC) NRC Resident Inspector State of New York l I i 1 l l l i t I l 1 NUREG-0940 1.A-125 l
)
ol 1 iv NOTICE OF VIOLATION AND
' PROPOSED IMPOSITION OF CIVIL PENALTY (l} '
l . Docket No. 50-220 {' Niagara Mohawk Power Corporation Nine Mile Point, Unit 1 License No. DPR-63 EA 87-45 During three NRC inspections conducted between August 4 and September 19, 1986, violations of NRC requirements were identified. In accordance with the
" General Statement of Policy and Procedure for NRC Enforcement Actions, 10 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Commission proposes to-impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:
' A. Technical Specification 6.8.1 requires that written procedures and administrative policies be established, implemented and maintained that cover the activities recommended in Sections 5.1 and 5.3 of ANSI Standard N18.7-1972. Section 5.1 of ANSI N18.7-1972' specifies that a maintenance program be developed to maintain safety-related equipment which includes the following: (1) proper preplanning and performance of maintenance in acco'edance with written instructions or procedures 1 that incorporate appropriate vendor manual information, (2) documented permission by responsible operating personnel to release equipment for work, and (3) post-maintenance review, testing and return to service to verify functional acceptability. -
Contrary to the above, written procedures and administrative policies were not either established, implemented, or maintained covering the following maintenance activities, as evidenced by the following examples:
- 1. On August 21, 1986, maintenance was performed on the Control Rod Drive (CRD) hydraulic control unit scram inlet and outlet valves, safety' m / M equipment, without establishment and implementa-tion apprg e ate written procedures for conducting th'is main-tenan w. Spec:tIcally, the packing for the valves was tightened withous p rc pt . rpproval of shift supervision, without proper pre-planning # witter instructions, and without any post 9 maintenance testing.
- 2. In April 1986, a local leak rate test of the Feedwater Isolation Check Valve was not conducted in accordance with the approved Nine Mile. Nuclear Station Procedure N1-ISP-25.7. Specifically, the cavity between the inboard isolation valve and outboard check valve was initially pressurized to 100 psig rather than 35.5 psig as stated in the procedure, and this change was not evaluated for its effect on the validity of the test.
NUREG-0940 1.A-126
Notice of Violation 2
- 3. In July 1986, two Local Power Range Monitor (LPRM) cable connectors'were replaced with a model-connector that was not in accordance with NMNS Procedure N1-IMP-LPRM-1. Specifically,
'Amphenol Type BNC connectors were used instead of the required Amphenol Type SMA connectors.
- 4. On September 15, 1986, the restoration of' safety-related equipment to an operable status after the maintenance. activities was.not performed in accordance with Administrative Procedure 5.0, " Procedure for-Repair," in that physical. separation of electrical equipment was not maintained. Specifically, three-steel panel isolation barriers which separate safety-related from non-safety-related equipment were not reinstalled within Remote Shutdown Panel No. 11. Additionally, switch and relay covers and a spare instrument were not reinstalled,
- 5. NMNS Procedure N1-ST-Q3 and N1-ST-105 used for the performance of surveillance -testing of the High Pressure Coolant Injection (HPCI) pumps were not revised to incorporate new HPCI flow acccptance criteria. Further, on July-14,~ 1986 these procedures were not-used during the surveillance testing of the HPCI pumps.
- 6. The control and use of metering and test equipment (M&TE) was not conducted in accordance with Administrative Procedure AP-8.4,
" Procedure for Control and Calibration of Equipment Used in Tests and Inspections", as evidenced by the following examples:
- a. On April 16, 1985, Transition Minitemp Calibrator (Serial No.
18947) was calibrated off-site and, as of September 18, 1986, a current calibration report was not tr.aintained with the responsible supervisor, as required,
- b. On November 4,1985, a Gould recorder (Serial No.1155) was used (
on at least thirteen instances during the performance of timing tests on scram valves without the required recording of its use on a protected log sheet.
- c. As of September 18, 1986, recorder channel modules, which were individually calibrated, were interchanged between several Gould recorder units without recording this fact on a protected log sheet, as required. ;
l
- 7. On June 18, 1986, NMNS Procedure N1-ST-C3, " Automatic Startup of l HPCI System," was not properly followed in that the procedure was signed-off as complete without documenting the completion of the i Feedwater (HPCI) System and Condensate System " return to service" i alignments on the procedure Data Sheet. -
i 1 l I NUREG-0940 I.A-127 i
Notice of Violation 3 i 8 'As of September-18,:1986,. housekeeping and cleanliness was not. performed in-accordance with Administrative Procedure 8.5 in that , loose nuts,-. bolts,' relay and switch covers, and other loose hard- } ware.and trash'were present in the Recirculation Pump Motor-Generation Field Breaker Cubicles and Remote Shutdown Panels. l Design' drawings that reflect plant. modifications were.not' prepared l 9. and delivered to the Station Superintendent in a timely manner as-
- required by Administrative Procedure APN-9, Procedure for Station Permanent and Temporary Modifications and Replacement," as evidenced g
by the following examples:
- a. In 1984, a Plant Modification (No. 84-36) was made to the i
. wiring-for Anticipated Transient Without Scram (ATWS) Panel i No. 1548, and as of September 12, 1986, the associated j wiring l diagram (No.C-34122-C/1) at the facility was not ]
prepared to accurately reflect the Modification. I
- b. On September 17, 1986, the latest available wiring diagram. !
(No. C-3481C, Sneet 5, Revision 0, and Sheet 6, Revision 1) at the f acility for the Remote Shutdown Panels was not prepared ' .; to reflect the as-1nstalled wiring configuration in that ten ! wiring configurations were different than indicated on the ; diagram, l
- 8. '10 CFR Part 50, Appendix B, Criterion XI, requires, in part, that test results be documented and evaluated to assure that test requirements have been satisfied.
Contrary to the abuve, on August 14, 1986, test results were not ' evaluated to assure that test requirements had been satisfied. Specifically, although Raw Water Pump No. 121 motor current was observed as outside the acceptable range, an evaluation of the data i was not completed and NMNS Procedure N1-ST-06, " Containment Spray and Raw Water Pumps Operability Test," was completed as satisfactory. i
.C. 10 CFR 20.201(b) requires, in part, that each licensee make or cause to q be made such surveys as may be necessary to comply with the regulations in 10 CFR Part 20 and are reasonable under the circumstances to evaluate the .i extent of radiation hazards that may be present. 10 CFR 20.201(a) defines a survey, in part, as an evaluation of the radiation hazards incident to the presence of sources of radiation.
Contrary to the above,
- 1. although an Instrument and Control (l&C) technician's pocket dosimeter went off-scale while performing maintenance on local power range monitors unaer the reactor vessel on April 28, 1986, the individual reentered the area and performed additional work NUREG-0940 1.A-128
Notice of Violation 4 under the vessel, without an evaluation being performed to determine , the extent of the radiation hazards that may have been present and i without ensuring that the limits set forth in 10 CFR 20.101 were not i exceeded. 1 l
- 2. on April 29, 1986, an adequate survey was not performed of an area I under the reactor vessel area where maintenance on local power range monitors was to be performed in that the radiation levels from the control rod drive (CRO) flanges were not determined. An individual performing the maintenance could come in contact with the CRD flanges which had a contact radiation level of approximately 1200 millirem per hour. A technician was not instructed to avoid the area of these flanges, and this resulted in the technician working with his head resting against a flange without knowing that the flange had a contact radiation level of approximately 1200 millirem per hour.
D. Technical Specification 6.11 requires, in part, that procedures for personnel radiation protection be prepared consistent with the requirements of 10 CFR Part 20, and be adhered to for all operations involving personnel radiation exposure. Contrary to the above, in several instances, procedures for personnel radiation protection were not adhered to for operations involving personnel radiation exposure, as evidenced by the following examples:
- 1. On April 28 and 29, 1986, an I&C Technician working under the reactor vessel received an uncontrolled radiation exposure as evidenced by off scale dosimetry readings, and Radiological Occurrence Reports were not issued in accordance with NMNS Procedure S-RP-5, " Radiation and Radioactive Contamination Control," Revision 4.
- 2. On April 28, 1986, an I&C Technician, whose dosimeter indicated an accumulated dose of 300 millirem, did not rezero his dosimeter, as required by NMNS Procedure S-RP-1, " Access ano Radiological Control,"
Revision 5, prior to entering an area under the reactor vessel where the radiation field could result in an off-scale reading.
- 3. On April 29, 1986, an I&C Technician, designated as the Leadman for work performed under the reactor vessel, did not ensure, as required by NMNS Procedure S-RP-2, " Radiation Work Permit Procedure," Revision 4, that the instructions of a Radiation Work Permit (RWP) were strictly followed. Specifically, the Leadman entered the area without the extremity dosimeter required by RWP No. 2043.
- 4. On April 28, 1986, an 1&C Technician returned his extremity dosimeter to dosimetry personnel, but did not return his whole body film badge at the same time, as required by NMNS Procedure S-RTP-7, " Issuing and Collecting Dosimetry Devices," Revision 6.
NUREG-0940 1.A-129
Notice of Violation 5
- 5. On April 28, 1986, an I&C Technician's pocket dosimeter went off-scale indicating a potential high exposure, but the film badge was not submitted to the vendor for processing as required by NMNS Procedure S-RRI-12, " Sending Special Records to Landauer," Revision 0.
E. Technical Specification 6.12.1 requires, in part, that each individual or group of individuals permitted to enter areas with radiation levels greater than 100 mrem / hour be provided with or accompanied by one or more of the following:
- a. A radiation monitoring device which continuously indicates the radiation dose rate in,the area. 1
- b. A radiation monitoring device which continuously integrates the l radiation dose rate in the area and alarms when a preset inte- l grated dose is received. Entry into such areas with this monitoring I device may be made after the dose rates in the area have been j established and personnel have been made knowledgeable of them. j I
- c. An individual qualified in radiation protection, with a j radiation dose rate monitoring device, who is responsible for i providing positive control over the activities wi' thin the area, !
shall perform periodic radiation surveillance at the frequency i specified by the Radiation Protection Supervisor or designated I in the Radiation Work Permit. ] l Contrary to the above, on April 29, 1986, an I&C technician er.tered j an area under the reactor vessel and performed work on the Local Power ! Range Monitors (LPRMs) where the upper part of his body could come in j contact with the Control Rod Drive (CRD) flanges where the radiation l levels were as high as 1200 mrem /hr on contact. The technician was not l provided with a continuously indicating or continuously integrating l device, nor was he accompanied by an individual qualified in radiation l protection to perform periodic surveillance at the frequency specified j on the RWP. j Collectively, the violations have been categorized in the aggregate as a Severity Level III problem (Supplement I and IV). Cumulative Civil Penalty - 550,000 (assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, Niagara Mohawk Power Corporation is hereby required to submit a written statement or explanation to the U.S. l Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, USNRC Region I, and a copy to the NRC Resident Inspector, Nine Mile Point, Nuclear Station, Unit 1, within 30 days of the date of this Notice. This reply should be clearly marked as a
" Reply to the Notice of Violation" and shoul'd 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 NUREG-0940 I.A-130
Notice of Violation ~ 6 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, Niagara Mohawk Power Corporation may pay the civil penalty by letter addressed to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Fifty Thousand l Dollars ($50,000) or may protest imposition of the civil penalty in whole or l' -in part by a written answer addressed to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555. Should Niagara Mohawk Power Corporation fail to answer within the time specified, an order will be issued imposing the. civil' penalty in the amount proposed above. Should Niagara L Mohawk Power Corporation elect to file an answer in'accordance with 10 CFR 2.205 protesting the civil penalty, such answer should be clearly marked as.an
" Answer to a Notice of Violation" and may: (1) deny the violation listed in
.this Notice in whole or in part', (2) demonstrate extenuating circumstances, (3)' slaw error in this Notice, or (4) show other reasons why the penalty shovid 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. I in requesting mitigation of the proposed penalty, the five factors contained in Section V.B of 10 CFR Part 2, Appendix C (1987), should be' addressed. .Any written answer in accordance with 10 CFR 2.205 should be set fcrth 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 Niagara ' Mohawk Power Corporation is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. I Upon failure to pay any civil penalty due, which has been subsequently deter- 2 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. 2282. FOR THE NUCLEAR REGULATORY COMMISSION l M7 William T. Russell ! Regional Administrator , i DatedatgingofPrussia, Pennsylvania this/p day of April 1987 j NUREG-0940 1.A-131 l
UNITED STATES
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- Docket No. 50-344 License No. NPF EA'87-60 Portland General Electric Company 121 S. W. Salmon Street-Portland, Oregon 97204 ATTN: David W. Cockfield, Vice President, Nuclear Gentlemen:
Subject:
NOTICE OF VIOLATION AND' PROPOSED' IMPOSITION OF CIVIL PENALTY. l (NRC INSPECTION REPORT NO. 50-344/87-15) ~j 1
.This refers'to the special inspection conducted on April 15-24, 1987 at the Trojan Nuclear Power Plant, Rainier, Oregon. Several examples of apparent violations involving radiation safety matters were identified by an NRC Radiation Specialist during this inspection and were discussed with you during ;
the. Enforcement' Conference held on May 14, 1987. j Since July 1982, your facility has operated with an estimated 112 fuel pellets unaccounted for in the reactor coolant and support systems. .The existence _of this type of radiological hazard was known to you and has been periodically reemphasized by NRC. industry representatives, and members of your facility staff. Shortly after beginning your 1987 refueling outage on April 1, a substantial increase in the rate of personnel contamination incidents was observed, followed by.a significant dispersal of highly radioactive particulate fission products in the upper elevations of the reactor containment building on April 9, 1987. The apparent' violations of NRC requirements in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty indicate your failure to establish and i implement radiation protection procedures, train workers, perform radiation surveys and maintain records of radiation survey results. Collectively, the violations. demonstrate a programmatic breakdown in your radiation safety program that resulted in several workers receiving significant, unnecessary, radiation exposures. Only fortuitously did these workers not receive exposure to radia-tion in excess of regulatory requirements. An NRC review indicates that your performance-in the area of radiological l controls has declined during the last SALP evaluation period to a category 2
- f. rating. In the December 19, 1986 SALP report, NRC recommended that you :
consider action to increase the level of management attention and oversight i directed toward the radiological controls area. The April 1987 incidents indicate a , continuing failure on your part to improve performance in this area. The NRC has noted deficiencies including inadequate training of the radiation protection technicians, very general safety requirements on work pennits, broad CERTIFIED MAIL REluRN RECEIPT REQUESTED NUREG-0940 I.A-132 C ..
.I JUN. 41987 Portland General Electric Company ,itschniEian authority with minimum direction and oversight, organizational weak-n2ss,'and insufficient corporate involvement. The NRC believes the root cause of'the apparent violations and deficiencies is a lack of management involvement in radiation control activities.
- To emphasize the need-for-programmatic improvements in the radiological. ,
; controls area, I have been authorized, after consultation with the Director, I Office of Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $50,000 Dollars for the violations discribed in the enclosed Notice. In accordance with the " General Statement' of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C -(1987),.the violations described in the enclosed Notice have been categorized . in the aggregate as a Severity Level:III problem.
The base value of a civil penalty for a Severity Level III protlem is $50,000. The escalation and mitigation factors.in the Enforcement Policy were ccasidered. The. Policy allows for reduction of a civil penalty under certain circumstances. Although the NRC. recognizes that your corrective actions were prompt and exten-sive and included upgrading your radiation protection program, mitigation of the civil penalty is considered inappropriate in view of (1) your failure to promptly recognize the seriousness of the fuel fragment contamination issue , considering prior notice of similar events, and .(2) the multiple examples Lof
-apparent' failures to comply with regulatory requirements identified during.the inspection period. Accordingly, in this case it is our conclusion that neither mitigation nor escalation is warranted.
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 I 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. 1 The responses directed by this letter and the enclosed Notice are not subject to the cletrance procedures of the Office of Management and budget as required by the Pape work Reduction Act of 1980, Pub. L. No. 96-511. Since ely, John B. Martin Regional Administrator
Enclosure:
l Notice of Violation and Proposed ' Impositioti of Civil Penalty NUREG-0940 1.A-133 3
l
.JUN 41987 ,
Portland General'. Electric Company cc'w/ enclosure: l J.'W. Durham, Sr. Vice President ' C. A. Olmstead, Plant' General Manager-W. Dixon,-DOE l l i 1 j NUREG-0940 I.A-134
NOTICE OF VIOLATION AND t PROPOSED IMPOSITION OF CIVIL PENALTY Portland General Electric Company Docket No. 50-344 ! Trojan Nuclear Plant License No. NPF-1 EA No. 87-60 ! 1 During an NRC inspection conducted on April 15-24, 1987, several violations of u NRC. requirements were identified. In accordance with the " General Statement ; ef Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix ! C (1987) the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CRF 2.205. The particular violations and associated civil penalty are set forth below: A. Technical Specification 6.11 requires that procedures for personnel radiation protection shall.be prepared consistent with the requirements of 10 CFR Part 20 and shall be approved, maintained, and adhered to for all operations involving personnel radiation exposure. Contrary to the above requirement, as of April 17, 1987, the licensee had not developed radiation protection procedures to ensure that survey methods and control techniques would limit the exposure to workers from highly radioactive particles such that compliance with the general provisions expressed in 10 CFR 20.1(c) and specific dose limits of 10 CFR 20.101 would be met. B. Technical Specification 6.11 requires that procedures for personnel radiation protection shall be prepared consistent with the requirements of 10 CFR Part 20 and shall be approved, maintained, and adhered to for all operations involving personnel radiation exposure. The licensee's Radiation Protection Manual specifies the radiation dosimetry requirements for personnel. Radiation Protection Procedure RP 109, Personnel Dosimetry Program, provides the details to ensure implemen-tation of these requirements. Section III.C.1.b. states, in part, that extremity TLDs will be required when the extremity dose is expected to be five times greater than the whole body dose and the dose to the extremities is expected to exceed 1 rem for the quarter. Contrary to the above requirement, on April 17, 1987, a radiation protection technician entered the upender trench to perform radiation surveys, an area with hot spots on the floor with exposure rates up to 22 R/hr and whole body exposure rates up to 1.0 R/hr, without the use of lower extremity personnel monitoring devices even though he had prior knowledge from previ-ous surveys that the extremity dose could be expected to be 5 times greater than the whole body dose and the dose to the extremities could exceed 1 rem for the quarter. C. 10 CFR 19.12 requires, in part, that all individuals working in or frequenting any portion of a restricted area, shall be instructed in the health protection problems associated with exposure to radioactive NUREG-0940 I.A-135
Notice of Violation , 1 materials and precautions or procedures to minimize exposure. The extent of these instructions shall be commensurate with potential radiological health problems in the restricted area.* 1 Contrary to the above, on April 13 and 14,1987, about ten contract refueling crew workers were permitted to enter the refueling cavity and refueling floor areas without being instructed on the potential radiolog-ical health protection problems associated with exposure to highly radio-active fuel fragments even though the licensee was aware of the increused radiological health hazard from fuel fragments from an inc14nt that occurred on April 9, 1987. In addition, during April 9-17, 1987, contract and facility radiation protection technicians providing coverage for refueling cavity and refueling floor work had not been instructed in pre-cautions or procedures to minimize their exposure and that of their co-workers. D. 10 CFR Part 20.201(b) requires that each licensee make such surveys as (1) are necessary to comply with regulations in 10 CFR 20 and (2) 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 radiction under a specific set of conditions.
- 1. Contrary to the above requirements, on April 9, 1987, seven workers engaged in reactor vessel stud removal and plugging operations were exposed to highly radioactive loose surface contamination (a smear from the outer layer of protective clothing from one worker appeared to indicate a level of 4.1 rad /hr beta and 180 mR/hr gamma) and no survey or evaluation was made to determine the extent of radiation hazard to portions of their bodies resulting from the presence of radioactive material on their clothing.
- 2. Contrary to the above requirements, on April 9, 1987, a radiation protection technician, following the dispersal of significant quantities of radioactive material in and around the refueling cavity, measured a spot on the floor near the reactor head flange that indicated an exposure rate of 30 rad /hr beta and 1.0 R/hr gamma; and on April 10, 1987, a different radiation protection technician measured another spot on the floor near the reactor vessel flange which indicated an exposure rate of greater than 100 rad /hr beta and 30 R/hr gamma and no evaluations were made in either case to determine the radiation hazard to individuals who had previously worked in this area.
- 3. Contrary to the above requirements, on April 12, 1987, a radiation protection technician measured radioactive contamination levels on the knees of his outer layer of protective clothing that indicated exposure levels of 1.0 R/hr gamma and no evaluation was made to determine the radiation dose to his leg.
NUREG-0940 1.A-136
Notice of Violation 4. Contrary to the above requirements, on April 17,'1987, a radiation protection technician entered the refueling cavity and, upcn exiting the upender trench, handled and othsrwise manipulated his contaminated : rubber shoe cover, which had an exposure rate of greater than 50 ! R/hr gamma at contact, and an evaluation of the radiation hazard to l his hand and other portions of his body was not performed. E. 10 CFR 20.401(b) requires, in part, that each licensee shall maintain records showing the results of surveys required by 10 CFR 20.201(b),
" Surveys." 10 CFR 20.201(b) requires that each licensee make or cause to be made surveys as: (1) may be necessary for the licensee to comply with 1 the regulations in 10 CFR 20, and (2) are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present.
l 1. Contrary to the above requirements, as of April 20, 1987, the l licensee failed to maintain a record of a wipe survey from a ( worker's outer layer of protective clothing on April 9, 1987 that appeared to indicate 4.1 rad /hr beta and 180 mR/hr gamma. l 2. Contrary to the above requirements, as of April 21, 1987, the licensee failed to maintain a record of a survey from the knees of a radiation protection technician's outer layer of protective cloth'ng l on April 11, 1987 that appeared to indicate 1.0 R/hr gamma. Collectively, these violations have been classified as a Severity Level III l problem. (Supplement IV) l l Cumulative Civil Penalty - $50,000 - assessed equally among the violations. Pursuant to the provisions of 10 CFR 2.201, Portland General Electric 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 I I 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 revsked 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 Secticin 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, i Of fice of Enforcement, U.S. Nuclear Regulatory Commission, with a check, NUREG-0940 I.A-137
Notice of Violation l 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 . f imposition of the civil penalty in whole or in'part by a written answer ! addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory l Commission. Should the Licensee fail to answer within the time specified, an i 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 five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1987), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately I 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 Upon failure to pay any civil penalty due which subsequently has been determined in acccrdance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c. The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region V, 1450 Maria Lane, Suite 210, Walnut Creek, California, and a copy to Robert Barr, Senior Resident Inspector, at the Trojan Nuclear Power Plant. FOR THE 'UCLEAR REGULATORY COMMISSION 1 John B. Martin Regional Administrator Dated at Walnut Creek, California, this day of June 1987 NUREG-0940 1.A-138
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NUCLEAR REGULATORY COMMISSION
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.....f KING Of PRUsSI A, PE NNsVLV ANIA 19406 Docket No. 50-333 2 2 APR 1987 License.No. OPR-59 EA-87-48 i Power Authority of the State of'New York James A. FitzPitrick Nuclear Power Plant ATTN: John C. Brons Senior Vice President Nuclear Generation 123 Main Street White Plains, New York Gentlemen:
Subject:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY
- i. (NRC Inspection No. 50-333/87-07) l This refers to the NRC inspection conducted on February 18-20, 1987 of activi-ties authorized by License No. OPR-59 at the James A. FitzPatrick Nuclear Power Plant. The report of the inspection was forwarded to you on March 11, 1987.
The inspection was. conducted to review the circumstances associated with an unplanned radiation exposure of 30.27 rem in one calendar' quarter to the right hand _ of a contractor worker at your f acility', an amount in excess of the - regulatory limit. The unplanned, radiation exposure was identified by a member of your staff and reported to the NRC. On March 25, 1987, an enforcement conference was held with you and members of your staff during which the exposure, the associated violations, their causes, and your corrective actions were discussed. The majority of the radiation exposure (29.6 rem) was received by the individual on February 13, 1987 while performing an activity which involved the cutting and replacement of instrument dry tubes in the reactor. When the cutting tool was removed from the water on February 13, 1987, and placed on the refuel floor, a piece of the dry tube fell from the tool onto the refuel floor. The contractor tec.hnician, who had not been instructed in the radiological hazards associated with these instrument tubes, immediately grabbed the piece of tube and threw it into the refueling pool. A subsequent underwater survey of the piece of tube indicated a contact radiation level of 13,000 R/hr, which is equivalent to approximately 16,300 R/hr in air. The NRC is concerned that although area radiation monitors ( ARMS) alarmed in three different areas as the cutting tool was being removed from the pool, the tool was nonetheless removed without performing a survey of the tool prior to removal from the pool. Further, the Radiation Technician who was monitorir.g the . activity was not informed of the alarms, and an adequate evaluation of the i cause of the alarms was not performed. The NRC is also concerned that althou" two Radiation Protection technicians had been assigned to the Refuel floor to provide radiological control for these activities, one of the technicians had 1 CERTIFIED MAIL l hETURN RECElPT REQUESTED 1
.NUREG-0940 I.A-139
p_ , p 1-Power Authority of the State ' 2 .~ of New York left the area to perform another task, and the'other technician was actually involved in the work activity by' washing and rinsing the tool as it was being removed;.rather than providing radiological oversight and control of the
' activity. i Further, communication between the Radiation Protection technician and the work -
crew was inadequate in that the Radiation Protection Technician had not been informed that (1) a piece of tube had been cut or (2) that alarms had been received as the tool was being removed from the refueling pool. These' events demonstrate the need for. improved planning and control of radiation protection activities, improved training in radiological hazards, and improved communication l I between Radiation Protection personnel and the work crews they are monitoring. In addition, the NRC-is concerned that your staff has not in thr: past / adequately responded to indications of radiological problems,'tand has not "L V implemented effective corrective actions.to prevent recurrence.of previously identified violations. For example, on the shift immediateh prior'to the s shift.during'which the overexposure. occurred, a highly radioactive (415 R/hr) particle was' found in the cutting tool, 'yet action was not taken to revise the oI ALARA Review and associated Radiation Work Permit for the opentions'toibe , conducted on the next day, Further, although & Notice of Violation. (NOV) was issued on June 21, 1985 identifying several Jailures to adhere to. radiological " I procedures, including the failure to ensure compliance with Radiation Work Permits,.and most notably, the f ailure to survey a dry tube cutting tool prior to allowing personnel to handle the tool, procedures again were not fcilowed and the tool again was removed without a survey first being performed. . lf an adequate survey had been performed prior to removal, the overexposure could s have been prevented. These failures demonstrate a serious breakdown in management control of the radiation safety program. To emphasize the need to (1) assure adherence to radiation' safety procedures, and (2) take timely and effective corrective actions to prevent recurrence of identified violations, I have been authorized after consultation with the Director, Office of Enforcement and Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Prb oned Imposition of Civil Penalty in the amount of Seventy Five Thousand Dollars 454.000) for the violations set forth in the h'otice.s fhe violations are classified in the aggregate as a Severity level III problem in accordance with the 7)eneral Statement of Policy and Procedure for NRC Ev orcement Actions," 1h fFR Part 2, Appendix C (Enforcement Policy) (1987). Although Vio ktion A co@ n individually be classified at Severity Level 111, the violations'have been classified in the aggregate to focus on the underlying deficiencies. The base civil pena ~lty amount for a Severity level 111 violation or problem is $50,000. The NRC considered increasing the civil penalty, amount by 100 percent because of the repeated f ailures totassure adherence tp procedures, the failure to implement adequate corrective. action for the previously identified similar violations, and the failur'e to respond to the indications of a radiation probler. However, the penalty was only estalated by 50% in recognition of your unusually > prompt and extensive corrective actions af ter the overexposure was identified. T NUREG-0940 1.A-140 i t o ? o
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I Power' Authority of the State 3 of New York You are required to respond to the enc'losed Notice and, in preparing your'- response,.you should follow the instructions specified in the Notice, in your
; response,-you should document the specific actions taken or planned.to prevent.
recurrence. . in. your response, you may reference, as apprortate~, your
; presentation at the enforcement conference. 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
- d. -g .is necessary to ensure compliance' with NRC regulatory requirements, y , ,
An accordance with Section 2.790 of'the NRC's :" Rules of Practice," Part 2, l Title _10, Code of Federal Regulations, a' copy of this letter and the enclosure wi.ll-be pl, aced in the NRC's Public Document Room. 1T}s responi.es directed by this letter and the enclosed Notice are not subject M n the &learance procedures of the Office of Management and. Budget as required' bR the' Paperwork Reduction. Action of 1980, PL 95-511. ( Sincerely, M. T. I I n1 dm t ator En' closure: Notice of Violation . and Proposed Imposition of Civil Penalty cc w/ encl: s h L W. Sinclair, President
, J. P. Bayne, First Executive Vice President and Chief Operations Officer A. Klausmann,: Vice President - Quality Assmance and Reliability 4 R. J. Converse, Resident Manager, FitzPatrick R. L. Patch, Quality Assurance Superintendent N" George M. Wilverding, Chairman,. Safety Review Committee Gerald C. Goldstein, Assistant General Counsel 7 NRC Licensing Project Manager Dept. of Public Service, State ofdiew York Public' Document Room (PDR) i Local Public Document Room (LPDF.)
Nuclear Safety Information Center (NSIC) NRC Resident inspector State of New York s F
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NOTICE OF VIOLATION AND PROPOSE 0 IMPOSITION OF civil PENALTY Power Authority of the State of New York Occket No. 50-333 James A. FitzPatrick Nuclear Power Plant License No. OPR-59 EA 87-48 During an NRC inspection conducted on February 18-20, 1987, in response to an overexposure identified by the licensee and reported to the NRC, violations of NRC rtocirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1984, as amended ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and the associated civil penalty are set forth below: A. 10 CFR 20.101(a) limits the total occupational radiation exposure to the hands of an individual in a restricted area to 18.75 rem per calendar quarter. Contrary to the above, during the first calendar quarter of 1987, a con-tractor individual working on the refuel floor, a restricted area, re-ceived a total occupational radiation exposure to the right hand of approximately 30.27 rem, of which 29.6 rem was received on February 13, 1987 while the individual was performing an activity associated with the cutting of Source Range Monitor (SRM) and Intermediate Range Monitor (IRM) instrument dry tubes. B. 10 CFR 20.201(b) requires that each licensee make such surveys as may be necessary to comply with all sections of Part 20. As defined in 10 CFR 20.201(a), " survey" means an evaluation of the radiation hazards incident to the productien, use, release, disposal, or presence of radioactive materials or other sources of radiation under a specific set of condi-tions. Contrary to the above, on February 13, 1987, adequate surveys were not performed to assure compliance with 10 CFR 20.101(a), which limits the radiation exposure to the extremities in any calendar quarter. Specifi-cally,
- 1. workers removed a cutting tool from the refueling pool and placed it on the refuel floor without a survey or evaluation first being per-formed to determine the radiological hazards associated with removal of the cutting tool. Further, although a survey of the tool was performed after it was removed from the pool, the survey was inade-quate in that it only detected an exposure rate of 2.1 R/hr, when in f act the actual exposure rate, as determined during a subsequent -
NUREG-0940 I.A-142
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4 survey, waY 10,300 fdhr. A s .1 resu h , when a worker picked up a [@, f4 piece of highly irradiatted dry tube that fell f rom the tool, he j , received an extremity exposui in exce:s of thd regulatcry limit; and 1 ' 2., th.! worker who received the evpesure set fort *: f1 Violation A sube sequently began to irepair the dry tube cutting, tool . wit %ut M.e i s. Radiation Protectdn technician having first perfvmed ilurvey of 3 i .the tool. (3rvoi conducted or. the previous shif t irdv.ated that
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A ' ) ]K( "tc 71 ) . chips" wi.iys@re rates as high as 415 R/br had betin found in' t he y x p s 3 ,, , , e A C. 106FRlp.12 requirer,inp&t, that all individuals working in a re- ! l strO.deo? area L3 insc,ructed it, the precautions and procedures to minimize I s expos @e'to radiat ko and radioactive materials,' and in' the applicable provisions 'of the Con 51!,sion is regulations and licenses. s Contrary to the abova,\ on NEruary L13,1987, 7
- 1. , a contractor worker remov(eg R. instrument dry tube cutting tool f rom the refueling pool, a restHcted area, had not been instructed in the proper procedures to follow if a segment of highly radioactive dry
, [, N-i tube remained in, or fell from, the tool; and t
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, c. Wo Radiatioti Protection technicians providing job. coverage for dry J tt be cutt $ng cperations in tFe restricted area, hM not been provided r ,'a pre-job Driefing of the work they were covering, r.or were they
rrovided instructions, is described in procedure RAP 7.1.23 " Removal t aM lt stallation of IRM/SRM instrument Dry Tubes," concerning the radiological prceautions to be taken in covering such activities.
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D. Technical Specification $1.ction 6.8(A) requires that written procedures be established, iriplemented and maintained covering the requirements and
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recommendations?refarenced i.n Appand;;x A df Regulatory Guide 1.33 (1972). l Appen. dix A of Regulatoi., Gufw 1.33 recommends that th.) Bypass of Safety i t tFunctions and Jumonc Contrcl be covered by written procedures. Procedur.e WACP 20.1.3, entit*mi " Jumper Control". Step 4.12, defines a fuupe as the m oval of an N ectrical wire from 4 circuit, and requires. In part, that hapcring be properly identified, at thoHzed, recorded, at;d periodically reviewed. 3 pontrary to the above, as of February 13, 1987,'and for an undeterminr:0 persod of time prior to this date, a jumper which defeated the Area Raaiation Monitor (JB ARM-7) alarm horn was removed without the jumper being authorized or recorded as reovired. j E, Technical Specification Section 6.11 requires, in part, that procedures f6r per<dnnel radiation protection shall be prepared and adhered to for all plar t 'operaticis. NOREG-h40 I.A-143 e* 1 , EMOEMAMM'SMM
Appendix A 3
- 1. Procedure RPOP-4, entitled " Radiation Work Permit," Section 4.9.3.d, requires, in part, that the leadman ensure that all personnel working on the RWP comply with all dosimetry and protective clothing require- i ments. RWP 87-2099-S, dated February 13, 1987, requires that high l range (0-500 mrem) direct reading dosimeters be worn during dry tube cutting activities.
1 Contrary to the above, at about 8:00 a.m. on February 13, 1987, the ] leadman for RWP 87-2099-S did not ensure that all personnel complied I with the dosimetry requirements set forth in the RWP. Specifically, , three of the six workers that signed in on RWP 87-2099-S performed l dry tube cutting activities without wearing a high range direct i reading dosimeter. !
- 2. Procedure RPOP-7, entitled " Radiological Incident Investigations", j Section 4.2, requires, in part, that whenever a radiological incident occurs, Radiological and Environment Services (RES) Department J personnel shall stop associated work and notify RES Supervision.
Contran to the above, at about 9:00 a.m. on February 13, 1987, a ) radio'ogical incident occurred on the refuel pool involving a ; contractor worker receiving a radiation overexposure to his right I , hand, and RES Department personnel allowed work to continue for 1 approximately one and one-half hours before notifying RES Super-vision. l Collectively, these violations have been classified as a Severity 1.evel 111 problem. (Supplement IV) Cumulative Civil Penalty - 575,000 - assessed equally among the violations. Pursuant to the provisions of 10 CFR 2.201, Power Authority of the State of j New York is hereby required to submit a written statement or explanation to the Director, Of fice of Enforcen.ent, U.S. Nuclear Regulatory Comnission, ATTN: l l Document Control Desk, Washington, D.C. 20E55, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, 631 Park Avenue, King of Prussia, Pennsylvania 19406, 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) correc-tive steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid future 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 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 may be issued. 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 1.A-144
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i Appendix.A_ 4 i
.i Within the same' time as provided for.-the response required above under 10 CFR 2.201, Power Authority of the. State of New York may pay the civil' penalty by.
letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control'0esk, Washington, D.C., 20555 with a check,
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draf t, 'or money order payable to: the Treasurer of the United States in the cumulative. amount of Seventy Five Thousand Dollars ($75,000) or may protest
. imposition of. the civil penalty in whole or in part by a written answer' address'ed to.the Director Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: . Document Control' Desk, Washington, D.C., 2.0555. Should Power Authortty cf'the State of;.New York fail to answer within the' time specified, an order
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imposing the civil penalty in'the amount proposed above will.be' issued. ._ Should Power Authority of the State,of New York elect to file -an answer in accordance with 19 CFR 2.205 protesting the civil penalty, such answer should be clearly marked'as an " Answer to a Notice 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 in whole or in part, such answer may request remission or. mitigation of
-the penalty.
In requesting mitigation of the proposed penalty, the five factors contained-in Section V.B of 30 CFR Part 2, Appendix C (1986) 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 by specific reference.(e.g. citing page and paragraph numbers) to l , . avoid repetition. The attention of the Power Authority of the State of.New York is directed to the'other provisions of 10 CFR 2.205 regarding the pro-ceoure for imposing a . civil penalty. Upon failure to pay any civil penalty due, which has been subsequently 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. 2282. FOR THE NUCLEAR REGULATORY COMMISSION J Jo. T. M William T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania this $2- day of April 1987 , 1 NUREG-0940 I.A-145
UNITED STATES [f * *s t,4,q'%, NUCLEAR REGULATORY COh5AISslON { v(' g E MEoloN til
$, ' 739 ROOSEVELT RO AD CLEN ELLYN. ILLINOl& plat
***** May 14, 1987 Docket No. 50-341 License No. NPF-43 EA 87-50 The Detroit Edison Company ATTN: Mr. Walter J. McCarthy Chief Executive Officer 6400 North Dixie Highway Newport, MI 48166 Gentlemen:
SUBJECT:
NDTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORTS NC 50-341/87002(DRP); 50-341/87006(DRP); AND 50-341/87008(DRP)) This refers to the inspections conducted on October 17, 1986, through February IC, 1987, of activities at Fermi 2, authorized by NRC Operating License N:. NPF-43. During these inspections, violations of NRC requirements were identified. Several of those violations were identified by your plant staff and several were identified by the NRC resident inspection staff. The details of these findings were provided in Inspection Report No. 50-341/87002(DRP) rent to you by letter dated February 10, 1987, and Inspection Reports No. 50-341/87006(DRP) and 50-341/87008(DRP) sent to you by letters dated February 20, 1987. These findings, your corrective actions and your actions to prevent recurrence were discussed during the Enforcement Conference conducted with Mr. B. R. Sylvia and other members of your staff on February 23, 1987. The violations described in the enclosed Notice of Violation and Proposed Impositior of Civil Penalty (Notice) involved sigr.ificant deficiencies in implementation of your surveillance testing program: (1) Violations A and B concerned your operations staff not properly controlling equipment availability ; during testing activities; (2) Violation C ccncerned inadequate schedulino of ' a surveillance test; and (3) Violations D through G concerned deficiencies in individual test procedures and personnel errors in performance of test activities. Violations A through E resulted in operation of the unit without the minie r complement of equipment and controls required by your Technical Specification Limiting Conditions for Operation. To emphasize the importance of proper control of equipment availability during surveillance testing activities artd the need to effectively implement your testing program to provide early identification of equipment deficiencies, I have been authorizcd, after consultation with the Director, Office of En f orcerrent , and the h puty Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty NUREG-0940 1.A-146
The Detroit Edison Company 2 May 14, 1987 in the amount of One Hundred Thousand Dollars (5100,000) for the problem
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described in the enclosed Notice. In accordance with the " General Statement ' i of 'rolicy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), Violations A through G described in the enclosed Notice have been categorized in the aggregate as a Severity l Level III problem. We carefully assessed the safety significance of each { individual violation and considered the lack of substantial operating history J at the time of'those violations which resulted in relatively low levels of ' reactor decay heat and core fission product inventory. However, the number and frequency of the deficiencies in your implementation of the. test program which impacted on your limiting conditions for operations and your control of cquipment availability during testing activities are of significant regulatory concern. This perform 1nce must be improved. Additional management attention is required to ensure that further violations do not occur. We noto that your own audit by the Independent Safety Engineering Group identified similar procedural deficiencies in November 1986. In considering all of these factors, we have categorized the violations described in the enclosed Notice as a Severity Level III problem in order to focus on the weaknesses in the surveillance testing area. The base value of a civil penalty for a Severity Level III violation or problem is $50,000. The escalation and mitigation factors in the Enforcement Policy were considered. The base civil penalty amount has been increased by 100 percent because: (1) your prior performance in the surveillance testing area since issuance of your operating license in April 1985 has been poor in that Severity Level IV violations have been issued and an Enforcement Conference was held in May 1986 concerning this area and (2) your corrective actions to prevent recurrence of the violations described in the February 1987 Enforcement Conference were incomplete in that you had not initiated an appropriate end comprehensive program to reexamine the technical adequacy of surveillance and preoperational test procedures. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional ) actions you plan to prevent recurrence. Af ter reviewing your response to this i I Notice, including your corrective actions and the results of future inspections, I the NRC will determine whether further NRC enforcement action is necessary to cnsure 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. l NUREG-0940 I.A 147
The Detroit Edison Company 3 May 14, 1987 The response directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511. Sincerely, 0 Y .bh A. Bert Davis Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty NUREG-0940 I.A-148 ,
The Detroit Edison Company 4 May 14, 1987 cc'w/ enclosures: , F. H. Sondgeroth, Licensing Engineer P. A. Marquardt, Corporate Legal Department DCS/RSB (RIDS) Licensing Fee Management Branch i Resident Inspector, RIII Ronald Callen, Michigan l Public Service Commission i I Harry H. Voight, Esq. Nuclear Facilities and Environmental Monitoring Section Monroe County Office of Civil Preparedness NUREG-0940 I.A-149
l i j 1 NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Detroit Edison Company Docket No. 50-341 Fermi 2 License No. NPF-43 EA 87-50 i During NRC inspections conducted from October 17, 1986 through February 10, 1987, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 20 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below: A. Technical Specification (TS) Limiting Condition for Operatior. (LCO) 3.5.1.c requires that the High Pressure Coolant Injection (HPCI) system be operable when the unit is in Operational Condition 1 or Operational Condition 2 or 3 with reactor steam dome pressure greater than 150 psig. The HPCI system may be inoperable provided that, among other systems, the Reactor Core Isolation Cooling (RCIC) system is operable. TS LCO 3.7.4 requires that the RCIC system be operable when the unit is in Operational Conditions 1, 2, or 3 with reactor steam dome pressure greater than 150 psig. Tne RCIC system may be inoperable provided that the HPCI system is operable. TS LCO 3.5.1.c and 3.7.4 specify an operable flow path to be capable of taking suction from the suppression chamber and transferring the water to the reactor vessel. Wher. an LCO or its associated action statement cannot be met, TS 3.0.3 requires that action be initiated within one hour to place the unit in an Operational Condition in which the LCO does not apply. Contrary to the above:
- 1. On October 9, 1986, between the hours of 8:40 and 10:40 a.m. and between the hours of 12:55 and 2:55 p.m., while the unit was in Operational Condition 1 with reactor stream dome pressure greater than 150 psig, both the RCIC and HPCI systems were made inoperable during performance of Surveillance Procedure 44.030.154 by closing and de-energizing those systems' s.uppression chamber suction valves.
Action was not initiated within one hour to place the unit into an Operational Condition in which TS LCOs 3.5.1.c and 3.7.4 did not apply.
- 2. On December 24, 1986, between the hours of 12:50 and 5:00 p.m.,
while the unit was in Operational' Condition 2 with reactor steam dome pressure greater than 150 psig and the HPCI system inoperable, NUREG-0940 I.A-150
J Notice of Violation' 2
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the RCIC system was made inoperable by valving out the RCIC flow transmitter during performance of Surveillance Procedure 44.110.04. Action was not initiated within one hour to place the unit into an i Operational Condition in which TS LCOs 3.5.1.c and 3.7.4 did not apply.
- 3. On December 26, 1986, between the hours of 1:30 and 3:50 p.m.,
while the unit was in Operational Condition 2 with reactor steam dome pressure greater than 150 psig and the HpCI system inoperable, the RCIC system was rendered inoperable after calibration and troubleshooting activities when the system flow controller was set at 505 gpm instead of the required 605 gpm flow rate. Action was not initiated within one hour to place the unit ir.to an Operational Condition in which TS LCOs 3.5.1.c and 3.7.4 did not apply. B. TS LCO 3.10.2.b allows, when the unit is in Operational Condition 1 or 2, f the bypassing of the sequence constraints imposed on contfoi rod groups I by the Rod Sequence Control System (RSCS) required by TS LCO 3.1.4.2 whe . performing control rod scram testing provided the Rod Worth Minimizer (RWM) is operable. TS Surveillance Requirement 4.10.2 requires that the following verification be performed when operation occurs under TS i.C0 3.10.2.b: Within eight hours prior to bypassing any sequence constraint and at least once per 12 hours while a sequence constraint is bypassed, verify the operability of the RWM and verify that movement of control rods between 502, rod density and the RSCS pra set power level is blocked or limited to the singic notch mocie. Contrary to the above, during the period between 10:00 p.m. on November 3, 1986, and 10:15 p.m. on November 5, 1986, while the unit was in Operational 1 Condition 2 and the sequence constraints imposed on control rod groups by l the RSCS were bypassed during control rod scram testing, the verifications j specified in TS Surveillance Requirement 4.10.2 were not performed at the ! required frequencies. The RWM was only verified operable on November 4, l 1986, at 4: 35 a.m. and 5:15 p.m. and on November 5, 1986, at 7:30 p.m. The movement of control rods between 50'a rod density and the RSCS preset power level was only verified to be blocked or limited to the single notch mode on November 4, 1986, at 6:30 p.m. and November 5, 1986, at 7:09 p.m. C. TS LCO 3.6.1.3.b requires that each primary containment air lock shall be ! operable with an overall leakage less than or equal to 0.05 La at 56.5 psig when the unit is in Operational Condition 1, 2, or 3. TS Surveillance Requirement 4.6.1.3.c.1 requires that an air lock Isakage test at 56.5 psig i be conducted prior to fuel loading and every six months to verify that the overall air lock leakage rate is within its limit. TS 4.0.4 requires that entry into an Operational Condition shall not be made unless the applicable LCO surve'11ance requirements have been satisfied within the required surveillance interval. NUREG-0940 1.A-151 i J
Notice of: Violation 3 4 Contrary to the above, the unit entered Operational. Conditions 1, 2, and 3 at various times between 4i35 a.m. on January 24, 1987, and 9:30 a.m. on
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February 2, 1987, in violation _of TS 4.0.4, in that TS Surveillance Requirement 4.6.1.3.c.1 was not satisfied within in the- required interval. The testing interval expired on ~ January 12, 1987. Testing conducted on , February 2,1987 disclosed that the overall air lock leakage exceeded the { allowed leakage rate of 0.05 La 'at 56.5 psig.
'D. TS LCO 3.6.6.1 requires that two independent drywell and suppression l chamber hydrogen recombiner systems shall be operable when the Unit is 1 in Operational Conditions 1 or 2. TS Surveillance Requirement' 4.6'.6.1.a specifies testing' to demonstrate hydrogen recombiner systee operability be performed every six months to verify that the recombiner system heater ;
outlet gas temperature increases to greater than 1150 F within 75 minutes J and is maintained at that temperature for one hour. TS 4.0.4 requires that e.ntry into an Operational Condition shall not be made unless the applicable LCO surveillance requirements have been satisfied within:the required surveillance interval. l Contrary to the. above, the unit entered Operational Condition 2 on eleven L. occasions between August 29, 1985, and December 19, 1986, in viclation of TS 4.0.4 in that the test procedure to implement TS Surveillance Requirement 4.6.6.1.a did not verify that the recombiner syster heater l outlet gas temperature increased to greater than 1150'F within 75 sinutes l and was maintained at that temperature for one hour under emergency 8 conditions with the Residual Heat Removal system operating. Testing conducted on January 8 and 9,1987 disclosed that the Division II hydrogen recombiner system war, inoperable and could only reach 761*F within i 75 minutes due to an original equipment deficiency not disclosed during preoperational testing. E. TS LCO 3.3.2 and the associated Table 3.3.2-1, Section 2.C, require that the Reactor Water Cleanup System (RWCU) isolation actuation instrumentation for the heat exchanger / psp area ventilation differential temperature high function be operable when the unit is in Operational Condition 1, 2 or 3. Further, with the one channel inoperable, the licensee is required to close the affected syster isolation valves within one hour and declare the affected system inoperable. TS 3.0.4 requires that entry into an Operational Condition shall net be ; made unless the applicable LCOs are met without reliance on the provisions ) of the action requirements. ; Contrary to the above, on December 18, 1986 the unit entered Operational Condition 2 and 3 in violation of TS 3.0.4 and remained in Operational l Condition 2 until December 20, 1986 in violation of LCO 3.3.2 with the RWCU isolation actuation instrumentation for the heat exchanger / pump area ; NUREG-0940 1.A-152
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Notice'of Violation 4 a ventilation differential temperature high function inoperable without { satisfying the applicable action requirements. The trip. function was j made inoperable on December 3, 1986 when the leads for the therwocouples. i in one of the differential temperature trip systems had been reversed and-
~ improperly landed following a surveillance test.
F. TS Surveillance Requirement 4.4.3.1.b requires that the drywell floor drain and the drywell equipment drain sump pump-run-time systems receive j a channel functional test at least once per 31 days and a channel calibration test at least once per 18 months when the unit is in i Operational Conditions 1, 2 or 3. TS 4.0.4 requires that entry into an i Operational Condition shall not be made unless the applicable LCO ' l l surveillance requirements have been satisfied within the required time interval. Contrary to the above, the' unit entered Operational Conditions 2 and 3 l in violation of TS 4.0.4 several times between August 1985 and October 1986 ' without satisfying TS Surveillance Requirement 4.4.3.1.b in that the procedure to implement this requirement did not include channel functional and calibration testing for the drywell floor drain and equipment drain sump pump-run-time systems. G. TS Surveillance Requirement 4.3.7.12 and the associated Table 4.3.7.12-1, Section 2.b require a daily channel check for the noble gas activity ! monitor in the offgas system at the 2.2 minute delay piping dutIng main 1 condenser air ejector operation. Contrary to the above, froe the beginning of facility operation to September 16, 1986, the required daily channel check for the noble gas activity monitor in the offgas syster at the 2.2 minute delay piping during main condenser' air ejector operation had not been performed. 1
)
This is a Severity Level Ill problem (Supplement I). Cumulative Civil Penalty - 5100,000 (assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, Detroit Edison Company (Licensee) is hereby required to submit a written statement or explanation to the Director, j l- Of fice of Enforcement, U.S. Nuclear Regulatory Commission within 30 days of I 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) 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 cdequate 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 te 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 1.A-153
Notice of Violation 5 Within the same time as provided for the response :equired above under 10 CFR 2.201, the Licensee may pay the civil pena ny by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission with a check, draf t, oi money order payable to the Treasurer of the United States in . the cumulative amount of the civil penalty proposed above, or the cumulative l 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 a part by a written i 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, I 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 er 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 j protesting the civil penalty in whole or in part, such answer may request , remission or mitigation of the penalty. j In requesting mitigation of the proposed penalty, the five factors addressed I in Section V.B of 10 CFR Part 2, Appendix C (1987), should be addressed. Any l written answer in accordance with 10 CFR 2.205 should be set forth separately l from the statement or explanation in reply pursuant to 10 CFR 2.201, but may I incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing j page and paragraph numbers) to avoid repetition. The attention of the Licensee l 1s directed to the other provisions of 10 CFR 2.205, regarding the procedure l for imposing a civil pentity. 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.7. 2282c. The responses to the Director, Of fice 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. Nu: lear Regulatory Commission, ATTN: Document Control Desk, Washington, i' DC 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, for the appropriate Region, and, if applicable, a copy to the NRC Resident inspector, at the facility which is the subject of this Notice. FOR THE NUCLEAR REGULATORY COMMISSION A- ~~b A. Bert, Davis Regional Administrator l Dated at Glen Ellyn, IL this I P day of May 1987 NUREG-0940 I.A-154
I b Docket Nos. 50-072 50-407
/o f g License Nos.-R-25 i R-126 EA 86-136-1 University of Utah ATTN:. Dr. James J. Brophy Vics President of Research Salt Lake City, Utah
SUBJECT:
NOTI'CE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NOS. 50-072/86-01 and 50-407/86-01) l This refers to the inspection conducted on June 9-12, 1986 of the activities suthorized by NRC. Operating License Nos. R-25 and R-126 at the University of Utch, Salt Lake City, Utah. During this inspection, both violations of NRC
. requirements and a deviation from a commitment made to the NRC were identified.
NRC Inspection Reports 50-72/86-01 and 50-407/86-01, which documented the in-spection findings, were sent to you on July 14, 1986. An enforcement conference to diset ss the inspection findings was held at your office on July 21, 1986. The violations in the. enclosed Notice of Violation involve transportation, h2nith physics, safeguards, and operation violations. The transportation violations result from radioactive material in the form of a TRIGA reactor core component being transported from the University of Utah campus to a location in Salt Lake City for maintenance and back to the university without shipping pspars, proper labeling, or radiological surveys to determine external radiation or contamination limits. The health physics violations involve the failure to parform adequate surveys and the failure to maintain control of the TRIGA rasetor core component. Three safeguards violations involving failure to comply with the Physical Security Plan and four vioistions involving the operation of the TRICA reactor were also identified. Collectively, these violations demon-strate the need for inproved control of your licensed activities to ensure adherence'to NRC requirements and safe performance of licensed activities. I To cmphasir.e the need for improved control of your licensed activities. I have bacn authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of Three Thousand Dollars ($3,000) for the violations described in the enclosed Notice. In accordance with the " General i Stctement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, App 2ndix C (1986) (Enforcement Policy), the violations grouped in scetions 1.A and I.B of the enclosed Notice have been collectively categorized as Severity
~Laval III violations under Supplements V and IV, respectively. The base value of a S2 verity Level III violation for a Supplement V violation is $500 and for a .
Supplement IV violation is $2500. The escalation and mitigation factors in the i i REMOVAL OF THE PAGES M ARKED "SAFEGUA A09 INFODM ATION DECONTROLS THE RE.%* lNCER OF THIS OM..v. . . NUREG-0940 I.A-155 i
eniversity of utan -/- Enforcement Policy were considered and no adjustment has been deemed appropri-ate. The base civil penalty amounts for the violations could have been increased because multiple occurrencce were identified, but they were not increased because of your prior record of good performance. The violations in Part II of the Notice have been characterized as Severity Level IV violations. i The inspection findings also indicate the failure to implement a commitment regarding personnel exposure records and this matter is discussed in the enclosed Notice of Deviation in Appendix C. You are required to respond to this letter and should follow the instructions specified in the enclosed Notices 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 these Notices, including your proposed corrective actions, the NRC will determine whether further NkC 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, except Appendix B vill be placed in the NRC Public Document Room. Appendix B contains Safeguards Information as defined by 10 CFR Part 73.21. Its disclosure to unauthorized individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as amended and this material vill not be placed in the Public Document Room. Therefore, in your response to this letter and Ap-pendix B, place all Safeguard Information in a separate enclosure. The responses directed by this letter and the enclosed Notices 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, OrisipAl sicred b *- hMurt D, uty,;y Robert D. Martin Regional Administrator 1
Enclosures:
Appendix A - Notice of Violation and Proposed Imposition of Civil Penalties Appendix B - Notice of Violatten Appendix C - Notice of Deviation cc w/o Appendix B: Utah Radiation Control Program Director I CEMOVAL OF THE PAGES M ARKCD SAFCGU MATION" ARDS INF l QECONTROLS THE FM itNCEri OF THs DOCUMdro I k I NUREG-0940 I.A-156 l
--_a
l l AIPLNblX A NOTICE OF VIOLATION
.AND PROPOSED IMPOSITION OF CIVIL PENALTIES University of Utah Docket Nos. 50-072 Salt Lake City, Utah. 50-407 License Nos. R-25 R-126 f EA 86-136 l During an NRC inspection conducted on June 9-12, 1986, 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 ,
-(1986), the Nuclear Regulatory =~ommission proposes to impose civil penalties !
pursuant to Section'234 of the Atomic EnerFy Act of 1954, as amended, ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and associated civil penalties are set forth below:
- 1. Violations Assessed Civil Penalties ,
A. Failure to Identify Radioactive Material 10 CFR 71.5(a) requires, in part, that each licensee who transports licensed material outside of the confines of its plant or other place of use shall comply with the applicable requirements of the regulations appropriate to the mode of transportation of DOT in 49 CFR Parts 170 through.189. 49 CFR 171.2(b) requires, in part, that no person may transport a hazardous material in commerce unless that material is handled and transported in accordance with Subchapter C of 49 CFR.
- 1. 49 CFR 172.200(a) requires, in part, that each person who offers a hazardous material for transportation shall describe the hazardous material on the shipping paper.
49 CFR 172.203(d) requires, in part, that the description for a shipment of radioactive material must include the name of each radionuclides and the activity contained in each package of the shipment in terms of curies, mil 11 curies, or.microcuries. . Contrary to the above, on or about January 25, 1986, radioactive material in the form of a TRIGA reactor core component was transported from the University of Utah campus to a location in Salt Lake City for maintenance and back to the university without shipping papers.
- 2. 49 CFR 172.403(a) requires that unless excepted from labeling by 49 CFR 173.421 through 173.425, each package of radioactive material must be labeled as provided in this section.
REMOVAL OF TH{PPES UpR3FD "T.~EGjjA_RDS WMOl8 ATIO*J , DECONTRJF.S THE P ': L.i!O.' ". c9 i . n:. . ,, NUREG-0940 1.A-157
'i i i .
Contrary to the above, on er.about January 25, 1986,'a radioactive reactor core. component which was not excepted from l labeling as provided by 40 CFR 173.471 through 173.425 was I transported from the University of Utah campus to a location in Salt Lake City without inbeling. i
- 3. 49 CFR 173.475(i) requites, in part, that before each shipment of any radioactive materials package, the shipper shall ensure by examination or appropriate tests that external'rndiation and contamination levels are within the allowable' limits specified in Subchapter C of 49 CFR.
Contrary to the above, on or about January 25, 1986, a 1 radioactive reactor core component was transported from the ( University of Utah campus to a location in Salt Lake City without i first conducting- a' radiological survey to determine external ] radiation or contamination levels. l 1 These violations have been categorized in the aggregate as a Severity J Level III problem (Supplement V). l (Civil Penalty - $500). _B. Failure to Perform Adequate Surveys and Control Licensed Material
- 1. 10 CFR 20.201(b) tequires that each licensee shall make or cause to be made such surveys es (1) may be necessary for the licensee to comply with the regulations in this part, and (2) 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 j radioactive materials or other sources of radiation under a specific set of conditions. 1 Contrary to the above: I
- a. The radiological survey program regarding loose surface radioactive contamination and radiation dose rates conducted 1 during 1985 and 1986 was not adequate to evaluate the extent .)
of radiation hazards present in that it failed to identify j loose. surface contamination and radiation levels up to 100 times greater than ambient background levels in the reactor facility. 1
- b. Surveys performed in the University of Utah Engineering Machine Shop (unrestricted area), following maintenance work on radioactive TRIGA reactor components on January 15, 16, 23, and 24, 1986 were not adecuate in that they failed to identify extensive radioactive contamination on the floor and on several machines.,
( ) 1Evc /.g5 rj z- - . . , . . . , . , , , , , , ,, , p". .~~- ' - - _ u.:.z__ o 4 ,, NUREG-0940 I.A-158
- c. The licensee infled to identify, during surveys conducted on June 11, 1986, the extent of radioactive contamination present throughout the University of Utah Engineering Machine Shop.
- d. As of June 10, 1986, the licensee had not performed j radiological surveys of the Merrill Engineering Building I potable water supply that had been cross connected to the TRIGA reactor pool water recirculation system since 1983.
- 2. License Condition 2.A for the TRIGA reactor establishes the location of the TRIGA reactor facility as on the campus of the University of Utah. License Condition 2.B.(1) authorizes the licensee to possess, use, and operate the facility at the desig-nated location in Salt Lake City, Utah, in accordance with the procedures and limitations set forth in the license.
License Condition 2.C states, in part, that the license shall be deemed to contain and is subject to the conditions specified in Parts 20, 30, 50 of 10 CFR, Chapter I. 10 CFR 30.34(c) requires, in part, that each person licensed by the Commission pursuant to the regulations in this part shall confine his possession.and use of the byproduct material to the locations and purposes authorized in the license. Contrary to the above, during January 1986, the licensee removed radioactive core support components from the TRICA reactor and took them to unauthorized locations off campus for maintenance work. These violations have been categorized in the aggregate as a Severity Level III problem (Supplement IV). (Civil Penalty - $2,500). l i II. Violations Not Assessed A Civil Penalty 1
)
Three Physical Security Plan violations are discussed in Appendix B. j The material enclosed in Appendix B contains Safeguards Information ! as defined by 10 CFR 73.21 and its disclosure to unauthorized individuals is prohibited by Section 147 of the Atomic Energy Act of 1954, as amended. Therefore, the material in Appendix B will not be placed in the Public Document Room. A. Feilure to ' Implement Operator Requalification Program 10 CFR 55, Appendix A, establishes the requirements for the implementation of a reactor operator requalification program. The licensce's Resetor Operator Requalification Program, submitted to the NRC on March 8, 1983, and approved on April 12, 1984, requires, in REMOVAL OF THE PAGES M AP'("? "WGUa nT WronMATIOte DECONTROLS THE f 6 ".irC.M Ur I n, ) v% . . . . NUREG-0940 I.A-159 l l
'1 I
pa r t' , that "the requalification program will include planned-lectures, an annual evaluation of the?1icensed operator'n knowledge'and performance,-and.that-records will be maintained for each individual-p and will.contain the following information: J Current copy of either the individual's reactor operator or senior reactor. operator. license. Copies of all written examinations administered to the individual and correct answers given to the individual during
'the' requalification period. q The annual evaluations of the individuals documented in a memorandum for record.
The individual's requalification program progress checklist. The summary.of additional training received by.the individual l documented in a memorandum for record and any additional documentation."
' Contrary to the above, as of June' 12, 1986, the licensee had not con-ducted. planned lectures, documented annual operator evaluations, nor maintained certain records required for individual operators.
This is a Severity Level IV violation (Supplement I). B. Failure to Establish Procedures TRIGA Technical Specification 6.8, " Operating Procedures," requires,
-in.part, that operating. procedures shall be in ef fect for performing preventive maintenance and calibration tests on the reactor and u associated equipment.
Contrary to the above, as of June 12, 1986,' written procedures had not been established for maintenance work performed on the IRIGA reactor core upper support structure during December 1985 and January 1986. This is a Severity Level IV violation (Supplement I). C. Failure To Perform A 10 CFR 50.59 Evaluation 10 CFR 50.59(a) requires, in part, that the holder of a license i- may make changes in the facility as described in the safety analysis i report without prior Commission approval., unless the proposed change involves a change to the Technical Specifications or is an unreviewed safety question. An unreviewed safety question is created if the consequences of an accident or the malfunction of equipment.inpor-tant to safety previously evaluated may be increased.
" " ' ~ ^ ' " * * *
- AEM O_VitET,"Z"f ' ' ^ " ~ " ' ' ; ,
ccc: . . s i . c. . . r .. NUREG-0940 I.A-160
L. N u 10 CFR 50.59(b) requires that the licensee maintain records of changes tu the facilfry to,the extent that such' changes constitute-changes in the safety _analyais-report. . These~ records shall include a written safety. evaluation which. provides the bases for the determination that' the change does not involve an unreviewed safety question. Contrary to. the above. during March 1985,- the licensee made a .modifi-cation to its TRIGA. reactor coolant recirculation system involving the interface-of two systems with the. reactor water tank' recirculation system. .No written safety evaluation was performed to determine whether this change constituted an unreviewed safety question even though the. release of radioactive effluents via these two pathways
- was not discussed in the'SER.' {
_j This is a Severity Level IV violation (Supplement 1). D. Failure to Properly Install and Test Filter System TRIGA Technical Specification 3.5 requires that the reactor _shall [ not.be operated unless the facility ventilation system is operable, i except for. periods of time not to exceed 48 hours to permit repair or testing of the ventilation system. Technical Specification 5.6 states that "the facility is designed so that the ventilation systhm c will normally maintain a negative pressure with respect to atmosphere L to sinimite uncontrollable leakage to the environment. The free air volume within the reactor building is confined when there is an emer-gency shutdown of the ventilation system." The Safety Analysis Report. Section 4.6.'2, Emergency Operation, states, "The outlet vent will be equipped with a by-pass HEPA filtration system which will be darpered into operation. This will provide a continuous filtered exhaust and maintain the reactor area...under negative pressure. The flow under.filterinF conditions will be such that a negative pressure of at-lenet 0.1 inches of water will be maintained "- Contrary to the above, as of June 10, 1986, HEPA filters in the reactor ventilation system were not properly installed to ensure the requirements of Technical Specification 5.6 and Section 4.6.2 of the Safety Analysis Report would be satisfied. The filter was installed so that it was not sealed to its mounting opening, the flow of air was in the wrong directioti through the filter, and the filter was installed in the wrong orientation. The HEPA filters were in this configuration for a period of time exceeding 48 hours, and no documentation was available to verify that either an evaluation or in-place testing had been performed to ensure the system was operable. This is a Severity Level IV violation (Supplement 1). Pursuant to the provisions of 10 CFR 2.201, the University of Utah is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear ReFulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission Region IV, 611 Ryan l Plaza Drive, Suite 1000, Arlington, Texas 76011, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation ' (1) admission or denial of the alleged violation, (2) the reasons NUREG-0940 I.A-161
for the violation if admitted, (3) the corrective rteps 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 rect 1ved within the time specified in this hotice. the Director, Office of Inspection end Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be F ven i to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 223? this response shall be submitted under oath or affirmation. Vithin the same time as provided for the response required above under 10 CFR 2.201, the University of Utah may pay the -ivil penalties by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Three 1housand Dollars ($3,000) or may protest imposition of the civil penalties in whole or in.part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should the University of Utah fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalties in the amounts proposed above. Should the University of Utah elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violations listed in this Notice in whole or in part , (2) demonstrate extenuating circumstances, (2) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, such answ'er may request remission or mitigation of the penalties. In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The University of Utah's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing civil penalties. Upon failure to pay any civil penalties 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 penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION Y Robert D. ar )n NY Regional Administrator Dated at Arlington, Texas, WOVAL OF TQrv.m * ' this /Jsday of October 1986. DECONTP M i .___
./ ENT.
NUREG-0940 I.A-162
l APFENDIT (-
' NOTICE OF DEVIATION I
' University of Utah- Docket: 50-407 I Salt Lake City,; Utah License: k-124 EA 86-136 Based on the results of an NRC inspection conducted on June 9-12, 1966, a 4 daviation of a commitment to the NRC was identified. In accordance with the l "G3neral-Statement of Policy and Procedure for NRC Enforeccent Actions," )
10 CFR Part 2, Appendix C.(1986), the deviation is listed below: I. Failure to Establish Personnel Expopure Records The University.of Utah's TRICA reactor license renewal application
-submitted to the NRC by letter dated November 29, 1984 and approved by letter dated April 17, 1985 contained commitments made to the NRC regarding operation of the TRICA teactor facility, The licensee's response to NRC question number 48, which asked the licensee to describe its personnel monitoring program, stated, in part, that the per-sonnel monitoring program at the nuclear reactor facility includes issuance of a dosimeter and creation of a personal radiation history and record.
Contrary to the above, as of June. 10. 1986, the licensee had not created exposure records for at least two licensed reactor operators who had been issued dosimeters in 1985 and 1986. Tha University of Utah is hereby requested to submit to this office, within 30 days of the date of this letter transmitting this_ Notice, a written statement or explanation in reply, including for the deviation: (1) the reason for the
'dsviation if admitted, (2) the corrective steps which have been taken and the ,
results achieved, (3) the corrective steps which' will be taken to avoid further i daviations, and (4) the date when full comp:iance vill be achieved. Where good c:use is shown, consideration will be given to extending the response time. Dated at Arlington, Texas, this 6 $~ day of October 1986., REMOVAL OF THE PAGFS M ATWED DECONTHCl S THE 6 f. .mJ,_ ci ud inib w ATIC "FMFGUAR ' NUREG-0940 L A-163
/ga aseg%,
- UNITED STATES
?* 3y7 7, NUCLEAR REGULATORY COMMISSION
, .I WASHINGTON, D. C. 20555 CP 131987 Docket Nos. 50-072 and 50-407 License Nos. R-25 and R-126 EA 86-136 University of Utah ATTN: Dr. James J. Brophy Vice President of Research Salt Lake City, Utah 84112 Gentlemen:
SUBJECT:
ORDER IMPOSING CIVIL MONETARY PENALTIES This acknowledges receipt of your two letters dated October 29, 1986, in response to the Notice of Violation and Proposed Imposition of Civil Penalties (Notice of Violation) sent to you by our letter of October 6,1986. The Notice of Violation described violations found durina an NRC inspection conducted at your facility in Salt Lake City, Utah, on June 9-12, 1986. After careful consideration of your responses, and for the reasons aiven in Appendix A attached to the enclosed Order, we have concluded that the violations assessed civil penalties did occur as set forth in the Notice of Violation. We have aiven careful consideration to your protest of the proposed penalties and have concluded that mitiaation of any of the civil penalty amount in this case is not warranted. Accordingly, we hereby serve on the University of Utah the enclosed Order Inposina Civil Penalties in the amount of Three Thousand Dollars (53000). The effectiveness of your corrective actions will be reviewed durina subsequent inspections. NRC's evaluations and conclusions reaardina the violations not assessed civil penalties and contested by the licensee are addressed in Appendix B attached to the enclosed Order. The Notice of Violation also discussed three Phvsical Security Plan violations in Appendix B marked "Safeauards Information." The licensee's letter of October 29, 1986 correctly indicates that Appendix B should not have been marked "Safecuards Information." Therefore, we have deleted these: markinas, and have discussed these evaluations and conclusions in Appendix B. In decordance 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 I will be placed in the NRC Public Document Room. 1 CERTIFIED MA!L RETURN RECEIPT REQUESTED NUREG-0940 1.A-164
J i University of Utah The responses directed by this letter and the enclosed Order are not subject to the clearance procedures of the Office of Manacement and Budoet as recuirea hv the Paperwork Reduction Act of 1980, PL 96-511. ' Sincerely, , s ~W ~ a- //: < 7C arres M. Taylop[, Director
/ ffice of Instection and Enforcement
Enclosures:
As stated cc: Utah Racietion Control Procram Director I i i NUREG-0940 1.A-165
UNITED STATES OF AMERICA NUCLEAR REG'JLATORY COMMISSION
- n the Matter of )
}
University of Utah ) Docket t'os. 50-072 TRIGA ond AGN Reactor Center ) 50-407
) License Nos. R-25 i R-126
) EA 86-136 ORDER IMPCSING CIVIL MCNETARY PENALTIES i
University of Utan (the licensee) ds the hoicer of Operatina License Nos. R-25 and 126 (the licenses) issued by .the Nucleer Reaulatory Commission (the Commission or NRC). The licenses authorize the licensee to operate the TRIGA h and AGN reactors in accordance with the conditions specified therein. II An inspection of the licensee's activities under its licenses was conducted on June 9-12, 1986. The results of this inspection indicated that the licensee had not conducted its activities in full compliance with the conditions of its license and NRC requirements. A written Notice of Violation and Preposed Imposition of Civil Penalties was served upon the licensee by letter dated Octeher 6, 1986. This Notice stated the nature of the violations, the provisions of the NRC requirements that were violated, and the amount of civil penalties proposed. The licensee respor.ded to the Notice of Viciation anc Proposed imposition of Civil Fenalties by two letters dated October 29, 1986. After consideration of the licensee's response and the arouments for mitication of the proposed civil penalties contained therein, the Director, Office of Inspection and Enforcement, has determined, 45 set fortn in the Appendices to , this Order, that tne penalties preposed for the v4olations desianated in the Notice of V Mlation and Propcsed Imposition of Civil Penalties should be imposedq NUREG-0940 I.A-166
m_; I i III q r H 1
-In view lof the forecoina and pursuant to Section 234 of the Atomic Eneray Act ]
1 of-1954,'as amended (42 U.S.C. 2282, PL 96-295), and 10 CFR 2.205, IT IS FEREBy LORDERED THAT: The' licensee pay civil penalties-in the total amount of Three Thousana Dollars ($3,000)-within 30 cays'of the.date of this Order, by check,
~
'drdf t, or monev order, payable to the Treasurer of the United States 'and mailed to the Director, Office of Inspection and Enforcement, U.S. Nuclear Reaulatory Commission, Washinaton, D.C. 20555.
IV The licensee may, within 30 days of the date of this Order, request a hearina. A request for hearina shall be addressed to the Director, Office of Inspection dnd Enforcement, U.S. Nuclear Reaulatory Commission, Washinaton, D.C,, 20555. l A copv. of any request' for hearina also shall be sent to the Assistant General d I; Counsel far Enforcement, Office of the General Counsel, at the same address.
'If a'hearina is requested, the Commission will issue on Order desianatine the
. time and place of the hearina. If the licensee fails to request a hearina w1 thin 30 days of the date of this Order, the provisions of this Order shall be p effective without further proceedings. If payment has not been made by that Ltime, the matter may be referred to the Attorney General for collection. In the event the licensee requests a hearina as provided above, the issues to be '
! considered at such hearina shall be: NUREG-0940 I.A-167
;;g IT t .
f
>e.,,.
(a) whether the 10densee violated the Commission's requirements as set forth inj.the Notice cf Violation and Proposed Imposition of Civil Penalties, and (b) whether, on the basis of such violations, this Order should be { 4 ( t sustained. \ l FOR THE NUCLEAR REGULAT0FtY C0f'F13Sph >
< \
/ \
l
- n,ns- f
- tes M. Tayl d , Director ffice of Ins'pection and Enforcement 7
Dated at Bethesda, Maryland, f' the /.3 day of March 1987. I 1
/,.
l
}
NUREG-0940 I.A-168
t , i
/ 1 l
l 1 APPENDIX A ; EVALUqTIONANDCONCLUSIONS In its two October 29, 1986, responses to the hotice of Violatica and Proposed
' imposition of Civil Penalties issueo Oc tober 6,1986, the 7icensee admits certain cf -the violations, denies certain violations in whole or in part, and j'
> provides reasons why it believes that the civil penalties should be remitted. !- Provided below are: (!) a restatement of each violation assesseo' civil penalties i ze.d contestec by the lictnsee, the licensee's response, and the NRC's evaluation f l of the licensee's response, {II) a summary of the licensee's arauments protestiro the civil peralties and in support of remission or nitiaation of the proposed , penalties and the NRC's evaluation of these arauments, and (III) the NRC's i conclusion., s i f.A Restatement of V..iolation I.A.2 f 10 CFR 71.5(d) requires, in cart, that each licensee who transports l licensec material outsidte of the confines of its plant or other place of l use shall comply with ths apclicable requirements of the requiations appropriate to the mode of transportation of D0T in 49 CFR Parts 170 throuch 1R9. 1 49 CFR 1H.2(b) requires, in part, that no person may transport a hazardous materia 7 in commerce unless that material is handled and }; transported in hccorcence with Subchapter C of 49 CFR. l 49 CFR'173.475(i) recairas. in part, that before each shipment of any radioactive materiais packace, the shipper shall ensure by examination or appropriate tests: that external raoiation and, contamination levels are within the allowable limits specified in Subchapter C of 49 CFR. Contrary to tre above, on or about January 25, 1966, a radioactive reactor core component was transported from the Univers4ty of Utah campus to a lecation in Sal.t take City without f1rst conductinc a radiological survey to determine external radiation or contamination levels. i Sunmary of Licensee's Response ' The licensee denies that proper radiological surveys were not taken prior to the transport of the TRIGA reactor core support structure offsite. The licensee allecer that the Actino Reactor Supervisor performed an external radiation surver of the core support structure on January 20, 1986 but failed to properly document the survey until after the NRC inspection. NRC Evaluation of Licensee's Response The licensee's response of October 29, 1985, asserts only that an external radiation survey was performed. This bare assertion by the licensee in the absence of records ct such a survev ',5 not sufficient to demonstrate that an external raoiaticn survey was sperformed. Recardless of whether the licensee perforneo an external survev, the licensee has not addressed in its response whether a survey w6s performeo to assure that contamination NUREG-0940 1. A-lF3 , I i d
Appendix A levels.were within the allowable levels. An adequate survey would also have included monitorino for contamination. The licensee has not provioeo sufficient infomation to warrant withdrawal of the violaticn. Therefore, the violation remains as proposed, 1.B Restatement of Violation 1.B.I.a and 1.B.I.d 10 CFR 20.201(b) requires that each licensee shall make or cause to be made such surveys as (1) may be necessary for the licensee to comoly witn l the regulations in this part, and (2) are reasonable under the circumstances to evaluate the extent of raciation hazards that may be present. As defined in 10 CFR 20.201(a), " survey" means an evaluation of I tne radiation hazards incident to the production, use, release, disposel, l or presence of radioactive materials or other sources of radiation ut.cer a specific set of conditions. Contrary to the above:
- a. The radiological survey procram reoardino loose surface raoicactive contamination and radiation dose rates conducted durino 1985 and 1986 was not adequate to evaluate the extent of radiation hazards present in that it failed to identify loose surface contamination and raciation levels up to 100 times areater than ambient backcround levels in the reactor facility.
- d. As of June 10, 1986, the licensee had not perfortned radiological surveys of the Merrill Enoineerino Buildino potable water supply that had been cross connected to the TRIGA reactor pool water recirculation system since 1983.
Sumary of Licensee's Response, The licensee admits that the survey records were incomplete, i.e., that many details pertainino to radiation exposure rates or contamination levels were not recorded on the survey report. However, the licensee does not admit that the surveys themselves were inadequate. The licensee denies that its failure to perfom a survey of the potable water supply constitutes a violation of 10 CFR 20.201(b). The licensee states that surveys of the potable water. supply would not be the most effective method of detectino or preventino cross-contamination of the potable water source since routine measurements of radioactivity in the reactor pool and continuous mcnitorino of the pool water level provide a better control and basis for analysis. The licensee states that surveys are necessary only if reverse flow from reactor pool to potable water supply were identified. NPC Evaluation of Licensee's Response l The NRC maintains the survev records were unreasonable under the circumstan:ts to evaluate the extent of radiation hazards since they centained 4rsufficie r cetail and mistakes such that thev were of no practical use for the purpose i of radiological control. In the absence of further evidence to substantial I that the surveys were in fact properly accomplished in accoroarce with 10 CFR 20,201(b), Violation I.B.I.a remains as proposed. NUREG-0940 1.A-170 L
pI f' ,, . cc _ O) l' s p ,^ e ' ., ;
.j, ) :
- n. a , ..
[ , . p Appendix A
's i 3
4 Jhe licenJee's position that reactor ccal.monitorina makes potsble water A 5 A ' supply mFtorino unr ecessary cannot hit Ecepted. Monitorina the
/ M 3 netrot.al source of a relead is a ne.essary but not sufficient cspect of 1 95 dahdonitorina procram. Ee:ause ulves b . leak and pressures can chance, l it is ricessary that potedtial reieasa paths as well .as sources be monitored. ]L( l Therefore, Violation I.B.I.o; ram 4 ire, as propcsed.
I II / Sumarv of LicJnsee's Request prote dno the Civil Venalties and in c Ei;pporIof 9ernission or Vit' cation of titivil PerTTEes ' t ; The licensee requests renistBr or mRiaa , ion of the civil penalties based hon its pronpt identification and reportino its corrective actions and its prior acod performance. b i t: recard to the three transportation violations ,
,x in Section !zA oi t9e Notice hf Violaticn (10V), the licensee arcues that )
. Since these 'v!ob tMs resulted frox, a sincie incident, cateaorizina them 5 /
as meltiple OccdrenccEis unjustified Rearrdina the violations involvinc inadecuate'$urvr4 4 'in Sectior. I.B.l'of the N67, the licensee maintains tnat 1 l thesed took Hass Within a relat ve*y short period o' time and were correctea i l
\ pronDtip i Wr.tQrvre; the 1 unsee maintains that v iolathn I. A.1 (trans-part do %e reactor ccre cee d nents without shippinc papers) and Violation i 1.A.2 (tran:portino the react 6r: core ;omponent withwt proper lhbelina) -l
'1reU;1jed ,frce a sincicuerror in judoment and should rot be assested a !
Seym tv !.ew ? JIII. The licensee further araues that violation 1.B.2 l 7 a (remvGa tf e' cork component ano takina 4t to an unauthorized location) I s also 4tunc6 from & same isolated incident causina the transportation
< violations iand Sit $ tN . nature and numotr of violations do not warrara s
s e_ catecaricat on as' a Ses arity Level III.
+c (t,
,p . .k * -
P Q NRCs Chluatienjdficensee's Requgsj As noted in the letter of October 6, 1986 proposino the civil penalties,
'the es:.alatiSn oc nitiaation f actors were considerni and no adjustments
. ,were deemet b propriate. Escalation was considered tecause multiple
' occurrences wr t: ider.+.i fie.d. liowever, because of the licensee's prior Mcord of cued performant.e, escalaticn of the civil pet alties was not pEcposed. tWith readrd to the iicensee's ccrrective actions, the sthff ,
concluded that ;hese. actions were na trore than would be spected.uncer- ! the circost ances, anc becane these actions were neither unusually prompt i nor eaten @.e. Pitiaatice of any of the proposed civil penalties for j prcn.pt an4 titensive correctin actihns wculd not be warranted. Further, ! becanM rN licensee did not identify or repcet these violstions, no adjuswint teltbe civil penelties for prcmpt identification and reportino wovlf M ept,ropriate.
\
TThe Nfd s','af f acrees that the three transportation violations in Section I. A i of the NOV did result'frem a sincle. incident involvino the transportation
. of racicactive material in the form of a TRIGA reactor core component.
,HOWever, the NRC maintains that each of the transportation violations
' shod d be considered separately since each h a violation of a different transpectation requirement. The NRC suf' mentains that the transportation violations cascribed in Section I. A and too viciatiers described in Section 1.B.
Mcludino Walation I.B.?, do warrant categorization as Severity Level III d olations under Supplements V and VI, respectively. NUREG-0940 1.A-171 i
,O ' a L) ? /) r
{ I i 1 Appendix-A 4- j i i Ill. NRC Conclusion The licensee's arauments with respect to each violation have been fuliy considered. The NRC concludes that the alleaed violations on which the l civil penalties were based occurred as stated in the Notice of Violation 1 ano Prcposed Imposition of Civil Penalties ana that the licensee has not j provided a sufficient basis fer either mitiaation or withdraw 61 of the h cdvil perialties. Therefore, the NRC concludes that the civil penalties of Teree Thousand Dollars (53,000) shoulo be imposed. J 0 NUREG-0940 I.A-172
APPENDIX B ; EVALUATION AND CONCLUSIONS i FOR VIOLATIONS NOT ASSESSED CIVIL PENALTIES Provided below are a restatement of the violations not assessed civil penalties ) contested by the licensee in Appendix A and Appendix B of the Notice of . Violation and Proposed Imposition of Civil Penalties issued October 6,1986, the licensee's responses, and the NRC's evaluations of the licensee's responses. A. Restatement of Violation II.B in Appendix A -
-TRIGA Technical Specification 6.8, "Operatino Procedures," requires, in part, that operatino procedures shall be in effect for perfonMno preventive maintenance and calibration tests on the reactor and associateo equipment.
Contrary to the above, as of June 12, 1966, written procedures had not been established for maintenance' work performed on the TRIGA reactor core upper support structure durino December 1985 and January 1986. Suninary of Licensee's Response The licensee denies the alleoed violation. The licensee maintains that all work'on the TRIGA upper core support structure was performed under previously existino procedures and new procedures that were submitted on January 31, 1986, and approved by the Reactor Safety Committee. NRC Evaluation of Licensee's Response The licensee's assertion that all work on the upper core suppurt structure was performed under approved procedures is accepted. Therefore, this violation is withdrawn. B. Restatement of Violation II.D in Appendix A q TRIGA Technical Specification 3.5 requires that the reactor shall not be operateo unless the facility ventilation is operable, except for periods of time not to exceed 48 hours to ptrmit repair or testino of the ventilation system. Technical Specification 5.6 states that "the facility is desianed so that the ventilation system will normally maintain a neoative pressure with respect to atmosphere to minimize uncontrollable leakaoe to the environment. The free air volume withir the reactor buildino is confined when there is an emeroency shutdown of the 1 ventilation system." The Safety Analysis Report, Section 4.6.2, Emeroency 1 Operation, states, "The outlet vent will be equipped with a by-pass HEPA j filtration system which will be dampered into operation. This will provide a continuous filtered e::haust and maintain the reactor area . . . under neoative pressure. The flow under filterino conditions will be such that a neoative pressure of at least 0.1 inches of water will be maintained." l l NUREG-0940 1.A-173
Appendix B , Contrary to the above, as of June 10, 1986, HEPA filters in the reactor ventilation system were not properly installed to ensure the requirements of Technical Specification 5.6 and Section 4.6.2 of the Safety Analysis Report would be satisfied. The filter was installed so that it was not sealed to its mountina openina, the flow of air was in the wrona direction throuah the filter, and the filter was installed in the wrona orientation. The HEPA filters were in this configuration for a period of time exceedina 48 hours, and no documentation was available to verify that either an evaluation or in-piece testina had been performed to ensure the system was operable. Summarv of Licensee's Response The licensee admits that the filter was not adequately sealed to its mountino openir;a, thus violatina the technical specification. However, the licensee denies part of this violation concernina the c'irection cf air flow and the filter's orientation. The licensee provides information that the flow arrow on the HEPA filters indicates only the direction of flow when the filter was tested. The licensee also states that filter orientation does not affect filter efficiency. The licensee's corrective action indicates that the HEPA filter has been installed properly, and
- that written procedures for HEPA filter testina and maintenance will be I reviewed by the Reactor Safety Committee.
NRC Evaluation of Licensee's Response The licensee is correct that the flow of air was not in the wrona direction and the filter was not installed in the wrona orientation. Therefore , Violation II.D in Appendix A is amended accordingly. Althouah the flow of air was not in the wrona direction and the filter was not installed in the wrona orientation, the licensee has admitted that. the filter was not adequately sealed to its mountina openina. Therefore, the violation as rewritten below occurred: TRIGA Technical Specification 3.5 requires that the reactor shall not be operated unless the facility ventilation is operable, except for periods of time nct to exceed 48 hours to permit repair or testina of the ventilation system. Technical Specification 5.6 states that "the fecility is desianed so that the ventilation system will normally maintain a neaative pressure with respect to atmosphere to minimize uncontreliable leakaae to the environment. The free air volume within the reactor buildino is confined when there is an emeroency shutdown of the ventilation system." The Safety Analysis Report, Section 4.6.2, Emeroency Operation, states, "The outlet vent will be equipped with a by-pass HEPA filtration system which will be dampered into operation. This will provide a continuous filtered exhaust and maintain the reactor area . . . under neaative pressure. The flow under filterina conditions will be such that a neaative pressure of at least 0.1 inches of water will be
~
maintained." Contrary to the above, as of June 10, 1966, HEPA filters in the reactor ventilation system were nut properly installed to ensure the requirements of Technical Specification 5.6 and Section 4.6.2 of the Safety Analysis NUREG-0940 I.A-174
Appendix B ^ Report would be satisfied. A filter was installed so that it was not < sealed to its mountina openina. The HEPA filter was in this crnfiouration i for a period of time exceedina 48 hours, and no documentation was available tu ver.ifv that either an evaluation or in-place testino had been performed to ensure the system was operable. C. Restatement of Violation i.A.3 of Appendix B License Condition 2.C(3) for the AGN-201 and TRIGA reactors states that:
"The licensee shall maintain and fully implement bli provisions of the Commissio'n-approveo physical security plan, includina amendments end chanaes made pursuant to the duthority of 10 CFR 50.54(p)." The approvea physical security plan was revised as Revision 1 on July 28, 1980.
Chapter 1, Section 1.1 of the PSP states, in part, that coor 2 (Reactor Supervisor Office & TRIGA Control Rccm) keys are controlled by the Mechanical and Industrial Enaineerina Office, physical plant, and the university key shop. These keys are oniv issued to staff of the univercity and no students are issued these keys. Keys to door 3 (AGN-201 and TRIGA Reactor Room 1001-E) are maintained by the reactor supervisor and only three keys are maintained. One key is retained by the reactor supervisor, another by the senior reactor operator, and the third is maintained in a locked box for use by authorized personnel durino off-hour 8CCess. Contrary to the above, on June 11, 1986, a student possessed a key to door 2 and 3, and the third key to the TRIGA and AGN-201 reactor room (Room 1001-E) was not beino kept in a locked box, but was kept in an unsecured electrical fuse panel in a file cabinet in Room 1001-C. Surrana ry of Licensee's Response The licensee denies the alleoed viol 6 tion concernina the possession of a controlled key to the reactor complex by an unauthorized student of the University of Utah. The licensee states that the student referenced by the NRC was a licensed reactor operator. NRC Evaluation of Licensee's Response The NRC had determined that the operator's possession of a door 2 key was not in violation of PSP. However, possession of a door 2 key by the Reactor Supervisor's cauchter was a violation of the PSP. The Supervisor's dauohter, althouah not enrolled in any reacter facility f courses, was a student at the University. The licensee is correct that I the Reactor Supervisor's dauchter did not possess a key to door 3, and Violation 1.A.3 in Appendix 5 is amended accordingly. However, while the l Supervisor's dauohter did not have a door 3 key, she did have access to the unlocked fuse panel. Therefore, the violaticn remains, and is restatec as follows: ) License Condition 2.C(3) for the AGN-201 and TRIGA reactors states that:
"The licensee shall maintain and fullv implement all provisions of the Commission-approved physical security plan, includino amendments and chances made pursuant to the authority of 10 CFR 50.54(p)." The approved physical security plan was revised as Revision 1 on July 28, 1980.
NUREG-0940 I.A-175 '
Appendix B Chapter 1 Section 1.1 of the PSP states, in part, that door 2 (Reactor Supervisor Office & TRIGA Control Room) keys are controlled by the Mechanical and Industrial Enoineerino Office, physical plant, and the university key shop. These keys are only issued to staff of the university and no students are issued these keys. Keys to door 3 (AGN-201 and ThlGA Reactor Room 1001-E) are maintained by the reactor supervisor and only three keys are maintained. One key is retained by the reactor supervisor, another by the senior reactor operator, and the third is maintained in a locked box for use by authorized personnel durino off-hour access. Contrary to the above, or. June 11, 19EC, a student possessed a kev to door
- 2. Further, the third key to the TRIGA and AGN-201 reactor room (Room 1001-E) was not beino kept in e locked box, but was kept in an unsecured electrical fuse panel in a file cabinet in Room 1001-C.
D. Restatement of Violation 1.B.1 in Aopendix B Chapter 1 Section 1.1 of the PSP states, in part, that laminated-fixed safety class windows provide a clear view of the reactor room (1001-E) from the Cirector's cffice (reactor supervisor's office, room 1001-A), and the AGN and TRIGA control roorrs (rooms 1001 and 1001-D respectively). Contrary to the above, as of June 9-11, 1986, 100 percent of the view afforded by the window in room 1001-A was obscured by a stack of empty soda pop cans placed on the window sill area, ano approximately 50 percent of the view from room 1001 windows was obscured by a chart, the AGN-201 reactor censole, and books which were stacked on the AGN-201 console. Summary of Licensee's Response The licensee denies the violation concernino the view afforded by the windows in rooms 1001 and 1001-A. The licensee states that the reactor rooms could be viewed throuch other winoows in room 1001, and that the Reactor Supervisor was on leave and his office, room 1001-A, was beino used by students who had no need to view the reactor room. NRC Evaluation of Licensee's Response The licensee has provided no basis for withdrawal of the violation. As stated in the Notice of Violation, at the the of the inspection the view of the reactor room from room 1001-A was t A ly obstructed and the view from room 1001 was significantly obstructeo '.n that the majority of the individual wint:ows in that room were substantially cbstructed by materials l stacked in frcnt of them. Furtner, the Physical Security Plan makes no
- allowance for the occupancy status of the rooms in determining whether a clebe view of the reactor room exists.
NUREG-0940 1.A-176 i
O 4ro UNITED ST ATES [g p, NUCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20555
<j a....
/ MAY 0 71987 Docket No. 30-03465 License No. 48-09843-18 EA 86-179 University of Wisconsin ATTN: Acting Chancellor Bernard C. Cohen Room 153, Bascom Hall 400 Lincoln Drive Madison, WI 53706 Gentlemen:
SUBJECT:
ORDER IMPOSING A CIVIL MONETARY PENALTY This refers to your letter dated January 6, 1987, in response to the Notice of Violation and Proposed Imposition of Civil Penalty (Notice) sent to you by cur letter dated December 11, 1986. Our letter end Notice describe two violations of NRC regulatory requirements, identified during an NPC special safety inspection conducted from September 2 through 19, 1986. To emphasize the importance of implementing adequate control and oversight of your radiological One Thousand Two safety Hundredprogram during(licensed Fifty dollars activities, a civil penalty of
$1,250) was proposed.
In your response you admit that the violations occurred as described in the Notice, but you request reclassification of the violations at Severity Level IV and remission or further mitigation of the proposed civil penalty. After consideration of your responses, we have concluded for the reasons given in the appendix attached to the enclosed Order Imposing Civil Penalty, that you have not provided a sufficient basis for modifying our proposed action. Accordingly, we hereby serve the enclosed Order on the University of Wisconsin imposing a civil monetary peralty in the amount of One Thousand Two Hundred Fifty Dollars ($1,250). We will review the effectiveness of your corrective actions during a subsequent inspection. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room. Sincerely,
/
Q=C ? James M. Te or Deputy Executive Director for v' Regional Operations
Enclosures:
Order Imposing Civil Monetary Penalty with Appendix NUREG-0940 1.A-177
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of University of Wisconsin Docket No. 30-03465 Madison, Wisconsin Licensee No.- 48-09843-18 EA 86-179 j ORDER IMPOSING CIVIL MONETARY PENALTY I j The University of Wisconsin, Madison, Wisconsin.(licensee) is the holder of Materials License No. .48-09843-18 issued by the Nuclear Regulatory Commission (NRC) on March 12, 1981. The license authorizes the licensee to conduct (1) research and development; (2)' medical research, diagnosis, and i therapy; and (3) tracer studies in accordance with the conditions specified therein. 1 II A special safety inspection of the licensee's activities was conducted from September 2 through 19, 1986. The results of that inspection indicated that the licensee had not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was served upon the licensee by letter dated December 11, 1986. The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalty proposed for the violations. The licensee responded to the Notice by two letters dated January 6,1987. NUREG-0940 I.A-178
1 III After consideration of the licensee's responses and the statements of fact, explanation, and argument for mitigation contained therein, the Deputy Execu ive Director for Regional Operbtions, has determined, as set forth in the appendix to this Order,.that the violations occurred as. stated and that the penalty proposed for the violations designated in the Notice should be imposed. IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Actof1954,asamended(Act),42U.S.C.2282,and10CFR2.205, ITIS HEREBY ORDERED THAT: The licensee pay a civil penalty in the amount of One Thousand Two Hundred Fifty Dollars ($1.250) within 30 days of the date of this Order by check, draft, or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555. ' The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing shall be addressed to the Director, Office of Enforce-ment, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, 1 Washington, D.C. 20555. A copy of the hearing reauest also shall be sent to I the Assistent General Counsel for Enforcement, Office of General Counsel, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 and to the Regional Administrator, U. S. Nuclear Regulatory Commission, Region III, 799 Roosevelt l Road, Glen Ellyn, Illinois 60137.
' NUREG-0940 I.A-179 J
If a hearing is requested, the Comission will issue an Order designating i the time and place of the hearing. If the lict isee fails to request a hearing within 30 days of the date of this Order, the provisions of this Order shall be effective without further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection. In the event the licensee requests a hearing as provided above, the issues to 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 referenced in Section II above and I (b) whether, on the basis of such violation, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION ames M. Ta or
/ Deputy Executive Director for Regional Operations Dated at Bethesda, Maryland this T hday of May 1987.
NUREG-0940 1.A-180
APPENDIX EVALUATIONS AND CONCLUSIONS On December a Notice of Violation and Proposed Imposition of Civil Penalty (Notice11,)1986, was issued for violaticas identified during an NRC.special safety inspection. The University of Wiscensin, Madison, Wisconsin, responded to the Notice by two letters dated January 6,1987. In its response, the l licensee admits the violations occurred as described in the Notice, but requests remission or further mitigation of the proposed civil penalty.
- 8. Restatement of Violations i
10 CFR 20.201(b) requires each licensee to make or cause to be made such ! 1 surveys as (1) may be necessary for the licensee to comply with the l regulations in this part and (2) are reasonable under the circumstances I 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 oti.cr sources of radiation under a specific set of ! conditions. 10 CFR 20.105(b) rr: quires in part that no licensee possess, use, or transfer licensed material in such a manner as to create in any unrestricted area radiation levels that, if an individual were continuously present in the area, could result in that individual receiving a dose in excess of two millirems in any I hour, or 100 millirems in any 7 consecutive days.
- 1. Contrary to the above, on June 26 and 27, 1986, the licensee failed .
to perform a survey of unrestricted areas to assure compliance with 10 CFR 20.105(b) following the implant of 557 1ridium-192 seeds in i animals at the Charmany Instructional Facility.
- 2. Contrary to the above, from June 26 until August 21, 1986, the licensee failed to perform reasonable surveys under the circumstances to deter- a mine the extent of radiation hazards that may have been present. !
Specifically, surveys of the floor, rubber nats, and animal feces were not conducted to detect loo _se radioactive sources immediately prior to having the feces washed down the drain. This resulted in the ; loss of seven iridium-192 sealed sources. Collectively, these violations have been categorized as a Severity Level III problem (SupplementIV). Civil Penalty - $1,250 - assessed equally among the violations, fl. Licensee's Response and NRC Evaluation of Licensee's Response In its response, the licensee admits the violations occurred as described in the Notice, states reasons why the violations occurred, states corrective l action taken and steps to avoid further violations as well as the dates when full compliance was achieved. The licensee also acknowledges that l the NRC mitigated the base civil penalty by 50 percent for unusually prompt and extensive corrective action. However, the licensee submits that, given all the circumstances of the incident, the violations identified are not at NUREG-0940 I,A-181 i l
i Appendix the same level of concern as the example of a Severity Level III violation set forth in Supplement IV.C.2 of the Enforcement Policy regarding radiation exposure rates in unrestricted areas. The licensee also requests remission or further mitigation of the proposed civil penalty based on the additional reasons set forth below: A. Severity Level Licensee Assertion The licensee agrees that the unrestricted areas were not surveyed, but argues that the likelihood of exposures at the level identified in Supplement IV.C.2 of the Enforcement Policy as meriting classifi-cation at Severity Level III was small. The licensee also asserts that the loss of the sources occurred because of a series of unfor-seeable happenings, and it is mere speculation to conculde that adequate control and oversight were not exercised. NRC Evaluation The violations described in the Notice concern the licensee's failure to conduct adequate radiation hazard surveys in unrestricted areas as well as within the animal experimental area, which resulted in the loss of seven sealed iridium-192 sources. As such, these viola-tions represent a failure to control licensed material, which is properly categorized at Severity Level III pursuant to Supplement IV.C.2 of the Enforcement Policy. It is not speculation to say that increased oversight would have recognized and prevented the violations. This was an unusual experiment which was authorized without a full review by the Radiation Safety Committee. Furthermore, the health physics staff was not actively involved in the experirrent until the seeds were reported missing. More active health physics staff involvement would have resulted in more appropriate surveys and radiological controls being performed. B. Remission or Mitigation Licensee Assertion The licensee offers five reasons why it believes the proposed penalty should be remitted or mitigated further based on its prompt actions taken in response to the event. These are: (1)uponnotification that sources were missing, University personnel innediately surveyed the facility and physically inspected and surveyed the grounds surrounding the facility, (2) when sources could not be located within the facility, health physicists phys.ically inspected and surveyed the creek which receives effluent water from the sewer system and did dosimetry calculations for potential exposures, (3) the NRC was promptly notified, (4) a press release was prepared and a press conference was held, and (5) the primary investigator's authorization to use radio-nuclides was revoked pending full University Radiation Safety Committee (URSC) review and the radionuclides in his possession were confiscated. NUREG-0940 1.A-182
I 4 Appendix The licensee also asserts that, in addition to these immediate steps, j the University critically reviewed the internal procedures used to ] review and monitor experiments with radionuclides and extensively J revised its process for reviewing and approving radionucide experi-ments. The licensee also states that assessment of 50 percent of , the fine is inappropriate because of the University's past record I of compliance and commitment to safety. j NRC Evaluation The NRC has already recognized both the licensee's imediate and long-l range corrective actions, and has reduced the base civil penalty by the maximum allowable 50 percent for unusually prompt and extensive corrective actions. Further reduction for the licensee's past record of compliance is not considered appropriate because of the seriousness of this event which could have been provented by appropriate surveys in response to available information. With regard to the licensee's assertion that the NRC was promptly notified, the NRC agrees that the licensee promptly reported the loss of licensed material once the licensee determined the seeds were lost. However, the NRC Enforcement Policy. 10 CFR Part 2, Appendix C, Section V.B.1 states, " Reduction of up to 50 percent of ' the base civil penalty may be given when a licensee identifies the violation and promptly reports the violation to the NRC. In weighing this factor, consideration will be given to, among other things, the ! length of time the violation existed prior to discovery, the oppor-tunity available to discover the violation, the ease of discovery and the promptness and completeness of any required report." In addition, immediate corrective action is required to apply this factor. This, experiment began on June 26, 1986, and concluded on August 21, 1986. On June 29, 1986, the licensee became aware that there were problems i with the experiment when it discovered a template holding sources was l partially hanging from an animal and some sources had separated from the template and migrated into the animal tissue. Furthermore, the i l licensee found one catheter containing sources loose on the floor. The licensee discovered the discrepancy in a source inventory on August 21, 1986. On August 25, 1986, the licensee determined that the sources were lost and notified the NRC as reauired by 10 CFR 20.402. The licensee had ample opportunity to involve the health physics staff and incorporate comprehensive survey procedures, which may have averted the loss of sources, more promptly than it did. Therefore, mitigation for this factor is not warranted. l fil. NRC Conclusion The NRC staff has concluded that all violations did occur as originally stated in the December ll, 1986 Notice of Violation and Proposed Imposition of Civil Penalty and that the problem represented by these violations was properly categorized at Severity Level III in accordance with 10 CFR Part 2, Appendix C, Supplement IV. In addition, the staff concludes that a sufficient basis was not provided for remission or further mitigation of the proposed civil penalty. Therefore, the NRC staff has concluded that a $1,250 civil penalty shoulo be imposed. NUREG-0940 I.A-183
- w. h . . . < .
#ps* m%k. NUCLEAR REGULATORY COMMISSION
.f). * 'k RECloN lli E l too noosevett mono cLcN ELLYN, ILLINOIS 40M7 DEC 1 1 1986 Docket No.'30-03465-License'No. 48-09843-18 EA 86-179 University of Wisconsin
' ATTN: Chancellor Irving Shain Room 153 Bascom Hall 400 Lincoln Drive Madison, WI- 53706 i
Gentlemen:
SUBJECT:
NOTICE OF VIDLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 30-03465/86001(DRSS)) This refers to the NRC special safety inspection conducted September 2 through ' 19, 1986, of activities authorized by NRC License No. 48-09843-18. The ! inspection was conducted to review the circumstances surrounding the loss f of seven iridium-192 seeds which the university reported to this office on l August 25, 1986. The iridium seeds were used in animal experiments conducted ! between June 26'and August'21, 1986. The results of the inspection were discussed on September 24, 1986, during an enforcement conference between j H. Attix and others of your staff and A. B. Davis and others of the NRC staff. The inspection identified violations of NRC requirements that involved a failure to conduct appropriate radiological surveys during the course of an experiment. l and the loss of licensed material. Collectively, these violations are of concern > to the NRC because they indicate that adequate control and oversight of the radiological safety program were not exercised during licensed activities. In particular, this unusual experiment was authorized without a full review by the Radiation Safety Committee. Furthermore, the health physics staff was not actively involved in the experiment until the seeds were reported missing. These significant deficiencies contributed to the failure to conduct appropriate radiological surveys and consequent loss of the seeds. ) To emphasize the importance of adequate control and oversight of the J radiological safety program during licensed activities, I have been authorized, afterconsultation with the Director, Office of Inspection and Enforcement, to issuethe enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of One Thousand Two Hundred Fifty Dollars (51,250) for the I L violatioris described in the enclosed Notice. In accordance with the " General ! l Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR part 2, ) Appendix C (1986) (Enforcement Policy), the violations described in the enclosed i Notice have been categorized in the aggregate as Severity Level III. The base L value of a civil penalty for a Severity Level III violation is 52,500. The NRC CERTIFIED MAIL RETURN RECElpT REQUESTED NUREG-0940 I.A-184
j i University of Wisconsin 2 l DEC 1 1 1986 Enforcement Policy allows for reduction of a civ11' penalty under certain circumstances. In this case, the base civil penalty is reduced by 50 percent because of your unusualiy prompt and extensive corrective actions. These corrective actions included (1) radiation surveys of the building in which j the experiments were performed, (2) surveys of a nearby creek which receives l
- l. treated effluent water, (3) issuance'of a press release; (4) modifications i I to procedures to ensure more active involvement by the Radiation Safety l Committee including advance approval of unusual experiments, and (5) increased monitoring of such experiments by the health physics staff. ,
You are required to respond to this letter and should follow the instructions l 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 fincluding
' your propos'ed 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, l Title 10, Code of Federal Regulations, a copy of this letter and its enclosures will be placed in the NRC's 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 97-511. Sincerely, A _ eSpMg 82w
/JamesG.Kepper Regional Administrator Enclosures
- 1. Notice of Violation
- 2. Inspection Report No. 30-03465/86001(DRSS) l l
l
)
l I I i NUREG-0940 1.A-185 L i 1 1
NOTICE OF VI0l.ATION AND PROPOSED IMPOSITION OF CIVIL PENALTY University of Wisconsin Docket No. 30-03465 Madison, Wisconsin License No. 48-09843-18 EA 86-179 During an NRC special inspection conducted during the period September 2 through 19, 1986, violations of NRC requirements were identified. The violations resulted in a significant failure to control licensed material. 'As a result, 7 iridium-192 seeds used in animal experiments were lost. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to section 234 of the Atomic Energy Act.of 1954, as amended, ; ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The violations and
. associated civil penalty are set forth below:
l 10 CFR 20.201(b) requires each licensee to make or cause to be made such i surveys as (1) may be necessary for the licensee to comply with the l regulations in this part and (2) 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 j conditions. j l 10 CFR 20.105(b) requires in part that no licensee possess, use, or transfer j licensed material in such a manner as to create in any unrestricted area j radiation levels that, if an individual were continuously present in the ( area, could result in that individual receiving a dose in excess of two q millirems in any I hour, or 100 millirems in any 7 consecutive days.
- 1. Contrary to the above, on June 26 and 27, 1986, the licensee failed I to perform a survey of unrestricted areas to assure compliance with 10 CFR 20.105(b) following the implant of 557 iridium-192 seeds in animals at the Charmany Instructional Facility. '
l
- 2. Contrary to the above, from June 26 until August 21, 1986, the licensee !
failed to perform reasonable surveys under the circumstances to deter- I mine the extent of radiation hazards that may have been present. I Specifically, surveys of the floor, rubber mats, and animal feces were I not conducted to detect loose radioactive scurces immediately prior to having the fcces washed down the drain. This resulted in the loss of seven iridium-192 sealed sources. ' Collectively, these viciations have been categorized as a Severity Level III problem (Supplement IV). . Civil Penalty - 51,250 - assessed equally among the violations. s NUREG-0940 I.A-186
1 l Notice of Violation 2 DEC 1 1 1986 l Pursuant to the provisions of 10 CFR 2.201, the University of Wisconsin is l hereby required to submit to the Director, Office of Inspection and Enforcement, l U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the j Regional. Administrate'or, U.S. Nuclear Regulatory Commission, Region III, within j 30 days of the date of this Notice a written statement or explanation, including ! 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 j 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 j will be achieved. If an adequate reply is not received within the time ! specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be. proper should not be taken. Considerations 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 University of Wisconsin may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforc~ement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of One Thousand Two Hundred Fifty Dollars ($1,250) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should the University of Wisconsin fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should the University of Wisconsin elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violation listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The University of Wisconsin's attention is directed to the other provisions of 10 CFR 2.205, regarding the i procedure for imposing a civil penalty. 1 i l 1 NUREG-0940 1.A-187
.j Notice of Violation 3 DEC 1 1-1986 Upon failure to pay any civil penalty due which has been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION c%Lu ~~ % y - 0,_ [ James G 7Keppfe f ~~ ' Regional Administrator Dated atJ1en Ellyn, Illinois, this s M ay of December 1986. i NUREG-0940 1.A-188 4
l I I.B. REACTOR LICENSEES, SEVERITY LEVEL III VIOLATIONS, NO CIVIL PENALTY l I NUREG-0940
p atog UNITED STATES j Do NUCLEAR REGULATORY COMM!$stON l [' " ,'n REGION 11 f g g: to1 MARIETT A STREET,N.W. g- ATL ANTA, GEORGI A 30323 l MAY 051987 Docket Nos. 50-269, 50-270, 50-287 License Nos. DPR-38, DPR-47, DPR-55 ) EA 87-43 Duke Power Company l ATTN: Mr. H. B. Tucker Vice President i Nuclear Production Department j { 422 South Church Street
. Charlotte, NC 28242
( Gentlemen:
SUBJECT:
NOTICE OF VIOLATION (INSPECTION REPORT NOS. 50-269/87-02, 50-270/87-02 AND 50-287/87-02) l This refers to the Nuclear Pegulatory Commission (NRC) inspection conducted on January 26-30, 1987 at the Oconee Station. As a result of this inspection, a failure to comply with NRC regulatory requirements was identified. The report t documenting this inspection was sent to you with a letter dated February 19, 1987. [ NRC concerns relative to the inspection findings were' discussed by L. A. Reyes, Director, Division of Reactor Projects, NRC, Region 11, with R. B. Priory, Vice President, Design Engineering, in an Enforcement Conference held on March 6, 1987. A summary of this Enforcement Conference was sent to you by a letter dated March 25, 1987. The violation described in the enclosed Notice of Violation involved a failure to provide the alternate shutdown capability with the required independence of cabling for reactor coolant letdown valves. The licensee took prompt corrective action to remedy any potential problems which may have occurred in the event of a fire, which included closing the appropriate valves and de-e.,ergizing the power supply to the motor operators for the valves involved. The cause of the violation was the use of improper assumptions when preparing Appendix R fire protection analyses. We are also concerned with your fire hazards analysis which did not recognize a condition that could have affected the ability to maintain reactor coolant inventory. While not a violation, the fire hazards ' analysis did not consider circuit failure modes which could cause spurious ! operation of valve operator motors for the decay heat removal suction isola-l tion valves. It was fortuitous that an after-the-fact analysis indicated that simultaneous opening of the valves, which provide a high to low pressure system interface, would not take place during a fire, in accordance with the " General Statement of Policy and Procedure for URC 4 Enforcement Actions," 10 CFR Part 2 Appendix C (1987) (Enforcement Policy), j the violation described in the enclosed Notice has been classified at a Severity Level 111. Normally, a civil penalty is proposed for a Severity Level 111 violation. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operatiers, 1 have decided that a civil penalty will not be proposed in this case because unusually prompt and extensive corrective actions were initiated to prevent recurrence, and because your prior performance in the area of fire protection has been good. NUREG-0940 1.B-1
)
1 Duke Power Company MAY 051987 i i You are required to respond to this letter ar.d should follow the instructions i specified in the enclosed Notice when preparing your response. In your j response, you should document the specific actions taken and any additional 1 actions you plan to prevent recurrence. After reviewing your response to this J Notice, including your proposed corrective actions, the NRC will determine I 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 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. ; 1 Sincerely, , J - l f J. Nelson Grace ,
.o Regional Administrator !
Enclosure:
Notice of Violation 1 cc w/ enc 1: M. S. Tuckman, Station Manager ] i NUREG-0940 I.B-2
-i I
NOTICE OF VIOLATION ! Duke Power Company. Docket Nos. 50-269, 270, 287 j Oconee, Units 1, 2, and 3 License Nos. DPR-38, 47, 55. ; EA 87-43 ] During the Nuclear Regulatory Commission (NRC) inspection conducted on January 26 30, 1987, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement _ Actions," 10 CFR Part 2, Appendix C (1987), the violation is listed below: - 3 1 A. 10 CFR 50.48(b) requires, in part, that all nuclear power plants licensed : to operate prior to January 1,1979 shall satisfy the requirements of 1 10 CFR Part 50, Appendix R, including specifically, Section III.G, Fire i Protection of Safe Shutdown Capability. Section III.G.2 specifies that, where cables or equipment, including associated non-safety circuits that could prevent operation or cause maloperation due to hot shorts, open circuits, or shorts to ground, of redundant trains of systems necessary to achieve and maintain hot shutdown conditions are located within the same fire area outside of primary containment, a means to ensure that one of the redundant trains is free of fire damage shall be provided. Section III.G.3 requires an alternative or dedicated shutdown capability independent of cables, systems or components in the specified fire aree under consideration where the protection of systems does not satisfy the requirements of Paragraph G.2. Contrary to the above, as of January 26, 1987, cabling to the motor operator for the letdown cooler B outlet valve (HP-4), for each Oconee unit', which is required to satisfy the alternative shutdown capability of Section III.G.3 above, was not independent of the specific design basis fire area. The cabling was routed through the east penetration room, the design basis fire area. A fire in this area could result in the loss of reactor coolant inventory in excess of the makeup capacity of the specified safe shutdown equipment. . This is a Severity Level III violation (Supplement I). I' Pursuant to the provisions of 10 CFR 2.201, Duke Power Company is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC .20555 with a copy to the Regional Administrator, Region II, and a copy to the NRC Resident Inspector, Oconee Nuclear Station, within 30 days of the date of the letter transmitting this Notice. This reply should be clearly marked as a " Reply to Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted, (2) the corrective steps which have been taken and the results achieved, (3) the corrective steps which will be taken to avoid further violations, ard (4) the date when full compliance will be achieved. If an adequate reply is not received within the time specified NUREG-0940 1.B-3
i-Notice of Violation in th'is 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. FOR THE NUCLEAR REGULATORY COMMISSION I -l t
)
/
[ J. Regional NelsonAdministrator Grace Dated at Atlanta, Georgia this5'Mday of May 1987-1 j NUREG-0940 1.B-4
UNITED 51 ATES
/p, af '
.o NUCLEAR REGULATORY COMMISsloN REClo,N 88
(( ,,, 101 MARIETT A STREILT, N.W. g ,. j
- t ATL ANT A, GEORGI A 30323
/ MAY 151987 Docket Nos. 50-413, 50-414 License Nos. NPF-35, NPF-52 l EA 87-57 l Duke Power Company ATTN: Mr. H. B. Tucker, Vice PresiJent j Nuclear Production Depertment 422 South Church Street Charlotte, NC 28242 Gentlemen: j l
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT N05. 50-413/87 06, 50-414/87-06, AND 50-413/87-08, 50-414/87-08) , This refers to the Nuclear Regulatory Commission (NRC) inspections conducted i at the Catawba facility on January 30 to February 19, 1987 and February 26 to l March 25, 1987. The reports documenting these inspections were sent to you with letters dated March 12, 1987 and April 10, 1987, respectively. Associated with these inspections, failures to comply with NRC regulatory requirements were identified by your plant staff. NRC concerns relative to these findings were discussed by M. Ernst Deputy Regional Administrator, NRC, Region II, with you and members of your staff in an Enforcement Conference held on April 16, 1987. l Violation A described in the enclosed Hotice of Violation involved failures in the design control process. These failures resulted in systems being placed in service whicn, under certain conditions, were in a degraded enndition. In . the first example, because curbs had not been specified on the design drawings, l l the units have operated since initial startup with Containment Air Return Fans I that would be susceptible to flooding and degraded operation under postulated loss of coolant accident (LOCA) conditions. In the second example, due to unclear design drawings, one of two required Pressurizer Power Operated Relief Valves was connected incorrectly to the backup nitrogen supply and would not have operated under certain postulated conditions. These examples emphasize the need to assure that design control is adequate such that proper equipment is installed to fulfill regulatory requirements and the design basis. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), Violation A described in the enclosed Notice has been classified at a Severity Level III. A civil i p:nalty is considered for a Severity Level III violation. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, I have decided that a civil penalty will not be proposed in this case because both examples of the violations were identified l by your staff and promptly reported to the NRC and prompt actions were taken to I comply with appropriate Technical Specificathns. Mitigation is also ap'propriate l because the licensee had initiated an extensive ongoing program to remedy the l type of design engineering deficiencies es identified herein. These deficiencies in design control, which occurred before this program was initiated, have been thoroughly discussed in conjunction with other recent enforcement actions NUREG-0940 1.B-5
l Duke Power Company - MAY 151987 1 related to the McGuire, Oconee and Catawba Stations, as w' ell as during the management meeting on this subject held at the Region II Office on March 6, 1987. Because Violations B and C involve issues of lesser safety significance, each has been categorized as a Severity Level IV violation, in Violation B, involving a failure to promptly evaluate the operability of components in the Containment Spray System, poor design / operations interface was a contributing factor to the untimely evaluation. There was not a violation of technical specification requirements in that your staff's final evaluation determined that the heat exchanger was never below its_ required heat exchange capability. Violation C involved the failure to properly follow a station surveillance testing procedure and additionally procedural deficiencies were identified. 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 l' inspections, the NRC will detennine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. Based on the design control program deficiencies identified at your Oconee and McGuire' Stations the NRC recognizes that corrective actions are currently being implemented which should also significantly reduce the likelihood of occurrence of violations such as in the enclosed Notice. Therefore, please address what additional measures, if any, your staff has identified to improve your management system which controls and encourages the quality of your engineering support and the communications interface between the site and design engineering. Also, please describe any additional measures you may have or are planning to take to improve the timeliness of engineering support for your nuclear sites. 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. Sincerely j q We e
/
-J. e son Grace ;
Regional Administrator j
Enclosure:
Notice of Violation cc w/ encl: J. W. Hampton, Station Manager Senior Resident inspector - McGuire NUREG-0940 1.B-6
NOTICE OF VIOLATION Duke Power Company Docket Nos. 50-413 and 50-414 Catawba Units 1 and 2 License Nos. NPF-35 and NPF-52 EA 87-57 - During the Nuclear Regulatory Commission (Nru ) inspections conducted on January 30 - February 19, 1987, and February 26 - March 25, 1987, violations ' of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, %pendix C (1987), the violations are listed below: 1 A. 10 CFR Part 50, Appendix B, Criterion,lM requires that measures .be ' established to assure that applicable regulatory requirements and the design basis, as defined in 10 CFR Part 50.2 and as specified in tne d license application, for those structures, systems, and components to which this Appendix applies, are correcly translated into specific 4tions, drawings, procedures, and instructions, Contrary to the above, measures had not been established to assure that I regulatory requirements and the design bases were correctly translated l into specifications, drawings, procedures, and instructions in that: ) l 1. The containment design drawings did not indicate a means for maintaining the Containment Air Return Subsystem Fans operable during a design basis Loss of Coolant accident in that measures, such as curbing, were not identified on the drawings for prevention of flooding of l the fans. Thus, both fans were placed in a degraded condition.
- 2. The design drawings for installation of air lines to the Pressurizer '
Power Operated Relief Valves (PORV) were unclear and did not ensure that the two instrument air lines with backup nitrogen capability were connected to the correct PORVs. This resulted in one of two required PORVs not being connecttd to the backup nitrogen system as required by design. j i l l This is a Severity Level III. violation (Supplement I). { B. ( 10 CFR 50, Appendix B, Criterion XVI, requires, in part, that measures be i established to assure that ,tenditions adverse to quality are promptly identified and corrected. , . l Contrary to the above, on January 2, V187, the licensee did not establish l measures to assure that conditions adverse to quality were promptly ! identified and corrected when test data indicated possible fouling of Containment Spray System Hat Exchanger 2A. This information was not brought to the attention of appropriate personnel until February 17, 1987. This is a Severity Level IV violatlon (Supplement I). i l l C. Technical Specification 6.8.1 requires that written procedures shall be established, implemented, and maintained cover 4ng the applicable procedures recommended in Appendix A to Regulatory Guide 1.33, Revision 2, February 1978. Appendix A of Regulatory Guide 1.33, states that procedures are required covering the surveillance testing of safety-related equipment. NUREG-0940 1.B-7 i
}
n u ;r; . y; l . .g M i h, m ,
-) '
h.Noticeof ik0ation
, 3 Contrary to the above, on November 6, 1986, operators failed to properly
~
T implement surveillance testing procedure PT/1/A/4600/03C in that the vent t valve in the normal' air. supply line was closed at the wrong point in the g procedure. In addition, the procebre was inadequate to establish the
; test of the PORVs utilizing the nitrogen backup supply in that' air. trapped-
,between a check valve and the pressurizer PORVs was capable of stroking the PORV more than one complete cycle.
'This is a Severity; Level IV violation (Supplement 1).
Pursuant to the provis"fons.of 10 CFR 2.201', Duke Power Company is hereby . rq uired to submit a written' statement or explanation to the U.S. Nuclear I Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with ! a copy to the Regional A hinistrator, Region 11, and a copy to the NRC Resident-Inspector, Catawba Nuclebe Station within 30 days of the date of the letter transmitting this' Notice', This reply,should be clearly marked as a " Reply to a , Notice of Violat %a" and should include for each violation: (1) the reason for the violation if vdmitted, (2) the corre'ctive steps that have been taken and
!!he results achieved, (3)-the corrective ',tepsithat will be taken to avoid q further violations, and (4)Vthe 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 s Notice, an order may be issued to show cause why the license should not be l
. modified, suspended, or' revoked or why such other action as may be proper 1 should not be taken.
- l h j FOR THE NUCLEAR REGULATORY COMMISSION ]
1 i
, h J. Nelson Grace n
- Regional Administrator i batedatAtlanta, Georgia this/5d day of May 1987 i
i NUREG OsM I.B-8
.t
t 1 n> U
/gemich*% UNITED STATES -
fj.,,#( "" NUCLE AR REGULATO.RY COMMISSION 5 S, 4 l REGION I 631 PARM AVINUE e...+
./ xiNo or PnucstA,PINNsVLVANIA 19406 April 28,1987 ,
l Docket No'. 50-412 License No. CPPR-105 EA 86-190 l Duquesne Light Company ATTN; Mr. J. J. Carey Vice President Nuclear Group
' Post Office Box 4-Shippingport, Pennsylvania 15077 Gentleman:
Subject:
NOTICE Of VIOLATION (INSPECTION REPORT NO. 50-412/86-29) This refers to the routine NRC inspection conducted between September 29 and October 3, 1986 at the Beaver Valley Nuclear Power Station, Unit 2,
$hippingport, Pennsylvania of activities authorized by NRC Construction Permit
.CpPR-105. During the inspection, a violation of NRC reporting requirements was identified. The details were provided in the inspection report sent to you by letter dated December 30, 1986. Specifically, in response'to NRC Information Notice 83-38 which described potential' deficiencies with printed circuit cards in the-Westinghouse 7300 Process Protection System, (1) Stone and Webster Engineering Corporation (SWEC), your principal contractor, conducted a review in 1983 and identified deficiencies with certain Temperature Channel Test (NTC) cards, but the' final Construction Deficiency Report (COR) submitted to the NRC in'accordance with 10 CFR 50.55(e) did not adequately describe, as required, the' actions taken to correct the deficient NTC cards; and (2) after your Quality Control Department subsequently identified the existence of Loop Power Supply (NLP) cards at Beaver Valley 2, contrary to statements in your interim and final CDRs, a su;plemental CDR was not sent to the NRC until approximately 20 months later,
'Although actions were promptly taken to correct both the NTC and NLP circuit card deficiencies once they were identified, thereby minimizing any potential safety issue, the NRC is concerred that SWEC did not perform an adequate review in response to the hRC Information Notice, resulting in failure to detect promptly the problem with the NLP cards, and the transmittal of traccurate ir. formation to the TAC. This lack of early resolution of potential safety issues demonstrates the importance of adequate managemer.t control of activities performed by your c:* tractors. Therefore, you should assure, during presert and~ future work perf ormed by contractors at your f acility, that their activi-ties are given adequate management oversight and control. Further, you shculd ensure that identified prcblems are not only promptly cerrected, b i are promptly and completely reported to the NRC when required.
NUREG-0940 1.B-9
[
/-
m
!i Duquesne Li9nt Company 2 a
The ilolation of 10 CFR,.b0.55(e) is described in the enclosed Noti:e of m VicShtion. in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), this violatio1 is classified as 3. Severity Level 111 violation. A civil peanity 15 (qnsidered for a Severity Le,el 111 violation. However, after consultation with the Conmistion, I nave decided that a civil penalty will not be proposed in this cate decause (!) written reports were made to the NRC, although the supplemen-tal report w&s untj7ely, (2) although the description of the cerrective actions irithe final report vis inadegaate, tMe specific problems, when identified, were promptly corrected, and (3) based on your history of reporting, this appears to be an isolated occurrence. Nonetheless,,we esphasize that any similar problems in the future may res;1t in additional enforcement action. _- , The Ni.C is also concerned that your interim and . fir,al CDRs submitted on July 19 and Augdst 26, 1983, contained inaccurate inforNatien in that they stated thas no NLP cards existed at Beaver Valley 2, wber, in fact, the subsequent. review in le34 by your QC Depa'tmeot concluded otherwise. S.nce the transmittal of the inaccurate information was apparently caused by in inadequate review and site inspection by SWEC, and there was no apparert attenpt to deceive the NRC, no enforcement action is being takeF in this instar.ce. Nonetheless, tne NRC emphisizes that the traesnittal of inaccurate informatico will not be tolerated.
'v ed should take those actions nec35sary to assure that all communications with
,the NRC are cnmpi'te and accurate, and all rev'tws upon which the communication,s ct e' based hav0 been thoroughly performed.
Yo) are required to respond to this letter and the erclased Notice, and in
. i pcepering your response, you sheuld follow the instructions set forth in the Hotice, in your response, you should docudent the specific actions teken and ar.y additional actions j.Su plan to prevent recurrence. After reviewing your response to the Notice, including your proposed corrective actions and the re: tts of future inspections, the NT,C will determine whether f urther N9C t
e n i a rc emer.t action is necessary to ensure compliance with NRC regulatory s , re airements.
- !? ,in accerdarce e'th Secticn 2.790 of the NRC'.s " Roles of Practice." Part 2.
' Title 10, Code of Federal Regulations, a ccpy of. this letter and its enclosure will be olaced in the NRC Public Documant Roon .
The responset t rected by this letter and the enclosed Notice are not subject to the clear 3nce procedures of the Office of Management znd Budget as required by the aperwork L Recu:.t.or - Act of 1980, Pub. L. No >96-511. i . 6t' REG-0940 1.3-10
y
- Duquesne: Light Company l 3'
[ ,,.-
.Your cooperation with us-in-this matter is' appreciated.
Sincerely, h.T William T. Russell Regional Administrator
Enclosure:
. Notice of Violation
'cc w/ enc 1:
[; J. Woolever, Vice President, Special Projects E. Ewing, Quality Assurance Manager R. - J. Swiderski, Manager, . Startup Group J, P. Thomas, Manager, Engineering R. L Martin, Manager,. Regulatory Affairs C. 0. Richardson. . Stone: and Webster Engineering Corporation Public. Document Room (POR)
' Nuclear Safety Information Center (NSIC)
NRC Resident Inspector C ommonwe a l t'.- of Pennsylvania
'NUREG-0940 I.B-11
'i.1 NOTICE OF VIOLATION Duquesne Light Company Docket No. 50-412 Beaver Valley Nuclear Power Station, Unit 2 License No. CPPR-105 EA 86-190 q During an NRC inspection conducted between September 29 and October 3, 1986, a violation of NRC requirements was identified. In accordance with the " General i Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the violation is set forth belew:
10 CFR 50.55(e) requires, in part, that the Commission be notified within 24 hours, and with a written report within 30 days, of each deficiency in design and construction which, were it to have remained uncorrected., could have affected adversely the safety of operations at any time throughout the expected lifetime of the plant, and which represents a significant deficiency in construction which will require extensive redesign or repair to establish the adequacy of the component to perform ' its intended safety function. The written report shall include a des-cription of the corrective actions taken and sufficient information to permit analysis and evaluation of the deliciency and of the corrective action. Contrary to the above, Duquesne Light Company (DLC) did not adequately describe, as required by 10 CFR 50.55(e), the corrective actions taken and provide sufficient information to permit analysis and evaluation of a deficiency and of corrective action for the deficiency that, were it to have remained uncorrected, could have affected adversely the safety of operations and that required extensive repair / redesign to establish its adequacy to perform its intended safety function. Specifically:
- a. On June 16, 1983, the NRC was notified by DLC that an error was I identified in the Westinghouse 7300 Process Protection System i involving deficient Temperature Channel Test (NTC) circuit cards at a' Beaver Valley 2. The final written report of the deficiencies submitted to the NRC on August ?6, 1983 did not adequately describe :
the corrective actions in that the report stated the NTC circuit ! cards would be replaced. However, NTC circuit card, in safety-related l Balance-of-Plant applications were subsequently determined to be I acceptable and NTC cards in the process protection system were subsequently modified by the installation of an additional circuit board, and the NRC was not notified of this change in corrective ; actions. ] I NUREG-0940 I.B-12
l 4 l i Appendix A 2
- b. On July 25, 1984, deficiencies were identified by DLC involving 21 deficient Loop Power Supply (NLP) circuit cards in the Westinghouse 7300 Process Protection System and the Commission was not notified within 24 hours, and a written report required to be submitted within 30 days was not provided until March 13, 1986.
This is a Severity Level III violation (Supplement II). Pursuant to the provisions of 10 CFR 2.201, Duquesne Light Company is hereby required to submit to this office within thirty days of the date of the letter which transmitted this Notice, a written statement or explanation in reply, including: (1) the reason for the violation, if admitted; (2) the corrective steps which have been taken and the results achieved; (3) corrective steps which will be taken to avoid fu.ther violations; and (4) the.date when full compliance will be achieved. Where good.cause is shown, consideration will be given to extending this response time. FOR THE NUCLEAR REGULATORY COMMISSION
& .T. f = = >d William T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania, this2(Aday of April 1987.
l NUREG-0940 I.B-13
UNITED 5f ATES [gs* IfcgD^ o NUCLEAR REGULATORY COMMISSION y" , REatoN n jf j 101 MARIETTA STRE ET.N.W. j
*
- ATLANT A, GEORGI A 30323 l
\,..u / ... JUN29 E 1
i i Docket Nos. 50-321, 50-366 J License Nos. OPR-57, NPF-5 1 EA-87-111 { l i Georgia. Power Compey ATTN: Mr. James P. O'Reilly Senior Vice President-Nuclear Operations P. O. Box 4545 Atlanta, GA 30302 Gentlemen: , i
SUBJECT:
NOTICE OF VIOLATION ) (NRC INSPECTION REPORT NOS. 50-321/87-13 AND 50-366/87-13) { l This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by J C. H. Bassett at your Hatch facility on June 8-12, 1987. The inspection : included a review of the circumstances surrounding a shipment of radioactive ' materials with dose rates on the external surface of the packages in excess of I regulatory limits. At tne conclusion of the inspection, the, findings were discussed with those members of your staff identified in the . enclosed inspection report. NRC concern: relative to the inspection findings were discussed.by V. L. Brownlee, Chief, Reactor Projects Branch 2, NRC, Region II, and L. Gucwa, Manager, Nuclear Safety and Licensing of your staff in an Enforcement Conference held by telephone on June 17, 1987. The violation described in the enclosed Notice of Violation involves a failure to comply with regulations applicable to the t'ansportation r of licensed material. Two boxes of radioactive material with dose rates above the Department of Transportation (DOT) limit of 1000 millirem per hour at the surface of the package were shipped to the radioactive waste disposal site near Barnwell, SC. This event occurred due to the fact that personnel responsible for shipping such material were unaware of changes in the DOT regulations. In accordance with the " General Statement of Policy and procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the violation described in the enclosed Notice has been classified a Severity Level III violation. Normally, a civil penalty is considered for a Severity Level III violation. However, af ter consultation with the Director, Of, Lice of Enforcement, I have decided that a civil penalty will not be proposed in this case because a civil penalty has already been assessed by the State of South Carolina. 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 doc.ument the specific actions taken and any additional actions you plan to prevent recurrence. Af ter reviewing your response to this Notice, including your proposed corrective actions, the NRC will determine whether further NRC enforcement action is necessary to- ensure compliance with NRC regulatory requirements. NUREG-0940 I.B-14
Georgia Power Company 2 Yourl attention is' invited to the unresolved. item identified in the inspection-
. report.- This matter will be pursued during. future inspections.
- 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 placedlinthe NRC Public Document Room.
The responses. directed by this letter and its enclosures are not subject to the clearance procedures of the Office of Management and Budget as required by the
' Paperwork Reduction Act of 1980, PL 96-511.
Should you have any questions concerning this letter,_please contact us. Sincerely, v J. elson Grace d Regional Administrator
Enclosures:
- 1. Notice of Violation
- 2. Inspection Report cc w/ enc 15:
J. T. Beckham, Vice President, Plant Hatch
.H. C. Nix, Site Operations General Manager A. Fraser, Acting Site QA Supervisor L. Gucwa, Manager, Nuclear Safety and Licensing l
l d (; i NUREG-0940 I.B-15
ENCLOSURE 1 NOTICE OF VIOLATION Georgia Power Company Docket Nos. 50-321 and 50-366 Edwin I. Hatch Nuclear Plant License Nos. DPR-57 and NPF-5 EA-87-111 During the Nuclear Regulatory Commission (NRC) inspection conducted on June 8-12, 1987, a violation of NRC requirements was identified. The violation involved failure to comply with DOT shipping requirements. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the viole. tion is listed below: 10 CFR 71.5(a) requires each licensee who transports licensed material outside the confines of its plant or other place of use to comply with the applicable requirements of the regulations of the Department of Transportation (DOT) presented in 49 CFR Parts 170 through 189. 49 CFR 173,441 (b) (1) requires that radiation levels at any point on the external surface of a package transported by exclusive use vehicle not exceed 1000 millirem per hour. Contrary to the above, on February 27, 1987, the licensee failed to ensure compliance with 00T shipping requirements in that two metal boxes of radioactive material', shipment number 87-012-RW, were shipped to the low level radioactive waste disposal site near Barnwell, SC, with radiation levels in excess of 1000 millirem per hour. One box, designated as HPN-87-033, had a contact radiation level of 1300 millirem per hour and the other box, designated as HPN-87-034, had a contact radiation level of 2200 millirem per hour. This is a Severity Level III violation (Supplement V). Pursuant to the provision of 10 CFR 2.2A1, Hatch Nuclear Plant is hereby required to submit to this Office within 30 days of the date of the letter transmitting this Notice a written statement of explanation in reply including (1) admission or denial of the violation, (2) the reason for the violation if admitted, (3) the corrective steps which have been taken and 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. FOR THE NUCLEAR REGULATORY COMMISSION f Yw[
' J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia this i!M day of June 1987 NUREG-0940 I.B-16
8[t>90tCy o g e UNITED STATES NUCLEAR REGULATORY COMMISSION
$ ,I REGION I e 631 PARK AVENUE
\g ,o#c KING OF PRUSSIA, PENNSYl.VANIA 194o6
***O JUN 151987 Docket Nos. 50-387 and 50-388 License Nos. NPF-14 and NPF-22 EA 85-112 Pennsylvania Power & Light Company ATTN: Mr. H. W. Keiser Vice President Nuclear Operations 2 North Ninth Street Allentown, Pennsylvania 18101 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NOS. 50-387/85-06 : AND 50-388/85-06) This refers to a special team inspection conducted on February 11-15, 1985, at the Susquehanna Steam Electric Station to review compliance with the requirements of 10 CFR Part 50, Appendix R. The inspection report was forwarded to you on April 29, 1985. During the inspection, violations of NRC requirements were identified. Two violations were described in a Notice of Violation transmitted with the April 29, 1985 letter. The other violations were discussed with you and members of your staff at meetings in Betnesda, Maryland on February 26 and May 15, 1985, and at an enforcement conference on October 1, 1985 during which the causes of the violations and your corrective actions were discussed. The enforcement action on this matter was then held in abeyance while the Commission resolved a number of issues pertaining to Appendix R implementation and enforce-ment. Those actions have now been resolved and we are proceeding to issue this enforcement action. Violation I described in the enclosed Notice of Violation (Notice) involves the i failure to provide adequate fire protection features for systems necessary to achieve and maintain hot shutdown as required by your license. The failure to provide adequate fire protection features was caused, in large part, by a deficiency in the fire hazards analysis. In the fire hazards analysis, indivi-dual fire zones were evaluated without taking into account the fact that the fire zones were separated by fire barriers which were not properly fire l rated. Without fire barriers of proper fire rating, there was no assurance that a fire would not propagate to adjacent fire zones. Therefore, redundant , safe shutdown equipment, although within separate fire zones, was not provided with sufficient separation or fire detection and suppression features as required by 10 CFR Part 50, Appendix R, Sectio'n III.G. Three examples were identified by the NRC in which redundant systems were found not to have been provided the required fire protection features. NUREG-0940 I.B-17
. Pennsylvania Power &. Light Company 2 I The NRC views the violation to be significant in.that the NRC had provided specific guidance in this. area. The need for licensees to conduct further analysis to assure compliance with the requirements of Section III.G of.
-Appendix R was brought to the attention of members of.your staff during the NRC Appendix R workshop held in King of Prussia, Pennsylvania on April 18, 1984.
Nonetheless, it appears that the original analysis by fire zones was viewed as meeting Appendix R requirements and no re-analysis was performed. The failure to perform a re-analysis by fire area demonstrates the lack of adequate manage-ment attention-to your fire protection program. After the NRC identified these concerns, your actions demonstrated an appreciation of the significance of these-matters in theLprompt initiation of an expedited re-analysis and commitment to any required modifications,-the immediate initiation of compensatory fire watches, and a commitment to maintain these fire watches. until final resolution-of these Concerns. In accordance with'the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), Violation I described in the enclosed Notice has been categorized as a Severity Level III violation. A civil penalty is considered for a Severity Level III violation or problem. However, af ter consultation with the Commission and the Deputy Executive Director for Regional Operations, I have been authorized to issue the enclosed Notice, without a civil penalty. A civil penalty is not being proposed beccuse of the apparent lack of clarity which existed regarding the fire protection requirements, the significant time that has elapsed since the inspection occurred and your prompt actions after the violations were identified. Given these factors, a
. civil penalty is not considered warranted. Violation II in the' enclosed Notice )
involves the .inadequcte battery rating for an emergency lighting unit. Because this violation involves an issue of less serious concern, it has been categorized. at a Severity Level IV. You are required to respond to this letter and should follow the instructions specified in.the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. You may reference previous submittals regarding this matter in your. response to this letter. In accordance with Section 2.790 of the NRC's " Rules and 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 1.8-18
J. Pennsylvania Power.& Light Company 3 4 The responses directed by this letter and the enclosed Notice are not subject j to the clearance procedures of the Office of Management and Budget,'otherwise. required by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, ' l 7 f _ AA0 William T. Russell Regional Administrator
Enclosure:
Notice of Violation cc w/ enclosure: A. R. Sabol, Manager, Nuclear Quality Assurance E. A. Heckman, Licensing Group Supervisor R. G. Byram, Superintendent of Plant-SSES H. W. Hirst, Manager, Joint Generation Projects Department R. J. Benich, Services Project Manager, General Electric Company B.' D. Kenyon,. Senior Vice President-Nuclear Bryan A. Snapp, Esquire, Assistant Cooperate Counsel Herbert D. Woodeshick,-Special Office of the President J. C. Tilton, III, Allegheny Electric Cooperative Public Document Room (PDR) Local Public Document Room (LPDR) Nuclear Safety Information Center (NSIC) i NRC Resident Inspector Commonwealth of Pennsylvania i j
)
1 l l l 1 NUREG-0940 I.8-19 i I
l NOTICE OF VIOLATION Pennsylvania Power & Light Company Docket Nos. 50-387, 50-388 Susquehanna Steam Electric Station, License Nos. NPF-14, NPF-22 Units 1 and 2 EA 85-112 An NRC inspection was conducted on February 11-15,.1985 to review the implementation of fire protection requirements delineated in 10 CFR Part 50, Appendix R, at the Susquehanna Steam Electric Station, Units 1 and 2. During the inspection, certain violations of NRC requirements were identified. Two of the violations were described in a Notice of Violation issued on April 29, 1985. In accordance with the " General Statement of Policy and Procedure for ) NRC Enforcement Actions," 10 CFR Part 2. Appendix C (1987), the violations are set forth below:
- 1. The SusqJehanna Unit 1 Operating License NPF-14, Paragraph 2.C(6), requires k the licensee to maintain the fire protection program set forth in Appendix !
R to 10 CFR Part 50. The Susquehanna Unit 2 Operating License NPF-22, I Paragraph 2.C(3), requires the licensee to maintain in effect and fully I implement all provisions of the approved fire protection program. In a letter dated March 26, 1981 to the NRC, the licensee stated that the Susquehanna Fire Protection Program would be implemented in accordance l with Appendix R, particularly Sections III.G, J, and O. The fire protec-tion program was approved by the staff in the Safety Evaluation Report and associated Supplements 1 - 3. 10 CFR Part 50, Appendix R. Section III.G.1 requires that fire protection features shall be provided for structures, systems, and components important to safe shutdown. These features shall be capable of limiting fire damage so that one train of systems necessary to achieve and maintain hot shutdown conditions from either the control room or emergency control station (s) is free of fire damage. Sections III.G.2 and III.G.3 specify four alternatives that may be implemented j outside of primary containment to assure that one redundant train of equipment ' cabling and associated circuits necessary to achieve and maintain hot shut-down remain free of fire damage. The alternatives are: Separation of redundant trains of equipment, cabling and associated circuits by a three-hour rated fire barrier. l Separation of redundant trains of equipment, cabling and associated circuits by a horizontal distance of 20 feet with no intervening combustibles and fire detectinn and automatic fire suppression ( I systems installed in the area. Enclosure of redundant trains of equipment, cabling and associated j circuits by a one-hour rated fire barrier with fire detection and i automatic fire suppression systems installed in the area. I NUREG-0940 1.B-20
2 l
, Installation of alternative or dedicated shutdown capability inde-pendent er the equipment, cabling and associated circuits under consideration, and installation of fire detection and fixed fire suppression systems in the area under consideration.
i f Contrary to the above, as of February 15, 19.85, fire protection features were not provided for certain redundant trains of equipment and/or cabling located outside the primary containment and necessary to achieve and maintain hot shutdown conditions from either the control room or emergency control stations-such that one train would remain ~ free of fire damage and none of the alternatives provided by Section III.G.2 and III.G.3 were implemented. Specifically: A. Redundant trains of residual heat removal (RHR) pumps located in the RHR pump rooms of Units 1 and 2 (Fire Zones 1-1E,1-IF, 2-1E, 2-1F) were separated by more than 20 feet with no intervening combustibles and provided with fire detection capability. However, the suppression system provided was not automatic. No alternative or dedicated shutdown capability was provided. B. Electrical power and control raceways (Nos. E1K 715, E2P J19, E2K J19, F2K 123) located in the Containment Access Area of Unit 2 (Fire Zone 2-4A) were provided with fire detection and automatic suppression capabilities, but were not enclosed by a one-hour fire barrier, or separated by a horizontal distance of 20 feet. No alternative or dedicated shutdown capability was provided. C. Redundant trains of safe shutdown equipment , located in the Equipment Removal Room of Unit 2 (Fire Zone 2-3B) were not separated by three-hour fire barriers and were provided with automatic suppression capability in only a portion of the area. No alternative or dedicated shutdown capability was provided. This is a Severity Level III violation (Supplement I). II. The Susquehanna Unit 1 Operating License NPF-14, Paragraph 2.C(6), requires the licensee to maintain the fire protection program set forth in Appendix ; R to 10 CFR Part 50. The Susquehanna Unit 2 Operating License NPF-22, Paragraph 2.C(3), requires the licensee to maintain in effect and fully i implement all provisions of the approved fire protection program. In a l letter dated March 26, 1981 to the NRC, the licensee stated that the Susquehanna Fire Protection Program would be implemented in accordance with Appendix R, particularly Sections III.G, J, and O. The fire protec-tion program was approved by the staff in the Safety Evaluation Report and associatea Supplements 1 - 3. 10 CFR Part 50, Appendix R, Section III.J. requires that emergency lighting units with at least an 8-hour battery . power supply be provided in all areas needed for operation of safe shutdown equipment and in access and egress routes thereto. I NUREG-0940 I.B-21 i
')
3 I l
- Contrary to the above,'as of February 15, 1985, the battery power supply {
for the emergency lighting unit provided in the stairwell to the Remote { Shutdown Panel at elevation 670-feet of the Unit 2 Reactor Building was
.only rated for 3.75 hours.
This is a' Severity Level IV violation (Supplement I). Pursuant to the provisions of '10 CFR 2.201, Pennsylvania Power and Light. . Company.is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with a copy.to the Regional Administrator, Region I'and 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 i
- Violation" and should include for each violation: (1) the reason for the vio-lation 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. 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 licensee should not be modified, suspended, or revoked or why such other action as inay be proper should not be taken. Consideration may be given to extending the response time for good cause shown.
FOR THE NUCLEAR REGULATORY COMMISSION
}
h f f/ __ _
,D D William T. Russell (
Regional Administrator
]
Dated at King of Prussia, Pennsylvania, this l$ day A of June 1987.
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I l 4 NUREG-0940 1.B-22 __a
, f nc jo, UNITED STATES l
8, ' ,e NUCLEAR REGULATORY COMMISSION l$ o ,$ REGION I
$ 4 631 PARK AVENUE
,o# KING oF PRUSSIA. PENNSYLVANIA 1M06 '
JW I 51987 Docket No. 50-272 License No. DPR-70 EA 84-36 Public Service Electric and Gas Company ATTN: Mr. Corbin A. McNeill, Jr. Vice President - Nuclear P. O. Box 236 Hancock's Bridge, New Jersey 08038 Gentlemen:
Subject:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 50-272/83-37) This refers to a special team inspection conducted on December 5-6, 1983, and January 16-20, 1984, at the Salem Nuclear. Generating Station, Unit 1, Hancock's Bridge, NJ of activities authorized by NRC Licer se No. DPR-70. The inspection report was forwarded to you on March 2, 1984. T ht- inspection was conducted to review your compliance with the requirements of 10 CFR Part 50, Appendix R, Section III.G, regarding fire protection features for equipment necessary to achieve and maintain safe shutdown. During the inspection, several viola-tions of these requirements were identified. The violations were discussed with members of your staff at the meeting held on January 20, 1984. The enforcement action on this matter was then held in abeyance while the Commission resolved a number of issues pertaining to Appendix R implementation and enforce-ment. These actions have now been resolved and we are proceeding to issue this enforcement action. Violation A in the enclosed Notice of Violation (Notice) involves the failure to provide adequate fire protection features for systems necessary to achieve and maintain hot shutdown as required by Section III.G for_ redundant equipment located outside the primary containment. Violation B in the Notice involves the failure 90 provide adequate fire protection features for systems necessary to achieve cold shutdown conditions or provide evidence of the capability to repair such equipment within 72 hours. Violation C in the Notice involves the failure to provide adequate fire protection features for systems necessary to achieve and maintain hot shutdown conditions for equipment located inside a non-inerted containment. i The violations identified indicate weaknesses in your fire protection program l at the time of the inspection. In accordance with the " General Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem. A civil penalty is considered for a Severity Level III violation or problem. However, after consultation with the Commission and the Deputy Executive Director for Regional Operations, I l have been authorized to issue the enclosed Notice without a civil penalty. A , NUREG-0940 I.B-23
a Public Service Electric and Gas Company. 2 c'ivil penalty is not being proposed because of the apparent lack of clarity which existed regarding the fire protection requirements and the significant time that has elapsed since the inspection occurred. Given these factors, a civil' penalty is not considered warranted. You are required'to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. You may reference previous submittals regarding this matter in your response to this letter. 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 j will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject s to the clearance procedures of the Office of Management and Budget as required ' by the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, M .T. [_m = t0( William T. Russell Regional Administrator
Enclosure:
Notice of Violation cc w/ enc 1: J. M. Zupko, Jr., General Manager - Salem Operations B. A. Preston, Manager, Licensing and Regulation C. P. Johnson, Manager, Quality Assurance Nuclear Operations General Manager - Nuclear Safety Review M. J. Wetterhahn, Esquire 1 R. Fryling, Jr., Esquire ) Public Document Room (PDR) l Local Public Document Room (LPDR) ' Nuclear Safety Information Center (NSIC) f NRC Resident Inspector l State of New Jersey NUREG-0940 1.B-24
l , j l
'l NOTICE OF VIOLATION j
Public Service Electric and Gas Company. Docket No. 50-272 3
-Salem Nuclear Generating Station License No. DPR-70 Unit 1 EA 84-36 A special fire protection inspection conducted at the Salem Nuclear Generating Station on December 5-6, 1983'and January 16-20, 1984 identified violations of NRC requirements. In accordance with the " General Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the violations are set forth below:
10 CFR 50.48(b) requires in part that all nuclear power. plants licensed to operate prior to January.1,1979, such as Salem Nuclear Generating Station, Unit-1, shall. satisfy the applicable. requirements of Appendix R to Part 50 including, specifically, the requirements of Sections III.G, Fire Protection of Safe Shutdown Capability, III.J, Emergency Lighting, and III.0, Oil Collection System for Reactor Coolant Pump. A. 10 CFR Part 50, Appendix R, Section III.G.1 requires that fire protection features shall be provided for structures, systems, and components important.to safe shutdown. These features shall be capable.of limiting fire damage so that one train of systems neces-sary to achieve and maintain hot shutdown conditions from either the control room or emergency control stations is free of fire damage. Section III.G.2 and III.G.3 specify alternatives that may be implemented outside of primary containment to assure that one redundant train of equipment, cabling and associated circuits necessary to achieve and maintain hot shutdown remains free of fire damage. The alternatives are:
- 1. Separation of redundant trains of equipment, cabling and associated circuits by a three-hour rated fire barrier.
- 2. Separation of redundant trains of equipment, cabling and associated circuits by a horizontal distance of 20 feet with no intervening combustibles and fire detection and automatic fire suppression systems installed in the area.
- 3. Enclosure of redundant trains of equipment, cabling and associated circuits by a one-hour rated fire barrier with l- fire detection and automatic fire suppression systems installed in the area.
- 4. Installation of alternative or dedicated shutdown capability i independent of the equipment, cabling and associated circuits under consideration, and installation of fire detection and fixed fire suppression systems in ttle area under consideration. I I
1 l NUREG-0940 1.B-25
2 Contrary to the above, as of January 20, 1984, fire protection features were not provided for certain redundant trains of equipment and/or cabling located outside the primary containment necessary to achieve and maintain hot shutdown conditions from either the control room or emergency control stations such that one train would remain free of fire damage and none of the alternatives provided by Section III.G.2 or III.G.3 were implemented. Specifically:
- 1. Redundant charging pumps 11, 12, and 13 in the auxiliary building, 84' elevation, required for hot shutdown were not separated by a three-hour fire barrier and the separation distance was less than 20 feet. Fire detection was provided; j however, the automatic fire suppression was not area wide. One 4 of the redundant trains was not enclosed in a one-hour fire barrier and no alternative or dedicated shutdown capabilities were provided.
- 2. The redundant 460 VAC/230 VAC switchgear located in the l auxiliary building, 84' elevation, and required for hot shutdown, were not separated by a three-hour fire barrier. l Although the separation distance was greater than 20 feet, l there were intervening combustibles consisting of horizontal l cable trays and cables. The installed CO 5"PP"'5SI " 5Y5t'*5 2
were not automatic. The installed one-hour fire barriers ; (partial height partitions) between the redundant switchgear i did not completely enclose one of the redundant trains and ) there were no alternative or dedicated shutdown capabilities ! provided. I
- 3. The redundant service water motor control centers (MCCs) located in the intake structure and required for hot shutdown, were separated by three-hour rated concrete walls. However, the doors on these walls were not three-hour rated. The distance between the MCCs was greater than 20 feet and there was fire detection in the area; however, there was no automatic fire suppression. In addition, neither of the redundant trains were enclosed in a one-hour fire barrier and there were no alterna-tive or dedicated shutdown capabilities provided.
B. 10 CFR Part 50, Appendix R, Section III.G.1.b, requires that systems necessary to achieve and maintain cold shutdown from the control room I or emergency control station (s) can be repaired within 72 hours. Contrary to the above, as of January 20, 1984, redundant Resident Heat Removal pumps (11 and 12) required for cold shutdown were not capable of being repaired within 72 hours as demonstrated by the absence of planning, procedures, and/or materials necessary to implement fire damage repairs. NUREG-0940 1.B-26
3 i C. 10 CFR Part 50, Appendix R, Section.III.G.2, requires that, for redundant trains of systems necessary to achieve and maintain hot shutdown conditions inside non-inerted. containments, one of six i (III.G.2.a-f) fire protection means shall be provided. Contrary to the above, as of January 20, 1984, none of the alternatives , (III.G.2.a-f) were satisfied for the pressurizer heater termination ! cabinet and pressurizer level and pressure instrumentation cabinet 355, ! which were located inside the primary containment and relied upon in the i fire hazards analysis to achieve and maintain hot shutdown conditions; This is a Severity Level III problem (Supplement I). ! Pursuant to the provisions of 10 CFR 2.201, Public Service Electric and Gas Company is hereoy required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, Region I and a copy to the NRC Resident Inspector within 30 days of the date of the letter trans-mitting this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted, (2) the corrective steps that have been taken and the results achieved, (3) *' corrective steps that will be taken to avoid further violations, and (4) the datr hen full compliance will be achieved, tihere good cause is shown, considert . on 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 licensee 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. FOR THE NUCLEAR REGULATORY COMMISSION
- h. Y. =' _
William T. Russell Regional Administrator Dated a3 King of Prussia, Pennsylvania, this l$'tiay of June 1987.
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JUN 0 8 1987 ; i Docket No. 50-328 License No. DPR-79 EA 85-48 Tennessee Valley Authority ATTN: Mr. S.A.. White. Manager of Nuclear Power ! 6N 38A-Lookout Place 1101 Market Street Chattanooga, TN. 37402-2801
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT N05. 50-327/85-01 AND50-328/85-01) Gentlemen: As.a result of deficiencies identified by the NRC during a July 16-20, 1984 Appendix R inspection at Tennessee Valley Authority's (TVA) Watts Bar facility, a Confinnation of Action Letter concerning the implementation of 10 CFR Part 50 Appendix R, Sections III.G III.J. III.L and III.0 was issued to the Sequoyah
-Nuclear. Plant (SNP) by Region II on August 10, 1984. TVA's re-evaluation at SNP was completed on December 21, 1984. A special safety inspection was conducted on January 14-18, 1985 at SNP Units 1 and 2 to evaluate the adequacy of TVA's perfonnance with respect to fire protection at SNP. As a result of the inspection, numerous violations of NRC. requirements were identified, some j of which you had' identified previously. The report which documents this l inspection was sent to you with a letter dated March 29, 1985. An Enforcement '
Conference to discuss the violations was held in the NRC Region II Office on February 28, 1985. The enforcement action on this matter was then held in abeyance while the Comission resolved a number of issues pertaining to Appendix R implementation and enforcement. Those actions have now been resolmd and we are proceeding to issue this enforcement action. Violatun I.A.1 described in the enclosed Notice of Violation (Notice) involves 36 examples in 19 different plant areas in which b3th trains of redundant hot shutdown systems could have been rendered inoperable in the. event of a fire. . ; Thus, the plant's ability to achieve and maintain hot shutdown was not assured. ' Violation I.A.2 involves 245 circuits that had a common power source with other shutdown equipment and which were not properly electrically protected from the
' circuit of concern. These circuits could have prevented operation or caused malfunction of equipment necessary to achieve and maintain hot shutdown conditions in the event of a fire., Violation I.B involves 13 examples in which both redundant trains of cabling for systems necessary to achieve and maintain cold shutdown were located in the same fire area and therefore could have been rendered inoperable had there been a fire.
The number of examples of noncompliance that were identified in 1984 are of I concern to the NRC because they are indicative of weaknetses in TVA's original review, design, construction and modifications made to implement the requirements of 10 CFR Part 50, Appendix R for Sequoyah Unit 2. We recognize that since this NUREG-0940 I.B-28
Tennessee Valley Authority . inspection you have taken actions to correct t.he deficiencies. We expect that ) SNP 2 will either be in compliance with Appendix R or have approved compensatory I measures in place prior to restart. However, in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions " 10 CFR Part 2 Appendix C (1987), Violations I.A and I.B described in the enclosed Notice have been categorized in the aggregate as a Severity Level II problem because the numerous violations identified in hot shutdown and cold shutdown systems ' lead us to conclude that a fire in these areas would have damaged equipment to the extent that safe shutdown would not have been achieved and maintained in the event of a fire. A civil penalty is normally proposed for a Severity Level II violation or problem absent mitigating circumstances. However, after consultation with the Comission , and the Deputy Executive Director for Regional Operations, I have been authorized to issue the enclosed Notice without a civil penalty. Because of the apparent lack of clarity which existed regarding the fire protection requirements, the significant time that has elapsed since the inspection associated with these violations, and after considering the unique circumstances at TVA involving the extensive efforts to identify and correct problems including some of the cited violations, I have concluded that issuance of a civil penalty at this time is unnecessary. - Violation II.A in the enclosed Notice involves design deficiencies associated
.with the reactor coolant pump oil collection systems; Violation II.B involves deficiencies associated with cable fire barrier assemblies; and Violation II.C involves deficiencies associated with the emergency lighting units. Collectively, these violations have been characterized as a Severity Level IV 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 retorrence. You may reference* previous submittals regarding this matter in your response to this letter. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC's Public Document Room. The responses directed by this letter and its enclosure are not subject to the clearance' procedures of the Office of Management and Budget issued under the Paperwork Reduction Act of 1980, PL 96-511. . Sincerely, 1 S h qA c- - ames G. Keppler, Director j Office of Special Projects l l
Enclosure:
See next Page NUREG-0940 1.8-29
Tennessee Valley Authority - 3.-
Enclosure:
Notice of Violation ec w/ encl: H. L.-Abercrombie, Site Director Sequoyah Nuclear Plant J. A. Kirkebo, Acting Director Nuclear Engineering-R. L. Gridley, Director Nuclear Safety and Licensing M. R. Harding, Site Licensing Manager ! { l I i i i i NUREG-0940 1.B-30
i NOTICE OF VIOLATION Tcnnessee VaMey Authority Docket No. 50-328 S:quoyah Un',t 2 License No. DPR-79 EA 85-48 As a result of an inspection conducted on January 14-18, 1985, violations of NRC fire protection requirements were identified. In accordance with the j
" General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR ~
Part 2. Appendix C (1987), the violations are set forth below:
- i. Operating License DPR-79, Section 2.C.(13)c for Unit 2 requires that TVA shall comply with Section III.G, III.J. III.L. and III.0 of Appendix R of 10 CFR Part 50, except where NRC has approved deviations. The NRC had not approved any deviations from these sections.
A. 10 CFR Part 50, Appendix R, Section III.G.1 requires that fire protection features shall be provided for structures, systems, and components important to safe shutdown. These features shall be capable of limiting fire damage so that one train of systems necessary to achieve and maintain hot shutdown from either the control room or emergency control station (s) is free of fire damage. Sections III.G.2 and III.G.3 specify four alternatives that may be implemented outside of primary containment to assure that one redundant train of equipment, cabling, and associated circuits necessary to achieve and maintain hot shutdown remains free of ! fire damage. The alternatives are: Separation of redundant trains of equipment, cabling, and associated circuits by a three-hour rated fire barrier. Separation of redundant trains of equipment, cabling, and associated circuits by a horizontal distance of 20 feet with no intervening combustibles and fire detection and automatic fire suppression systems installed in the area. Enclosc*e of redundant trains of equipment, cabling, and associated circuits by a one-hour rated fire barrier with fire detection and automatic fire suppression systems installed in the area. Installation of alternative or dedicated shutdown capability independent of the equipment, cabling, and associated circuits under consideration, and installation of fire detection and J fixed fire suppression systems in the area under consideration. j i Contrary to the above, as of August 10, 1984, fire protection features were not provided for certain redundant trains of l equipment and/or cabling necessary to achieve and maintain hot shutdown from either the control room or emergency control stations such that one train would remain free of fire damage. The redundant i trains of equipment and/or cabling were located in the same fire ) l NUREG-0940 I.B-31
Notice of Violation . area outside the primary containment. None of C e alternatives provided by Section III.G.2 and III.G.3 were implemented. Specifically:
- 1. Thirty-six examples within 19 plant areas existed in which both redundant trains were located in the same fire area and not provided the fire protection features of Section III.G.2 or '
III.G.3. These areas involved systems such as auxiliary feedwater, component cooling water, essential raw cooling water, chemical volume and control, pressurizer heater controls, steam generator inventory control, and on-site power distribution.
- 2. Two hundred forty-five associated circuits having a common j power source with shutdown equipment which could prevent operation or cause malfunction of equipment necessary to I achieve and maitetain hot shutdown conditions were not properly electrically protected from the circuit of concern nor provided the fire protection features of Section III.G.2 or III.G.3.
B. 10 CFR Part 50, Appendix R, Section III.G.1.b requires that systems i necessary to achieve and maintain cold shutdown from the control room I or emergency control station (s) can be repaired within 72 hours. l Contrary to the above, as of August 10, 1984, the redundant trains of equipment and cabling necessary to achieve cold shutdown conditions were not capable of being repaired within 72 hours as demonstrated by the absence of planning, procedures, and/or materials necessary to implement fire damage repairs. Thirteen areas existed in which : both redundant trains of cabling were located in the same fire area. Collectively, these violations have been categorized 6s a Severity Level 11 problem (Supplement I). II. Operating License DPR-79, Section 2.C.(13)c for Unit 2 requires that TVA shall comply with Section III.G III.J, and 111.0 of Appendix R of 10 CFR Part 50, except where NRC has approved deviations. The NRC has not approved deviations in the areas of Sections 111.0 and III.J. cited below. A. 10 CFR Part 50, Appendix R, Section III.0, requires the reactor coolant pumps to be equipped with an oil collection system if the containment is not inerted during normal operations. The system is required to be designed, engineered, and installed such that failure will not lead to fire during normal or design basis accident conditions and such that the system will withstand the Safe Shutdown Earthquake. All leakage from potential pressurized and unpressurized leakage sites is to be collected and drained to a vented closed container that can hold the entire lube oil system inventory. NUREG-0940 I.B-32
i 1 Notice of Violation i Contrary to the above, as of August 10, 1984, and with a containment. l not inerted during nomal operations, the reactor coolant pump oil collection systems were not designed, engineered, or installed to withstand the Safe Shutdown Earthquake. In addition, the drainage tank m not designed to hold the entire reactor coolant pump lube oil system inventory.-
- 8. Technical Specification, Section 6.8.1.f. requires that written procedures be established, implemented, and maintained for the fire 3 I
protection program. TVA's. approved fire protection program, as discussed in an October 23, 1979 response to the NRC's Auxiliary , Systems Branch, indicates in Table 1.3 which circuits- are to be protected by a 1/2-hour. fire rated barrier. Contrary to the above, as of January 14-18, 1985 TVA had not implemented its procedures fcr the approved fire protection program in that the 1/2-hour fire barriers required by Table 1.3 for conduits 2PM101I, 2PM21141I, and 2PM2084I in the auxiliary building were found to be partially missing or damaged and, therefore, did not meet the required fire rating. C. 10 CFR Part 50, Appendix R, Section III.J., requires emergency lighting units with at least an.8-hour battery power supply to be provided in all areas needed for operation of safe shutdown equipment and in access and egress routes thereto. Contrary to the above, as of January 14-18, 1985, the existing emergency lighting units had battery power supplies rated at 3 3/4-hours and lighting units were provided for only 76 of approximately 150 areas needed for operation of safe shutdown equipment and in access and egress routes _thereto. Collectively, these violations have been categorized as a Severity Level IV problem (Supplements). Pursuant to the provisions of 10 CFR 2.201, Tennessee Valley Authority is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC l 20555 with a copy to the Director, Office of Special Projects, and a copy to the NRC Resident Inspector within 30 days of the date of the letter trans-mitting this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted, (2) the corrective steps that have been taken and the results achieved. (3) the corrective steps that will be taken.to avoid further violations, and (4) the date when full tonipliance will be achieved. Where good cause is shown, consideration will be given to extending the response NUREG-0940 I.8-33
t Notice of Violation 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 licensee 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. FOR THE NUCLEAR REGULATORY COMMISSION
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C % m h g feV, otrector 65amess.Kepp Office of Special Projects Dated at Bethesda, Maryland this s#day of June 1987. l NUREG-0940 I.B-34
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Dock't e No. 50-271 -
' License No. DPR-28 EA 84-7 ,
Vermont Yankee Nuclear Power Corporation h" ATTN: Mr. Warren P. Murphy Vice President and Manager of Operations ' RD 5, Box 169 i Ferry Road . Brattleboro, Vermont 05301 { Gentlemen: t
'l
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECT 1'0N REPOR7 NO. 50-271/83-26) y This refers to a special team inspection conducted on August 19 - September 2, 1983, at the Vermont Yankee Nuclear Power Stathn, Vernon, Vermont, of activi-ties authorized by NRC License No. OPR-28. Ay.opy of the inspection report was forwarded to you on November 2, 1983. The in~spection was conducted to review your compliance with the requirements of 10 CFR Part 50, Appendix R, Section III.G, regarding fire protection featuresifor equipment necessary to achieve and maintain safe shutdown. During the inspection, violations of these requirements were identified. The violations were discussed with you and
' members of your staff at a meeting in Region I on November 22, 1983 and at an ;
Enforcement Conference on January 10, 1984. The enforcement action on this matter was then held in abeyance while the Commission resolved a number of issues pertaining to Appendix R implementati6n and enforcement. These actions 3 have now been resolved and we are proceeding to issue this action. The violation in the enclosed Notice of Violation (Notict) involves five examples of the f a, are to provide adequate fire protection features for systems and electrical cabling necessary to achieve and maintain hot shutdown as required by Section III.G of Appendix R, for redundant equipment,, located outside the , primary containment. The violation appears to have been the result of an l inadequate reassessment of the fire protection features'at Vermont Yankee. ] Discussions with y: mel at the time of the inspection indicated that I no modifications had oe s lesented by Yermont Yankee Nuclear Power-i Corporation beyond those previously made to comply with NRC Bruch Technical Position (BTP) 9.5-1. This BTP stated the NRC's fire protection guidelines prior to Appendix R becoming effective. NAC Generic Letter 82-12 dated February 20, 1981 specifically emphasizech he need to reassess fire protection features at your f acility to assure comphance with the new NRC requirements in this area, Your ef forts to improve fire protection f atures at Vermont Yankee prior to the adoption of the requirements contained in Appendix R were considered. However, the failure to recognize the need to upgrade the fire protection features after NUREG-0940 I.B-35 1
, 7-4' h:
I' k Vefrant Yankee Nuc? ear, Power i
% f.prporation. g 2 7- .
5, _ t.imse requirements became effective indicates a significant breakdown in your i e f ferts for assuring compliance with NRC requirements. The failure to recognize l
.this need for evaluation and upgrade was evidenced by the five examples of the violation in the enclosed Notice and also by the fact, that a study. was not i performed to assure that associated circuits in the Reactor Building were adequately protected from the effects of a fire. )
In,accordance with the " General Policy and Procedure for NRC Enforcement Actions," j ICi CFR Part' 2, Apperdix C (1987), the violation described in the enclosed Notice i hwe been categorized as a Severity Level III violation. A civil penalty is ccm.idered for a Severity ' Level III violation or problem. However, after Mnsultation with the Commission and.the Deputy Executive Director for Regional Operations, I have'been authorized to issue the enclosed Notice without a civil penalty. -A_ civil penalty is not being proposed because of the apparent lack of clarity which existed regarding the fire protection . requirements and the , significant time that has elapsed since the inspection occurred. Given these I factors, a civil penal _ty is not considered warranted. i
~ I You are hquired to respond to.this letter and should follow the instructions l' specifitd in the enclosed Notice when preparing your response. .In your response, you should document the specific actions taken and any additional actions you plan.tp prevent recurrence. You may reference previous submittals regarding this ;
matter' jn your response to this letter, 1 i In accordance.with Section 2.790 of the NRC's " Rules and Practice," Part 2 j Title 10, Code of Federal Reguistions, a copy of this letter and its enclosure 1 will be placed in the NRC Public Document Room. j The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Managemerit and Budget, otherwise required by the Paperwo k Reduction Act of 1980, PL 96-511. S n Sincerely, i 1 hWilliam lW-_-f~ faR T. Russell 5 Regional Administrator i
Enclosure:
Notice of Violation cc w/ enc 1: I R. W. Capstick, Licensing Engineer J. Gary Weigand, President and Chief Executive Officer
~
J. P. Pelletier, Plant Manager > Donald-Hunter, Vice President Cort Richardson, Vermont Public Interest Research Group, Inc. Gernald Tarran). Commissioner, Department of Public Service
, State of New Hampshire ;
State of Vermont NUREG-0940 I.B-36
NOTICE OF VIOLATION I Vermont Yankee Nuclear Power Corporation Docket No. 50-271 i l Vermont Yankee Nuclear Power Station License No. OPR-28 EA 84-7 A special fire protection inspection conducted at the Vermont Yankee site during the period of August 29 - September 2,1983 identified violations of NRC require-ments. In accordance with the " General Policy and Procedure for NRC Enforcement Actions," 10 CTR Part 2, Appendix C (1987), the violations are set forth below: 10 CFR 50.48(b) requires in part that all nuclear power olants licensed to operate prior to January 1, 1979, such as Vermont Yankee Nuclear Power Station, shall satisfy the applicable requirements of Appendix R to Part 50 including, specifically, the requirements of Sections III.G, Fire Protection of Safe Shutdown Capability, III.J. Emergency Lighting, and 111.0, 011 Collection System.for Reactor Coolant Pump. 10 CFR Part 50, Appendix R, Section III.G.1 requires that fire protection features shall be provided for structures, systems, and components impor-tant to safe shutdown. These features shall be capable of limiting fire damage so that one train of systems necessary to achieve and maintain hot shutdown conditions from either the control room or emergency control station (s) is free of fire damage. Sections III.G.2 and III.G.3 specify four alternatives that may be implemented outside of primary containment to assure that one redundant train of equipment, cabling and associated circuits necessary to achieve and maintain hot shutdown remains free of fire damage. The alternatives are: l Separation of redundant trains of equipment, cabling and associated circuits by a tnree-hour rated fire barrier. l i Separation of redundant trains of equipment, cabling and associated l circuits by a horizontal distance of 20 feet with no intervening I combustibles and fire detection and automatic fire suppression systems installed in the area. Enclosure of redundant trains of equipment, cabling and associated , circuits by a one-hour ratec fire barrier with fire detection and I automatic fire suppression systems installed in the area. Installation of alternative or dedicated shutdown' capability independent of the equipment, cabling a1d associated circuits under consideration, and installation of fire detection and fixed fire suppression systems in the area under consideration. NUREG-0940 I.B-37
u 9' 7 ,
)
y , Appendix A 2 r ,
~,
"3 '
Centrary to the above, as of September ?,1983, fire protection features were not provided for certain redundant trains of equipment and/or cabu ng necessary to achieve and maintain hot shutdown conditions from either the the control room or emergency cor trol stations such that one train woulri t remain free of fire damage. These equipinent and/or cables were located in the reactor building (RB) outside primary containment. None of the ' alternatives provided by Appendii R, Section III.G.2 or IILG.3 were irrpj emented. Sticifically: g , A ," a. For redundant trains of s';stemt necessary for hot shutdown t s j and in the northwest of the1RD, elevation 252', although the i ' redundant ccble trays, ::onta41ng control, instrumentation, and some power cables, were separated by more than 20' feet and there g was fire detection in tne area, au ssequate" fire' suppression system was not instal _ led in that the fitit suppression system was-1 placed beneath the louest' level of cable P Ays which contained cable not qualified as. fire resistant by IEEE-383. No alterna-tive or dedicated snuhdown capabilities were provided.
- k. ,For redundant controi' cables located in cable tray'R330SII ano conduit .ll188JSIIX for the high pressure coolant injection '
(HFCI) ard the re;ctor core isolation cooling (RCIC) inboard ' isolation valves V13-15 and V23-15, there was less than 20 feet
'@Y '
of separation and there wat no fire suppression or fire detectier.- system at elevation 252' of the RB. No alternative'or dedicated
,;y ,
, shutdog capabilities were provided. 1
' ~
- c. Wator control centers 89B and 99 W.ch power RCIC and HPCI i
; inboard isolation valves V13-15 and V23-35 respecti M y, were 4 ~
>eparated by greater than 20 feet; however, there were inter-vening combustibles in t% form of epan cJble trays-and there was no automatic fire suppression.fn the trea. No alternative y or dedicated shutdown capabilities were prcvided.
I
- d. For the reactor vessel level an6 pressure ',.ransmitter's located '
at elevation 280' of the RB, althcagh thera was more than 20 feet of separation, there was no automtic fire suppression or detection in the vicinity of the inst"vesnt racks. No alterna-tive or dedicated shutdown capabilities were provided.
- e. The redundant power cables to motor control centers BB and 98, j in the personnel corridor which lead to the r.orthwest corner of the RB, were separated by less that 20 feet and did not have
. automatic fire suppression or detection in the wea. No alter- i o
native or dedicated shutdown capabilities were provided. ! l This is a Severity Love; III violation (Supplemer' ./. s l
'NUREG-0940 1.B-38
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i 1 l i Appendix A 3 1 l l Pursuant to the provisions of 10 CFR 2.201, Vermont Yankee Nuclear Power Corporation is hereby required to submit a written statement or explanation to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, Region I and a copy to the NRC Resident Inspector within 30 days of the date of the letter trans-mitting this Notice. This reply should be clearly marked as a " Reply to a Notice of Violation" and should include for each violation: (1) the reason for the violation if admitted, (2) the corrective steps that have been taken '
.and the results achieved, (3) the corrective steps that will be taken to avoid further violations, and (4) the date when full ccepliance 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 licensee 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. FOR THE NUCLEAR REGULATORY COMMISSION g;[t Cf f William T. Russell Pegional Administrator Dated at King of Prussia, Pennsylvania this If d ay d of June 1937. l l l 1 i NUREG-0940 I.B-39
l 1 j II.A. NATERIALS LICENSEES, CIVIL PENALTIES AND ORDERS l l NUREG-0940
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fbrch 13, 1987 Docket No. 70-27 License No. SNM-42 EA 87-24^ Babcock and.Wilcox Company ATTN: Mr. R. E. Tetrault, Vice President Naval Nuclear Fuel Division P. C. Rox 785 Lynchburg, VA 24505-0785 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 70-27/87-01) This' refers to the Nuclear Regulatory Commission (NRC) inspection onducted by Dr.-B. 'K. Revsin at the Babcock and Wilcox Naval Nuclear Fuel Division (NNFD) on
, January 12-16, 1987. The report documenting this inspection was sent to you with a letter dated January 28, 1987. As a result of this inspection, significant failures to comply with NRC regulatory requirements pertaining to your radiological protection program were-identified. Accordingly, NRC concerns relative to the inspection findings were discussed by Dr. J. N. Grace, Regional T Administrator, NRC, Region II, with you and members of your staff in er Enforcement Conference held on .lanuary 29, 1987.
Collectively, the violations described in the enclosed Motice of Violation and Proposed Imposition of Civil Penalty indicata a failure to implement critical-elements of your Radiation Protection Program and demonstrate the need for . improved management control of your licensed activities to ensure adhererce to ! NRC requirements and safe performance of licensed activities. On the basis c' our inspection and your presentation at the Enforcemmt Conference, it appears that the radiation protection program at NNFD contained deficiencies that have the potential to adversely affect the fac41ity's ability to ensure effective protection of employees from licensed radioactive raterial. While we recognize ,
.that your corrective actions, as described during the Enforcement Conference, should result in a significant improvement in the performance o' your licensed activities, it is essential that management involvement be an ongoing effort. !
To emphasize the importance of adherence to NRC requirements, I have been l authorized, after consultation with the Director Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Six Thousand Two Hundred Fifty Dollars ($6,250) for the-violations described in the enclosed Notice. In accordance with the" l
" General Statement of Policy and Procedure for NRC Enforcement Action," 10 CFR j Part 2, Appendix C (1986) (Enforcement Policy), the violations described in the 'i enclosed Notice have been categorized in the aggregate as a Severity Level III 2 problem. The base value of a c1vil penalty for a Severity level III problem is
$12,500. The NRC Enforcement Policy allows for reduction of a civil penalty under CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-1
Babcock and Wilcox Company 2 March 13, 1987 certain circumstances. In this case, the base civil penalty amount has been reduced by 50 percent because unusually prompt and extensive corrective actions , have been undertaken. 1 You are required to respond to the letter and should follow the instructions in the enclosed Notice when preparing your response. in your response ( you ; should'doce:nent the specific actions taken end any additional actions you plan i to prevent resurrence. -After reviewing your response to this Notice, including 1 your proposed corrective ections, the NRC will determine whether further NRC l 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 i will be placed in the NRC Public Document Rnom.
]
The. responses directed by this letter and its enclosure are 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. Should you have any questions concerning this letter, please contact us. ; Sincerely, ca p . / --- +o [ J. Nelsor. Grace ; Regional Administrator i
Enclosure:
l Notice of Violation and Proposed ' Irrposition of Civil Penalty cc w/ enc 1: C. Boyd, Nuclear Safety and Licensing Officer NUREG-0940 II.A-2
i NOTICE OF VIOLATION AND
' PROPOSED IMPOSITIU F0F CIVIL PENALTY o
' Babcock and Wilcox Company Docket No. 70-27
-Naval Nuclear Fuel Division License No. SNM-42 EA 87-24 During the Nuclear' Regulatory Commission (NRC) inspection conducted on January 12-16, 1987, violations of NRC requirements were identified. In accordance with Enforcement the "10 Actions," General Statement CFR Part of Policy 2, Appendix C 1986),(and theProcedure for NRC Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic.EnergyActof1954,asamended("Act"),42U.S.C.2282,and10CFR2.205.
-The particular violations and associated civil penalty are set forth below:
A.. 10 CFR 20.201(b) requires each. licensee to make or cause to be made such surveys as may be necessary for the licensee to comply with the regulations in 10 CFR Part 20 and are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present. 10 CFR 20.201(a) defines a survey to mean an evaluation of the radiation
'hezards' incident to the production, use, release, disposal, or presence of radioactive materials or cther sources of radiation under a specific-set of conditions. When appropriate, such evaluation includes a physical survey of the location of materials and equipment, and measurements of levels of !
radiation or concentrations of radioactive material present, j Contrary to'the above,
- 1. From 1984 to January 16, 1987, release surveys of personnel exiting restricted areas were inadquate since personnel monitoring devices used by the licensee.were not calibrated.
- 2. On January 14, 1987, surveys were not performed by personnel exiting the decontamination laundry, a restricted area, since N personnel monitoring device was available.
- 3. On January 15, 1987, licensee personnel failed to perform surveys to ersure that clean area contamination limits were met when licensee personnel,werf observed removing cans of uranium from Storage Vault JA, a contaminated area, to a clean area.
- 4. On January 14, 1987, containers used to transport contaminated .
protective clothing to the decontamination laundry facility were not adequately surveyed prior to release from the restricted area in that both removable and fixed contamination levels in excess of license limits were measured by the NRC inspector on containers present in the laundry. NUREG-0940 II.A-3
r Notice of Violation B. 10 CFR 20.203Id)(2) requires that each airborne radioactivity area be conspicuously posted with a sion or signs bearing the radiation caution symbol and the words: " Caution (or Danger), Airborne Radioactivity Area." ' 10 CFR 20.203(d)(1) defines airborne radioactivity area to mean (1) any room, enclosure, or operating area in which airborne radioactive materials composed wholly or partly of licensed material exist in concentrations in excess of the amounts specified in Appendix R, Table 1, Column 1 of 10 CFR Part 20, or (2) any room, enclosure, or operating area in which airborne radioactive material composed wholly or partly of licensed
.aterial exists in concentrations which, averaged over the number of hours in any week during which individuals are in the area, exceed 25 percent of the amounts specified in Appendix B, Table 1, Column 1 of 10 CFR Part 20.
Contrary to the above, weekly airborne radioactivity concentrations in the highly enriched uranium (HEU) area of the research reactor fuel element (RRFE) area exceeded 25 percent of the concentrations specified in 10 CFR Part 20, Appendix B, Table 1. Column 1, during the third week cf October, the first three weeks of November, and the second week of December 1986, and during the first week of January 1987. In addition, the area was not posted as an airborne radioactivity area. C. 10 CFR 20.203(f)(1) and (3) reouire each container of licensed material to bear a durable, clearly visible label identifying the radioactive contents when licensed material is present in quantities greater than the applicable cuantities specified in Appendix C of 10 CFR Part 20. 10 CFR 20.203 (f)(2) specifies that the above label shall bear the radiation caution symbol and the words: " Caution (orDanger), Radioactive Material," and shall provide sufficient information to permit individuals handling or using the containers, or working in the vicinity thereof, to take precautions to avoid or minimize exposures. Contrary to the above, on January 14, 1987, containers used to transport contaminated protective clothing to the decontamination laundry and contain-ing greater than 10 CFR Part 20, Appendix C, quantities of uranium-235 were not labeled. D. License Condition 9.of Special Nuclear Material License No. SNM-42 requires that licensed material be used in accordance with statements, representations, and conditions contained in Sections I through IV and IX of the application dated February 22, 1982, and supplements, dated February 21 and November 8, 1083, March 14, April 11, and May 3, 1984. Section IV, Chapter 3, Paragraph 3.5.3.C, of the application reouires air filters to be changed after each shift if the quarterly average of the results for the area exceed 10 percent of the maximum permissible concentration (MPC) specified in 10 CFR 20, Appendix B, Table 1, Column 1. Section IV, Chapter 3, Paragraph 3.3.1, of the application reouires that fixed air sampler stations whose weekly average exceed 25 percent of the MPC
!.pecified in 10 CFR 20, Appendix B. Table 1, Column 1, be investigated and the corrective action taken to be dncumented.
NUREG-0940 11.A-4
Notice of Violation Section IV,' Chap"tr 3, p 41ph 3.5.3, of the application requires outside areas with a= smear test action level of 3 dpm/100 cm2 to be surveyed on a weekly frequency. Section II, Chapter 2, Paragraph 2.6.C. of the application states that audi+s performed at the facility shall be performed per a written plan and that the radiation control officer shall make quarterly audits of plant areas, report to management concerning the operational adequacy.of the radiation protection program, and maintain records of these audits. Section IV, Chapter 3.2, Nragraph 3.2, of the application requires hand-monitor source counts to 'oe performed weekly using a National Bureau nf Standards (NPS) traceable source. Section II, Chapter 2, of the application requires the Radiation Control Supervisor or the Manager, Radiation Safety and Licensing, to overcheck j instrument calibrations. j Section IV, Chapter 3, Paraoraph 3.5.3.C. of the application requires shoe covers and coveralls to be worn in hot areas (areas greater than 100 dpm/100 cm2) and lab coats to be worn in " intermediate" and "special" areas. Contrary.to the above,
- 1. The requirement to change air samples on a shift. basis when the quarterly average exceeds 10 percent of MPC was not met during the
. fourth quarter 1986 when air samples collected near the are melting furnaces of the HEU area of the RRFE exceeded 10 percent of MPC on a quarterly average and air sample filters were not changed each shift. '
The licensee continued to collect daily air samples.
\
- 2. Weekly averages of air sample stations exceeding 25 percent of MPC were I not investigated nor corrective action taken in the HEU area of the RRFE during the first week of November 1986 when one air sample station averaged 25.89 percent of MPC and during the third week in November 1986 when three air sample stations averaged 28.51 percent, 27.58 percent, and 43.05 percent.
- 3. Surveys of outside areas with a smear test actinn level of 3 dpm/100 cme were not performed weekly from February through ,
December 1986, and the laundry (an outside area) was surveyed only monthly.
- 4. Quarterly audits by the radiation control officer did not meet the spectfied requirements during 1986 and 1987 when audits were not performed pursuant to a written plan.
- 5. The requirement to use an NBS traceable source when performing hand- !
monitored source counts was not met. Since 1984, instrument responses -l to radiation were performed using sources not traceable to NBS. NUREG-0940 II.A-5 1
Notice of Violation 6. On January 15, 1987, the requirement _for the Radiation Control Supervisor or the Manager, Radiation Safety and licens k;. to overcheck instrument calibrations was not met when a review of the iistrument calibration data had not been performed by either individuti.
- 7. On January 15, 1987, a licensee employee crossed the contamination contro'1 boundary in storage vault 1A, e hot area, and was not vearing the required protective clothing.
- 8. On January 15, 1987, a licensee employee handled one-gallon cans of radioactive material in Storage Vault IA, a hot area, and was wearing protective clothing' inappropriately in that the lab coat worn by the individual was unbuttoned, providing no protection to the front of the body.
- 9. On January 14, 1987, personnel assigned to the decontamination laundry were not provided with adequate protective clothing when surface contamination levels required the use of coveralls and shoe covers. I E. 10 CFR 19.12 reouires that all individuals working in or frequenting any portion of a restricted area shall be instructed in the health protection problems associated with exposure to such radioactive materials or radiation, in precautions or procedures to ininimize exposure, and in the purposes and functions of protective devices employed. This section further !
provides that the extent of the instructions shall be commensurate with potential radiological health protection problems in the restricted area. License Condition 9 of Special Nuclear Material License No. SNM-4? requires that licensed material be used in accordance with statements, representations, and conditions contained in Sections I through IV and IX of the application dated February 22, 1982, and supplements dated February 21 and November 8, 1983, March 14, April 11, and May 3, 1984. Section IV, Chapter 2, Paragraph 2.1, of the application states that employees ! handling uranium in a readily dispersible form (unciad uranium) shall receive additional on-the-job training. Contrary to the above, on January 15, 1987, one individual, assigned to work , in the decontamination laundry, a designated restricted area, handled protective clothing contaminated with unciad uranium and had not received on-the-job training commensurate with the radiological hazard associated with the handling of that form of material. F. License Condition 9 of Special Nuclear Material License No. SNM-42 requires that licensed material be used in accordance with statements, representations, and conditions contained in Sections I through IV and IX of the application dated February 22. 1982, and supplements, dated February 21 and November 8, 1983, March 14 April 11, and May 3, 1994. Section IV, Chapter 1, of the application requires that radiation safety procedures to ensure compliance with regulatory requirements be maintaired. NUf1G-0940 II.A-6
Notice of Violatier Procedure A66-23, Fixed Air Samples, October 15, 1986, Paragraph 3.2 states that a " Notice of Radiation Incident" report will be completed when the action point for fixed air samplers is exceeded based on a weekly average. ; Paragraph F.P.4 of this procedure states that copies of a monthly report i summarizing weekly air sample reports shall be sent to the Manager of !' Health, Safety and Licensing, and the Health Physicists. Procedure A66-05, Contamination Control Procedure, September 27, 198a, j specifies a two-tier action level for loose contamination which includes: ) (1) when the action level for an area is exceeded, the area will be cleaned and retested at least by the following work day and (2) if the loose contamination test exceeds 200 disintegrations per minute per one hundred I square centimeters (200 dpm/100 cm r ), immediate cleaning and retesting of I the area are required. I Contrary to the above,
- 1. During the first and third weeks of November 1986, an action point of 25 percent of MPC was exceeded for four fixed air samplers in the PEU-RRFE, and no " Notice of Radiation incident" was completed.
- 2. During 1986, copies of the monthly report summarizing weekly air sample reports were not routed as required in that no copies were sent to the Manager of Health, Safety and Licensing.
- 3. Retesting of areas exceeding action levels by the followirg work day was not performed in the Chemistry laboratory on October 14, October 28, i November 4, November 20, and December 16, 1986, when loose contamination I exceeded the 5 dpm/100 cmr action level, and retesting was not performed by at least the following work day.
4 Immediate retesting of areas exceeding 200 dpm/100 cm2 was not performed as required in the recovery / incinerator area when 365 dpm/100 cmr and , 330 dpm/100 cmr were measured on September 26, 1986, and 242 dpm/100 cmr was measured on September 11, 1986. I
- 5. The requirement for the tacility to maintain procedures for the control of radiation safety and to ensure regulatory compliance was not met in that Procedure.E78-17, Operation of Hand Monitor, September 14, 1984, j was inadequate because it addresses a generation of hand monitors no longer in use at the facility.
G. 10 CFR 19.11(a)(4) recuires each licensee to post any notice of NRC i violations involving radiological working conditions and any response from the licensee. 10 CFP 19,11(e) requires the Notice of Violation to be posted within two working days after receipt of the documen's from the Commission and the licensee's response to be posted within two working days after dispatch by the licensee. Such documents shall remain posted for a minimum of five l working days or until action correcting the violation has been completed, whichever is later. l NUREG-0940 II.A-7 l l i
i flotice of Violation Contrary to the above, as of January 16, 1987, the licensee had failed to post a Notice of Violation forwarded by letter dated November 26, 1986, in conjunction with Inspection Report No. 70-27/86-17, and the licensea's < response to the Notice of Violation dated December 23, 1986. Collectively, these violations have been evaluated in the aggregate as a Severity Level III prcblem (Supplements IV and VI). 1 (Cumulative Civil Penalty - $6,250 assessed equally among the violations.) ! l Pursuant to the provisions of 10 CFR 2.201, Babcock and Wilcox is hereby required to submit within 30 days of the date of this Notice to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission. Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Pegulatory Commission, Region II,101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, a written statemert or explanation including for each violation: I"i admission or denial of the violation, (2) the reasons for the violation if a uitted. (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 f5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may 1ssue en order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, < 42 U.S.C. 2232, this response shall be submitted under oath or affirmation. I Within the same time as provided for the response required above under 10 CFR 2.201, Babcock and Wilcox may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Six Thousand Two Hundred Fifty Dollars ($6,250) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of I Inspection and Enforcement. Should Babcock end Wilcox fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Babcoch q and Wilcox elect to file an answer in accordance with 10 CFD. 2.205 protestine the civil penalty, such answer 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 raay i request remission or mitigation of the penalty. l ! NUREG-0940 IL A-8
Notice of Violation - 7-
. In'~ requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C, should'be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate- s parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and j paragraph rumbers) to avoid repetition. Babcock and Wilcox's attention 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 orovisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, i or mitigated, may be collected by civil action pursuant to Section 234c of the j Act, 42 U.S.C. 2282. l FOR THE NUCLEAR REGULATORY COMMISSION. j
-s
,A N
/ J. Nelson Grace Regional Administrator Dated at Atlanta, Georgia i this /f day of March 1987 !
1 NUREG-0940 II.A-9 1
L: ' J s. .*,e'og . UNITED STATES ' f[' , , . , 'j NUCLEAR REGULATORY COMMISSION f 5 l REGION I
'p .j
, c 631 PARK AVENUE
,o" MING OF PMUSSIA. PENNSYLVANIA 19406
" a MAR 2 61987 j Docket No.-70-687- i LicenselNo. SNM-639 EA'87-30~
Cintichem, Inc.
.. ATTN: .Mr. James J. McGovern Plant Manager.
P.O. Box'324 Tuxedo, New York' 10987 Gentlemen:
Subject:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION Di CIVIL PENALTY {
.(NRC Inspection No. 87-01) )
l This refers.to the Nuc' lear-Regulatory Commission (NRC) inspections of activities j authorized'by NRC License No. SNM-639 conducted at your facility on December 15- ! through 19, 1986, and January 14 and'15, 1987. During the inspections, violations '; of.NRC requirements were identified, and the details involving these violations were' documented m the inspection report sent to you on February 4, '1987. One of the violations occurred during the third calendar quarter of 1985 and involved an' accumulated radiation exposure of 21.453 rem to the left hand of a maintenance worker'who was handling equipment contaminated with radioactive material. This i exposure, which is in excess of the NRC regulatory limit of 18.75, was not reported to the NRC as required. 'Accordingly, on February 13, 1987, an enforcement conference was held in the Region I Office with you and members of your staff during which these violations, their causes, and your corrective actions were discussed. The majority of the accumulated exposure was received by the worker on July 2 and September 10, 1985 while he performed maintenance on mechanical manipu-lator hands af ter they had been removed from the hot cells for repair. The manipulator hands, which are used during the separation of byproduct material fremsuranium, were contaminated with a mixture of uranium and fission products. 3 Although a 13.946 rem exposure was received by this individual on July 2 which ! comprised approximately 75 percent of the regulatory limit and which was signi-ficantly higher than the 1-2 rem exposure normally encountered during this activity, this individual was nonetheless allowed to perform subsequent mainte-nance on manipulator hands without (1) an adequate evaluation having first been performed to determine the cause of this abnormally high exposure and (2) esta-blishment and implementation of appropriate corrective measures to prevent recurrence. As a result, during the performance of maintenance on a manipulator hand on September 10, the individual received a 5.824 rem exposure which resulted in the accumulated overexposure. l CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-10
j h' ; r- N '. Cintichem, Inc. 2 s
'Notwithstanding this accumulated exposure during the third calendar quarter, .
the worker again performed repairs of a manipulator hand on November 15, 1985 i and received an exposure of.15.641 rem. Allowing this maintenance worker to perform additional; work on' the manipulator hands af ter July 2,1985, without - having first identified and corrected the cause of the' unusually high exposure, . demonstrates a lack of attention. to and control of.the radiation safety program at your facility. 1This. lack of attention and control is further. evidenced by= the other violations identified during the inspection.. including the failure to
. provide these workers adequate instruction regarding (1) occupational exposure limits, (2) performance of surveys, and (3) use of survey results. These deficiencies demonstrate the need for enhanced management involvement-in the -
radiation; safety program to assure adherence to NRC requirements and the. safe performance of licensed activities. To emphasize this need for enhanced management involvement, I have been. authorized, after consultation with the Director, Office of Inspection and Enforcement, to Jssue the. enclosed Notice of Violation and Proposed Imposition of Civil Penalty in:the amount of Twelve'Thousand Five Hundred Dollars.($12,500) for the violations
~
setLforth in the Notice'. The violations are classified in the. aggregate as a
' Severity Level !!! problem-in accordance with the " General Statement.of. Policy and Procedure.for NRC Enforcement Actions," 10 CFR part 2, Appendix C'(1986)
(Enforcement Policy). Although Violation A could individually be classified ~ at Severity Level ,III,. the violations have been classified in the aggregate to focus on the underlying deficiencies. The escalation and mitigation factors in:the Enforcement Policy were considered and no adjustment has been deemed appropriate because (1) you did not report the overexposure to the NRC, (2).the corrective actions were neither prompt nor comprehensive (in fact, many of the actions were not taken until after NRC issuance of a Confirmatory Action Letter on January 20,1987), and (3) three other violations in the area of. radiological controls were identified during previous inspections in 1986. You are required to respond to the enclosed Notice and you should follow the instructions specified in the Notice in 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 enforcement action is necessary to ensure compliance with NRC regulatory requirements.
4 In'accordance with Section 2.790 of the NRC's " Rules of Practice," part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosure will be placed in the NRC's Public Document Room. i NUREG-0940 II.A-11
m if n. l C'i nt i c hem , ' I nc . 3-l- L. l l L ;The: responses directed by this; letter and the enclosed Notice are not subject
;to the clearance procedures of the Office of Management and Budget as' required
~
E> sby the Paperwork Reduction Act'of 1980, PL 96-511. H-l Sincerely, Thomas E. Murley
. Regional . Administrator
Enclosure:
- Notice of Violation'and Proposed Imposition of Civil Penalty-
.cc w/ encl:
Public Document Room-(POR) Nuclear Safety Information Center (NSIC)
' State of.New York NUREG-0940 II.A-12 L
1
o I NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY
, 'C i n t i c h'em , I n c . Docket No. 70-687.
Tuxedo, New York .10987 License No. SNM-639 EA 87-30 During' Nuclear Regulatory Commission (NRC) inspections conducted on December 15
'through 19, 1986, and January 14 and 15,1987, violations of NRC requirements were identified. In accordance'with the " General Statement of Policy and-Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the l
Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1984c as. amended (Act), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and the associated civil penalty are set forth below. A. 10 CFR 20.101(a) limits the total occupational radiation exposure to the hands of an. individual in a restricted area.to 18.75 rem per calendar quarter. Contrary to the above, during the third calendar quarter of 1985, a maintenance worker received a' cumulative exposure to the left hand of 21.453 rem while performing repairs on mechanical manipulator hands in the Radiopharmaceutical Laboratory, a restricted area. B. 10 CFR 20.405(e) requires that each licensee shall notify the NRC in writing within 30 days of an exposure of an individual to radiation in excess of the' applicable limits set forth in 10 CFR 20.101. Contrary to the above, during the third calendar quarter of 1985, a maintenance worker performing repairs on mechanical manipulator hands in the Radiopharmaceutical Laboratory, a restricted area, received a cumula-tive exposure to the left hand of 21.453 rem, an amount in excess of the litrit set forth in 20.101, and the NRC was not notified of the exposure. 1 C. 10 CFR 20.202(a)(1) requires that each licensee shall supply and require l the use of appropriate monitoring equipment by each individual who enters a restricted area under such circumstances that he receives, or.is likely '
-to receive, a dose in any calendar quarter in excess of 25 percent of the k applicable value specified in 20.101(a).
Contrary to the above, on several occasions during 1985 and 1986, an individual entered the Radiopharmaceutical Laboratory, a restricted area,
. where he was likely to receive a radiation exposure to the hands in excess of 25 percent of the limits set forth in 20.101(a) during the l performance of maintenance on highly contaminated manipulator hands, i NUREG-0940 II.A-13
u
,I i
Notice of Viola' tion 2 l l and the individual was not required to use appropriate personnel I monitoring equipment.(TLD rings) on the hands to measure the radiation received..from this activity. D. 10 CFR 20.201(b) requires that each licensee make such surveys as may be necessary to comply with the regulations in Part 20 and are reasonable to evaluate.the extent of radiation hazards that may be present. 10 CFR 20.201(a) defines " survey" as an evaluation of the radiation hazards incident to the production, use, release, disposal, and presence of radioactive materials. Contrary to the above, adequate surveys or evaluations to assure compliance with the regulations were not performed to evaluate the radiological hazards i associated with and the radiation exposure received from operations invol-ving the repair of manipulator hands. Specifically, although the ring ' badge,of a maintenance worker performing repairs of manipulator hands on July 2, September 10, and November 15, 1985 indicated radiation exposures of 13.9 rem, 5.8 rem, and 15.6 rem, respectively, to the hands, amounts significantly in excess of amounts normally received, a subsequent timely, in-depth survey was not performed to evaluate'the work practices associated with this activity and its associated radiation hazards. Furthermore, a l timely evaluation was not performed to determine the actual dose to the worker's hand or to identify the cause of the increase in exposure, in order to prevent subsequent overexposure and to assure compliance with the limits of 10 CFR 20.101. E. 10 CFR 20.401(b) requires each licensee to maintain records showing the l results of surveys required by 10 CFR 20.201(b). j Contrary to the above, records were not maintained of surveys of manipu-lator hands removed from the hot cells during the third and fourth calen-dar quarters of 1985. -) 1 F. 10 CFR 19.12 requires in part that all individuals working in or frequenting i any portion of a restricted area shall be instructed in precautions and procedures to minimize exposure, in the purposes and function of protective 4 devices employed, and in the applicable provisions of Commission regulations I and l' enses for the protection of personnel. Contrary to the above, during the third and fourth calendar quarters of 1985, two individuals performed repair activities of radioactively con-taminated manipulator hands in the Radiopharmaceutical Laboratory, a restricted area, without having been adequately instructed in (1) procedures for performing surveys of radioactive material, as well as instruments and technique to be used; and (2) appropriate criteria and actions to be taken in response to the results of survey measurements; and (3) NRC extremity dose limits in Part 20. l I l
.NUREG-0940 II.A-14 )
i
I 1: 1 J I Notice of Violation 3
'G. 10 CFR 20'.202(b)(3) defines a '.'High radiation area" as any area accessible to personnelfin which there exists radiation originating in whole or .inl j part within' licensed material at such levels that a major. portion of the body'could receive in.any one hour a dose in excess of'100 millirem.
j' 10 CFR 20.203(c)(1) requires that each high radiation area shall be conspicuously posted with a sign or signs bearing the radiation caution I symbol and the words " Caution (or Danger) .High Radiation Area." j Contrary to the above, 1
- 1. .On December'16, 1986, a high-radiation area existed in the ya'rd area outside the Waste Storage Building in which a B-25 shipping container filled with radioactive waste was located, and the " Caution - High Radiation Area" sign was posted inside the 100 mR/hr boundary and thus was not serving as a warning to anyone approaching the boundary.
- 2. On January 15, 1987, a high radiation area existed inside the hot cell conveyor' station:within Building 2, and neither the upper hatch' nor lower door access to the. conveyor station were posted with'a
" Caution - High Radiation Area" sign. Radiation levels in the general area of the conveyor station were as high as 900 mR/hr.
H. 10 CFR 20,203(c)(2)(iii) requires that.each entrance or access point to a high-radiation' area shall be maintained locked except'during periods when access to the area:is required, with positive control over each indi-vidual entry. Contrary to the above, on January 15, 1987, a high radiation area existed inside the hot cell conveyor station within Building 2, and neither the upper hatch nor lower door. access to the hot cell conveyor station was locked or guarded. Collectively, these violations have been classified as a Severity Level III problem (Supplements IV and VI) Cumulative Civil Penalty - 512,500 - assessed equally among the violations. Pursuant to the provisions of 10 CFR 2.201, Cintichem, Inc. is hereby required to submit to the Directc , Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission Region I, 631 Park Avenue, King of Prussia, Pennsylvania 19406, within 30 days of the date of this Notice, a written statement or explanation in reply, including 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 future violations, and (5) the date when full compliance will be achieved. If an NUREG-0940 II.A-15
J Notice of. Violation: 4 I
)
adequate reply is not received within the tirie'specified in' this Notice,' the Director, Of fice of, Inspection and Enforcemen.t, may issue an order to show l 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 ]
i under oath or affirmation. ]
-j Within the same time as provided for the response required above under 10 CFR.
i
'2.201, Cintichem, Inc. may pay the civil penalty,by letter addressed to
- the Director, Office of.-Inspection and Enforcement, with a check. draft, or money order payable to the Treasurer of the United States in the cumulative amount of: Twelve Thousand Five Hundred Dollars ($12,500) or may protest imposi-tion of the civil penalty in whole or in part'by a written answer addressed to the Director,' Office of Inspection and Enforcement. Should Cintichem, Inc. fail to answer within' the time specified, . the Director, Of fice of-Inspection and Enforcement, will issue an order imposing the civil penalty in the amount
- proposed above. Should Cintichem .Inc. elect to file an answer in accordance-l with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the i . violations listed in this' Notice in whole or'in part, (2) demonstrate extenuating l -circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty; in whole or in part, such answer may request remission or mitigation of the penalty.
In requesting mitigation of 'the proposed penalty, the five f actors addressed in Section V.B of 10 CFR Part 2, Appendix C (1986) should be addressed. Any i written answer in accordance with 10 CFR 2. 205 should be set forth separately L from the statement or explanation in reply pursuant to 10 CFR 2.201, but may i incorporate by specific reference (e.g., citing page and paragraph numbers) to ! avoid repetition. The attention of Cintichem, Inc. 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 has been subsequently 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. 2282. FOR THE NUCLEAR REGULATORY COMMISSION Thomas E. Murle Regional Administrator Dated at King of prussia, Pennsylvania, this g day of. March 1987 N UREG-0940 11.A-16
4 e UNITED STATES p**fcg[% NUCLEAR REGULATORY COMMISSION p , ; -) S REolON lli 5M
* :l no moostvELT moao GLEN ELLYN. SLUNOl$ 801 H APR 151987 Docket No. 03000394 License No. 34-00466-02 EA 87-42' Cleveland Citnic Foundation ATTN: William S. Kiser, M.D.
Chairman Board of Governors 9500 Euclid Avenue Cleveland, OH 44106 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION REPORT NO. 030-00394/86001(DRSS) NRC ENFORCEMENT CONFERENCE REPORT NO. 030-00394/87001(DRSS) This refers to the NRC special inspection of activities authorized by NRC license No. 34-00466-02 conducted during the period November 20, 1986 through February 10, 1987. The inspection was conducted in response to a teletherapy misadministration that you identified on November 11, 1986 and reported to the NRC Region III office on November 17, 1986. The inspection report was sent to you on February 12, 1987. During the inspection, violations of NRC requirements were identified. The results of the inspection were discussed on March 4, 1987, during an enforcement conference held in the NRC Region III office between you
. and members of your staff and.Mr. A. B. . Davis and members of the NRC staff. A report addressing the content of the enforcement conference was sent to you on March 18, 1987.
The two violations described in the enclosed Notice, together with statements made by you and members of your staff during the March 4,1987 enforcement conference, have led the NRC staff to conclude that there was a significant programmatic breakdown in management oversight and control of your radiation therapy program. The NRC relies on a licensee's radiation safety staff as well as management personnel at the highest levels to ensure that licensed activities are conducted in accordance with regulatory requirements and the licensee's radiation safety procedures. It should be noted that a contributing factor in the misadministration was a failure to follow a Cleveland Clinic Foundation procedure that required verification of dose calculations before patient treatment was initiated. Although this failure to verify your physicist's calculations is not'a violation of a regulatory requirement, it is the basis of serious concern because it is probable that such a verification would have prevented the misadministration from occurring. The NRC staff has concluded that in the p.ast management has had limited involvement in the radiation safety program at NUREG-0940 II.A-17
Cleveland Clinic Foundation APR i 51987 Cleveland Clinic Fouadation. In reaching this conclusion, we considered that: (1) until mid-1986, the entire radiation safety program was implemented by one individual, the Radiation Safety _ Officer, who reported to many individuals and had many responsibilities within the Clinic which prevented him from devoting adequate time to the radiation safety program; (2) the Radioisotope Committee had not carried out all required actions such as approval of authorized users; (3) there was no effective QA/QC program for radiation safety regulatory compliance, especially as related to reporting of medical therapy misadministra-tions on a timely basis; and (4) there was a significant breakdown in comuni-cation among your staff, especially among the Radiation Safety Officer, the Radioisotope Committee, and the Medical Therapy Staff. In this regard, the Radiation Safety Officer was one of the last individuals to be informed that a misadministration had occurred. To emphasize the importance of (1) adequate understanding of your license conditions and radiation safety procedures by all cognizant personnel and (2) adequate management oversight to verify and ensure adherence to regulatory requirements and procedures, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Two Thousand Five Hundred Dollars ($2,500) for the violations set forth in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, (1986 Enforcement Policy) the violations have been classified in the aggregate as a Severity Level III problem. The base civil penalty for a Severity Level III problem 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. During the enforcement conference it appeared that your corrective actions thus far included, among other things, retaining two consultants to evaluate your radiation therapy program. Further, in a March 13, 1987 letter from you to J. A. Hind of the NRC Region III office you offered to amend your licenses to include a QA/QC Statement of Principles for the Department of Nuclear Medicine. We are concerned, however, that similar ; problems might exist in your nuclear medicine program which is conducted under a brcad scope license. Therefore, in your response describe not only what corrective actions have or will be taken in response to findings of your consultants but also describe how you will make a similar evaluation to ensure the adequacy of the radiation safety aspects of the diagnostic and therapeutic nuclear medicine programs and your research activities. After reviewing your i response to this Notice, including your proposed corrective actions, the NRC ( will determine whether further NRC enforcement action is necessary to ensure i compliance with NRC regulatory requirements. { In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 l Title 10, Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NRC Public Document Room. , i NUREG-0940 II.A-18 ,
l L , Cleveland Clinic Foundation APR 151987 i The responses directed by this letter and the enclosed Notice are not sub.fect to the clearance procedures of the Office of Management and Budget as required by .the Paperwork Reduction Act of 1980, PL 96-511. Sincerely, w A. Bert Davis Acting Regional Administrator
Enclosures:
- 1. Notice of Violation and Proposed Imposition of Civil Penalty 2.- Inspection Report No. 030-00394/86001(DRSS) l I
1 l 1 l NUREG-0940 II.A-19 1
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY Cleveland Clinic Foundation Docket No. 03000394 9500 Euc11d Avenue License No. 34-00466-02 Cleveland, OH-'44106 EA 87-42
- During an NRC inspection conducted during the period November 20, 1986 through February 10, 1987, in response to a teletherapy misadministration identified and. reported to NRC, 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 (1986), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2282 and 10 CFR 2.205. The.
particular violations anc' associated civil penalty are set forth below: A. 10 CFR 35.42(a) requires that', when a misadministration involves any therapy procedure, the licensee notify.the appropriate NRC Regional Office by telephone within 24 hours after the licensee discovers the misadministration. Contrary to the above, on November 11, 1986, the licensee discovered that a misadministration involving a therapy procedure had occurred; however, ; it did not notify the NRC Regional office until November 17, 1986. ' B. License Condition No.12 requires that' licensed material be used by, or under the supervision of, physicians certified by the American Board of Radiology in Radiology or Therapeutic Radiology, and approved by the Cleveland Clinic Radioisotope Committee. Contrary'to the above, as of November 20, 1986, licensed material had been used by, or under the supervision of, physicians who, although
, ' certified by the American Board of Radiology in Radiology or Therapeutic Radiology, had not been approved by the Cleveland Clinic Radioisotope Committee.
Collectively, the above violations have been categorized as a Severity ! Level III problem (Supplement VI). Cumulative Civil Penalty - 52,500. Pursuant to the provisions of 10 CFR 2.201, Cleveland Clinic Foundation is hereby' required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, j Region III, 799 Roosevelt Road, Glen Ellyn, IL 60137 within 30 days of the i date of this Notice a written statement or explanation, including for each ; alleged violation: (1) admission or denial of the alleged violation, (2) the I l 1 NUREG-0940 II.A-20
Notice of Violation APR 151987 reasons for the violation if admitted, (3) the corrective steps that have been i 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. 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 timc as provided for the response required above under l 10 CFR 2.201, Cleveland Clinic Foundation may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, . draf t, or money order payable to the Treasurer of the United States in the i cumulative amount of Two Thousand Five Hundred Dollars (52,500) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should i' Cleveland Clinic Foundation fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should Cleveland Clinic Foundation elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written j answer in accordance with 10 CFR 2.205 should be set forth separately from the ' statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., cite page and paragraph numbers) to avoid repetition. The attention of Cleveland Clinic Foundation 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 has been subsequently i determined in accordance with the applicable provisions of 10 CFR 2.205, this I matter may be referred to the Attorney General, and the penalties, unless I compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. ' FOR THE NUCLEAR REGULATORY COMMISSION CN k k% 9 A. Bert Davis Acting Regional Administrator DatedatglenEllyn,
# Illinois, day of April 1Q87.
this /f-1 I NUREG-0940 II.A-21 l l
p u rg'o UNITED STATES g 8 o NUCLEAR REGULATORY COMMISSION h ,$ ' REGION I 631 PARK AVENUE Q KING OF PRUS$8A, PENNSYLV ANIA 19406
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MAY 1997 Docket No. 030-21261 License No. 37-20848-01. EA 87-54
~Comdustrial Roofing Contractors, Inc.
ATTN: Mr. William McCloskey
. Vice President 3047 Unionville Pike P.O. Box 429 Hatfield, Pennsylvania 19440 1
Gentlemen:
Subject:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection No. 030-21261/86-01) This refers to the NRC inspection of activities authorized by NRC License No. 37-20848-01, conducted on November 19, 1986 and March 10 and 18, 1987 at your former facility in Horsham, Pennsylvania and your current' facility in Hatfield, Pennsylvania, and also at the Harrisburg Steam Generating Station. The report of the inspection was forwarded to you on April 3,1987. During tFe inspection, violations of NL requirements were identified. On April 9, 1987, we held an enforcement conference with you during which the violations, their r causes, and your corrective actions were discussed. The violations, which are described in the enclosed Notice of Violation (Notice), involve the unauthorized storage of a moisture density' gauge containing licensed material and the failure to secure the gauge against unauthorized removal from the place of storage. Following the fire at the licensed location in July 1986, the licensee should have sought prompt authorization for storage of the licensed material in its new location. The failure to adequately secure the device resulted in the apparent inadvertent disposal of the gauge to a landfill. Although it is unlikely that the public health and safety would be adversely affected by this disposal, the violation was preventable and could have resulted in unnecessary exposure of individuals to radiation. To emphasize the importance to assure licensed material is not released into the public domain, including unauthorized disposal, and the importance to notify the.NRC of changed storage locations for licensed materials, I have been autho-rized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Five Hundred Dollars (5500) for the violations described in the enclosed Notice. In.accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. NUREG-0940 II.A-22
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.You are required to respond to the enclosed Notice and should fcl1.cv 3the j ' instructions'specified in the Notice in preparing your response "In?your j response, you should document the' specific actions taken to correct ne viola- ;
tions and.any additional-actions you plan to prevent recurrence. After- i reviewing your response to this Notice, including your proposed cchrective 1 actions, the NRC will determine whether further enforcement action is necessary to, ensure compliance with NRC. regulatory requirements. In accordance with'Section 2.790 of the NRC's " Rules of Practice," Part 2- , Title 10,CodeofFederalRegulations,acopyofth(sletterandtheenclosure will be placed in the NRC's Public Document Room. y 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,, , p w t Willian T. Russell Region 41 Administrator
Enclosure:
Notice of Violation and ; Proposed Imposition of Civil Penalty cc w/ enc 1: Public Document Room (PDR) Nuclear Safety Information Center (NSIC) Commonwealth of Pennsylvania o NUREG-0940 II.A-23
< (+ W h,r $ ys 4'
NOTICE OF VIOLATION l AND PROPOSED IMPOSITION OF CIVIL PENALTY y
- Comdustrial Roofing Contractors, Inc. Docket No. 030-21261 Hatfield,' Pennsylvania, 19440 License No. 37-20848-01 EA 87-54
'During an NRC inspection conducted on November _ 19, 1986 and March 10 and 18, 'l y :1987, violations of NRC, requirements'were identified. In accordance with the :
" General Statement'of Policy and Procedure for NRC Enforcement Actions,"- 1
-10 CFR Part 2,' Appendix:C'(1987), the Nuclear Regulatory Commission proposes ;
to impose a civil penalty-pursuant to Section 234 of the Atomic Energy Act of 1984, as amended (Act), 42 U.S.C. 2282', and 10 CFR 2.205. The particular
- violations and the associated. civil penalty are set forth below.
- 1. 10 CFR 20.207(a) requires that licensed materials stored in'an unrestricted
-area be. secured against unauthorized removal from the place of storage.
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 July 24, 1986 until sometime prior to November 19,- 1986, a moisture density gauge containing approximately 50 ; mil 11 curies of americium-241 was stored in a garage at 3047 Unionville l Pike, Hatfield, Pennsylvania, an area to which access was not controlled ; for purposes of radiation protection, i.e., an unrestricted area, and was i not secured against unauthorized _ removal from the place of storage in that , the gauge was lost. ]
- 2. Condition 16 of License No. 37-20848-01 specifies that licensed material 4 will be possessed and used in accordance with statements, representations, and procedures contained in the application dated May 14, 1985 and the letter dated June 6, 1985. The licensee's letter dated June 6, 1985 states that the permanent storage location for the nuclear gauge will be 40 Keith Valley Road, Horsham, Pennsylvania.
-Contrary to the above, at the time of the inspection on November 19, 1986, the licensee had changed the permanent storage location of the nuclear j gauge to 3047 Unionville Pike, Hatfield, Pennsylvania, a location not :
authorized by the license. Collectively, these violations have been categorized as a Severity Level III
; problem (Supplement IV).
Cumulative Civil Penalties - $500 (assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, Comdustrial Roofing Contractors. Inc. (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within ?0 days of the date of this Notice. This reply should be clearly marked a NUREG-0940 II.A-24
1 , Notice of Violation 2 l l as a " Reply to a Notice of Violation" and should include for each alleged viola-tion: (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 prope r 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, A2 U.S.C. 2232, this response shall be submitted under oath or affirmation. WMhin 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 penal-ties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil pencity, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2 Appendix C (1987), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due which subsequently hts been determined in accordance with the applicable previsions of 10 CFR 2.205, this matter may be d 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, Of fice of Enforcement, U.S. 1 Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555 NUREG-0940 II.A-25
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$[ .; Noticeofviolhtion, 3 i with 2._ copy to 't'he Regional Administra' or, U.S. Nuclear Ragul6 tory Commission, Region'I, 631 Park Avenue, King of Prussia, Pennsylu nfa 19<i00. FOR THE NUCLEN REGULATort COMMIS510ii l 4.r./L.a t.- i William T. Russell Regional Administrator
- J Dated at King of Prussia, Pent.sylvania, this // day't!.Vay 1987 i
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r 58 AfC o UNITED STATES - 8' c NUCLEAR REGULATORY COMMISSION j [ >E 7tEGION I [ , 1 g# 041 PARK AVENUE 4,***** KING oF PRUSSIA, PENNSYLVANIA iM06 3 MAY 2 81987
' Docket No. 30-28902 License No. 20-00320-21 EA 87-69 E. I. duPont de Nemours & Co., Inc.
Medical Products Department /Bostoa Area ATTN: Roger Heiser Operations Manager 549 Albany Street Boston, Massachusetts 02118 *' . Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC Inspection Report No. 30-28902/87-04) This refers to the special safety inspection conducted on April 10, 1987 at your facility in N. Billerica, Massachusetts of activities authorized under NRC License No. 20-00320-21. The inspection report was sent to you by facsimile on May 6, 1987. The inspection was conducted to review the circumstances
. associated with a calculated radiation exposure of at least 650 rem to a small area (approximately 1.0 cm2) of the left thumb of a laboratory technologist.
This exposure, which is in excess of the regulatory limit of 18.75 rem, was identified.by your staff and promptly reported to the NRC. On May 8, 1987, an enforcement conference was conducted with you and members of your staff during ! which the violations, their causes, and your corrective actions were discussed. The enposure occurred when the technologist used his hand, rather than a remote handling device, to remove the cap from a vial containing approximately 300 militcuries of molybdenum-99/ technetium-99m. Apparently, while removing ] this cap, a small amount of the material passed through a slight tear in the glove, thereby causing the overexposure. If the individual had followed your procedure and used a remote handling device, the overexposure would have been ! preverted. The NRC is concerned that individuals at your facilities have, in j the past, received unnecessary radiation exposure because of improper handling of materials. For example, in November 1985, an individual received an "
-overexposure to her hand because she wore the wrong type of glove while handling carbon-14.
This recent overexposure, as well as the previous occurrence, demonstrates the inportance of adequate pocedures for handling radioactive materials, and ' strict adherence to those procedures, to ensure that licensed activities are ccnducted safely. To emphasize the importance of these concerns, I have been authorized, af ter consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed CERTIFIED MAIL RTURN RECEIPT REQUESTED NUREG-0940 II.A-27
t l E. I. duPont de Nemours & Co., Inc. 2 Notice of Violation and Proposed Imposition of Civil Penalty in the amount of. Twelve Thousand Five Hundred Dollars ($12,500) for the violations described. in . the enclosed Notice. ' In accordance with the " General Statement of. Policy and Procedure for NRC ..aorcement' Actions," 10 CFR Part 2 Appendix C;(1987) . j
~
(Enforcement Policy), the violations described'in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem. . Although the overexposure could be classified as a Severity Level I violation in accordance
'with Section A.1 of Supplement IV of the Enforcement Policy, the violations have been classified at Severity Level III since the safety implications'of the exposure are reduced given the fact that only a small portion of the skin of the thumb was affected. The base civil penalty for a Severity Level III I
. violation or, problem is $12,500, The NRC considered mitigating the civil f penalty since (1) the exposure was identified by your staff and promptly i reported to the NRC,' and (2) your corrective actions were prompt and extensive.
' However, mitigation was considered inappropriate in view of your prior enforce- i ment history, in'cluding the previous overexposure caused by the improper handling of radioactive materials.
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 to correct the violations and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed correc-tive actions -and the results of future inspections, the NRC will determine whether furtaer NRC enforcement' action is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 er 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, 4.7, & At William T. Russell Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty i NUREG-0940 II.A-28
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY E. I. dupont de Nemours & Co., Inc. Docket No. 30-28902 Medical Products Department / Boston Area N. B111arica, Massachusetts 02118 License No. 20-00320-21 EA 87-69 On April 10, 1987, an NRC inspection was conducted in response to a notification by the licensee that a worker received a radiation exposure to his left thumb in an amount in excess of the regulatory limit. During the inspection, 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 (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty , pursuant to Section P.34 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 j penalty are set forth below: A. 10 CFR 20.101(a) limits the total occupational radiation exposure to the hands of an individual in a restricted area to 18.75 rem in any one calendar quarter. Contrary to the above, during the second calendar quarter of 1987, in particular, on April 8,1987, a laboratory technologist, while handling a vial containing approximately 300 millicuries of molybdenum-99/ technetium-99m, was contaminated with this material and received a calculated radia-
. tion exposure of at least 650 rem to the left thumb.
B. Condition 25 of License No. 20-00320-21 requires that licensed material be possessed and used in accordance with the statements, representations and procedures contained in the license application dated July 17, 1985 and letter dated September 12, 1986, with enclosures. Section III.B.I.a of the Handbook of Radiation Protection, enclosed with the letter dated September 12, 1986, requires that each person handling radioactive material be responsible for conducting their work in a manner that will keep radiation exposure to themselves and other employees as low as reasonably achievable. As one rethod of maintaining radiation exposure as low as reasonably achievable, Procedure 06-014-100, entitled " Sterile Fission Generator", Section 3.0 (Notes and Precautions), requires that all ; receptacles containing radioactive material be shielded or handled remotely. " Contrary to the above, on April 8,1987, a laboratory technologist used his hand, rather than a remote handling device, to unscrew an unshielded screw i l cap on a vial containing approximately 300 millicuries of molybdenum-99/ technetium-99m. 1 NUREG-0940 II.A-29
2 These violations have been categorized in the aggregate as a Severity Level III . . problem (Supplements IV and VI) Civil Penalty - $12,500 - assessed equally between the violations. Pursuant to the provisions of 10 CFR 2.201, E. I. dupont de Nemours & Co., 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) 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 a.s 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 saay 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 whnle or in part, such answer should be clearly marked as an " Answer to a Notice of Violation" and may: (1) deny the violation (s) listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1987), sheuld 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. NUREG-0940 II.A-30
I 3 Upon failure to pry any civil penalty due which subsequently has been deter- I 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, er mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c. ) I The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil pesalty, 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 I, 631 Park Avenue, King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COMMISSION
&g DO William T. Russell Regional Administrator Dated at King of Prussia, Pennsylvania this 26
- day of May 1987
)
NUREG-0940 II.A-31
UNITED STATES '# jo,, 8 a NUCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20566 j
*# APR 01198T Docket No. 030-06728 License No. 48-02844-01 EA 86-201 ,
Grede Foundries, Inc. ATTN: William Irvine, Vice President ! 1320 South First Milwaukee, WI 53204 Gentlemen:
SUBJECT:
DEMAND FOR INFORMATION AND NOTICE OF VIOLATION AND PROPOSED
IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORT NO. 030-06728/86002(DRSS))
This refers to the special safety inspection conducted on October 8, 9, 27, and 28, 1986 of activities authorized by NRC License No. 48 02844-01. The special inspection was conducted to review the circumstances surrounding misleading statements to the NRC in letters of June 5 and September II, 1986 in which Grede Foundries Inc. requested that its license be amended to add an additional j individual to its license as an authorized radiographer. The report of the ; inspection was forwarded to you on November 26, 1986. During this inspection, j several violations of NRC requirements were identified. On November 20, 1986, ] we held an enforcement conference with Mr. Bipin Shah and others of your staff ( j in the NRC Region III office. During the conference, these violations, their ' causes, and your corrective actions were discussed. The violations described in the enclosed Notice of Violation and Proposed ! 1 Imposition of Civil Penalties (Notice) collectively represent a significant '{ breakdown in management oversite and control of the radiation safety program.
)
Vio'lation A resulted when an individual who was not authorized acted as a radiographer.and made 43 radiographic exposures in a fixed facility without any_ supervision. The individual had been trained and qualified to work as an ! assistant radiographer, but was neither authorized or qualified to work as a radiographer. Violation B involves the preparation of a falsified radiography log on August 6, 7, and 8,1986 by an authorized radiographer although the radiographic exposures made on those dates were made by the unauthorized and l' unqualified individual. To emphasize the need for improvement in management control of your licensed ) program, I am issuing the enclosed Notice in the cumulative amount of Seven Thousand Five Hundred Dollars ($7,500) for the violations set forth in the enclosed Notice. Violations A and B have been collectively classified as a Severity Level III problem in accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986) (Enforcement Policy). The base civil penalty for a Severity Level III problem or violation is $5,000. However, the base civil penalty has been increased by 50 percent because of the multiple examples of unauthorized radiographic exposure ( In view of the circumstances surrounding the violations, mitigation for past performance and corrective action is not warranted. NUREG-0940 II.A-32
Grede Foundries, Inc. ; In-addition, because your actions raise serious questions about management's understanding of basic regulatory requirements, its ability to control its radiation safety program, and'its commitment to provide accurate information to the NRC, I have decided to issue the enclosed Demand for Information. ; i You are required to respond to the enclosed Demand for Information-and Notice I and, in preparing your response you should follow the instructions specified 1 in the Demand for Information and Notice. In your response you should cocument j the specific actions taken ana any additional actions you plan to prevent i recurrence. After reviewing your response to this Demand for Information and i hotice, including your proposed corrective actions, the NRC will determine whether further enforcement action is necessary to ensure compliance with.NRC regulatory requirements. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," Part 2. Title 10, Code of Federal Regulations, a copy of this letter and its enclosures
.will be placed in the NRC's Public Document Room.
The response directed by this letter and the enclosed Order and Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511. , Sincerely,
/
%w$ &
dmesM.TaylokDirector
/
/ ffice of Inspection and Enforcement Enclosures.
- 1. Demand for Information 2, Notice of Violation and Proposed Imposition of Civil Penalties l
l NUREG-0940 II.A-33
-UNITED STATES OF AMERICA NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket No. 030-06728
) License No. 48-02844-01 GREDE FOUNDRIES, INC. ) EA 86-201 1320 South First Milwaukee, WI 53204 DEMAND FOR INFORMATION I.
4 Grede Founories Inc. (licensee) holds byproduct material license No. 48-02844-01, issued by the Nuclear Regulatory Commission (NRC or Commission) l pursuant to 10 C.F.R. Parts 30 and 34. The license was initially issued on July 8, 1957 and last renewed in its entirety on May 1, 1986. The license authorizes the licensee to perform industrial radiography within a fixed radio- i graphy facility. The licensee's facilities are located in Milwaukee, Wisconsin.
]
This license is limited in that authorized users are specifically named on the license. II. In a letter dated June 5, 1986 to NRC Regicn III Materials Licensing ! Section, the licensee requested that Ms. Christine Walloch be added to its license as a radiographer. The letter stated that Ms. Walloch had been a radiographer at Wehr Steel, had taken and passed the Magnaflux Quality Services Radiation Safety and Control Program, and had passed the licensee's Emergency Procedures Test. The NRC learned from a review of the Wehr Steel license that Ms. Walloch was not listed as an authorized user (radiographer). j A deficiency letter dated August 14, 1986 was sent to the licensee from the j NRC Region III office requesting documentation of Ms. Walloch's Magnaflux I NUREG-0940 II.A-34
training and confirmation that she had been instructed in the licensee's operating and emergency proceo..es and had demonstrated competence in the use of the' licensee's r6diographic. devices. The licensee's response, in a letter received September 11, 1986, included a copy of a test taken by Ms. Walloch
.at Magnafluy Quality Services entitled " Radiation Safety Control Program -
Assistant Radiographer Ex6mination." The word " Assistant" had been crossed out. A special safety inspection was conducted by the NRC on October 8, 9. 27, dnd 28, 1986 to review the validity of the information supplied by Grede in support of its request to have the license amended to include Ms. Walloch as an authorized user (radiographer). Mr. Richard San Felipe, the Radiation Safety Officer, apparently was not familiar with 10 CFR Part 34 requirements for training of radiographer. Mr. San Felipe stated that he believed the same test form was used for both an assistant radiographer and radiographer exami-nation. He f0rther stateo that since the licensee was requesting a radiographer to be added to the license, he lineo out the word " Assistant." This incident demonstrates that the licensee submitted inaccurate information to the NRC on two occasions. Furthermore, it was determined that on August 6, 7, and 8,1986, an unauthorized and unqualified individual (Ms. Walloch) made 43 radiographic exposures contrary to a condition of the license. This individual made the exposures with the knowledge of an authorized radiographer, Mr. George Rasic. Ms.- Walloch gathered all necessary information to be entered into a radiography log; however, the data was actually entered into the log and signed off by an l NUREG-0940 II.A-35
authorized radiographer (Mr. Rasic), although he had not made any of the exposures. As a result, the radiography log did not identify the individual that actually made the radiographic exposures. Anyone auditing the log would assume that the radiographic exposures were mode by an authorized individual (Mr. Rasic). This situation demor.strdtes a lack of regard for and adherence
' to procedures and a lack of management control and supervision over licensed activities.
III. On the basis of the above, the NRC has concluded that the licensee submitted two letters to the NRC in support of a requested license amendment and each of these letters contained inaccurate information. This, raises a question as to whether the licensee will in the future provide complete and accurate information to the NRC, A' radietion safety officer is responsible for management of the radiographic sdfety program. A radiographer is responsible to the licensee for assuring that the requirements of the Commission's regulations and the conditions of the license are met. In this case, the licensee, by the acticns of the radiation safety officer and one of its radiographer, has demonstrated a lack of effective management control over licensed activities by requesting on unqualified person to be listed on its license as a radiographer and permitting an unauthorized person to make radiographic exposures contrary to a condition of the license. Acr.ordingly, further information is needed to determine whether the Commission can have reasonable assurance that in the future, the licensee will conduct its activities in accordance with the Commission's requirements. NUREG- U 0 II.A-36
l
.4.-
IV. Therefore, to determine whether the license should be modified or other enforcement action taken to ensure compliance with NRC regulatory requirements, you are required to submit within 30 aays to the Director, Office of Inspection and Enforcement, the following Information in writing and'under oath or affir- l mation pursuant tv Section 182 of the Atomic Energy Act of 1954, as amended. Actions taken or to be taken to provide assurance that (a) the licensee will submit complete and accurate information to the Commission, (b) management will exercise adequate control and supervision over licensed activities, (c) the radiographer and radietion safety offictr will underst6,1d and implement applicable l
. regulatory requirements, and (d) per. sons not listed on the license will not conduct licensed activities.
V. After reviewing your response, the NRC will determine whether further dCtioh is necessary to ensure Compliance with regulatory requirements. FOR THE NUCLEAR REGULATORY COMMISSION
- i
__y [ es M. Tay1 , Director pffice of Inspection and Enforcement
../
Dated at Bethesda, Maryland this _ day of April 1987. NUREG-0940 II.A-37
( NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES Grede Foundries, Inc. . Docket No. 030-06728
; Milwaukee,. Wisconsin . License No. 48-02844-01' EA'86-201 During an NRC inspection conducted on'0ctober.8, 9, 27 and 28, 1986, violations
' of NRC re'quirements were identified. In accordance with the " General: Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C
"(1986), thel Nuclear: Regulatory Commission ' proposes to impose civil pensities-pursuant to Section 234 of. the Atomic Energy Act of 1954, as amended,-("Act").
42.U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular violations and
-associated civil penalties are set.forth below:
A. License ConditionLNo.'11 specifies the. persons authorized by~the license to'act as radiographer as defined in-10 CFR 34.2. No radiographer's assistants are authorized. Contrary.to the-above, on August 6, 7 and 8, 1986, a person who was not authorized or qualified to act as a radiographer made 43 radiographic
< exposures while working alone in the licensee's fixed radiography facility.
- 8. License Condition _ No.16 requires that the licensee conduct its: program in accordance With statements, representations, and procedures contained in a letter dated Maren 7,1985 and the attached revised Manucl. Item 6.0 of the referenced manual . requires that a log of ell radiographic exposures be maintained. The log contains, among other things, the date, a listing of times. radiographer, exposure times, source used, daily dosimeter readings, and a ' signature of the radiographer which indicates that the source has been retracted, locked, checked, a radiation survey made, and the time of day.
. Contrary to the above, on August 6, 7, and 8, 1986, an authorized radiographer completed the log and entered required information for 43 radiographic exposures; however, all 43 of these exposures, radiation surveys..etc. were octually made by an individual that was not authorized or qualified.
Collectively, Violations A and B have been categorized as a Severity Level III problem (Supplements VI and VII). Cumulative-Civil Penalty - $7,500 - assessed equally between the violations. Pu-suant to the provisions of 10 CFR 2.201, Grede Foundries, Inc. is hereby l required to submit a written statement or explanation to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, f l NUREG-0940 II.A-38 j l i
Notice of Violation D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, within 30 days of the date of this Notice. This reply should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved. (4) the correct steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. 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 rcsponse shall be submitted under oath or affirmation. Within the same time as provided for the response required above under 10 CFR 2.201, Grede Foundries, Inc. may pay the civil penalties by letter sddressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Seven Thousand Five Hundred Dollars ($7,500) or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Grede Foundries, Inc. fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalties in the amounts proposed above. Should Grede Foundries, Inc. elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may rquest remission or mitigation of the penalties. In requesting mitigation of the prcposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1986), should be addressed. Any written answer in accordsr.ce 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 Grede Foundries, Inc. is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing civil penalties. Upon failure to pay any civil penalties due which subsequently have been determined in accordance with :he 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. 2282. FOR THE NUCLEAR REGULATORY COMMISSION
, mr -
Ja es M. Taylor Wetor (
/ fice of Insp(ction and Enforcement ]
Deted at Bethesda, Meryland thislit day of April 1987 NUREG-0940 II.A-39
fM 4 UNITED STATES
. [' NUCLEAR REGULATORY COMMISSION REGION IV
- U, ..
D 611 RYAN PLAZA DRIVE, SUITE 1000
, #[
k, ARLINGTON. TEXAS 78011 J#l 21 1987
' Docket No. 30-19652 I
License No. 49-21004-01 EA 86-185 HCA Riverton Hospital ATTN: .Mr. Bruce Birchell, Administrator 2100 W. Sunset Drive i P. O. Box 1280 i Riverton, Wyoming 82501
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES ) (NRC INSPECTION REPORT NO. 30-19652/86;01) j I This refers to the special, unannounced inspection conducted on September 30 and October 1, 1986, at the Riverton Memorial Hospital in Riverton, Wyoming. During the inspection, violations of NRC requirements were identified and 1 discussed with you and members of your staff at the conclusion of the inspection. An enforcement conference was also held in the Region IV office ; on November 4, 1986, with you and members of the Region IV staff to discuss 1 these violations. Part I of the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (Notice), involved failures to (1) restrict use of licensed materials k tophysicianswhoareauthorizedandqualified,and(2)properlyfollowproce- { dures for the assay of molybdenum-99. These violations are of significant l concern to the NRC because you received prior information from the NRC that could have been used to prevent these violations. An NRC letter of March 22, 1983, to Mr. Roy Barraclough provided you with prior notice concerning the use of unqualified physicians. Information Notice 84-85, " Molybdenum Breakthrough . From Technetium-99m Generators," provided you with prior notice concerning i the importance of performing proper assays on molybdenum-99/ technetium-99m generators. These circumstances ~ indicate the need for increased management attention in your radiation protection program to ensure NRC regulatory requirements are satisfied. To emphasize the importance of complying with NRC requirements, I have been authorized, after consultation with the Director, Office of Inspection and l Enforcement, to issue of Civil Penalties in the the enclosed amount of Two Notice of Violation Thousand and Proposed Five Hundred DollarsImp (osition
$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 (1986) (Enforcement Policy), the violations described , CERTIFIED MAIL l RETURN RECEIPT REQUESTED NUREG-0940 II.A-40
HCA Riverton Hospital in Part I of the enclosed Notice have been categorized in the aggregate as a Severity Level III problem. The base value of a civil penalty for a Severity Level III violation or problem is $2,500. The escalation'and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. ' Several other violations which were not assessed a civil penalty are also described in the enclosed Notice, including'one which is a repeat violation. These violations have been characterized as two Severity Level IV problems and one Severity Level V 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, 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 ty the Faperwork Reduction Act of 1980, PL 96-511. Sincerely,
<J g[ -
Robert D. Martin Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalties cc: Wyoming Radiation Control Program Director { 1 l
)
l NUREG-0940 II.A-41
i I 1 NOTICE OF VIOLATION { AND i PROPOSED IMPOSITION OF CIVIL PENALTIES HCA Riverton Hospital Docket No. 30-19652 Riverton, Wyoming License No. 49-21004-01 EA 86-185 i During an NRC inspection conducted on September 30 and October 1, 1986, ' 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 (1986), the Nuclear Regulatory Commission proposes to impose civil. p(enalties "Act"), 42pursuant to Section U.S.C. 2282, 234 ofand PL 96-295, the 10 Atomic CFR Energy Act of 2.205. The 1954, as amended, particular s violations and associated civil penalties are set forth below: ' I. Violations Assessed A Civil Penalty A. License Condition 11 lists the individuals who are authorized to use or supervise the use of licensed material. Contrary to the above, on June 10, 1985, a physician, not listed on- l the license and whose qualifications were unknown to the licensee, was responsible for the performance of a procedure involving licensed material. Similarly, another physician was responsible for procedures performed on September 4, September 5, September 8, and September 9, ' 1986. 1 B. License Condition 12.8 requires that before visiting physicians are I authorized to use licensed material under the hospital's license, they , must be specifically named as a user on a Nuclear Regulatory Commission license authorizing human use. Contrary to the above, physicians working under a broac medical license and not specifically named on a Nuclear Regulatory Commission license were responsible for numerous procedures performed in the licensee's l facility during the period of August and September 1986. C. 10 CFR 35.14(b)(4)(ii) requires that each elution of technetium-99m from a molybdenum-99/ technetium-99m generator be tested to determine , either the total molybdenum-99 activity or the concentration of i molybdenum-99 according to written procedures, by personnel who have been specifically trained to perform the test. i Contrary to the above, during the inspection, the NRC inspector observed that the concentration of molybdenum-99 was not being determined according to written procedures. Furthermore, the technician stated that he was not aware of the proper procedure to perform the test. Collectively, these violations have been categorized as a Severity Level III problem (SupplcmentVI). Cumulative Civil Penalty - $2,500 assessed equally among the violations. NUREG-0940 II.A-42
l i Notice of Violation II. Violations Not Assessed A Civil Penalty A. License Condition 15 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in various specified documents.
- 1. The application of November 14, 1985, lists the type of personnel radiation monitoring to be used to monitor whole body and extremity '
exposure. ! 1 Contrary to the above, a representative of the licensee stated to the NRC inspector that he did not wear the whole body badge each l time he worked with licensed material.
- 2. Item 10 of the application of November 22, 1978, requires that dose calibrators be calibrated in accordance with procedures contained in Appendix D, Section 2, of Regulatory Guide 10.8, which requires that linearity be determined at installation and quarterly thereafter.
Contrary to the above, tests to determine linearity had not been perforne since October 14, 1985.
- 3. The ALARA program dated August 15, 1982, requires tnat the Radiation Safety Comitwe meet quarterly, j l
Contrary to the above, the Radiation Safety Comittee did not I reet during the fourth quarter of 1985, the second quarter of ; 1986, or the third quarter of 1986. This item was cited during l the previous inspection of September 12, 1983. j 1 This is a repeat violation. ) Collectively, these violations have been categorized as a Severity l Level IV problem (Supplement VI). B. 1. 10 CFR 35.14(e)(1)(1) requires, in part, that sealed calibration I l or reference sources possessed pursuant to 10 CFR 35.14(d) which contain byproduct material, other than hydrogen-3, with a half-life greater than thirty days in any form other than gas be tested for leakage and/or contamination at intervals not to exceed six months. Contrary to the above, leak tests had not been performed on calibration sources during the period of October 29, 1985, to September 30, 1986.
- 2. 10 CFR 35.14(f)(2) requires, in part., that sealed calibration i
or reference sources possessed be physically inventoried quarterly. NUREG-0940 II.A-43 l
Notice of Violation Contrary to the above, inventories had not been performed durina the period of October 5,1985, to September 30, 1986. Collectively, these violations have been categorized as a Severity ' Level IV problem (Supplement VI). i C. License Condition 1 lists the name of the licensee as Riverton Memorial Hospital. Contrary to the above, since the last inspection it was determined that the license had chanced its name from Riverton Memorial Hospital to HCA Riverton Hospital without notifyina the NRC. This is a Severity Level V violation (Supplement VI). Pursuant to the provisions of 10 CFR 2.201, HCA Riverton Hospital is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Reaulatory Commission, Washinaton, D.C. 20555, with a copy to the ' Recional Administrator, U.S. Nuclear Readlatory Commission, Reaion IV, 611 Ryan Plaza Drive, Suite 1000, Arlinaton, Texas 76011, within 30 days of the date of { this Notice a written statement or explanation, includina for each alleaed ) violation: (1) admission or denial of the allcaed 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, the Director, Office of Inspection and Enforcement, may issue an order to show ; cause why the license should not be modified, suspended, or revoked or why such i other action as may be proper should not be taken. Consideration.may be aiven ! to extendina the response time for cood cause shown. Under the authority of f Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under q oath or affimation. j i Within the same time as provided for the response required above under j 10 CFR 2.201, HCA Riverton Hospital may pay the civil penalties by letter ' addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Two Thousand Five Hundred Dollars ($2,500) or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should j HCA Riverton Hospital fail to answer within the time specified, the Director. ' Office of Inspection and Enforcement, will issue an order imposina the civil j penalties in the amount proposed above. Should HCA Riverton Hospital elect to file an answer in accordance with 10 CFR 2.205 protestino the civil penalties, such answer may: (1) deny the violations listed in this Notice in whole or in part, (2) demonstrate extenuating circumstances, (3) show errur in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protestina the civil penalties in whole or in part, such answer may request remission or mitication of the penalties, in requestina mitication of the proposed penalties, the five factors addressed in Section V.E 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 NUREG-0940 II.A-44
1 Notice of Violation l 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. HCA-Riverton Hospital's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for -
-imposing civil penalties.
Upon failure to pay any civil penalties 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 penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C.'2282. FOR THE NUCLEAR REGULATORY COMMISSION tt Y t~ Robert D. Martin Regional Administrator Dated at Arlington, Tc.xas, thisy*yday of January,1987. NUREG-0940 II.A-45
-!s }, NUCLEAR REGULATORY COMMISSION wAssiwarow,c.c.seses *
-l
~s...../ JUN 11 !!s7 Docket No. : 30-19652 -
License No. 49-21004-01 EA No. 86-185~ HCA Riverton Hospital
' ATTN: Mr. Bruce K.- Birchell, Administrator 2100 W. Sunset. Drive l Post Office Box 1280 i l
Riverton, Wyoming 82501 Gentlemen: j
SUBJECT:
- ORDER IMPOSING CIVIL MONETARY PENALTY This refers to your letters dated February 12, 1987 and February 13, 1987 in 1 response to the Notice of Violation and Proposed Imposition of Civil ' Penalty sent to ; ou by our letter dated January 21, 1987. Our letter and Notice 'i described nine violations identified during an NRC inspection conducted September 30 and October 1,1986. j 1 To emphasize ] of two thousandthe fiveimportance of comply hundred Gc11ars (ingwas
$2,500) with NRC requirements, propsed for three of the a civil pe]
violations, q In your response, you acknowledged the violations end requested mitigation of the civil penalty for the reasons discussed. After consideration of your response, we have concluded for the reasons given in the Appendix attached to the enclosed Order Imposing. Civil Penalty that the violations did occur as set forth in the Notice of Violation and Proposed Imposition of Civil Penalty. We have given careful consideration to your ! request for mitigation of the proposed penalty and have concluded that the penalty should not be mitigated. Accordingly, we hereby serve the enclosed ; Order on HCA Riverton Hospital imposing civil monetary penalty in the amount ' of Two Thousand Five Hundred Dollars ($2,500). We will review the effectiveness of your corrective actions during a subsequent inspection. ! In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10. Code of Federal Regulations, a copy of this letter and the enclosures will be placed in the NRC's Public Document Room. Sincerely,_ _ // l h mes M. Ta r ,
Enclosures:
As Stated eputy Executive Director for Regional Operations cc: Wyoming Radiation Control Program Director CERTIFIED MAIL RETURN RECEIPT REQUESTED
'NUREG-0940 II.A-46 ;
1
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of HCA RIVERTON HOSPITAL Docket No. 30-19652 2100 W. Sunset Drive Licensee No. 49-21004-01 Riverton, Wyoming 82501 EA No. 86-185 ORDER IMPOSING CIVIL MONETARY PENALTY I HCA Riverton Hospital (licensee) is the holder of Byproduct Material License No. 49-21004-01 issued by the Nuclear Regulatory Commission on March 26, 1979. The license authorizes the licensee to use byproduct material for medical purposes in accordance with the conditions specified therein. II A special inspection of the licensee's activities was conducted on September 30 and October 1, 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 Penalty was served upon the licensee by letter dated January 21, 1987. The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the civil penalty proposed for the violations. The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalty by letters dated j l February 12, 1987, and February 13, 1987. l 4 NUREG-0940 II.A-47 j
_2_ III After consideration of the Itcensee's msponse and the statements of fact, explanation, and argument for mitigation contatiied therein, the Deputy Executive Director for Regional Operations has determined, as set forth in the Appendix to this Order, that the violations occurred as stated and that the penalty proposed for the violations designated in the Notice of Violation 4 and Proposed Imposition of Civil Penalty should be imposed. l IV i In view of the foregoing and pursuant to Section 234 of the Attmic 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 penalty in the ascunt of Twenty-Five Hund, rad J Dollars ($2,500) within 30 days of the date of this Order, by check, draft. or money order, payable to the Treasurer of the United States and mailed to the Dimetor. Office of Enforcement. U.S. Nuclear Regulatory Comissior, ATTH: Document Control Desk. Washington, D.C. 20555. V L The Itcensee may request a hearing within 30 days of the date of this Order. A request for a hearing shall be addressed to the Director 4 Off' : of E furce-ment, U.S. Nuclear.Regdlatory Comission; Washington, D.C.:r20555r A copy of the hearing request,also .shalbbe sent to the . Avis _ tant Genenal j i l NUREG-0940 II.A-48 j
1 l Counsel for Enforcement, Office of General Counsel, U.S. Nuclear Regulatory Comission Washington, D.C. 20555 and to the Regional Administrator, U.S. Nuclear. Regulatory Comission, Region IV, 611 Ryan Plaza Drive, Suite 1000, l Arlington, Texas 76011. 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 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 referenced in Section II above and I (b) whether, on the basis of such violations, this Order should be sustained. FOR THE NUCLEAR RE TORY COMMISSION
/
J s M. Tay r l eputy Exec ive Director for Regional Operations Dated at Bethesda, Maryland, this lithday of June 1987. NUREG-0940 II.A-49
APPENDIX EVALUATIONS AND CONCLUSIONS , On January 21, 1987, a Notice of Violation and Proposed Imposition of Civil I Penalty (Notice) was issued for nine violations identified during an NRC inspection. A civil penalty in the amount of $2,500 was proposed for three of the violations. HCA Riverton Hospital responded to the Notice in a letter dated February 12, 1987, listing actions to correct these violations and prevent recurrence, and in a letter dated February 13, 1987, acknowledging the occurrence of the violations, but asking for mitigation of the civil penalty. Provided below is the summary of the licensee's request for mitigation and the NRC's j evaluation and conclusions regarding the licensee's response. ) Sumary of Licensee's Request for Mitigation The following is quoted from the licensee's letter of February 13, 1987. ,
"The hospital feels +he fines should not be levied for the following reasons: !
- 1) This is the first deficiency noted at the hospital by the NRC. (
- 2) No patients were exposed to inappropriate care or harmed in any way.
- 3) Even though the formula used was inappropriate, no harm was done to any patients, employees, physicians, etc. Prior NRC inspections failed to uncover that the hospital was performing the Holley (sic) assay
, incorrectly. '
1
- 4) The hospital is small and does a low volume of procedures.
- 5) The locum tenens physicians which your agency noted were not on the license to read the examinations infonned us that they were on a license. l prior to us allowing them to read the examinations. We would not have allowed them to read the examinations, had we known that they were not on a nuclear medicine license. The hospital procedures were weak and should have been strengthened in this area; however, it was an unintentional error to allow the physicians to read the examinations. j
- 6) The radiologist the hospital was using at this time period, Dr. Ratajczak, was the Radiation Safety Officer and he was not fulfilling his responsibilities. He was the one who was to be responsible for the meetings, and to have linearity checks performed. This left the hospital in a difficult situation - not being able to compel him to perform the necessary functions.
- 7) The State Inspector of Wyoming felt that the fine was uncelled for and unreasonable because of the minor nature of the violations, since no injury, exposure, or risked exposure occurred to any patient or employee."
NUREG-0940 II.A-50
W, , y w d t h, _Appe.ndix . ] I NRC Evaluation of Licensee's Response
- 1. The' licensee. argues for mitigation based on prior good performance in the 9eneral area of concern.- 'The~1ast inspection made at the licensee's facility was^ conducted on September 12, 1983 and identified one. violation. q The' violation, failure to conduct quarterly safety meetings, was cited as -
'a' repeat violation-in the January 21,1987 Notice of Violation and Proposed Imposition of. Civil Penalty. This 1 fort 2M Mstory is not indicative'of prior good perfonnance. , q .
In addition to this, any mitigatid that might be' warranted for prior enforcement history is offset by the licensee's prior notice of previous similar problems. Specifically, the licensee received prior notice for-Violations'B'and C.,,An NRC letter of, March 22, 1983, to Mr. Ray Barraclough provided the licensee with prior notid concerning the use of unqualified 4 physicians. Information Notice 64-85, " Molybdenum Breakthrough From Technetium-99m Generators," provided the licensee with' prior notice . concerning the'importance of. performing proper assays on molybdenum-99/' technetium-99m generators.
- 2. The fact that no patients were harvM as tiresult of the licensee's x l- actions may simply be fortuitouk. 6 A. primarf purpose of the Consission's regulations is to prevent harmful events, not simply address such problems in retrospect. In perticular, the NRC's Enforcement Policy seeks to: (1) encourage compliance with NRC regulations and license conditions (2) obtain prompt' correction of; violations -(3) deter future violations, and (4) encourage improvement of licensee performance. Thus, consistent with the purposes'of the Enforcement Policy, promptiand vigorous enforcement action including issuance of civil penalties will be taken, es in this case, against licensees who do not achieve the necessary and meticulous 4 attention to detail and the Mgh Standard of compliance that is a part of each licensee's responsibility and' privilege under its license.
- 3. Concerning the issue. raised by the licensee regarding.no harm to individuals, ~
the same principles stated in subsection 2 above apply. Concerning the.
- (
licensee's argument that the NRC failed to discover the inadequacies in the- " licensee's elution procedures during prior inspections, NRC conducts audit type inspections. Inspections are not intended to examine every detail of q a licensee's program. 1
- 4. In response to the licensee's assertion tbat it is small and'does a 'iow i volume of procedures, records provided to the NRC inspector at the time of his visit indicated that 312 nuclear medicine procedures were performed in 1985 and 115 procedures were performed for the fIrst eight months of o
- q 1986. Therefore, in the twenty months immediately prior to the September 30 i 1
through October 1, .1986 inspection, ~ an average of approximately 21 procedures a month were conducted. This level of activity is not " low" and emphasizes the need for a sound radiation protection program. Moreover, the fact that a licensee in "small" and has had a'7ch level of procedure does not necessarily warrant mitigation of a civil penalt;yN (
,NUREG-0940 II.A-51 E 1
Appendix .3-
- 5. Although the NRC appreciates ti licensee's verbal communications with the visiting physicians, the fact remains that the requirement of License Condition 12.B 13 that such physicians may be utilized only if they are named on a specific NRC license. In this case the physicians utilized by the licensee were not named on a specific NRC license, but were instead
( authorized under a broad medical license. It is the licensee's responsi-bility to assure compliance with the Comission's regulatory requirements.
- 6. The licensee is responsible to assure that all aspects of'its ifcense requirements are complied with. - Licensee's select their employee's and
- agent's and are responsible for their actions. To adhere to any other policy would be to allow the licenses to be responsible for licensed activities.
- 7. The State of Wyoming has no jurisdiction in this matter.
NRC Conclusion The NRC concludes that the license has not provided an adequate basis for a reduction of the severity level or for mitigation of the proposed civil i penalty. Consequently, the proposed civil penalty in the amount of $2500 should be imposed. i s i NUREG-0940 II.A-52 ,
,s' ma cg ! UNITED STATES
./ o,. NUCLEAR REGULATOnY COMMISSION
? '
,r( ; p, REGION fil
! d 8
.f.' /
70s noostvtLT moAo l , ,8, cLEN ELLYN. ILUNol5 60 m ms 2 z e Docket Nos. 030-01993; 070-01396 Licenses No. 21-00338-02; SNM-1393 EA 85-89
'Hurley Medical Center ATTN: Mr. Jack Daginais Ass'stant Director One Hurley Plaza Flint,'MI 48502 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NRC INSPECTION REPORTS N05. 030-01993/85001(DRSS) AND 070-01390/85001(DRSS))
'This refers to the routine safety inspection conducted by Mr. W. P. Reichhold of this office on May 2, 3, and 24, 1985 of activities authorized by NRC Byproduct Material License No. 21-00338-02 and Special Nuclear Material License No. 1393, and to the oiscussion of our findings with you on May 24, 1985. During the inspection, fourteen examples of failures to comply with NRC requirements were identified. The results of the inspection were discussed on June 7, 1985 during an enforcement conference in the Region III office between you and others of your staff and Mr. J. A. Hind and others of the NRC Staff.
These violations are described in the enclosed Notice and they collectively represent a significant breakdown in management oversight and control of the radiation safety program. During our last inspection on June 23, 1981 the NRC , identified ten violations of NRC requirements. The current violations and past inspection history demonstrate the need for improvement in the administration and control of the program to ensure adherence to NRC requirements and safe _ performance of licensed activities. To emphasize the importance of adequate control of the radiation safety program, I 1_have been authorized, after consultation with the Director, Office of Inspection a.. d Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties 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 (1985) the violations described in the enclosed Notice have i been categorized in the aggregate as a Severity Level III problem. The base i civil penalty for a Severity Level III violation or problem is $2,500. The escalation and mitigation factors in the Enforcement Policy were considered and 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 CERTIFIED MAIL RETURN RECElPT REQUESTED NUREG-0940 II.A-53
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response, you should document the spectfic actions taken and any additional actions you plan to prevent recurrence; After reviewing yodr response to this fictice, f r.cluding your proposed:cirrective actions, the NRC will. aetermine whetherfurther.enforcementactioi'lisnecessarytoensurecompliar.ce'vithNRC E regulatory requirements. . r- .
/Inacccedancewith,Saction2.7Cr0oftheNRC's"RulesofPtActice,"Part2 s Title 10, Code of: Federal Regulations, a copy 'of tnis letter and its enclosure
! will be placed in the NRC Public Docurcent Room. +
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The responses directed by this letter and the enclosed Notice are not subject 4' to the clearance procedures of the Office of Matagement and Budget as required 4 - by the Paperwork Reduction Act of 1980, PL 96-51L '
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Enclosure:
Notice of Violatica. ' ' t e and Proposed Impod tion of Civil Penalties , 4h f l 4 s l{ l l ) NUREG-0940 II.A-54 '
NOTICE OF VIOLATION AND PROPOSED IMPOSITIOF OF CIVIL PENALTIES Hurley Medical _ Center Licenses No. 21-00338-02; SNM-1393 $ Flint,' Michigan .48502 EA 85-89 During an NRC inspection conducted on May 2, 3, and 24, 1985 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 11 (1985), the Nuclear Regulatory Commission proposes to impose civil penalties i pursuant to section 234 of the Atomic Energy Act of 1954, as amended, ("Act"), 42 U.S C. 2282, PL 96-256, and 10 CFR 2.205. The particular violations and associated civil penalties are set forth below: A. License Condition No. 24 of License 21-00338-02 requires that all licensed g material be possessed and used in accordance with statements and procedures 1 in the application dated September 23, 1983. The application dated September 23, 1983 states that the medical isotope committee shall meet not less than once in each calendar quarter. 1 Contrary to the above, the medical isotope committee did not meet quarterly. Specifically, the medical isotope committee failed to meet during the first, third, and fourth quarters of 1981 and 1982, the second and third quarters of 1983, the first and second quarters of 1984, and the first quarter of 1985.
- 8. License Condition No. 24 of License 21-00338-02 requires that licensed materials be used in accordance with the application received February 8, 1978, the application dated September 23, 1978, and the application dated September 23, 1983. These applications describe room 22, equipped with a ventilation system, as the area where xenon-133 gas would be used.
Contrary to the above, on several occasions since November 1984, xenon-133 2 was used in a room other than room 22. Specifically, xenon-133 was used in room 20, an area not authorized by the license. Although room 20 was equipped with an exhaust fan, the air flow rates and xenon-133 concentrations had not been evaluated or approved by NRC. C. License Condition No. 24 of License 21-00338-02 requires licensed material ; be possessed and used in accordance with the application received February 8, ! 1978. The application received February 8, 1978 contains precautions and procedures to be followed when caring for patients treated with j therapeutic quantities of radionuclides. Item 8 states nursing personnel ; l entering the patients' rooms are to wear film badges. Contrary to the above, nursing personnel entering therapy patients' rooms did not always wear film badges. Nursing personnel did not wear ' film badges in cases where brachytherapy (cesium-137) implants were performed on October 8 and 29, 1984, November 13 and 19, 1984, December 3, l 1984, January 22, 1985, and March 19 and 26, 1985. I NUREG-094A I1.A-55
Notice of Violation 2 AUG 2 2 E5 D. License Condition No. 24 of License 21-00338-02 requires that licensed material be possessed and used in accordance with statements and procedures in the application received February 8,1978. The application received February 8, 1978 contains precautions and procedures to be followed when caring for patients treated with therapeutic quantities of radionuclides. Item 4 states that surveys of exposure rates in the patient's room and adjacent areas will be performed. ! Contrary to the above, surveys were not always performed of the patients' ; rooms and adjacent areas. Specifically, fourteen (14) cesium-137 sealed l source implants were performed between February 6,1984 and March 26, l 1985 and only two surveys were conducted. No patient room surveys were I conducted during fourteen (14) cesium-137 sealed source implants between I April 5 and September 28, 1982. E. License Condition No. 16 of License SNM-1393 requires that licensed ) material be possessed and used in accordance with statements, j representations, and procedures in a letter dated April 24, 1973. The { letter dated April 24, 1973 states the physician responsible for nuclear I pacemaker studies was William J. Weber, M.D. 1 Contrary to the above, licensee personnel other than the physician listed i in the April 24, 1973 letter as the responsible individual are currently responsible for the nuclear pacemaker program. F. Item 9A of License SNM-1393 authorizes the possession of nuclear pacemakers for purposes of explantation, recovery, and disposal. License Condition No. 16 (license SNM-1393) requires that licensed material be possessed and used in accordance with statements and procedures contained in a letter dated April 24, 1973. The letter states that William J. Weber, M.D. is the individual responsible for nuclear pacemaker studies. Contrary to the above, the licensee failed to explant, recover, and return for disposal a nuclear pacemaker from a patient who died in February 1985. Specifically, licensee personnel other than the responsible individual listed in the April 24, 1973 letter requested that a funeral director remove a nuclear pacemaker from the body of a patient after realizing that the patient had been the recipient of a nuclear pacemaker. The funeral ; director, who was not authorized by this license, was also requested to I return the nuclear pacemaker to the manufacturer for disposal. The l licensee did not participate in or supervise the explant, recovery, or i return of the nuclear pacemaker. ! G. License Condition No. 13 cf License SNM-1393 states that the licensee shall report to the NRC, within 24 hours of occurrence, the death of any nuclear pacemaker patient. Contrary to the above, the licensee failed to report to the NRC that nuclear pacemaker patients died in November 1984 and January 1985. i NUREG-0940 II.A-56 i
l Notice of Violation 3 AUG 2 2145 l H. License Condition No. 14 of License SNM-1393 states that the licensee shall contact the NRC within 10 days after loss of contact with a nuclear ] pacemaker patient.
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Contrary to the above, the licensee failed to report the loss of contact I with nuclear pacemaker patients in March, April, and November 1982, and in March 1984. I. License Condition No. 16 of License SNM-1393 requires that all licensed material be possessed and used in accordance with statements, representations, , and procedures contained in a letter dated April 24, 1973. The letter dated April 24, 1973 states that nuclear pacemaker patients shall be contacted each month. Contrary to the above, nuclear pacemaker patients were not contacted each month. Specifically, the licensee failed to contact pacemaker patients approximately five times in 1982, eleven times in 1983, and eleven times in 1984. J. 10 CFR 35.14(b)(5)(v) states that the licensee shall conduct a quarterly physical inventory to account for all Group VI sources and devices received and possessed. Contrary to the above, the licensee failed to conduct a quarterly physical inventory to account for all Group VI sources and devices received and possessed. Specifically, Group V,I sources such as the 3M cesium-137 needles, the Nuclear Associates cesium-137 microrad after loading sources, , and the cobalt-60 needles were not inventoried quarterly. The last inventory was September 1983. K. 10 CFR 35.14(f)(2) states that quarterly physical inventories shall be performed to account for all calibration sources received and possessed. Contrary to the above, quarterly inventories of calibration sources were not performed. Specifically, a barium-133 source and a cobalt-60 source had not been inventoried since the last inspection on June 23, 1981. i L. 10 CFR 35.14(5)(i) states that Group VI sealed sources shall be tested . I for contamination and/or leakage at intervals not to exceed 6 months. I 1 1 ( Contrary to the above, Group VI sources had not been leak tested since the last inspection on June 23, 1981. M. 10 CFR 71.5 states that no licensee shall transport licensed material out of his facility unless the licensee complies with 49 CFR Parts 170-189. 1 49 CFR 173.475(i) states that before each shipment of any radioactive materials package, the shipper shall ensure by examination or appropriate tests that external radiation and contamination levels are within the allowable limits specified in this chapter. NUREG-0940 I1.A-57 E __ _
AUG 2 21985
, Notice of Violation 4 Contrary to the above, the licensee failed to ensure that the external radiation and contamination levels were within allowable limits for packages containing molybdenum / technetium returned to the manufacturer for disposal. Since the date of license issuance, the licensee had not performed direct radiation surveys and wipe tests for removable contamination on packages returned to the manufacturer.
N. 10 CFR 20.401(b) requires that the licensee maintain records showing the results of surveys made to assure compliance with 10 CFR 20.201(b). Contrary to the above, the licensee failed to maintain records of surveys I of technetium-99m contaminated waste to document that no measurable radiation above background was present before disposal. Records of l serveys have not been maintained since the date of license issuance. Collectively, the above violations have been evaluated in the aggregate as a ] Severity Level III problem (Supplements IV, V and VI). j
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(Cumulative Civil Penalties-$2,500 assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, Hurley Medical Center is hereby ' required to submit to the Director, Office of Inspection and Enforcement, U.S. 1 Nuclear Regulatory Commission, Washington, D. C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, within 30 days of tSe date of this Notice a written statement or explanation, including ft , each alleged violation: (1) admission or denial of the alleged { violation, (2) the reasons for the violation if admitted, (3) the corrective i steps that have been taken and the results achieved, (4) the corrective steps j which will be taken to avoid further violations, and (5) the date when full ( compliance will be achieved. If an adequate reply is not received within the time specified in the Notice, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper ! j 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, j j2U.S.C.2232,thisresponseshallbesubmittedunderoathoraffirmation. ) Within the same time as provided for the response required above under 10 CFR 2.201, Hurley Medical Center may pay the civil penalties by letter i addressed to the Director, Office of Inspection and Enforcement, with a check, l draft, or money order payable to the Treasurer of the United States in the ! cumulative amount of Two Thousand Five Hundred Dollars ($2,500.00) or may protest imposition of the civil penalties in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Hurley Medical Center fail to answer within the time specified, the Director, Office of Inpsection and Enforcement, will issue an order imposing the civil penalties in the amount porposed above. Should Hurley Medical Center elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny the violations listed in this Notice in NUREG-0940 II.A-58
Wotice of Violation 5 whole or in part,.~(2) demonstrate extenuating circumstance, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting the civil penalties in whole or in part, such answer may request remission or mitigation of the penalties.
'In requesting mitigation of the proposed penalty, the five factors addressed in 5:ction V.8 of 10 CFR Part 2, Appendix C (1985) 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 number) to avoid repetition. Hurley Medical Center's attention is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing civil penalties.
Upon failure to pay any civil penalties due which have been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this catter 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. 2282.
FOR THE NUCLEAR REGULATORY COMilSSION d[ O b b A [wJames G. Keppler Regional Administrator Dated a Glen El' lyn, Illinois This 22>} day of August 1985. i i NUREG-0940 II.A-59
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.! n NUCLEAR REGULATORY COMMISSION i j jE WASHINGTON, D. C. 20555
*%w.. / r24 g Docket Nos. 030-01993, 070-01396 Licenses No. 21-00338-02,'SNM-1393 EA 85-89 Hurley Medical Center ATTN: Jack Dagenois Assistant Director J One Hurley Plaza j Flint, MI 48502 -l Gentlemen:
SUBJECT:
ORDER IMPOSING CIVIL MONETARY PENALTIES I This refers to your letters dated October 4, 1985 in response to the Notice of Violation and Proposed Imposition of Civil Penalties sent to you by our l letter dated August 22, 1985. The Notice of Violation describes violations ) identified during a routine safety inspection conducted at your facility on j May 2, 3, and 24, 1985. To emphasize the importance of adequate control of j the radiation safety program, a civil penalty of $2,500 was proposed. In your response, you admitted the facts in 13 of the 14 violations as set' l forth in the Notice of Violation and Proposed Imposition of Civil Penalties. I Further, you stated that you could neither confirm nor deny the violation concerning the licensee's participation in the explant, recovery, or return of the nuclear pacemaker. After careful consideration of your responses and your request for mitigation of the proposed civil penalties, we have concluded that the violations did occur and that mitigation of the penalties is not warranted for the reasons given in the attached Appendix to the enclosed Order Imposing Civil Monetary Penalties. Accordingly, we hereby serve on Hurley Medical l Center the enclosed Order Imposing Civil Monetary Penalties in the amount of' Two Thousand Five Hundred Dollars ($2,500). We will review the effectiveness of your corrective actions during a subsequent inspection. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, j Title 10, Code of Federal _ Regulations, a copy of this letter and the enclosure ! will be placed in the NRC's'Public Document Room. I CERTIFIED MAIL RTURN RECElpT REQUESTED NUREG-0940 II.A-60
Hurley 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. Sincerely, s m .. / A J mes M.-Tay , Director
- ffice of I pection-and Enforcement
Enclosure:
Order Imposing Civil Monetary Penalties with Appendix NUREG-0940 II.A-61
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JMTaylor, IE RVollmer, IE-JGKeppler, RIII JAxelrad, IE PRobinson, IE JLieberman, ELD . i GJohnson, RM Enforcement Coordinators RI, RII, RIII, RIV RV l Fingram, PA BHayes, 01 GEdles, 01A JCrooks, AF i LCobb IE VMiller, NMSS DCHapell, NMSS DNussbaumer, OSP IE:ES IE:EA l DCS Y
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IE:ESM'L E rad RVollmer aylor PRobiWson JGKeppteF' 2/j}/86 /2//j/86 2/3/86 2/ /86 , 2/.c/86 2//i/86 mw .v,% 7, t4 L 3 ti<,<< NUREG-0940 II.A-62
' UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of .
Docket Nos. 030-01993, 070-01396 LHURLEY MEDICAL CENTER Licenses No. 21-00338-02, SNM-1393 0ne_Hurley Plaza ) EA.85-89 Flint, MI 48502 ) ORDER: IMPOSING CIVIL MONETARY PENALTIES I Hurley Medical Center (the licensee) is the holder of License Nos. 21-00338-02 and SNM-1393 issued by the Nuclear Regulatory Commission (the Commission). The licenses authorize. the licersee to operate Hurley Medical Center in accordance with the conditions specified therein, i II. 1 i A routine NRC safety inspection of the licensee's activities was conducted on i May 2, 3, and 24 1985. The results of this inspection indicated that the i l licensee had not conducted its activities in full compliance with Commission l requirements and the conditions of its licenses. A written Notice of Violation i and Proposed Imposition of Civil Penalties was served upon the licensee by letter dated August 22, 1985. The Notice states the nature of the violations, the requirements of the Commission's regulations or license conditions that were violated, and the amount of civil penalties proposed for the violations. The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalties with two letters dated October 4, 1985. l I NUREG-0940 II.A-63 ,
i III After consideration of the licensee's responses and the statements of fact, explanation, and-arguments regarding remission or mitigation contained therein, as set forth in the Appendix to this Order, the Director. Office of Inspection. and Enforcement, has determined that the violations occurred as stated and that . the penalties proposed for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalties should be imposed. ; IV In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act i 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 civil penalties in the amount of Two Thousand Five Hundred Dollars ($2,500) within thirty 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 Inspection and Enforcement, USNRC, Washington, D.C. 20555. Y \ The licensee may, within thirty days of the date of this Order, request a hearing. A request for a hearing shall be addressed to the Director, Office NUREG-0940 II.A-64
1' of. Inspection and Enforcement, USNRC, Washington, D.C. 20555. A copy of the hearing request also shall be sent to the Executive Legal Director, USNRC, Washington, D.C. 20555 and to the Regional Administrator, Region III, 799 Roosevelt Road, Glen Ellyn, Illinois 60137. If a hearing is requested, the Commission will issue an Order designating the time and place of hearing. If the licensee fails to request a hearing within thirty days of the date of
-this Order, the provisions of this Order shall be effective without further proceedings and, 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 Commission's requirements as set forth in the Notice of Violation and Proposed Imposition of Civil Penalties referenced in Section II above and (b) whether on the basis of such violation this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION
//
T< - , Director a es M. Tay1 ! fice of In pection and Enforcement l i Dated at Bethesda, Maryland I this.tfday of February 1986 l NUREG-0940 II.A-65
APPENDIX'
. EVALUATIONS AND CONCLUSIONS The licensee's October 4, 1985 responses to the August 22, 1983 Notice of Violation and Proposed Imposition of Civil Penalties for Hurley Medical Center admit the facts as stated in 13 of.the 14 violations in the Notice. The licensee can neither confirm nor deny the violation ;oncerning the licensee's participation .
in theJexplant, recovery, or return of a nuclear pacemaker. The licensee's responses provide its reasons.why the penalties are not appropriate. Provided : below are.(1) a' restatement of each violation, (2) a summary of the licensee's- l responses, and (3) the'NRC's evaluation of the licensee's responses. 1 A.. Restatement of the Violation Licensee Condition No. 24 of License 21-00338-02 requires that all licensed material be possessed and used in accordance with statements and procedures in the application dated September 25, 1983. The application dated September 23, 1983 states that the Medical Isotope Committee shall meet no less than once in each calendar quarter. ' Contrary to the above, the Medical Isotope Committe did not meet. quarterly. Specifically, the Medical Isotopa Committee failed to meet during the first, third, and fourth quarters of 1981 and 1982; the second and third quarters of ] L -1983; the.first and second quarters of 1984; and the first quarter of 1985. Licensee's Response During the specified period, Hurley Medical Center's Medical Isotope Committee did not meet quarterly because of a lack of understanding of NRC requirements. After the Medical Isotope Committee was reestablished as the hospital's Radiation i Safety Committee in November of 1982, it was the understanding of the Committee l representatives that the requirement was to meet semiannually. Following the NRC l inspection of May 2, 3, and 24, 1985, an administrative directive was distributed which' created standing quarterly meetings. Meetings have been held regularly since that time, and special monthly meetings have been held to monitor progress and compliance with other NRC requirements.
"In addition, committee membership has been strengthened to include additional representatives from the Department of Pharmacy, administrative and medical representatives from Cardiovascular Services, technical representation from the Divisions of Nuclear Medicine and Raciation Therapy. and additional medical staff representation from the Department of Radiology."
" Full compliance was achieved immediately following the most recent NRC ,
inspection." ! NRC Evaluation The licensee admits the violation. T M NRC staff acknowledges the licensee's position tnat noncompliance resulted from a misunderstanding of NRC requirements. However, the NRC review shows that the requirement to meet once in each calendar quarter is clear and should not have been subject to any misunderstanding. NUREG-0940 II.A-66 s:
i Appendix . B. Restatement of the Violation License Condition No. 24 of License 21-00338-02 requires that licensed materials be used in accordance with the application received February 8, 1978, the application dated September 23, 1978 and the application dated September 23, 1983. These applications describe Room 22, equipped with a ventilation system, as the area where xenon-133 would be used. Contrary to the above, on several occasions since November 1984, xenon-133 was used in a room other than Room 22. Specifically, xenon-133 was used in Room 20, an area not authorized by the license. Although Room 20 was equipped with an exhaust fan, the air flow rates and xenon-133 concentrations had not been evaluated or approved by NRC. Licensee's Response "Hurley Medical Center did not amend its license to reflect that the room used for xenon-133 procedures had been changed. Although failure to amend the license was an oversigh.t. the Radiation Safety Officer was aware that the air flow was sufficient in the room in question. The health and safety of patients and staff occupying these areas was not compromised." ;
"The xenon procedures imaging room license amendment and accompanying floor plan were forwarded to the NRC on June 6, 1985."
NRC Evaluation The licensee admits the violation in that the license was not amended to reflect a change in the room used for xenon-133 procedures. The licensee does state ; that the RSO was aware that the air flow was sufficient in the room where xenon-133 was used. Notwithstanding the licensee's evaluation, areas where radioactive material is used or stored are not in accordance with NRC regulatory requirements unless and until the area is specifically authorized in an NRC license. C. Restatement cf the Violation License Condition No. 24 of License 21-00338-02 requires licensed material be possessed and used in accordance with the application received February 8, 1978., The application received February 8, 1978 contains precautions and procedures to be followed when caring for patients treated with therapeutic quantities of radionuclides. Item 8 states nursing personnel entering the patient's rooms are to wear film badges. Contrary to the above, nursing personnel entering therapy patients' rooms did not always wear film badges. Nursing personnel did not wear film badges in cases where brachytherapy (cesium-137) implants were performed on October 8 and 29, November 13 and 19, December 3,1984, and January 22 and March 19 and 26, 1985, i NUREG-0940 II.A-67 1
b
.I r l i ' Appendix j
I Licensee's Response Hurley Medical Center dia not provide film badges to nurses entering therapy rooms. The Radiation Safety Officer stated: The number of Cs-137 Sealed Source therapies performed has i decreased to 30 in 1983 and 14 in 1984. Each treatment lasts ! about three days. Nursing involvement with these patients is minimal, about 14 minutes per day or 45 minutes to one hour total. The measured exposure rate at bedside of these patients is about 10Mr/hr 9 1 Meter, so that the probable exposure to nurses is 10mR. ; If the same nurse attended three patients per month, she would receive ! 10mR per month or 90mR per quarter. This is less than one quarter of I the maximum allowed dose of 1200mR per quarter. According to I 10 CFR 20.202a(1), film badges are not necessary under these ' conditions. Our results of monitoring nurses' radiation exposure confirms these calculations. In accordance with license conditions, badges are assigned to nursing personnel attending radioactive 1 implants and radioiodine therapies. j l
"Since the most recent NRC inspection, a new standard practice has been a developed to ensure assignment and monitoring of nursing personnel assigned to the care of radioactive implant patients. This policy states that ba'dges will j be ordered and assigned by the Radiation Safety Officer. The supervisor.of the (
. Radiation Therapy Department will provide the badges and be responsible for the evaluation of personnel for the duration of the patient's implant."
" Full compliance with this licensa condition was achieved June 7, 1985."
NRC Evaluation ' The licensee admits that film badges were not issued to nursing personnel but explairs that film badges were not necessary accordin While the NRC staff acknowledges that 10 CFR 20.202(a)(1)g wouldto 10require not CFR 20.202(a)(1 the issuance cf film badges, the violation is against the licensee's license condition which required film badges to be issued for nursing personnel. The more restrictive statement in the license is controlling. Part of License Conditior 24 states that the NRC's regulations shall govern the licensee's statements in application or letters, unless the statements in the application or letters are more restrictive than the regulations. 1 l 1 NUREG-0940 II.A-68
l4
-Appendix 'D. Restatement of the Violation License Condition No. 24 of License 21-00338 requires that licensed material be possessed and used in accordance with statements and procedures in the application received February 8, 1978. The application received February 8, 1978 contains precautions and procedures to be followed when caring for patients treated with therapeutic quantities of radionuclides. Item 4 states that surveys of exposure rates in the patient's room and adjacent areas will be performed.
' Contrary to the above, surveys were not always performed of. the patients' rooms and adjacent areas. Specifically, 14_ cesium-137 sealed source implants cere performed between February 6, 1984 and March 26, 1985 and only two -surveys cere conducted. No patient room surveys-were conducted during 14 cesium-137 sealed source implants between April 5 and September 28, 1982. Licensee's Response Hurley Medical Center acknowledges that it did not perform surveys of patients' rooms and adjacent areas following treatment with radionuclides. The Radiation Safety Officer stated: State of Michigan Radiation Rule 465(2) states " Calculations based on previous surveys will comply with this subrule," i.e., a survey performed for each patient. A series of surveys of patients' rooms and adjacent . areas were taken to determine the radiation levels present during treatment. No excessive radiation levels were recorded. Calculations were made of exposure rate per mci of activity used in treatment: 0.30 mR/hr @ 1 Meter. The exposure rates in subsequent therapies were caiculated from . this value. This complies with State of Michigan Radiation Rules. No I excessive radiation levels or exposures were measured or calculated.
"Since the last NRC inspection, a new standard practice has been developed and 4 implemented to assure compliance with this condition. It is the responsibility l of the Radiation Physicist to perform these surveys, and the responsibility of the Radiation Therapy Supervisor to monitor compliance with this practice. These actions will be reported at the quarterly Radiation Safety Committee meeting." : " Compliance was achieved by June 7, 1985."
NRC Evaluation The licensee admits the violation, although it contends that it was complying with the State of Michigan's radiation rules. If the licensee was implementing the less restrictive survey requirement imposed by the State of Michigan, the licensee was not complying with the requirement in its NRC license. i i NUREG-0940 II.A-69
Anpendix l
.LE. Restatement of the Violation License Condition No. 16 of License SNM-1393 requires that licensed material be -
possessed and used'in accordance with statements, representations, and procedures in a letter dated April 24, 1973. The letter dated April 24, 1973 states the physician responsible for nuclear pacemaker studies was William J. Weber, M.D. { Contrary to the above, licensee personnel other than the physician listed ' in the April 24, 1973 letter as the responsible individual are currently responsible for the nuclear pacemaker program. Licensee's Response j "Hurley Medical Center did not amend its license properly to reflect physicians in charge of the nuclear pacemaker program. While Hurley Medical Center did recognize the need to renew its nuclear pacemaker license, amending the physician's name responsible for the.new pacemaker program was overlooked. Hurley Medical Center has not implanted a nuclear pacemaker in a number of years. As a result, it was understood that no physician needed to be authorized for the implant of these pacemakers. 'On June 7,1985, Hurley Medical Center provided a new amendment to this license which was incorrect. Hurley Medical Center is providing a corrected amendment to its license naming a responsible physician so that the three remaining nuclear pacemaker patients may be monitored appropriately."
"h is the responsibility of the Director of Cardiovascular Services to cssure that any change in physician control or responsibility for this program be communicated to the Ra,iiation Safety Officer and to Administration for appropriate amendment of the license." "Hurley Medical Center will be in compliance with this condition when the N".
acknowledges this license amendment request." NRC Evaluation The licensee admits the violation. Although Hurley Medical Center personnel did not 'mplant a nuclear pacemaker over the last few years, there was still a nuclear pacemaker program in effect. The licensee failed to inform the NRC of the name(s) of the individual (s) responsible for nuclear pacemaker studies. F. Restatement of the Violation Item 9A of License SNM-1393 authorizes the possession of nuclear pacemakers for purposes of explantation, recovery and disposal. License Condition No. 16 (License SNM-1393) requires that licensed material be possessed and used in accordance with statements and procedures contained in a letter dated April 24, 1973. The letter states that William J. Weber, M.D. is the individual responsible for nuclear pacemaker studies. I NUREG-0940 II.A-70
LAppendix Contrary to the above, the licensee failed to explant, recover, and return for disposal a nuclear pacemaker from a patient who died in February 1985. Specifically, licensee personnel other than the responsible individual listed in the April 24, 1973 letter requested that a funeral director remove a nuclear pacemaker from the body of a patient after realizing that the patient had been the recipient of a nuclear pacemaker. The funeral director, who was not authorized by this license, was also requested to return the nuclear pacemaker to the manufacturer for disposal. The licensee did not participate in or supervise the explant, recovery, or return of the nuclear pacemaker. Licensee $, Response "Hurley Medical Center can neither confirm nor deny violation of this license condition. Conversations held with the funeral director in question indicate that he ccnnot recall whether the pacemaker was removed prior to contacting Hurley Meoical Center personnel or whether Hurley Medical Center personnel instructed him to remove the pacemaker. Hurley Medical Center personnel state that the pacemaker was removed prior to being contacted by the funeral home director and that at no time were instructions given to explant the pacemaker."
"A standard practice has been developed which outlines the proper procedure to be followed upon the death of a pacemaker patient . .. All Cardiovascular Study :
Unit staff have been informed of proper procedure, and it is the responsibility { of the supervisor of this unit to monitor compliance. This activity will be . monitored on a quarterly basis by the Radiation Safety Committee." !
"Hurley Medical Center cannot determine whether or not a violation of this nature occurred."
NRC Evaluation The licensee does not confirm or deny a violation of this license condition. In response to the licensee's comments, the funeral director was again contacted by the NRC staff on October 29, 1985 by telephone. The funeral director, who removed the pacemaker, stated that the patient had died at the hospital. He further stated the hospital staff called the funeral director and instructed him to ramove the pacemaker and that the hospital then sent the funeral director the package in which to return the pacemaker. Although the statements presented by the licensee and the NRC do not agree as to how the violation transpired, the NRC staff continues to believe that a violation occurred. Neither the statements presented by the NRC or by the licensee contradict the fact that the licensee failed, for some reason, to participate in or supervise the explant, recovery, or return to the manufacturer of the nuclear pacemaker. The NRC staff has concluded that a violation of the license condition occurred even 1 though disagreement remains concerning wno initiated the removal of the nuclear pacemaker. l 4 NUREG-0940 II.A-71 m_ _ _a
Appendix G. ' Restatement of the Violation License Condition No. 13 of License SNM-1393 states that the licensee shall report to the NRC, within 24 hours of occurrence, the death of any nuclear pacemaker patient. Contrary to the above, the licensee failed to report to the NRC that nuclear pacemaker patients died in November 1984 and January 1985. Licensee's. Response "Hurley Medical Center did not notify the NRC within 24 hours of discovering the death of two pacemaker patients. At the time of the deaths of these patients, l it was thought that is was the responsibility of the physician following the patient to notify the NRC. However, since this time, Hurley Medical Center has 1 officially' notified the.NRC of these deaths in a memorandum dated May 30, 1985." , 4 Hurley. Medical. Center has since developed a standard practice to ensure regular followup for its pacemaker patients at 6-month intervals and to include provisions i to contact the NRC within 24 hours of the death of a patient. The supervisor of the Cardiovascular Study Unit has the responsibility to notify the NRC of these deaths. This standard practice will be monitored by the Director of Cardiovascular Services and reviewed by the Radiation Safety Committee at its quarterly meetings. Hurley Medical Center was in full compliance with the condition on June 7, 1985. NRC Evaluation The licensee admits the violation. , H. Restatement of the Violation License Condition No. 14 of License SNM-1393 states that the licensee shall contact the NRC within 10 days after less of contact with a nuclear pacemaker patient. Contrary to the above, the licensee failed to report the loss of contact with 1 nuclear pacemaker patients in March, April, and November 1982, and in March 1984. i Licensee's Response i "Hurley Medical Center did not report the loss of contact with a nuclear pacemaker patient as required. This occurred as a result of failing to comply with the condition of contacting pacemaker patients at predetermined intervals. Since that time, Hurley Medical Center has contacted all current nuclear pacemaker patients and determined their whereabouts." NUREG-0940 II.A-72 i
i Appendix i "A standard practice has been developed that includes the provision that loss of j contact will be reported within [10] days. It is the responsibility of the supervisor for the Cardiovascular Study Unit to initiate this contact. It will be the responsibility of the Director of Cardiovascular Services to monitor this j activity with quarterly reports to be made to the Radiation Safety Committee." ; i "Hurley Medical Center was in compliance with this condition on June 7, 1985." NRC Evaluation The licensee admits the violation. Restatement of the Violation , I. License Condition No. 16 of License SNM-1393 requires that all licensed , material be possessed and used in accordance with statements, representations, l and procedures contained in a letter dated April 24, 1973. The letter dated April 24, 1973 states that nuclear pacemaker patients shall be contacted each month. Contrary to the above, nuclear pacemaker patients were not contacted each month. Specifically, the licensee failed to contact pacemaker patients approximately 5 times in 1982, 11 times in 1983 and 11 times in'1984. Licensee's Response "Nurley Medical Center did not contact all nuclear pacemaker patients monthly, as required. This occurred because Cardiovascular Study Unit staff were not properly trained in that they were unaware of the necessity for this contact. An amendment request has been filed to allow contact to be made semiannually."
"In addition, a standard practice has been developed which ensures that this activity will take place at regularly scheduled intervals. It is the responsibility of the supervisor of the Cardiovascular Study Unit to make this contact. The Director of Cardiovascular Services will monitor this activity and will report to the Radiation Safety Committee on a quarterly basis." " Full compliance with this license condition was achieved June 7, 1985."
NRC Evaluation The licensee admits the violation. Restatement of the Violation J. 10 CFR 35.14(b)(5)(v) states that the licensee shall conduct a quarterly physical inventory to account for all Group VI sources and devices received and possessed. l NUREG-0940 II.A-73 - __n
I l Appendix l
. Contrary to the above, the licensee failed to conduct a quarterly physical inventory to account for all Group VI sources and devices received and possessed.
Specifically, Group VI sources such as the 3M cesium-137 needles, the Nuclear Associates cesium-137 microrad af ter loading sources, and the cobalt-60 needles were not inventoried quarterly. The latt inventory was September 1983. Licensee's Response The licensee did not conduct quarterly physical inventories to account for all Group VI sources and devices. The Radiation Safety Officer stated: The Co-60 and Cs-137 needles have not been used in four years and are in storage. [10 CFR 35.14(e)(1)(1)(B)] states: 'no wipe tests are needed on sources which are being stored and not used.' This was confirmed by verbal communication the the NRC Region III Office in Chicago and the Inspector pointed out that the regulation cited concerns calibration Sources only. Also, the Co-60 needles had not been wipe tested during previous NRC inspection of June 23, 1981. We were not cited at that time nor were we informed of the required wipe testing even if source is in storage.
" Full compliance with this license condition was achieved June 7, 1985."
NRC Evaluation The licensee admitted this violation. The additional information provided by the licensee does not have any bearing on this citation. The licensee was cited for not conducting a quarterly inventory. The regulation cited by the licensee (10 CFR 35.14(e)(1)(i)(B)) has no relevance to this citation since it involves leak testing of sealed sources used as calibration or references sources. The 3 NRC staff concludes that the violation occurred as stated. The licensee's additional comments, while not relevant nere, have been addressed under violation L. K. Restatement of the Violation 10 CFR 35.14(f)(2) states that quarterly physical inventories shall be performed te account for all calibration sources received and possessed. Contrary to the above, quarterly inventories of calibration sources were not j performed. Specifically, a barium-133 source and a cobalt-60 source had not 1 been inventoried since the last inspection on June 23, 1981. 1 i Licensee's Response I l l
" Quarterly inventory of calibration sources was not performed. However, this was due to an oversight by the Radiation Safety Officer who believed that annual l
NUREG-0940 II.A-74
il 1 Appendix inventories (that were. conducted in December 1981, December 1962, December 1983 and December 1984) and wipe test [s] that were also conducted semiannually since ! June 23, 1981.(and are in effect an inventory), satisfied the intention of this requirement." I "A standard practice has been developed in order to ensure that quarterly inventories are now performed . . . . " J "Hurley Medical Center has been in full compliance with this requirement since" June 7, 1985." NRC Evaluation The licensee admits the violation. The NRC staff agrees that a wipe test can satisfy the inventory requirement dr.pending on the type of documentation retained. However, using the semiannual wipe test dates in conjunction with the annual inventory date would still leave a 6-month gap between inventory dates. The NRC staff has concluded that this violation did occur. L. Restatement of the Violation 10 CFR 35.14(5)(1) states that Group VI sealed sources shall.be tested for contamination and/or' leakage at intervals not to exceed 6-months. Contrary to the above, Group VI sources had not been leak tested since the last inspection on June 23, 1981. Licensee's Response Hurley Medical Center did not conduct 6-month leak tests at specified intervals.
"Since the last NRC inspection, the Co-60 and Cs-137 sources have been scheduled
-to be wipe tested at 6-month intervals. All other Group VI sources except the 4 3M Cs-137 tubes have been' wipe tested at the required 6-month intervals. The 3M Cs-137 tubes have a 3-year interval. A standard practice which outlines these procedures has been developed . . . and specifies that the Radiation Safety Officer will perform these tests. This policy also states that the supervisor of Radiation Therapy will monitor compliance and will report the results of these tests at the quarterly scheduled Radiation Safety Committee meetings."
"Hurley Medical Center has been in compliance with this requirement since June 7, 1985."
I NRC Evaluation The licensee admits the violation. The NRC's evaluation of the licensee's responses to violation J are addressed here because they pertain to leak testing. The licensee is correct in stating that under the provisions of 10 CFR 35.14(e)(1)(1)(B) certain sources do not need to be wipe tested if NUREG-0940 II.A-75 i
i
, i Appendix ' they are in storage. However, the sources at issue nere, Co-60 and Cs-137 needles,_are not calibration or reference sources and therefore are not exempt .from leak testing while in storage. Indeed, this was pointed out to the licensee by the inspector during the phone call mentioned by the licensee. .
Concerning the licensee's comment that the licensee was not previously cited for lack of Co-60 wipe te.sts, .NRC inspections consist of selective sampling techniques and may not have covered this area during the June 23, 1981. The licensee is held responsible for understanding and implementing all applicable regulations for which the license was granted.
~M. Restatement of the Violation 10 CFR 71.5 states that no licensee shall transport licensed material out of his facility unless the licensee complies with 49 CFR Parts 170-189.
49 CFR 173.475(i) states that before each shipment of any radioactive materials package, the shipper shall ensure by examination or appropriate tests that external radiation and contamination levels are within the allowable limits specified in this chapter, i Contrary to the above, the licensee failed to ensure that the external radiation and contamination levels were within allowable limits for packages , containing molybdenum / technetium returned to the manufacturer for disposal. Since the date of license issuance, the licensee had not performed direct l I radiation surveys and wipe tests for removable contamination on packages ! returned to the manufacturer. Licensee's Response "Hurley Medical Center did not document that it performed required tests of { external radiation and contamination levels of packages that were returned to manufacturers for. disposal. These tests, however, were performed during the past review perica. It should be noted that all generators undergo a 6-week decontamination period equivalent to 15 half lives. For this reason, it is not j felt that ' hot' radioactive material is being transported."
"A standard practice has been developed which outlines the required testing which i
must be perfcrmed and the fact that this activity must be documented. It is I the responsibility of the Nuclear Medicine technologist to perform these tests, and the responsibility of the Nuclear Medicine supervisor to assure that these activities are performed. The results will be reviewed at the quarterly < Radiation Safety Committee meetings."
" Full compliance with this license condition was achieved June 7, 1985."
NUREG-0940 II.A-76
l l Appendix NRC Evaluation The licensee admits the violation. The licensee states that during the past j review period the tests were performed but not documented. However, in i interviews during the inspection licensee personnel indicated that direct I radiation surveys- and wipe tests were not always performed on generator-shipments returned to the manufacturer. The licensee's practice of storing generators during a 6-week decontamination period is a good method of j operation; however, unless absolute inventory control is achieved, the only way 1 of ensuring contamination levels is by direct radiation surveys. ) i N. Restatement of the Violation j 10'CFR 20.401(b) requires that the licensee maintain records showing the results'of surveys made to assure compliance with 10 CFR 20.201(b). Contrary to the above, the. licensee failed to maintain records of surveys of technetium-99m contaminated waste to document that no measurable radiation above background was present before disposal. Records of surveys have not been maintained since the date of license issuance. Licensee's Response "Hurley Medical Center did perform the appropriate waste disposal activities, but did not maintain records of these surveys. It should be noted that waste is stored a minimum of 28 half lives (i.e., one week) prior to disposal. At this time, waste is surveyed to ensure that non-technetium radioisotopes have not been inadvertently mixed with technetium waste." '
"Our license renewal application of 1978 includes the procedures of radioactive waste disposal. These procedures explicitly describe the waste disposal methods we will follow.and did not mention recording results. These procedures were approved by the NRC and we were not cited for these methods during the p evious inspection of June 1981." ,
l "Since the most recent inspection, a standard practice has been developed which outlines that survey results will be recorded . . . It is the responsibility of j the Nuclear Medicine technologist to perform these activities. The supervisor l' Of the division of Nuclear Medicine will monitor these activities and report ~ quarterly.to the Radiation Safety Committee meeting."
"Hurley Medical Center has been in full compliance with this condition since June 7, 1985."
NRC Evaluation The licensee admits the violation. The licensee did not maintain records of waste disposal surveys and states that the procedure submitted by the hospital to the NRC concerning waste disposal activities did not discuss maintenance of survey results. The NRC staff agrees with the licensee that maintenance of survey results was not addressed. However,10 CFR 20.401(b) requires records be kept and, unless explicitly exempted, a licensee must comply with all NRC l regulations applicable to its licensed activities. j l j NUREG-0940 II.A-77 _ J
Appendix ) NRC inspections are a selective sampling of records, operating procedures,' independent measurements, and interviews with personnel. It is possible that violations identified during the May 1985 inspection were not found during the June 1981 inspection. It is also possible that the next inspection may identify violations not found during the May 1985 inspection. It is the licensee's responsibility to en:,ure that the program is in compliance with NRC requirements and regulations. NRC Conclusion For the above reasons, the NRC staff believes that the violations occurred as stated. The NRC has reviewed Hurley Medical Center's response to the proposed imposition of civil penalties and agrees with the licensee that management i initiatives were undertaken in the area of Radiation Safety. The staff l acknowledges that an Administrative Director was hired in July of 1984 and that the position of Nuclear Medicine Supervisor was also created. In addition to these newly created positions, a contract between Medical Physics Consultants, ! Incorporated and Hurley Medical Center for services starting October 1,1984 was signed to monitor and evaluate the Diagnostic Radiology and Nuclear Medicine Departments. , The NRC staff believes that all of the above steps are indications of, the sincerity and willingness of top level management representatives at the Medical Center to improve the radiation safety program. However, the Nuclear i Medicine Supervisor and the Administrative Director had been in their respective j positions for some time before the NRC inspection, the latter for 10 months ! before the discovery of the 14 violations. The consulting firm, according to the contract, should have visited the facility seven times before the NRC j inspection. Many of the violations identified by the inspector are clear i violations of the license conditions and NRC regulations for which misunder- I standings and oversight by personnel should not have occurred. The NRC staff has concluded that the 14-violations collectively represent a significant breakdown in day-to-day management oversight and control of the radiation safety program. The additional personnel retained by the licensee { are indications of management's willingness and desire to improve the radiation i safety program. Notwithstanding the sincerity of the licensee's efforts, the NRC staff believes that such actions (teken 7 to 9 months before the NRC inspection) should have identified many of the violations. The effectiveness of these actions ! is not apparent to the NRC staff. In fact, the licensee should determine how I these actions can be strengthened or better administered. Upon consideration of I the licensee's arguments concerning mitigation of the civil penalty, the NRC l staff has concluded that the licensee's actions were not effective in preventing l noncompliance with the license conditions or NRC regulations. For this reason, the licensee's argument concerning management action does not warrant mitigation I of the civil penalties. NUREG-0940 II.A-78
7 , s, I '\ \ UNIT E D '$ 7 AT.E s . [pa ascq\ NUCLEAR R E GU LATOfW COMMMSION y i) e ; REclCN Hs 5
' ,' - E 799 ROOSEvr.LT RO AD GLEN ELLYN) f.LINOIS 60137 kg y e M4 51997 l l
Docket No. 030-09491 ! License No. 21-15638-01 l EA 87-21 Mercy Hospital p f ATTN: Mr. Robert Beyer ' Chief Executive Officer 2601 Electric Avenue Port Huron, MI 48060 Gentlemen: ,
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY [NRC INSPECTION REPORT NO. 030-09491/86001(DRSS)] This refers to the NRC safety inspection 4/ activities authorized by 9RC License No. 21-15638-01 conducted on December,18 and 30, 1986. The inspection report , was sent to you on January 16, 1987. During the inspection, violaticns of NRC requirements were identified. On January 20, 1987 we held an enforcement conference in the NRC Region III office with Michael Parrott Ph.D., your s consultant, and Mr. Alan Wildman of your staff. During the conference, the violations, their causes, and your corrective actions were discussed. The violations described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice)-are significant because collectively they represent a lack of effective management control and oversight of licensed activities. Individually, improvement in the administration an(tiis. d control of violations demonstrate the radiatian the need safety program to assure adherence to NRC requirements and safe performance of licensed activities. Violation A.1 identifies the failure to perform a bioassay and is of particular concern because without a bioassay an iodine-131 uptake by a technologist would not be recognized. Therefore, timely corrective action could not have been taken to minimize any unnecessary dose to that individual. The root cause of these violationi appears to be the failure by your previous consultant to fully perform his re possibilities. However, this problem was aggravated by the failure of manage m t to implement a periodic and compre-hensive audit of the radiation safety program. A Confirmatory Action Letter addressing these concerns was sent to,you on December 24, 1986. To emphasize the need to implement dffective management control over the radiation safety program, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Two Thousand Five Hundred Dollars ($2,500). In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, l Appendix C (1986), the violations described in the enclosed Notice have been ! categorized in the aggregate as a Severity evel III problem. NUREG-0940 E . A-B f i
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I b' A 'bS Mercy Hospital 2 MAR E 1997 1 The base Civil Penalty for a Severity Level III problem 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 i 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 to describing an audit program, you should describe what other management actions will be implemented to ensure that the conditions of your license, as well as NRC regulations, are followed in the future. After. reviewing your response to this Notice, including l l9 your proposed corrective actions, the NRC will determine whether further NRC j enforcement action is.necessary to ensure compliance with NRC regulatory requirements. - g in accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, hh Title 10, Code cf Federal Regulations, a copy of this letter and the j F enclosures will be placed in the NRC Public Document Room. ) y ? Sincerely, a n , hl.& p4 A. Bert Davis Acting Regional Administrator L
Enclosures:
l l . 1. Notice of Violation and Proposed Imposition of Civil Penalty
- 2. Inspection Report No. 030-09491/86001(DRSS)
]'
I NUREG-0940 II.A-80 L
1 l l l NOTICE OF V:0LATION AND l PROPOSED IMPOSITION OF CIVIL PENALTY ! i Mercy Hospital Docket No. 030-09491 l 2601 Electric Avenue License No. 21-15638-01 i Port Huron, MI 48060 EA 87-21 i During an NRC inspection conducted on December 18 and 30, 1986, 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 (1986), the Nuclear Regulatory Commission proposes to impose a Civil Penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended 42 U.S.C. 2282 and 10 CFR 2.205. The particular violations and associated Civil Penalty are set forth below: A. License Condition No. 17 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in the application received June 6, 1983, and the letter dated October 20, 1983.
- 1. The referenced letter dated October 20, 1983, requires that bioassays be performed on personnel handling iodine-131 in amounts exceeding those in Table 1 of Regulatory Guide 8.20. Table 1 specifies 10 millicuries as the activity level above which bioassays for unsealed iodine-131 is required.
Contrary to the above, during 1984 and 1985, bioassays were not performed on a technologist who, an four separate occasicns, administered doses of approximately 100 millicuries of unsealed iodine-131 to patients.
- 2. The referenced application received June 6, 1983, requires that tests for instrument accuracy be performed monthly and all other test procedures be performed as described in NRC Regulatory Guide 10.8, Appendix 0, Section 2, October 1980, for calibration of a dose calibrator. Appendix 0 requires that a constancy test include all commonly used radionuclides settings and, if results of the constancy test vary from predicted activities by more than 5 percent instrumentrepairoradjustmentisindicated. In addition, Iinearity tests are to be performed over a 48-hour period.
Co.ntrary to the above, the interval between instrument accuracy tests was greater than one year. In addition, in November and December 1986,
~
results of daily constancy tests varied from predicted activities by greater than 5 percent and no corrective actions were taken. From November 23, 1983 to December 18, 1986, tests for instrument constancy did not include checks on the iodine-131 and xenon-133 settings, both commonly used settings. Routine tests for instrument i linearity were performed over a 24-hour period rather than the required 48-hour period, t NUREG-0940 II.A-81
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The referenced application received June 6, 1983, requires that , n nurses carino for brachytherapy patients be assigned film or T W
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*f badges anli that pocket dosin ters may be assigned in addition'.to
/' 'a film or.TLD. badge.
< t' Contrcry to the lbove, from January 25, 1984 to' December 18, 1986, although nurses caring for brachytherapy patients were provided pocket dosimeters, they were not provided with film orlTLD badges.
- 4. The referenced application received June 6,'1983, requires that 1
measurements sf airflow rates will be performed semiannually in rooms used for th storage and use of xenon-133. ,
-1 a ;
Contrary twthe above, f rom November 23, 1983 to December 18 1986, 1
. measurements'of airflowirates were not performed in rooms use,d for .]
; storage anc'euse of xenon-133. 1
- 5. Thereferenceispp'licationreceivedJune6,198.1,requiresthat ancillary personnel receive annual' instruction in the itees -
specifiedin10CCR19.{2. - h Contrary to the above, from November 23, 1983 to December E( 1%6, the licensee did not provide annual instructions in the items ,', < p specified % 10 CFR 13t12 to ancillary personnel. I ,-
- 6. The. referenced application received June 6, 1983, requires tha't the method of performing wipe tests will be sufficiently sensitive to detect 100 disintegratups per minute (dpm).
, 1 Contrary to the abgve, from November 23, 1983 to December 18,
., .! 1986, wipe' tests vfre performed with instrumer,ts that were
.v .
incapable of detecting contamination levels as low as 100 dpm. yd,e
"; 7. .The referenced application received June 6, 1983, requires that for each package of radioactive material, the exposure. rate (in units of milliroentgas per hour) be measured at three feet or one meter from the package surface and at the package surface, and wipes of the final source container be taken and assaye1
~
Contrary toI'tSe abcVe, from Novemberf /3,r1983 to December 18, 1986, the exposur y f'ates at theee feet or one meter were not reasured in 7 [ units of milliroentgen is per hour and se'aserements of the exposure
.. rate at the pack &ges surftce and wipes 'of the final sources container were not perforteed. ,;
+
d 8. The refercnced application E.eceived June 6, 1983, requires t'.at l
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theiRadiation Safety Committee meet quarterly. p! 4
+
J (? a HUREG-0940 /, l j II.A-32 ,,; ; r y y
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- l l
Notice of Violation 3 i MAR 9 1997 -) i Contrary to the above, only two meetings were held in 1984- . (February 1 and September 20) and two meetings were held in 1985.(May 13 and September 24). This is a repeat violation.
- 9. The referenced letter dated October 20, 1983, requires that survey meters be calibrated annually.
Contrary to the above, a Victoreen Model 495, a Victoreen Model 740, and a Atomlab Model CDV-700 survey meter were not calibrated during 1984 and 1985. This is a repeat violation. B. 10 CFR 71.5(a) requires compliance with the applicable requirements of the Department of Transportation regulations in 49 CFR Parts 170-189. 49 CFR 173.443 requires that sufficient measurements be taken to assess the non-fixed contamination levels on the external surfaces of each package offered for shipment. Contrary to the above, from November 23, 1983 to December 18, 1986, the licensee did not take measurements to assess the non-fixed contamination levels on the external surfaces of packages containing molybdenum-99/ technetium-99m that were offered for shipment. C. 10 CFR 20.401(b) requires that each licensee maintain records showing I the results of surveys required by 10 CFR 20.201(b). Contrary to the above, the licensee did not maintain records of surveys ; made, as required by 10 CFR 20.201(b): (1) in unrestricted areas around i rooms of patients being treated with iodine-131 for thyroid carcinoma or (2) m&de prior to disposal of linens and utensils used by these patients. Collectively, the above violations have been categorized as a Severity Level III problem (Supplements IV and VI). < Cumulative Civil Penalty - $2,500 (assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, Mercy Hospital is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with 3 copy to the Regional 1 i Administrator'r, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, IL 60137 within 30 days of the date of this Notice a written J statement or explanation, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if j l
)
NUREG-0940 II.A-83
- a I
J Notice of Violation 4 MAR S 1987- '
. admitted, (4) the corrective steps that have been taken and the results achieved, (4) the corrective steps wnicn wili ce taKen to aVolo Turtner violationsi and.(o) the date when fulliompliahce^Will be achie'ved."
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 respona shall be submitted under oath or affirmation. . l: . t Within the same time as provided for the response required above under i 10_CFR 2.201, Mercy Hospital may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or rhoney order payable to the Treasurer of the United States in the cumulative-amount of Two Thousand Five'Hundred Dollars ($2,500) or may protest imposition of the civil penalty.in whole or in part by a written answer addressed to the
' Director, Office of Inspection and Enforcement. Should .rcy Hospital fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount i . proposed above. Should Mercy Hospital elect to file an answer in accordance '
with 10 CFR 2.205 protestino the civil penalty, such answer may: (1) deny the violations. listed in this Notice in whole or in part, (2) demonstrate I extenuating circumstances, (3) show error in this Kotice,'or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. In requesting mitigation of the proposed penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C should be addressed. Any written answer in accordar.ce with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201 but may incorporate parts of the 10 CFR 2.201 reply by specific reference-(e.g., cite page and paragraph numbers) to avoid repetition. The attention.of Mercy Hospital 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 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 penalties, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282. Sincerely,
&,Q \ Q A. Bert Davis Acting Regional Administrator Dated at Glen Ellyn, Illinois, .this p day of March 1987.
NUREG-0940 II.A-84
-C ~
o' NUCLEAM MhWULA10HY COMMISSION
-[ . ,i ' WASHINGTON, D. C. 20066 e..**.
[ JUN- 01 1987 Docket.No. 030-09491-License No, 21-15638-01
~
-EA 81-21 '!
-Mercy Hospital.
ATTN: Mr Robert Beyer Chief Executive Officer
'2601 Electric Avenue Port Huron, MI 48060
-Gentlemen:
This refers to'your letter dated April 6,1987 in response to the Notice r# Violation and Proposed Imposition of Civil Penalty sent to you by our letter dated March 9,1987. 'The Notice of Violation describes violations identified during a safety inspection conducted at your Port Huron, Michigan facility on December 18 and 30, 1986. To emphasize the need to ensure implementation of effective management control.- over the radiation safety program, a civil penalty of $2,500 was proposed. In your response you admitted the violations occurred as set forth in the Notice of Violation; however, you protested imposition of a civil penalty because of immediata and substantial corrective action. After careful consideration of your response and your protest-against imposition ' of a civil penalty, we have concluded for the reasons set forth in the enclosed Order and Appendix that the violations did occur as originally stated and that mitigation or remission of the penalty is not warranted. Accordingly, we hereby serve the enclosed Order on Mercy Hospital in the am)unt of Two Thousand Five HundredDollars($2,500), We will review the effectiveness of your corrective actions during a subsequent inspection. In accordance with Section 2.790 of the NRC's.* Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosure ) will be placed in the NRC's Public Document Room. The response 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.
Sincerely, '
.A \
69iv i Jimes M. Tay eputy Executive Director ' l for Regional Operations ;
Enclosure:
Order Imposing i a Civil Monetary Penalty l l with Appendix l :NUREG-0940 11.A-85 l l
i i UNITED STATES
~
NUCLEAR REGULATORY COMMISSION In the Matter of ) Docket No. 030-09491 Mercy Hospital License No. 21-15638-01 2601 Electric Avenue EA 87-21 Port Huron, MI 46060 ) , ORDER IMPOSING CIVIL MONETARY PENALTY I 'I l I Mercy Hospital (the licensee) is the holder of 8yproduct Material License No. 21-15638-01 initially. issued by the Nuclear Regulatory Comission (the Comission/NRC) on June 7,1973. The ifcense was renewed in its entirety , on November 23, 1983 and will expire on November 30, 1988. The license-authorizes the licensee to use byproduct material for medical diagnosis and therapy. II A routine inspection of the licensee's activities was conducted on December 18 and 30, 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 Penalty was 1 served upon the licensee by letter dated March 9, 1987. The Notice stated the nature of the violations, the provisions of the Nuclear Regulatory Commission's requirements that the licensee had violated, and the amount of the civil penalty proposed for the violations. The licensee responded to the Notice of Violation and Proposeo Imposition of Civil Penalty by letter dated April 6, 1987. NUREG-0940 II.A-86
l III After consideration of the licensee's response and the statements of fact, explanation, and' argument for mitigation contained therein, the Deputy Executive Director for Regional Operations has determined, as set forth in the Appendix to this Order, that'the violations occurred as stated and 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 (Act), 42 U.S.C. 2282, and 10 CFR 2.205, IT IS HEREBY ORDERED THAT: The licensee pay a civil penalty in the amount of Two Thousand Five Hundred Dollars ($2,500) within 30 days of the date of this Order, by check,. draft, or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, I U.S. Nuclear Regulatory Comission, ATTN: Document Control Desk. Washington, DC 20555. The licensee may request a hearing within 30 days of the date of this Order. A request for a hearing should be clearly marked as a " Request for an Enforcement Hearing" and shall be addressed to the Director, Office of , Enforcement, U.S. Nuclear Regulatory Comission. ATTN: Document Control Desk, NUREG-0940 II.A-87
Washington, DC 20555, with a copy to the Regional.Administ'rator, Region III. If a hearir,g is requested, the Commission wil1 issue an Order designating the-time and place of the hearing. If the licensee fails to request a hearing within 30 days of the date of this Order, the provisions of this Order shall be effective without further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection. In the event the licensee requests a hearing as provided above, the issues 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 (b) whether, on the basis of such' violation, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION Y Ja s M. Tay1 puty Executive Director for Regional Operations Dated at Bethesda, Maryland this 1st day of June 1987 I l NUREG-0940 II.A-88 i
l l I ( l APPENDIX l ) EVALUATIONS AND CONCLUSIONS On March 9,1987, a Notice of Violation and Proposed Imposition of Civil Penalty (Notice) was issued to Mercy Hospital for violations identified during a routine ; NRC inspection. Mercy Hospital responded to the Notice on April 6,1987. During ) the inspection, three violations with a total of 11 examples were identified l which demonstrated a lack of effective management control and oversight of j licensed activities. In its response, the licensee admits the violations 4 occurred as described in the Notice but protests the imposition of a civil ! penalty because of its belief that it took immediate and substantial corrective action. Provided below are: (1) a sumary of the violations, (2) a sumary of the licensee's response regarding each violation, (3) the NRC evaluation of j the licensee's response, and (4) the NRC conclusion. 1 Sumary of Violations Nine examples of violations of License Condition No.17 were identified during the inspection. This Condition requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in the application received June 6,1983 and the letter dated October 20, 1983. Contrary to these requirements the licensee had failed to: (1) perform bioassays on personnel handling more than 100 millicuries of iodine-131 in unsealed form; (2) perform accuracy, constancy, and linearity tests of a dose calibrator as required; (3) provide film or TLD badges to nursing personnel caring for brachytherapy patients, (4) measure airflow rates in rooms used for storage and use of xenon-133 on a semiannual basis over a i three year period, (5) provide annual instructions in the items specified in 10 CFR 19.12 to ancillary personnel; (6) perform wipe tests with instruments ) i that were capable of detecting contamination levels as low as 100 dpm; (7) per- J form measurements of packages containing radioactive material; (8) hold quarterly Radiation Safety Comittee meetings, and (9) perform annual calibration of survey meters. In addition, the licensee did not: (1) assess contamination levels on the external surfaces of packages containing molybdenum-99/ technetium-99m that were offered for shipment, and (2) maintain records of surveys made in unre- ! stricted areas around rooms of patients being treated with iodine-131 for l thyroid carcinoma or made prior to disposal of linens and utensils used by these patients. Sumary of Licensee's Response In its April 6,1987 response, the licensee described corrective actions that had been taken and will be taken in the future. These actions included: (1) use of liquid iodine-131 has been discontinued; (2) required tests are now being performed on the dose calibrator, (3) film or TLD badges have been obtained for all nursing personnel; (4) airflow rates were measured in rooms used for storage and use of xenon-133 and will be performed in the future at six month intervals; (5) ancillary personnel have been NUREG-0940 II.A-89
Appendix ; instructed regarding their work movements around restricted radiation areas and , a program has been initiated for new employees to be informed about restricted l areas; (6) the wipe test procedure has been modified to use a thin window GM ! survey meter that will detect 0.1 milliroentgen per hour or a gamma camera J j when appropriate; (7) required measurements are now being made on packages containing radioactive materials, (8) Radiation Safety Comittee meetings are now being conducted as required, and (9) survey meters are being calibrated annually. In addition, (1) packages containing molybednum-99/ technetium-99m are now being surveyed on external surfaces, and (2) surveys will be made in rooms of patients being treated with therapy doses of iodine-131 and of the linens and utensils used by these patients. The licensee believed the proposed civil penalty should be mitigated in its entirety based on these corrective actions. 1 NRC Evaluation In its response, the licensee protests the imposition of a civil penalty $ because it had taken immediate and substantial corrective action. The NRC staff has concluded that the violations occurred as stated in the March 9, 1987 Notice and that the lic.ensee's corrective actions were not unusually prompt and extensive. For mitigation to be appropriate, corrective actions must be unusually prompt and extensive. The actions taken by the licensee were only what was necessary to bring its licensed program into compliance with NRC regulatory requirements. The licensee's corrective actions were not unusually prompt since it was noted during the enforcement conference that approximately three weeks after the NRC inspection was completed many of the licensee's corrective actions were still under consideration and had not been presented to the Radiation Safety Comittee for review and approval. NRC Conclusion Therefore, since the licensee has not provided a sufficient basis for mitigation or remission of the proposed civil penalty, the NR.C staff has concluded that a civil penalty in the amount of $2,500 should be imposed, t l l NUREG-0940 II.A-90
^<, UNITED STATES 7A > t. NUCLEAR HEGULATORY COMMISSION l
, -h REGION IV 611 HYAN PLAZA DRIVE, SUITE 1000
'?,, ,v AHLINGTON. TEX AS 76011
{ DCT E1 r2. Docket No. 30-20261 ) License No. 35-15486-02 EA 56-152 Nurrie Construction Company ATTN: Mr. Eugene Nurrie, President P.-0... Box 739 Muskogee, OK 74401' 4
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NOS. 30-20261/86-01and30-20261/86-02) This refers to the inspections conducted'on April 15 and 20-22, 1986, at the Nurrie Construction Company office at Muskogee, Oklahoma, and at two temporary job sites in Missouri. Violations identified during the inspections by Messrs. Holley and Reichhold were discussed with your representatives at the conclusion of the inspections and during the Enforcement Conference held at the NRC Region IV office in Arlington, Texas, on September 12, 1986. The violations identified as a result of the inspection are described in the-enclosed Notice of Violation and Proposed Imposition of Civil Penalty and involved the failure to:-(1) leak test a sealed source, (2) conduct physical inventories of licensed material, (3) maintain shipping package performance test records, (4) use shipping papers during transportation of licensed material, (5) use an authorized Radiation Protection Officer (6) use personnel dosimetry, l (7) maintain security of radioactive material, (8), maintain complete dosimetry records, and (9) maintain receipt records of licensed radioactive materials. ) The violations are of significant concern because they collectively indicate that adequate oversight and control of the radiological' safety program was not j exercised. In addition, the violations demonstrate the need for improvement -l in management control over activities to ensure adherence to NRC requirements and safe performance of licensed activities. To emphasize the importance of compliance with NRC requirements, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement,.to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Five Hundred Dollars ($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 j (1986) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem. The base civil penalty for a Severity Level III violation or problem is $500. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment-has been deemed appropriate. CERTIFIED MAIL RETURN RECEIPT REQUESTED NUREG-0940 II.A-91 m __
l l i flurrie Construction Company Ycu are required.to respond.to this letter and should follow the instructions specified in the enclosed Notice when preparir.g your response. In addition, I your response to this letter should describe the changes that have been or will be implemented to imp"ove management control and oversight of your radiation safety, program. Further, please identify the actions taken or planned to ensure . licensed activities tre conducted in accordance with the license including actions taken by Nurrie Construction Company to improve its management's responsiveness to NRC's recuests._ NRC encountered considerable difficulties in, reaching mutur11y agreeable dates for the inspection and the enforcement conference. Your reply to this letter and the enclosure, and the results' of ) future inspections, will be considered in determining whether further enforcement ' action is appropriate. In accordance with Section 2.790 of the NP.C'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 procedurcs of the Office of Managenent and Budget as required j by.the Paperwork Reduction Act of 1980, PL 96-511. , Sincerely, s Zh .fk Ob Robert D. Martin Regional Administrator
Enclosure:
Motice of Violation and Proposed Imposition of Civil Penalties cc: Oklahoma Radiation Control Program Director NUREG-0940 II.A-92
d f it0TICE OF VIOLATION Aff PROF 0 SED IMPOSITION OF CIVIL PENALTY Nurrie Construction Company Docket No. 30-20261 Muskogee, Oklahoma License No. 35-15a86-02 EA: 86-15? Durir.g NRC inspections conducted on April.15 and 20-22, 1986, violations j 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 (1986), 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, FL 96-295, anu 10 CFR 2.205. The particular l
- violations and associated civil penalty are set forth below:
A. License Condition 13 requires, in part, that each sealed source shall be tested for leakage and/or contamination at intervals not to exceed i six months. j Contrary to the above from January 1984 to April 1986, the licensee had not performed about'?6 percent of the required source leak tests on the v aled source in Troxler Density Gauge, Model 2401, Serial No. 1939.
- 8. License Condition 15 requires, in part, that the licensee conduct a physical inventory every six months to account for all sealed sources received and possessed under the license.
Contrary to the above, from January 1984 to April 1986 the licensee had not performed any physical inventories of sealed sources in its possession. C. License Condition 16 requires licensed material to be transported in accordance with 10 CFR Part 71. 10 CFR 71.5 requires compliance with the applicable requirements of the appropriate Departnent of Transportation regulations in 49 CFR Parts 170 through 189.
- 1. 49 CFR 173.415(a) requires, in part, that each shipper of a specification 7A package must maintain the package performance test records for at least one year af ter the latest shipment.
Contrary to the above, from January 1984 to April 1986, the licensee had not maintained the shipping package test records. >
- 2. 49 CFR 172.200 requires, in part, shipping papers to be prepared for each shipment and 49 CFR 203(d) specifies the information required on the shipping papers.
NUREG-0940 II.A-93
i 1 Contrery to the above, from Jenuary 1984 to April 1906, shipping papers were not used by tbc licensee during transportation of licensed materials ir its own vehicles and several shipments of licensed materials by common carriers without the shipping papers containing the radionuclides or activity. D. License Condition 17 requires that all licensed material be possessed and used in arcordance with statements, representations, and procedures contained ir application dated November 1, 1983, and letter dated December 6, 1983.
- 1. Thc l'icense application, dated November 1, 1983, names a specific ,
individual as Radiation Protection Officer (RP0). ) Contrary to the above, qualified individuals other than the authorized RPO acted as the RPO. Specifically, the authorizeo RPO left the company in 1982, and his duties as RP0 were assumed by two other ) individuals of Hurrie Construction Company. Additionally, in April 1986 the company named a third individual as RPO.
- 2. The licensee's letter, dated December 6, 1983, states, jn part, that !
workers would wear a film badge or other dose mea:uring device when i using or transporting the device. Contrary to the above, during March and April 1986, a worker did not wear a film badge when he used the moisture / density gauge about i 11 times.
- 3. The licensee's letter, dated December 6, 1983, states, in part, that when the gauge is stored, the area would be locked and that security of the instrument would be maintained at all times.
Contrary tc the above, the gauge was stored in an area that was not locked and security of the instrument was not maintained. Specifically, on April 20, 1986, the noisture-density gauge was stored in an unlocked construction trailer and no one was present ; to prevent unauthorized removal of the gauge. l E. 10 CFR 20.401(a) requires in part that cech licensee shall maintain records showing the radiation exposures of all individuals for whom personnel monitoring is required under 10 CFR 20.202, s I Contrary to the above, from January 1984 to April 1986, the licensee had not maintained the monthly dosimetry records for personnel for whom , record keeping is required under 10 CFR 20.202. ; F. 10 CFR 30.51(a) requires in part that eech person who receives byproduct naterial pursuant to a license shall keep records showing the receipt, transfer, and disposal of byproduct material. NUREG-0940 II.A-94
i 3 Contrary to the above, f rom Januery 1984 to April 1986, the licensee f ailed to. maintain receipt records of the licensed radioactive materials in its ; possession. Collectively, these violations have been categorized as a Severity Level III problem (Supplements-IV, V, and VI). (Cunulative Civil Penalty - $500 assessed equally among the violations.) ; Pursuant to the provisions of 10 CFR 2.201, Nurrie Construction Company is hereby required.to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region IV, 611 Ryan Plcza Drive, Suite 1000, Arlington, Texas 76011, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted,-(3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid i 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, the Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such ether nction as may be proper should not be taken. Consideration may be given to extending the response time for good-cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted i;nder oath or affirmation. Within the saine tine as provided for the response required above under 10 CFR 2.201, Nurrie Construction Company may pay the civil penalty by letter r dressed to the Director, Office of Inspection and Enforcement, with a check, ! draft, or money order payable to the Treasurer of the United States in the cumulative amount of Five Hundred Dollars ($500) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Nurrie Construction l Company fail to answer within the time specified, the Director, Office of < Inspection and Enforcement, will issue an order imposing the civil peralty in -{ the amount proposed above. Should Nurrie Construction Company elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: (1) deny the violations listed in this Notice in whole or in part,
-(2)demonstrateextenuatingcircumstances,(3)showerrorinthisNotice,or 1 (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty. '
In requesting mitigation of the proposed penalty, the five factors addressed in 1 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 i NUREG-0940 II.A-95 L_--_---__----____-_--__---_------_-------- -
parts cf the 10 CFR'2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. Nurrie Construction Company's attention 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 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 i Section 234c of the Act,.A2 U.S.C. 2282. { FOR THE NUCLEAR REGULATORY COMMISSION
~
< sF bl ktdD ,
Robert D. Martin Regional Administrator Dated at Arlington, Texas, this f fday of October, 1986.
)
l
\
l j s 1 t NUREG-0940 II.A-96 '
[ natea e, UNITED STATES [ j NUCLEAR REGULATORY COMMISSION
.l E WASHINGTON, D. C. 20555
%*****}
. Docket No.: 30-20261 MAY 0 71987 License No.: 35-15486-02 EA 86-152 Nurrie Construction Company ATTN: Mr. Eugene' Nurrie, President P. O. Box 739 Muskogee, Oklahoma 74401 Gentlemen:
Subject:
Order Imposing a Civil Monetary Penalty This refers to your letter dated November 18, 1986, in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you with our letter dated October 31, 1986. Our letter and Notice described violations identified during NRC inspections conducted on April 15 and April 20-22, 1986, respectively, at your facility and work sites. To emphasize the importance of compliance with NRC requirements, a civil penalty of Five Hundred Dollars ($500) was proposed. In your response, your comments on three of the nine cited violations suggested that NRC mistakenly identified these as violations. After careful consideration of your response, we have concluded, for the reasons given in the Appendix attached to the enclosed Ordet Imposing Civil Penalty, that two of the nine
' violations did not occur. Therefore, a sufficient basis exists for reducing the proposed civil penalty. Accordingly, we hereby serve the enclosed Order on Nurrie Construction Company, imposing a civil monetary penalty in the amount of Three Hundred Eighty-Eight Dollars ($388.00).
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 enclosures will be placed in the NRC's Public Document Room. Sincerely,
/ _
a "M.'p' Tay1puty Executive Director nr Region Operations
Enclosure:
Order Imposing a Civil Monetary Penalty with Appendix - Evaluation and Conclusion cc w/ enclosures: Oklahoma Radiation Control Program Director CERT! TIED MAIL R TURN RECEIPT RE00ESTED NUREG-0940 II.A-97
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of NURRIE CONSTRUCTION COMPANY Docket No. 30-20261 P. O. Box 739 License No. 35-15486-02 Muskogee, Oklahoma 74401 EA 86-152 ORDER IMPOSING A CIVIL MONETARY PENALTY I Nurrie Construction Company, Muskogee, Oklahoma, (the " licensee") was the holder of License No. 35-15486-02 (the " license") issued by the Nuclear Regulatory Commission (the " Commission" or "NRC") on January 6, 1984, and is now holder of a revised license No. 35-15486-02 issued on May 23, 1986 which is essentially the same as the original license. The current license, as well as the former license, authorizes the licensee to use licensed materials in Troxler Model 3400 Series moisture / density gauges and Troxler Model 2401 surface moisture / density gauges for measurement of properties of materials. The current license expires on January 31, 1989. II NPC safety inspections of the licensee's activities under the license were conducted on April 15 and 20-22, 1986. During these inspections, the NRC staff determined that the licensee hed not conducted its activities in full compliance with NRC requirements. A written Notice of Violation and Proposed Imposition of Civil Penalty was served upon the licensee by letter dated October 31, 1986 and nine violations were proposed. The Notice stated the nature of the violations, the provisions of the Commission's requirements that NUREG-0940 II.A-98
the licensee had violated, and the amount of the proposed civil penalty for the violations. -A response, dated November 18, 1986, to the Notice of Violation and Proposed Imposition of a Civil Penalty was received from the licensee. After' consideration of the licensee's response and the statements of fact, explanation, and argument for mitigation contained therein, the Deputy Executive Director for Regional Operations has determined, as set forth in the Appendix to this Order, that the penalty proposed in the Notice of Violation and Proposed imposition of Civil Penalty for the violations should be reduced because two of the nine violations have been withdrawn. Accordingly, the Notice of Violation has been amended as set forth in the Appendix. III In view of the foregoing and pursuant to Section 234 of the Atomic Energy Act of 1984, as amended (ACT), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205, IT IS l HEREEY ORDERED THAT: The licensee pay a civil penalty in the amount of Three Hundred Eighty-Eight Dollars ($388) within 30 days of the date of this Order, by check, draft, or mor;ey order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555. NUREG-0940 II.A-99
IV The licensee may request a hearin! 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 Commission, ATTN: Document Control Desk, Washington, D.C. 20555 with a copy to the Assistant General Counsel for Enforcement at the same address, and to the NRC Regional Administrator, Region IV, 611 Ryan Plaza Drive. Suite 1000, Arlington, Texas 70611. If a hearing is requested, the Commission will issue ar Order designating the time and place of the hearing. If the licensee fe hs to request a hearing within 30 days of the date of this Order, the provisions of this Order shall be effective without further proceedings. If payment has not been made by that time, the matter may be referred to the Attorney General for collection. In the event the licensee requests a hearing as provided above, the issues to be considered at such hearing shall be,
- a. whether the licensee was in violation of Commission requirements as set forth in violations B, C.1, C.2 D.1, D.2, D.3 and E of the Notice of Violation and Proposed Imposition of Civil Penalty referenced in
' action II above, and as amended by this Order, and NUREG-0940 II.A-100
I
]
i b.- whether, on the basis of such violations, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION
\-
[sM.Ta or, Deputy Executive Director for Regional Operations Dated at Bethesda,. Maryland,
- this 11" day of May 1987.
1 j .- t NUREG-0940 II.A-101
APPENDlX EVALUATION AND CONCLUSION On October 31, 1986, a Notice of Violation and Proposed Imposition of Civil Penalty was issued to the licensee for nine violations of NRC requi'rements. The licensee responded to the Notice in a letter dated November 18, 1986, and indicated that it did not deny that six of the violations occurred, but questioned the validity of the remaining three violations. Provided below are (1) a restatement of each violation, (2) a sumary of the licensee's response, j and (3) the NPC evaluation of the licensee's response. Several of the 7 licensee's responses suggest that the Notice of Violation and Proposed l Imposition of Civil Penalty referred to the wrong license conditions. Contrary i to that belief, the license in effect during the inspection was referred to i properly. The confusion resulted from a subsecuent license amendment which caused some conditions to be renumbered. A. I Restatement of Violation A j i License Condition 13 requires, in part, that each sealed source shall be j tested for leakage and/or contamination at intervals not to exceed six j months, Contrary to the above, from January 1984 to April 1986, the licensee had not performed about 25 percent of the required source leak tests on the i sealed source in Troxler Density Gauge, Model 2401, Serial No.1939. ! I Sumary of Licensee's Response to Violation A j The licensee contends that Troxler Gauge Model 2401, Serial No.1939 was j in storage during the periods in questior Therefore, the licensee 1 asserts that a violation did not occur si. e leak tests are not reouired { when a gauge is in storage. i NRC Evaluation of Licensee's Response l j l This violation was cited by the NRC inspector because leak test records j were not found for the last half of 1984 or the first half of 1985 and the licensee had not previously indicated that the Troxler Gauge was not being used and was in storage. However, based upon the licensee's statements in its letter of November 18, 1986, this violation is withdrawn. B. _ Restatement of Violation B 1 i License Condition 15 requires, in part, that the licensee conduct a physical inventory every six months to account for all sealed sources received and possessed under the license. Contrary to the above, from January 1984 to April 1986 the licensee had not performed any physical inventories of sealed sources in its possession. Summary of Licensee's Response to Violation B The lictnsee contends that physical inventory records of the licensed material were not in their files at the time of inspection, but they always maintain the inventory records. NUREG-0940 II.A-102
Appendix NRC Evaluation of Licensee's Response At the time of the inspection, the comptroller indicated that he did not know of any physical inventories that had been performed. Sin.ce no inventory records were found, a violation was proposed. The licensee's response to the Notice of Violation and Proposed Imposition of Civil , Penalty indicated that physical inventory records had been available. I Subsequently, the NRC requested the licensee to submit copies of those . records. The licensee submitted shipping records, not inventory records. ( Even these shipping records, which the NRC does not consider to be adequate l substitutes for the physical inventory records, indicated that six inventories were missing for two gauges. Therefore, the violation occurred as stated. ! C. Restatement of Violation C License Condition 16 requires licensed material to be transported in accordance with 10 CFR Part 71. 10 CFR 71.5 requires compliance with the applicable rcouirements of the appropriate Department of Transportation regulations in 49 CFR Parts 170 through 189.
- 1. 49 CFR 173.415(a) requires, in part, that each shipper of a specification 7A package must maintain the package performance test records for at least one year after the latest shipment.
Contrary to the above, from January 1984 to April 1986, the licensee had not maintained the shipping package test records.
- 2. 49 CFR 172.700 requires, in part, shipping papers to be prepared for each shipment and 49 CFR 203(d) specifies the information required on the shipping papers.
Contrary to the above, from January 1984 to April 1986, shipping papers were not used by the licensee during transportation of licensed materials in its own vehicles and several shipments of licensed materials were made by common carriers without shipping papers containing the radionuclides or activity. Sumary of Licensee's Response to Violation C Regarding Violation C.1, the licensee contends that it was not aware of the requirement to maintain package performance test records. Regarding Violation C.2, the licensee asserts that shipping papers were always used when the Troxler gauges were transported and each company vehicle had a copy of a oermanent type shipping paper in the cab when transporting the gauges. NRC Evaluation of Licensee's Response The licensee's lect of understanding of the requirement to have package performance test records does not provide a basis for withdrawal of the violation. Licensees are expected to be knowledgeable about applicable regulatory requirements. Therefore, Violation C.1 remains as stated. NUREG-0940 II.A-103
Appendix 3-Violation C.2 was cited because the comptroller indicated that he thought current shipping papers were not being utilized each time the gauges were transported and the absence of records verified his belief of this matter. The NRC inspector did find shipping papers for licensed material being shipped by comon carriers, but these papers did not contain a'11 the required information. The licensee's response to the Notice of Violation and Proposed Imposition of Civil Penalty indicated that each company vehicle contained. permanent shipping papers and that individual shipping papers were used for common carrier shipments. - The violation is hereby modified to read, Contrary to the above, from January 1984 to April 1986, several shipments of licensed materials by comon carrier were not accompanied by shipping papers showing the radionuclides or activity." D. Restatement of Violation D License Condition 17 requires that all licensed material be possessed and used in accordance with statements, representations, and procedures contained in application dated November 1,1983, and letter dated December 6,1983.
- 1. The license application, dated November 1, 1983, names a specific individual as Radiation Protection Officer (RPO).
Contrary to the above, qualified individuals other thLn the authorized RP0 acted as the RPO. Specifically, the authorized RP0_left the company in 1982, and his duties as RP0 were assumed by two other individuals of Nurrie Construction Company. Additionally, in April 1986 the company named a third individual as RPO.
- 2. The licensee's letter, dated December 6, 1983, states, in part, that workers would wear a film badge or other dose measuring device when using or transporting the device.
Contrary to the above, during March and April 1986, a worker did not wear a film badge when he used the moisture / density gauge about 11 times.
- 3. The licensee's letter, dated December 6, 1983, states, in part, that when the gauge is stored, the area would be locked and that security of the instrument would be maintained at all times.
Contrary to the above, the gauge was stored in an area that was not locked and security of the instrument was not maintained. Specifically, on April 20, 1986, the moisture-density gauge was stored in an un-locked construction trailer and no one was present to prevent unauthorized removal of the gauge. Summary of Licensee's Response to Violation D The licensee admitted Violation D and has implemented corrective actions, which include requesting on amendment to the license, estimating exposures and revising dosimetry records, and Stating its intent to always maintain strict security with gauges. l 1 NRC Evaluation of Licensee's Response l i Since the licensee admitted the violation, Violation D remains as stated. NUREG-0940 II.A-104
l l l Appendix E. Restatement of Violation E l 1 10 CFR 20.401(a) requires in part that each licensee shall maintain records showing the rediation exposures of all individuals for whom personnel monitoring is required under 10 CFR 20.202.
- 1 Contrary to the above, from January 1984 to April 1986, the licensee had i not maintained the monthly dosimetry records for personnel for whom record J keeping is required under 10 CFR 20.202.
Sumary of Licensee's Response to Violation E The licensee contends that, if records had not been misfiled, this violation would not have occurred because adequate records exist in the area of personnel monitoring. NRC Evaluation of Licensee's Response As a result of the licensee's response, the NRC requested the licensee to submit copies of those records. As received, those records were deficient in that several months of exposure data were missing. Therefore, the violation remains as stated. F. Restatement of Violation _F 10 CFR 30.51(a) requires in part that each person who receives byproduct material pursuant to a license shall keep records showing the receipt, transfer, and disposal of byproduct material, i l Contrary to the above, from January 1984 to April 1986, the licensee j failed to maintain receipt records of the licensed radioactive materials l in its possession. Summary of Licensee's Resp _onse to Violation F The licensee's response stated that it had shipping records proving
- receipt, delivery, or transfer of sealed sources.
_NPC Evaluation of Licensee's Response On February 24, 1987, the licensee submitted two " shipped from and shipp'ed to" forms showing shipments of Troxler gauges between the licensee and Troxler. Pending further review, these records will be accepted as satisfying the receipt and transfer record requirements of 10 CFR 30.51(a). Therefore, Violation F is hereby withdrawn. G. Summary of Licensee's Request for Mitigation The licensee states that it has improved its organization and has { corrected all of the problems brought to its attention by the NRC. The i licensee asserts that full compliance was achieved within days after l the inspection and that its mistakes should not necessitate a Severity l Level III problem and do not merit a civil penalty. NUREG-0940 II.A-105
. Appendix NRC Evaluation of Licensee's Reouest for Mit:igation During the. NRC inspection, it was apparent to the NRC inspector that licensee personnel lacked knowledge of NRC requirements and that an overall strengthening of management control of licensed activi. ties was necessary. Even with the withdrawal of two of the. violations, a0 discussed above, the weaknesses identified in the' license's control of its licensed activities is evidenced by the seven remaining violations and these violations constitute a problem area warranting a Severity Level III. No mitigation is considered appropriate.
Conclusion Violations A and F have been withdrawn. The.other violations occurred as stated
~1n the Notice, as amended in this Appendix, and the licensee has not provided information to support a reduction in the severity level of the problem. Based on the reductions in the number of violations,.a sufficient basis exists for reduction of the proposed civil penalty. Therefore, a civil penalty in the amount of Three.Hundred Eighty-Eight Dollars ($388) is imposed.
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%.++ NAY ?.11987 Docket Nos. 30-05985; 030-17815; 030-20679 License Nos. 37-00276-25; 37-00276-26; 37-00276-27 EA 87-65' PTL-Inspectorate, Inc.
ATTN: Mr. Kingsley Drake Executive Vice President 850 Poplar street Pittsburgh, Pennsylvania 15220 iGentlemen: Y$ubject: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY-(NRC Inspection No.'87-01)
- This refers to the NRC inspection of activities authorized by NRC License Nos.
37-00276-25, 37-00276-26, and 37-00276-27, conducted on November 18-19, 1986 at your office in St. Louis,' Missouri and at a field site in Illinois, and continued on March 10-12, 18-19 and 26-27, 1987 at your offices in Pittsburgh, Pennsylvania and St. Louis, and at various temporary field sites. The report of the inspection was forwarded to you on April 24, 1987. During the inspec- 1 tion, three violations of NRC requirements were identified. On May 5, 1987, we held an enforcement conference with you and a member of your staff during which the violations, their causes,-and your corrective actions were discussed. The violations, which are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice), include failure to maintain j direct surveillance of a high radiation area at a temporary field site in ; Hannibal, Missouri, resulting in an individual entering the area while a
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radiographic source was' exposed; allowing an individual at another field site in Bridgeville, Penray1vania to perform certain duties of a radiographer's assistant withcut being certified; and allowing one individual at your Pittsburgh, Pennsylvania facility and three individuals at your Anchorage, Alaska facility to handle moisture-density gauces without either completing, or having the necessary documentation to verify completion of, the required training course prior to using the gauges. With respect to this last viola-tion, the NRC recognizes that the three individuals at your Anchorage, Alaska facility had taken a training course similar to the course specified in your application. Although the individual who entered the high radiation area in Hannibal received an estimated radiation exposure that was less than any applicable regulatory limit, the NRC is concerned that the potential existed for a sig-nificant exposure. Furthermore, the failure to maintain direct surveillance CERTIFIED MIL KTURN REMPT REQUESTED NUREG-0940 II.A-108
l PTL-Inspectorate, Inc. 2 of a high radiation area, and the performance of licensed activities by uncertified individuals, are violations that 'have been identified by the NRC in the past, and have been the subject of previous enforcement actions (
Reference:
(1) EA 86-123, issued October 7, 1986, Violations A and F.3; and (2) EA 85-34, issued April 7, 1986, Violation A). The NRC is concerned that your past corrective actions were not effective in preventing recurrence. The NRC recognizes that, in response to the previous violations, you established and sent to your employees a structured disciplinary policy, and have demon-strated N ur willingness to implement this policy as evidenced by the fact that, since July,1986, disciplinary action, in the form of terminations, suspen-sions, monetary fines, and reprimands has been taken against seven individuals, including the Radiation Safety Officers of five district offices. However, the NRC is concerned that, at the time of the May 5,1987 enforcement conference, you had not yet informed your employees, other than those disciplined, of the actions taken so that all employees are aware of the company's willingness to take wk.tever action is necessary to assure compliance with NRC requirements. To emphasize the need for assuring that individuals comply with requirements, including maintaining direct surveillance of operations to avoid unauthorized entry and utilizing only properly certified individuals, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the amount of Five Thousand Dollars ($5,000) for the violations described in the enclosed Notice. In accordance with the " General Statement of Policy and Ptocedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987) (Enforcement Policy), the violations described in the enclosed Notice have been categorized in the aggregate as a Severity Level III problem. The escalation and mitigation factors in the Enforcement Policy were considered and no adjustment has been deemed appropriate. Although you identified the event in Hannibal and reported it to the NRC, and your recent additional corrective actions appear comprehen-sive, mitigation is inappropriate in view of your enforcement history described above. You are required to respond to the enclosed Notice and should follow the instructions specified in the Notice in preparing your response. In your response, you should document the specific actions taken to correct the violations and any additional actions you plan to prevent recurrence. Your response to this Notice, including your pruposed corrective actions and the results of future inspections will be considered in determining whether further : enforcement action is necessary to ensure compliance with NRC ref,ulatory require-cents. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and the enclosed Notice will be placed in the NRC's Public Document Room. i
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NOTICE OF VIOLATION AND - PR0p0 SED IMPOSITION C.' CIVIL PENALTY PTL-Inspectorate, Inc. Docket Nos. 030-05985 Pittsburgh, Pennsylvania 15220 030-17815 030-20679 L'icense Nos. 37-00276-25 37-00276-26 37-00276-27 EA 87-65 During an NRC inspection ccnducted on November 18-19, 1986 and March 10-12, 18-19, and 26-27, 1987, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the Nuclear Regulatory Commission proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1984, 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. 10 CFR 34.41 requires that, during each radiographic operation, the radio-grapher or' radiographer's assistant maintain direct surveillance of the operation to protect against unauthorized entry ir.to a high radiation area, unless the area is locked or equipped with a control device or alarm system as described in 10 CFR 20.203(c)(2). Contrary to the above, on February 9, 1987, at a field site in Hannibal, Missouri, radiographic operations involving the tank walls of a water tower resulted in a high radiation area outside the tower that was r.either locked nor equipped with an alarm system or control device, and direct surveillance to protect against unauthorized entry into the high radiation area was not maintained by a radiographer or radiographer's assistant, as evidenced by the f act that a non-radiation worker (boilermaker) entered . the high radiation area which was created when an 89 curie tridium-192 l source was exposed. B. 10 CFR 34.31(b) provides in part that no licensee permit any individual to act as a radiographer's assistant until that individual has received i copies of the licensee's operating and emergency procedures and has demon-strated an understanding of these procedures through successfully passing a written or oral test and a field examination on the subjects covered. l-Contrary to the above, on March 11, 1987, at a field site in Bridgeville, Pennsylvania, an individual employed by the licensee's client was permit-ted to perform duties of a radiographer's assistant. Specifically, this individual provided assistance in positioning the collimator and connecting the drive cable tube to the radiographic device. At the time, this indi-vidual had not received copies of the licensee's operating and emergency procedures nor had he demonstrated an understanding of these procedures through successfully passing a test. i l l NUREG-0940 II.A-111 l 4
C. Condition 11 of License No. 37-00276-27 requires that licensed material be used by, or under the supervision and in the physical presence of, l Individuals designated by the. licensee who have completed the training i course described in the licensee's application for a license dated i November 11, 1983. Section 8.2 of this application requires that the Radiation Safety Officer, who administers the training, document the results. i Contrary to the above,
- 1. On March 10, 1987, an individual used (calibrated) a moisture-density gauge at the Pittsburgh, Pennsylvania facility, and records were not ;
available to indicate that the individual had completed the training course identified in the application dated November 11, 1983, nor was { the individual under the supervision or in the physical presence of j an individual designated by the licensee who had completed the train-ing course.
- 2. At various times prior to March 11, 1987, at least three additional !
individuals associated with the licensee's Anchorage, Alaska district k office operated moisture-density gauges without having taken the I training course specified in the application and were not under the supervision or in the physical presence of an individual designated by the licensee who had completed the training course. < l Collectively, these violations have been categorized as a Severity Level III problem (Supplement IV). Cumulative Civil penalty - $5,000 (assessed equally among the violations). Pursuant to the provisions of 10 CFR 2.201, PTL-Inspectorate, Inc. (Licensee) is hereby reoutred 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, i 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 urder oath or affirmation. Within the same time as provided for the response required above under j 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, j or money order payable to the Treasurer of the United States in the amount of 3 the civil penalty proposed above, or the cumulative amount of the civil l'l NUREG-0940 II.A-312 j
l 4 3 l 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, Of fice 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 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 five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1987), should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g. citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty. Upon failure to pay any civil penalty due which subsequently has been deter-mined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c. The responses to the Director, Office of Enforcement, noted above (Reply to a Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, ATTH: Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, 631 Park Avenue, King of Prussia, Pennsylvania 19406. FOR THE NUCLEAR REGULATORY COMMISSION 4.r. & aA-William T. Russell Regional Administrator l Dated et King of Prussia, Pennsylvania, this ;Uri' day of May 1987 l 1 NUREG-0940 II.A- U 3 C ___
') i UNITED STATE 5
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- RtceoN o 7; 101 NIAR4ETTA sTRE ET. N W.
f,g. j ATL ANTA croRotA 30323 g ,.. f APR O 61987 Docket No: 030-13036
- License No: 45-17606-01
'EA 87 Rappahannuck General Hospital ;
ATTN: Mr. F. Baensch- I Hospital Administrator P. O. Box 1449 Kilmarnock, VA 22482 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY I (NRC INSPECTION REPORT NO, 45-17606-01/87-01) This refers to the Nuclear Regulatory Commission (NRC) inspection conducted by l R. Brown'at the Rappahannock General Hospital en January 13, 1967. The inspection included a review of the Radiation Safety Program.. The report 'l documenting this inspection was sent to you.with a letter dated February 26, 1987. During the inspection, several violations of NRC requirements were identified. The violations were discussed by J. P. Stohr, Director, Division of Radiation Safety and Safeguards, NRC, Region II, with you and members of your. staff in an Enforcement Conference held on February 9, 1987. The.vioistior.s described in the;epciosed Notice of Violation and Proposed 3 Imposition of-Civil Penalty invclved failure to have. quarterly Radiation Safety 'l Committee meetings, failure to perforn formal annual reviews of the Radiation Safety Program, and. failure to perform tests for contamination on external surfaces of the final source containers of radioactive material. The failure to conduct quarterly Radiation Safety Committee meetings is of particular concern because it is the third violaticn of this license condition and demonstrates management's failure to implement comprehensive corrective actions for prior similar problems. This violation was cited as a violation on June 30, 1982, and again on June 12, 1985. The failure to perform tests for contamination was also cited as a yiolation on June 12, 1985. These repetitious violations raise a substantial question as to whether you are willing or capable of , exercising control of licensed' activities. To emphasize the importance of having a properly functioning Radiation Safety Committee and the importance of adequately correcting violations to prevent l recurrence, I have been authorized, after consultation with the Director, Office ' of Inspection and Enforcement, to-issue the enclosed Motice of Violation and Proposed Imposition of Civil Penalty in the amount of Seven Hundred Fifty Dollars ($750) for the first violation describcd in the enclosed Notice. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 30 CFR Part 2, Appendix C (1986) (Enforcement Policy), the violations described in the enclosed Notice have been categorized as Severity Level IV violations. CERTIFIED MAIL KETURN RECEIPT REQUESTED i NUREG-0940 II.A-114 1 4
I Rappahannock General Hospital 2 , APR C) 61987 ] 1 i The escalation and mitigation factors in the Enforcement Policy were considered I and. no adjustment of the base civil penalty amount has been deemed appropriate. In addition to the need for corrective action regarding the specific matters identified in the enclosed Notice, we are concerned about the lack of implemen-tation of your management control systems that permitted this situation to develop. Because "similar violations," as described in the NRC Enforcement Policy, are of significant concern to the NRC, please give particular attention in your response to the identification of the root causes of this problem and describe those particular actions taken or planned to prevent recurrence and ! to improve the effectiveness of your program. ! You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In addition, your response should address why NRC should have confidence that in the future you will assture that all NRC requirements will be complied with. After reviewing your response to this Notice, including your proposed corrective actions, and . -ofter reviewing the results of future inspections, the NRC will determine whether ! further NRC enforcement action, including license suspension, is necessary to l ensure compliance with NRC regulatory requiremer,ts. In accordance with Section 2.790 of the NRC's " Rules of Prictice," 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, PL 96-511. Should you have any questions concerning this letter, please contact us. Sincerely,
~ c
. J. Nelson Grace Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty , i l l 4 NUREG-0940 II.A-115
f NOTICE OF VIOLATION PJOPOSEDIMPOSITI 0F CIVIL PENALTY I Rappahannock General Hospital Docket No: 030-13036 Kilmarnock, VA License No: 45-17606-01 i EA 87-34 ) 1 During the Nuclear Regulatory Commission (NRC) inspection conducted on I January 13, 1987, violations of NRC requirements were identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986), the Nuclear Regulatory Commission proposes to l impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, ; as amended ("Act"), 42 U.S.C. 2282, PL 96-295, and 10 CFR 2.205. The particular ; violations and associated civil penalty are set forth below: I I. Violation Assessed a Civil Penalty License Condition 16 requires that licensed material be used in accordance with statements, representations, and procedures contained in the licensee's application dated July 20, 1982. { { Item 7 of the licensee's application requires that its Radiation Safety Committee meet once in each quarter. J Contrary to the above, the licensee's Radiatior; Safety Committee has not l met once in each quarter since May 1985. Specifically, the Radiation i Safety Committee has met on only one occasion, May 9, 1985, since May 1985.
]
i This is a repeat violation. This is a Severity Level IV violation (Supplement VI). (Civil Penalty - $750) II. Violations Not Assessed a Civil Penalty ; A. License Condition 16 requires that licensed material be used in accordance with statements, representations, and procedures contained in the licensee's application dated July 20, 1982. Item 24 of'the licensee's application states that management will i perform a formal annual review of the Radiation Safety Program. ] Contrary to the above, the licensee did not conduct formal annual reviews of the Radiation Safety Program in 1985 or 1986. l 1 This is a 3everity Level IV violation (Supplement VI). B. License Condition 16 requires that licensed material be used in accordance with statements, representations, and procedures contained in the licensee's application dated July 20, 1982. i NURFG-0940 11.A-116
Notice of Violation Item 14 of the licensee's application requires that the external surface of final source containers be wipe tested to check for contamination. Contrary to the above, as of the date of the inspection, no required
. tests for contamination on the external surfaces of the final source containers of radioactive material had been performed.
This is a repeat violation. This is a Severity Level IV violation (Supplement VI). Pursuant to the provisions of 10 CFR 2.201, Rappahannock General Hospital is hereby required to submit to the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region II, 101 Marietta Street, N.W., Suite 2900, Atlanta, Georgia 30323, within 30 days of the dcte of this Notice a written statement or explanation including for each violation: (1) admission or denial of the violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an l adequate reply is not received within the time specified in this Notice, the ' Director, Office of Inspection and Enforcement, may issue an order to show cause why the license should not be modified, suspended, or revoked or why such other action as may be proper 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, Rappahannock General Hospital may pay the civil penalty by letter addressed to the Director, Office of' Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Seven Hundred Fifty Dollars (S750) or may prote t imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should Rappahannock General Hospital fail to answpr within the time specified, the Director, Office of 2nspection and Enforcement, will issue an order imposing the civil penalty in,the amount proposed above. Should Rappahannock General Hospital elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer 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, ln requesting mitigation of the proposed penalty, the five factors addressed in Section V,B of 10 CFR Part 2, Appendix C, should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from thc statement or explanation in :. ;1y 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 NUREG-0940 II.A-117
Notice of Violation paragraph numbers) to avoid repetition. Reppahannock General Hospital's attention 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. FOR THE NUCLEAR REGULATORY COMMISSION
. .s h J. Nelson Grace Regional ~ Administrator Dated at-Atlanta, Georgia-thiss/4 day of. April 1987 l-NUREG-0940 II.A-118
i sa 8' sop UNITED STATES 4 % NUCLE AR REGULATORY COMMISSION
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'f GLEN ELLYN, ILuNOIS $01 H
..... JAN 151987 Docket No. 50-186 License No. R-103 EA 86-191 University of Missouri '
ATTN: Dr. Robert M. Brugger Director, Research Reactor Facility )i Research Park Columbia, MD 65201
-G2nt1emen:
Subject:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY (NRC INSPECTION REPORT NO. 50-186/86003(DRSS)) This refers to the NRC safety. inspection conducted from August 26 through j 1 October 3,1986 at the University of Missouri Research Reactor Facility in Columbia, Missouri. The inspection was in response to an overexposure- l reported to the NRC by the licensee in a letter dated August 20, 1986. The results of the inspection were discussed with you during an enforcement conference in the Region III office on October 3, 1986. The extremity overexposure and inadequate radiation hazard evaluation constitute violations of NRC requirements as described in Section I of the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice). Our review of the' overexposure event shows that on July 29, 1986 you were informed by the J dosimetry vendor (R. S. Landauer Jr. and Co.) that a TLD finger dosimeter for ! the month of v;ne 1986 had recorded approximately 23 rem. The dosimeter had bsen worn by an' employee on June 9, 1986 while handling thulium-170 wafers. The extremity dose was subsequently revised to approximately 115 rem by the i dosimetry vendor af ter considering the calibration adjustment factors necessary for measuring thulium beta exposures. After carefully considering your arguments regarding the validity of the dosimetry, we have determined that the thulium-170 ! pellet handling operation could asily have produced the exposure reported by I the dosimetry vendor. We are concerned that you did not realize the actual j beta' dose rates associated with the thulium pellets either by calculation or j measure....nt and did not adequately preplan the operation. These inadequate evaluations may have contributed to the overexposure event. To emphasize the necessity of exercising effective control over licensed activities and employee radiation exposures, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty in the aucunt of Four Thousand Dollars (54,000) for the violations described in Section I of the enclosed Notice. In accordance with the l " General Statement of Policy and Procedure for NRC Enforcement Actions," 30 CFR Part 2, Appendix C (1986) (Enforcement Policy), the violations CERTIFIED MAIL kETURN RECEIPT REQUESTED NUREG-09.40 II.A-119
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v University.of. Missouri 2 JAN 151987 described.in Section I of the enclosed Notice have been categorized as a Severity Level'II problem. The base civil penalty for this type of violation
. or problem is $4,000,; and although the escalation and mitigation factors.in I the Enforcement Policy were considered, no adjustment has been deemed- H appropriate. ;
)
The inspection also identified other violations of NRC requirements which are - ; described in Section II of the. enclosed Notice. The violations included the ! failures to (1) maintain recorA of surveys; (2) provide information in a l
, report, and (3) accurately-reflect on a shipping paper the activity level of ~ thulium pellets being transported to another location. Because these violations l
are less significant than the overexposure event, they have been characterized as three Severity Level IV violations. However, they demonstrate that management i awareness needs to be strengthened in these areas to achieve full compliance j with NRC requirements. l 1
.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 I actions'you plan to prevent recurrence. After reviewing your' response to this ' Notice, including any proposed 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 enclusure 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 96-511. Sincerely, QvJames G. Keppler)6ll% Regional Administrator
Enclosure:
Notice of Violation and Proposed Imposition of Civil Penalty l 4 NUREG-0940 11.A-120
i 1 l f 1t l
- NOTICE OF VIOLATION AND PROPOSED IMPOSITIOR DF A CIVIL PENALTY L
University of Missouri' Docket No. 50-186 Research Reactor Facility License No. R-103 Columbia, Missouri EA 86-191 During an NRC inspection conducted from August 26 through October 3, 1986, j 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 (1986), the Nuclear Regulatory Commission ;-oposes to impose a civil. penalty 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. The particular violations and associated civil penalty are set forth below:
- 1. Violations Assessed A Civil penalty A. 10 CFR 20.301(a) provides in part that no licensee shall use licensed material in such a manner as to cause an individual in a restricted area to receive in any period of one calendar quarter from radioactive material and other sources of radiation a total occupational-dose in excess of 18.75 rems to the extremities.
Contrary to the the above, in June 1986 during the second calendar i quarter of 1986, an individual who handled radioactive'thul'um-170 l pellets in a restricted area received a dose of approximately 115 rem to the hands while transferring the pellets into'a container for shipment. B. 10 CFR 20.201(b) requires that each licensee make such surveys as (1) may be necessary for the licensee to comply with the regulations in this part, and (2) 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, i disposal, or presence of radioactive materials or other sources . of radiation under a specific set of conditions. Contrary to the above, in July, August, and October 1985 and June 1986 the licensee failed to adequately perform such surveys (evaluations) as were necessary to ensure compliance with 10 CFR 20.101. Specifically, during the above time periods, the licensee failed to adequately evaluate the potential personnel exposures associated with the handling of curie quantities of thulium pellets. The licensee did not perform exposure rate calculations and preoperational dry runs. Furthermore, the licensee did not satisfactorily evaluate extremity dosimetry placement to ensure that the researcher's extremity exposure was adequately monitored, i NUREG-0940 II.A-121
I i Notice of. Violation 2 JAN 151987 l l i
-Failure to adequately perform these evaluations may have contributed to the extremity overexposure of approximately 115' rem to a researcher's i hand in June 1986.
Collectively, these violations have been= categorized as a Severity 1 Level 'II problem (Supplement IV). Cumulative Civil Penalty - $4,000 assessed equally between the violations. II. Violations Not Assessed Civil Penalties A. .10 CFR 20.401(b) requires that records be maintained showing the ! results of surveys required by 10 CFR 20.201(b). 10 CFR 20.201(b) i requires surveys be made as necessary to comply with the regulations ! in Part 20 and are reasonable to evaluate the extent of radiation l hazards that may be present. Contrary to the above, as of the inspection on August 26, 1986, survey records wa e not maintained for the July 1985 thulium pellet handling operation, and incomplete records were maintained for the August'and October 1985 and the June 1986 thulium pellet handling operations. Furthermore, the survey results for the June 1986 operations were j recorded from memory in August 1986, and measured dose rates by the i 1icensee documented on Radiation Work Permits were several orders of ! magnitude lower than the radiation fields that should have been expected. j This is a Severity Level IV violation (Supplement IV).
~
B. 10 CFR 20.405(a)(1) provides in part that, w'ithin 30 days, each licensee make a writtan report to the Commission concerning each exposure to radiation in excess.of the applicable limits in 10 CFR 20.101 or 10 CFR 20.104(a) or in its license. 10 CFR 20.405(a)(2)(iii) and (iv) require that each report under 20.405(a)(1) must describe the cause of the exposure and corrective steps taken or planned to prevent recurrence. 10 CFR 20.405(b) requires that any report filed with the Commission pursuant to 20.405(a) include, among other information, the social security number and date of birth for each individual exposed. 1 Contrary to the above, the August 20, 1986 licensee extremity exposure report submitted to the Commission in accordance with 10 CFR 20.405(a)(1) did not describe the cause of the June overexposure to the hand of a researcher or corrective steps taken { or planned to prevent recurrence and did not include the social - l security number or Late of birth for the individual exposed. This is a Severity Level IV violation (Supplement IV). NUREG-0940 II.A-122
i JAN 1 5 1997 Notice of Violation 3
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C. 10 CFR 71.5(a) requires each licensee who transports licensed material _outside the confines of its plant or other place of use, or who delivers licensed material to a carrier for transport, to comply j with the applicable requirements of the regulations appropriate to the mode of . transport of DDT in 49 CFR Parts 170 through 189. 49 CFR 172.203(d)(iii) requires the description for a shipment of i radioactive material to include the activity contained in each package ; in terms of curies, mil 11 curies, or microcuries, i Contrary to the above, on June 10, 1986 the licensee failed to include ! the correct activity of thulium pellets contained in a shipment to Lixi, Incorporated in Downers Grove, Illinois. Specifically, the shipping paper litted the cumulative thulium activity as 4.0 curies when the correct activity was later determined to be 9.0 curies, 125%. This is a Severity Level IV violation (Supplement V). Pu'rsuant to the provisions of 10 CFR 2.201, the University of Missouri is hereby required to submit t.o the Director, Office of Inspection and Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555 with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region III, 799 Roosevelt Road, Glen Ellyn, IL 60137, within 30 days of the date of this Notice a written statement or explanation, including for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation, if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps which will be taken to avoid further violations, and (5) the date when full compliance will be achieved. ff an adequate reply is not received within the time specified in this Notice, j f the Director, Office of Inspection and Enforcement, may issue an order to show ! I cause why the license should not be modified, suspended, or revoked or why su'ch J other action as may be proper should not be taken. Consideration may be given j 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. dithin the same time as provided for the response required above under 10 CFR 2.201, the University of Missouri may pay the civil penalty by letter addressed to the Director, Office of Inspection and Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the amount of Four Thousand Dollars ($4,000) or may protest imposition of the civil penalty in whole or in part by a written answer addressed to the Director, Office of Inspection and Enforcement. Should the University of Missouri fail to answer within the time specified, the Director, Office of Inspection and Enforcement, will issue an order imposing the civil penalty in the amount proposed above. Should the University of Missouri elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, such answer may: NUREG-0940 II. A '"
i i Notice of Violation- 4 'JAN 151987 ! 1 I I (1) deny the violations listed in this Notice in whole or in part; 1 (2) demonstrate extenuating circumstances; (3) show error in this Notice, 1 or (4) show other reasons why the penalty should not be imposed. In addition l 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 penalty, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1986) 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 University of Missouri's attention 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 have been subsequently determined in accordance with the applicable provisions of 10 CFR 2.205, this 4 matter may be referred to the Attorney General, and the penalties, unless i compromised, remitted, or mitigated, may be collected by civil action pursuant { to Section 234c of the Act, 42 U.S.C. 2282. FOR THE NUCLEAR REGULATORY COMMISSION CL eJiib/QMo (fJamesG.Keppfer Regional Administrator Dated at, Glen Ellyn, Illinois, this i6* day of January 1987. i NUREG-0940 II.A-124
1 UNITED STATES
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NUCLEAR REGULATORY COMMISSION t; wAsNewoTog, o.c.sossa t, 4
- k' * *
- MAY 221987 - :
l Docket No. 50-186 License No. R-103l 3 EA 86-191 J University of Missouri . ATTN: - Dr. Robert M. Brugger l Director. Research Reactor Facility Research Park Columbia, MD 65201 ! Gentlemen: This refers to your letters dated February 13, 1987 in response to the Notice of Violation and Proposed Impesition of Civil Penalty sent to you by our letter dated January 15, 1987. The Notice describes violations identified during an NRC Safety inspection conducted at the University of Missouri-Research Reactor Facility in Columbia, Missouri during the period August 26 t through October 3, 1986. To emphasize the need to ensure implementation of effective management control j cver your radiation safety program, a civil' penalty of $4,000 was proposed.'
'In your response, you admitted the violations occurred as set forth in the Notice of Violation; however, you provided reasons why the civil penalty i sh:uld be mitigated. ,
After careful consideration of your response, we have concluded, for the reasons set forth in the enclosed Order and Appendix, that the violations did occur as , orhinally stated and that mitigation of the penalty is not warranted. Accordingly, ! we herr.by serve the enclosed Order Imposing Civil Monetary Penalty on the ' University of Missouri in the amount of Four Thousand Dollars ($4,000). We will
. review the effectiveness of your corrective actions during a subscquent inspection, 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 the enclosure will be placed in the NRC's Public Document Room.
Sincerely,
, /
==
s M. Taylor Deputy Executive frector for Regional Operations
Enclosure:
Order Imposing a Civil Monetary Penalty with Appendix NUREG-0940 II.A-125 l
UNITED STATES NUCLEAR REGULATORY COMMISSION In the Matter of i University of Missouri Docket No. 50-186 Research Park License No. R-103 Columbia, M0. 65201- EA 86-191 ORDER IMPOSING CIVIL MONETARY PENALTY I l University of Missouri (the licensee) is the holder of Research Reactor License No. R-103 (the license) issued by the Atomic Energy Comission on October 11, 1966. The responsibilities of the Atomic Energy Comission were assumed by the Nuclear Regulatory Comission (NRC/Comission) in 1974. The license authorizes the licensee to operate a research reactor in Columbia,. Missouri in accordance with the conditions specified therein. I II An inspection of the licensee's activities was conducted from August 26 through i l October 3,1986 in response to an overexposure reported to the NRC by the j licensee in a letter dated Augu:t 20, 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 Penalty was served upon the licensee by letter dated January 15, 1987. The Notice stated the nature of the violations, the provisions of the NRC's requirements that the licensee had violated, and the amount of the proposed civil penalty for the violations. The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalty by letters dated February 13, 1987. NUREG-0940 II.A-126
III After consideration of the licensee's response and the statements of fact, explanation, and argument for mitigation contained therein, the Deputy Executive Director for Regional Operations has determined, as set forth in the Appendix to this Order, that the violations occurred as stated and that the penalty proposed for the violations designated in the Notice of Violation and Proposed Imposition of Civil Penalty should be imposed. IV i 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 penalty in the amount of Four Thousand Dollars ($4,000) 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, DC 20555. I Th2 licensee may request a hearing within 30 days of the date of this Order. A request for a hearing should be clearly marked as a
- Request for an Enforcement Hearing" and shall be addressed to the Director, Office of Enforcement, U.S.
Nuclear Regulatory Comission, ATTN: Document Control Desk, Washington, D.C. 20555, with a copy to the Assistant General Counsel for Enforcement at the same l NUREG-0940 II.A-127 i
address, and to the NRC Regional Administrator, Region III, 799 Roosevelt Road,. Glen Ellyn, Illinois, 60137. If a hearing 1s requested, the Comission will issue an Order designating the j 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 l l be effective without further proceedings. If payment has not been made by ] i that time, the matter mcy be referred to the Attorney General for collection. . I In the event the licensee requests a hearing as provided above, the issues to q 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 linposition of Civil Penalty referenced in Section II above, and (b) whether, on the basis of such violation, this Order should be sustained. FOR THE NUCLEAR REGULATORY COPeilSSION
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h anes M. Tay1 0 puty Executive Director for Regional Operations l Dated [atBethesda, this day of May 1987Maryland NUREG-0940 II.A-128
i l APPENDIX EVALUATIONS AND CONCLUSIONS 10n January 15, 1987, a Notice of' Violation and Proposed Imposition of Civil l Panalty (N0Y) was issued for violations identified during an NRC inspection. The University of Missouri responded to the Notice on February 13, 1987. In its response, the licensee admitted that the violations occurred as set forth I in the NOV, but requested mitigation of the civil penalty and provided reasons ' to support its request. Provided below are a restatement of the violations assessed a civil penalty, a summary of the licenseets response, the NRC's evaluation of the licensee's response, and the NRC's conclusion. Restatement of Violation I.A 10 CFR 20.101(a) provides in part that no licensee shall use licensed material ) in such a manner as to cause an individual in a restricted area to receive in I any period of one calendar quarter from radioactive material and other sources ) of radiation a total occupational dose in excess of 18.75 rems to the l extremities. Centrary to the above, in June 1986 during the second calendar quarter of 1936,. an individual who handled radioactive thuliun-JJ ,.:llets in a restricted area received a dose of approximately 115 rem to the hands while transferring the pellets into a container for shipment. Summary of Licensee's Response The licensee argues that the proposed civil penalty should be mitigated for this violation based upon the factors set forth in Section V.B. of the NRC's Enforcement Policy,10 CFR Part 2 Appendix C. Specifically, the licensee argues that the penalty should be mitigated based upon its: (1)promptidentificetion and reporting. The licensee states that it was informed by its dosimeter vendor on July 29, 1986, of an apparent overexposure and reported this apparent over-exposure to the NRC within the 30 day reporting period. The licensen further states that it was infonned by the vendor on September 12, 1986, that.the over-exposure had been recalculated and the apparent dose increased from 23.5 rem to 115 rem, and reported this new information to the NRC on October 7,1986; (2) corrective action to prevent recurrence. The licensee's corrective actions include a decision made on July 29 not to repeat the thulium wafer process until resolution of this problem and the establishment of a committee the day of.the. -incident to review the unplanned exposure which then met the next day to review its investigations; (3) prior good performance. The licensee states that no . previous extremity overexposure have occurred, and that a whole body exposure ! that occurred on November 8,1979, was promptly reported and effective corrective I actions were taken; (4) lack of prior notice of similar events; and (5) lack of multiple occurrences. NRC Evaluation of Licensee's Response The NRC agrees that the licensee reported the extremity overexposure in accordance with regulatory requirements. However, reporting of overexposure is always required and submitting a report 22 days after becoming aware of the spparent overexposure is not considered prompt. In addition, the report was - ! NUREG-0940 II,A-129
Appendix incomplete in that it did not' describe the cause of the overexposure or correc-tive steps planned to prevent recurrence. Furthermore, the licensee did not
. itself identify the violation. The fact that. the vendor sent the licensee information concerning .tt e overexposure which a licensee is required to report is not' sufficient to merit crediting the licensee with identification of the violation.
With regard to the licensee's corrective actions, the NRC staff agrees. that , discontinuing the thulium-170 pellet handling operations was prudent. The NRC ' recognizes the licensee's corrective actions. However, the NRC does not consider the licensee's corrective actions to be unusually prompt and exten-sive but the usual corrective actions expected of licensees. With regard to the licensee's prior perfomance, the NRC staff agrees that the license < had no previous extremity overexposure. However, the simple absence
. of a previous extremity overexposure is not a sufficient' basis for mitigation of a proposed civil penalty. Indeed, to emphasize the seriousness of an over-exposure, had the licensee's previous actions resulted in a prior extremity overexposure, the currently proposed enforcement action would have been more severe. Finally, neither lack of prior notice nor lack of multiple occur- ,
rences provide a basis for mitigation of a civil penalty. Instead, these l factors are used to escalate a civil penalty if there are multiple occurrences i or prior notice. In sum, none of the five factors addressed by the licensee in response to : Violation I.A. provide a basis for mitigation of the proposed civil penalty. ! Restatement of Violation I.B 10 CFR 20.201(b) requires that each licensee make such surveys as (1) may be necessary for the licensee to comply with the regulations in this part, and (2) are reasonable unoer 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. i Contrary to the above, in July, August, and October 1985 and June 1986 the licensee failed to adequately perform such surveys (evaluations) as were necessary to ensure compliance with 10 CFR 20.101. Specifically, during the above time periods, the licensee failed to adequately evaluate the potential ! personnel exposures associated with the handling of curie quantities of ! thulium pellets. The licensee did not perform exposure rate calculations and ' preoperational dry runs. Furthermore, the licensee did not satisfactorily evaluate extremity dosimetry placement to ensure that the researcher's extremity exposure was adequately monitored. Failure to adequately perform these evaluations may have contributed to the extremity overexposure of approximately 115 rem to a researcher's hand in June 1986. Summary of Licensee's Response I The licensee argues that the proposed civil penalty should be mitigated for this violation based upon the factors set forth in Section V.B of the NRC Enforcement Policy. Specifically, the licensee argues that the penalty should NUREG-0940 II.A-130
l Appendix l be mitigated based on its: (1) prompt identification and reporting. The licensee asserts that identification of this failure was made by its "Comittee to Review Unplanned Unusual Exposure" on July 30, 1986,. the day after its dosimeter vendor 4 reported that the TLD finger ring had recorded a 23.5 rem dose, and that the Comittee recomended that a dose rate map be created to assist in evaluation of the accumulated dose; (2) corrective action to prevent recurrence, which consisted of discontinuing the thulium wafer process until resolution of the problem, and adopting a procedure for calculation and review of expected dose rates; (3) prior past performance. The licensee asserts that the thulium wafer . transfer process is unique at its facility and there are no other high beta { exposure sources for which to consider past perfonnance; (4) lack of prior notice of similar events; and (5) lack of multiple occurrences. In addition to its arguments for mitigation, the licensee appears to challenge the portion of this citation that criticizes its failure to perform preoperational dry runs. The licensee asserts that, because' of the exploratory nature of the thulium transfer operations, dry runs were not considered, and would not have contributed information of value for the July, August and October 1985 operations. NRC Evaluation of Licensee's Response While the NRC agrees that a Comittee was convened to review the event after notification of the apparent overexposure by the dosimeter vendor, licensee identification of its failure to adequately evaluate the thulium operation and of formal recommendations to improve future similar operations were not made by the Comittee until August 6,1986. As previously noted, similar thulium-170 operations were conducted on three previous occasions and the evaluation short-comings could have been identified based on earlier operations. In these circumstances, mitigation for prompt identification and reporting is inappro-j priate. With regard to the licensee's corrective action, the NRC agrees that discontinuing l an operation until that problem was resolved was prudent. Again, the NRC recognizes the licensee's corrective actions. However, the NRC does not consider the licensee's corrective actions to be unusually prompt and extensive but the i usual corrective actions expected of licensees. { l With regard to the licensee's prior past performance, the NRC considered miti- ) gation. However, after balancing the licensee's prior past performance against i 1 the multiple examples of failure to do adequate evaluations within the period of a year, the NRC concludes mitigation is not warranted. Finally, as already l discussed, lack of prior notice of similar events does not provide a basis for l mitigation of a proposed civil penalty. With regard to the licensee's arguments concerning its failure to perform dry runs, the NRC believes dry runs should always be done when curie quantities are handled, even for exploratory operctions, in order to familiarize personnel with the operations so that exposures can be minimized. NRC Conclusion The licensee has not provided a sufficient basis for mitigation of the civil penalty. Consequently, the proposed civil penalty in the amount of $4,000 should be imposed. NUREG-0940 II.A-131
##% UNfTED STATES 1
y1 f'; NUCLEAR REGULATORY COMMISSION q f, - ,I REGION IV S f $11 RYAN PLAZA DRIVE, SUITE 1000 j
, , ARLINGTON, TEXAS 79011
]
Docket No. 30-11802 ) License No. 25-16883-01 O8 IS87 i EA 86-198 Yellowstone County Surveyor's Office ! ATTN: Mr. Harlan M. Lund, County Surveyor ! Room 312, Courthouse 1 Billings. Montana 59101 l Gentlemen: 1
SUBJECT:
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES j (NRC INSPECTION REPORT NO. 30-11802/86-01) ) This refers to the routine, unannounced radiation safety inspection conducted ! by Mr. Wesley Holley of this office on October 21, 1986, at the Yellowstone ! County Surveyor's Office, Billings, Montana, of activities authorized by NRC { Byproduct Material License 25-16883-01. The inspection was an examination of ' the activities conducted under the license as they relate to radiation safety and to compliance with the Comission's rules and regulations, and the conditions i of the license. As ti result of this safety inspection, violations of NRC require- , ments were identified. The results of this inspection were discussed by the ' inspector with you at the conclusion of the inspection, and Inspection Report 30-11802/86-01 sent to you by letter dated November 6, 1986 documented these inspection results. Accordingly, these findings were discussed with you during the enforcement conference on November 13, 1986 The violations discussed in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties (Notice) involve the failure: to provide dosimetry to personnel using licensed material, to properly store licensed material, to maintain personnel exposure records, to maintain records of physical inventories of licensed material, to verify prior to shipment of radioactive material that the receiver was authorized for receipt, to perfonn leak tests on sealed sources, to maintain package performance test records, and to utilize shipping papers. The violations are of significant concern because collectively, they indicate that adequate oversight and control of the radiological safety program were not exercised. To emphasize the need to maintain an increased level of management oversight and control of your radiological safety program, I have been authorized, after consultation with the Director, Office of Inspection and Enforcement, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in t% amount of Five Hundred ($500) for the violations described in the enc 1rsed Notice. In accordance with the " General Statement of Policy and , Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1986) ] l (Enforcement Policy), the violations described in the e'iclosed Notice have j been categorized in the aggregate as a Severity Level III problem. The i escalation and mitigation factors in the Enforcement Policy were considered ' and no adjustment has been deemed appropriate. EXPRESS MAIL NUREG-0940 II.A-132 ;
i Yellowstone County Surveyor's Office You are required to respond to this letter and should follow the instructions specified in the enclosed hotice when preparing your response. In your response,.you should document the specific actions taken and any additional actions you plan to prevent recurrence. Additionally, we are concerned about the management control over the implementation,, of your program. Consequently, in your reply to this letter, you should describe those specific actions planned or taken to improve activities with particular emphasis on management control over radiation protection and other measures currently being taken to prevent further violations. After reviewing your response to this Notice, including I your proposed corrective actions and the result of future inspections, the j NRC will determine whether further NRC enforcement action, including possible i I license suspension, is necessary to ensure compliance with NRC regulatory requirements. In accordance with Section 2.790 of th'e 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 96-511. Sincerely, s Robert D. Martin Regional Administrator L
Enclosure:
Notice of Violation and Proposed ( Imposition of Civil Penalties cc w/ enclosure: Montana Radiation Control Director i I l l l l NUREG-0940 II.A-133
NOTICE OF VIOLATION AND . ; PROPOSED IMPOSITION-'UF CIVIL PENALTIES ' Yellowstone County. Surveyor's Office Docket No. 30-11802 Billings', Montana License No. 25-16883-01 EA 86-198 During an 'RC' N inspection conducted on October 21, 1986, 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 (1986), the Nuclear Regulatory Commission proposes to impose civil penalties pursuant to Section 234 of the-Atomic Energy Act of 1954, as amended (Act), 42 U.S.C 2282, and 10 CFR 2.205. .The particular violations and associated civil penalties are set'forth below:
- 1. License Condition 17. requires, in part, that the licensee possess and use licensed material in'accordance with statements, representations, and procedures contained in application dated November 19, 1980, and litters dated March 2, 1981 December 22, 1982, and January 14, 1983.
- a. The January 14, 1983, letter committed the licensee to evaluate dose to personnel on a quarterly basis.
Contrary to the above, the licensee had not used personnel dosimetry while perfoming work tasks with licensed material since 1983
- b. The above March 2, 1981, letter stipulates that the instrument /Troxler gauge containing licensed material will be in the office vault when it is not being used in the field, The December 22, 1982, letter changed the place of storage from the vault to the storage area of room 312 in the county courthouse as shown in Exhibit 1 attached to that letter.
Contrary to the above, at the time of this inspection the instrument was not being used and was being stored at an unauthorized location i in a county shop. '
- 2. 10 CFR 20.401 requires, in part, that each licensee shall maintain records showing the radiation exposures of all individuals for whom personnel j monitoring is required and such records'sht11 be kept on Fom NRC-5 in i accordance with instructions contained in tha.t form or on clear and !
legible records containing all the information required by Form NRC-5. ; Contrary to the above, the licensee's dosimetry records for 1977-1983 that were available for inspection did not contain the names of personnel, social security numbers, birth dates, or exposure history.
- 3. License Condition 15 requires, in part, that the licensee shall conduct physical inventories for all sealed sources every 6 months and maintain the records of the inventories for 2 years for inspecticn by the .,
Commission. Contrary to the above, at the time of the inspection, the licensee did not have any records of physical inventory. j 1 NUREG-0940 II.A-134
+
Notice of Violation- -E- ) J 4.. .10'CFR 30.41 requires,_in part, that the licensee as a transferor verify
,that'an intended. receiver of licensed material is authorized.to receive the type, form, and quantity of by-product l material to be transferred.'
Contrary to the"above, at the time of the inspection the licensee had.not- i verified-that1HKM EnginecNitg was authorized to receive the licensee's Troxler gauge that.was Ibaed to them for the period October 1984 to February 1985. 3
- 5. License Condition 14 requires, in part, that the licensee's sealed sources be leak tested for leakage and/or contamination at-intervals not to exceed 6 months.
4 Contrary to the above, the licensee had'not performed a leak test on the
. sources contained in the Troxler moisture / density gauge, Model 3511-D, Serial No. 408, for the period December 5, 1983, to October 21, 1986.
- 6. License Condition.'16 requires-licensed material to bd transported in accordance with-the provisions of 10 CFR 71. 10 CFR 71.5 requires compliance with the applicable requirements of the appropriate Department of Transportation regulations in 40 CFR Parts 170 through 189.
La. 49 CFR 173.415(a) requires, in part, that each shipper of a Specification 7A package must maintain the package performance test records for at least 1 year, subsequent to the shipment. Contrary to the above, the licensee had not maintained shipping package performance. test records'for those Shipments of-licensed material made using specification 7A packages during the last year.
- b. 49 CFR 172.200 requires, in part, that shipping papers be prepared for each shipment of licensed material. l Contrary to the above, shipping papers were not uti.ilzed by the licensee during transportation of licensed materials in its own vehicles for the period November 7, 1971, to October 21, 1986.
Collectively, these violations have been categorized as a Severity Level III problem (Supplements IV, V, and VI). f CumulativeCivilPenalties-$500(essessedequallyamongtheviolations). l 1 Pursuant to the provisions of 10 CFR 2.201, Yellowstone County Surveyor's
.0ffice is hereby required to submit a written statement or explanation to the Director, Office of Inspect hn and Enforcement, U.S. Nuclear Regulatory l
Comission, Washington, D.C. 20535 with a copy to the Regional Administrator. l U.S. Nuclear Regulatory Comission, Region IV, within 30 days of the date of ' l' this Notice. This reply should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. NUREG-0940 II.A-125
Notice of Violation If an adequate reply is not received within the time specified in this Notice, the Director, Office of Inspection and Enforcement, may issue an i order to show cause why the license sh'ould not be modified, suspended, or revoked or why such other action as may be proper should not be taken. i Consideration may be given to extending the response time for good cause { shown. Under the authority of Section 182 of the Act, 42 U.5,,C. 2232, J s this response shall be submitted under oath or affinnaticn. I Within the same time as provided for the response required above under j 10 CFR 2.201, Yellowstone County Surveyor's Office may pay the civil penalties by letter addressed to the Director, Office of Inspection and i Enforcement, with a check, draft, or money order payable to the Treasurer of the United States in the cumulative amount of Five Hundred Dollars ($500) or may protest imposition of the civil penalties in whole or in part by a written ansrer addressed to the Director, Office of Inspection and Enforcement. i Should Yellosstone County Surveyor's Office fail to answer within the time specified, the Director, Office of Inspection and Enfo-cement, will issue an order imposing the civil penalties in the amount proposed above. Should j Yellowstone County Surveyor's Office elect to file an answer in accordance j with 10 CFR 2.205 protesting the civil penalties, such answer may: (1) deny ] the violations listed in this Notice in whole or in part, (2) demonstrate l' extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalties should not be imposed. In addition to protesting 3 the civil penalties in whole or in part, such answer may request remission ' or mitigation of the penalties. In requesting mitigation of the proposed penalties, the five factors addressed in Section V.B of 10 CFR Part 2, Appendix C (1986), 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 noid repetition. The attention of Yellowstone County Surveyor's Office 3 directed to the other provisions of 10 CFR 2.205, regarding the procedure'for imposing civil penalties. Upon failure to pay any civil penalties due which have subsequently 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, cr mitigated, may be collected by civil action pursuant j to Section 234c of the Act, 42 U.S.C. 2232c. l FOR THE NUCLEAR REGULATORY COMMISSION Nf Robert D. Martin Regional Administrator l Dated at Arlington, Texas this f day of ^=y 1987, hiv NUREG-0940 II.A-136
UNITED STATES l f 'o,, o NUCLEAR REGULATORY COMMISSION l
?- mAsutworow.o.c.rossa
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MY 121987 i D:cket No. 30-11802
-License No. 25-16883-01 i EA No. 86-198 Yellowstone County Surveyor's Office ATTN: Mr. Harlan M. Lund, County Surveyor !
Room 312 Courthouse Billings, Montana 59101 Gentlemen:
SUBJECT:
ORDER IMPOSING A CIVIL MONETARY PENALTY This refers to your letter dated March 2,1987 in response to the Notice of Violation and Proposed Imposition of Civil Penalty sent to you by our letter dated February 9,1987, Our letter and Notice described six violations identified during the NRC inspection conducted on October 21, 1986 at your facility. To emphasize the need to maintain an increased level of management oversight and control of your radiological safety program, a civil penalty of Five Hundred Dollars (1500) was proposed. In your response you failed to specifically admit or deny the violations cnd did not address the reasons for the violations, as required by the Notice of Violation. However, your response states the corrective steps taken, to ensure compliance now and in the futu m. After consideration of your response, we have concluded for the reasons given in the Appendix attached to the enclosed Order Imposing Civil Penalty that the violations occurred as originally stated. However, we conclude that your ! c:rrective actions warrant mitigation of the civil penalty by 50 percent. 1 Accordingly, we hereby serve the enclosed Order on Yellowstone County Surveyor's ; Office imposing a civil monetary penalty in the amount of Two Hundred Fifty Dollars ($250). We will review the effectiveness of your corrective actions during a subsequent inspection. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2 Title 10, Code of Federal Regulations, a copy of this letter and the enciesures ) will be placed in the NRC's Public Document Room. Sincerely, l [ 4 J mh
., M. Taylo puty Executive Director l
Enclosures:
As Stated CC* Montana Radiation Control Program Director NUREG-0940 II.A-137 l
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. g' J r* UNITED STATES ,. L g NUCLEAR REGULATORY COP 9(ISSION In the Matter of I# .
Yelltwstone County Surveyor's Office Docket No. . 30-11802 Attn; Mr. Harlan M. Lund,. ' Micense No. 25-16883 County-Surveyor EA 86-198 Room 313, Courthouse: 4 Billing 4,-Nontana 59101 ORDER IMPOSING CIVIL MONETARY PENALTY L. , Yellowstone County Surveyor's Office (licensee) is the holder of Materials License No. 25-16803-01 issued by the Nuclear Regulatory Commission on April 6, 1981 and last amended on April 15, 1983. The license authorizes the licensee to possess and use cesium-137 and americium-241 in Truxler gauges to measure properties of materials 'in accordance with the conditions specified therein. II A routine inspection of the licensee's activities was conducted on October 21, 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 Penalty was served upon the licenset by letter dated February 9,1987. The Notice stated the nature of I the violations, NRC requirements that wre violated, and the amount of civil
- penalty proposed. The licensee responded to the Notice of Violation and Proposed Imposition of Civil Penalty by letter dated March 2,1987. i NUREG-0940 II.A-138
.)
III j l l
? After consideration of the licensee's response and the statements of fact, :!
explanation, and mitigation contained therein. .the Deputy Execctive Director for Regional' Operations, has determined as set forth-in the appendix to this ; Order that the violations occurred as stated. However 'because of the.1tcensee't c rrective actions the penalty proposed for the violations described in the Nstice of Violation and Proposed Imposition of Civil Penalty should be mitigated by 50 percent.. 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 penalty in the amount of Two Hundred Fifty Dollars ($250) within 30 days of the date of this Order, by check, draft, or money order, payable to the Treasurer of the United States and mailed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, i ATTN: Document Control Desk Washington, D.C. 20555.
)
i Th2 licensee may request a hearing within 30 days of the date of this Order. A J rcouest for a hearing should be clearly marked as a " Request for Enforcemerit Hearing" and shall be addressed to the Of rector, Office of Enforcement, U.S. Nuclear Regulatory Comission, ATTN: Document Contml Desk, Washington, D.C. NUREG-0940 II.A-139
20555, with a copy to the Regional Administrator, U.S. Nuclear, Regulatory Comission, Region IV, 611 Ryan Plaza Drive Suite 1000 Arlington, Texas 76011. l If a hearing is requested, the Comission will issue an Order designating the time and place of the hearing. If the licensee fails to request a hearing )
]
within 30 days of the date.of this Order, the provisions of this Order shall be " effective without further proceedings. If payment has not been made by that ; time, the matter may be referred to the Attorney General for collection. ] l
)
In the event the licensee requests a hearing as provided above, the issues to ! be considered at such hearing shall be: 1 (a) whether the licensee was in violation of the Connission's requirements as l set forth in the Notice of Violation and Proposed Imposition of Civil Penalty referenced in Section 11 above and (b) whether, on the basis of such violations, this Order should be sustained. FOR THE NUCLEAR REGULATORY COMMISSION
/_
(_$ J s M. Taylor, De ty Executive Director f Regional Operations Dated at A thesda, Maryland, this /g' day of May 1987. NUREG-0940 II.A-140
APPENDIX EVALUATIONS AND CONCLUSIONS On February 9,1987 a Notice of Violation and Proposed Imposit.fon of Civil Penalty (NOV) was issued for violationis identified during a routine NRC inspection. Yellowstone County Surveyor's Office (licensee) responded to the Notice on March 2, 1987. The licensee neither specifically admitted nor denied the violations; however, it described corrective steps taken to ensure compliance now and in the future. The licensee requested that the violations be reclassified at a lower severity level and the civil penalty.be mitigated to zero. The NRC's evaluation and conclusion regarding the licensee's request are as follows: Sumary of Licensee's Request for Mitigation
.The licensee argued: (1) that the instrument users are trained, certified, and aware of safety procedures, (2) that the instrument was used very little.
(3) that the citations basically were.for record keeping oversights, (4) that use of the instrument presented no threat to any person's health or welfare,
.and (5) that the licensee took prwmpt corrective action and cooperated fully with NRC. The licensee's corrective measures included immediately placing the instrument in storage, obtaining dosimetry film badges for all personnel.
advising all personnel of requirements for use and storage of the instrument, establi@ing a record of radiation exposure, establishing a physical inventory book, confirming HKM Engineering as an authorized user, completion of a leak test, obtaining a Type A Shipping Package Certificate, preparing a Shipper's Certificate, and establishes.g future management controls that includes a review of documentation and operator education. In addition, the licensee requested that the violations be reclassified to a lower severity level and that the civil penalty be dropped. NRC Evaluation of Licensee's Request for Mitigation Although the licensee contends that instrument users are trained, certified, and aware of safety procedures, the fact that the violations occurred is strong evidence that users were not sufficiently cualified at the time of the inspec-tion. The staff acknowledges the licensee's assertion that the instrument was used very little, and recognizes that this situation may have contributed to the licensee's inattention to regulatory matters; however, the NRC expectes a t high level of compliance with its requirements. The LRC does not accept the licensee's_ characterization of the violations as " basically... record keeping ! oversights." In these instances poor record keeping was symptomatic of a generally weak program for complying with regulatory requirements. In addition, the NRC does not agree that there was "no threat to any person's health or wel fart. " The violations involving the failure to provide personnel dosinetry and the failure to perfonn leak tests provide the potential for safety problems j to have gone- unrecognized, thus increasing the safety significance of the violations. For these reasons, the violations have been appropriately categorized at Severity Level III. Regarding the licensee's request for mitigation of the civil penalty based on its corrective actions, the Enforcement Policy allows mitigation up to 50% i for unusually prompt and extensive corrective actions. In this case, the licensee promptly put the licensed source into storage, perforted a leak test, obtained dosimetry and a shipping certification, and established a training ! f program and a periodic management audit, NUREG-0940 II.A-141
l Appendix i
~NRC Conclusion i
The NRC staff concludes that the licensee's request to reclass'ify the' violations ) at a lower severity level is not supported by the licensee's arguments made in I its March 2, 1987 response. However, the licensee's corrective actions do warrant reduction of the base civil penalty by 50 percent. . Therefore, a civil penalty in the amount of $250.00 should be imposed. 1 l I i i j l l l 1 i NUREG-0940 II.A-142 1
-i II.B. MATERIAL LICENSEES, SEVERITY LEVEL III VIOLATIONS, NO CIVIL PENALTY
'f huREG 0940
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/ "%, UNITED STATES y4 /, NUCLEAR REGULATORY COMMISSION
'$' ', f
. REGION IV k, 611 RYAN PLAZA DRIVE, SUITE 1000
*[ ARLINGTON, TEXAS 79011 Docket No. 30-20132~ M 8E
. License'No. 35-21272-01 EA 87-91 Tracer Profiles, Inc.
ATTN: Mr. Jack T. Carter Vice President
.100 N. Rockwell, Building 84 Oklahoma City, Oklahoma 73127 Gentlemen:
SUBJECT:
NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 30-20132/8201) This refers to the inspection conducted on March 5-6, 1987, at your facility in Oklahoma City, Oklahoma. Violations identified during the inspection by Messrs. L. T. Ricketson and R. J. Everett were discussed with you at the conclusion of the inspection and at the enforcement conference held in the Region IV office on March 26, 1987. The violations, which are described in the enclosed Notice of Violation, in-clude failure to (1) calibrate survey instruments at the required interval, (2) survey equipment for contamination and decontaminate as necessary, (3) return personnel monitoring clevice for processing at the appropriate time, (4) maintain records of bioassays, (5) maintain personnel exposure records, and (6) store licensed material at an authorized locatio.n. These violations 6re of concern to the NRC because they collectively demonstrate a significant breakdown in management oversight and control of your licensed program. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the violations described in the enclosed Notice have been classified as a Severity Level 111 problem. A civil penalty is generally proposed for a Severity Level III problem. However, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regional Operations, I have decided that a civil penalty will not be proposed in this case. After being informed of the deficiencies in your program, you agreed to implement extensive corrective actions which included hirin a consultant to (1) r;ake an assessment of your radiation safety program, (2 audit your operations, (3) review procedures and license requirements, and (4 develop management contacts to ensure compliance with NRC requirements. In addition, your past enforcement history has been
.. good.
CERTIFIED MAIL RETURN RECE!PT REQUESTED NUREG-0940 II.B-1
' Tracer Profiles, Inc. With regard to finding (2) of NRC inspection Report 30-20132/87-01 dated March 20, 1987, concerning the storage of radiation material in a truck, the NRC has concluded upon further review that this finding is not a violation.
As stated in our letter to you dated March 13, 1987, you have agreed to submit to Region IV supplemental information describing your procedure for storage of radioactive materials at your present location. 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 i 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 te 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. Sincereff,
$b<-
Ro ert D. Martin hu Regional Administrator
Enclosure:
Notice of Violation cc: Oklahoma Radiation Control Program Director I i NUREG-0940 II.B-2 i i
]
NOTICE OF VIOLATION Tracer Profiles, Inc. Docket No. 30-20132 100 N. Rockwell, Bldg. 84 License No. 35-21272-01 Oklahoma City, Oklahoma EA 87-91 During an NRC inspection conducted on March 5-6, 1987, several violations of NRC requirements were identified. In accordance with the " General State-ment of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1987), the violations are listed below: A. Condition 15 of the license requires that licensed material be possessed and used in accordance with statements, representations and procedures contained in the license application dated February 1, 1983, and letters dated July 11, 1983, November 14, 1983, August 10, 1984, and August 30, 1985.
- 1. Item 11.a. of the license application states that the licensee will have survey instruments calibrated every six months.
Contrary to the above, survey instrument serial number 3616 was last calibrated on May 5, 1985. Utilization records show that this instrument was used during the period January 14, 1986 to July 1, 1986. Additionally, survey instrument serial number 3569 was last calibrated July 28, 1986, but was used during the period January 28, 1987 to February 12, 1987.
- 2. Section IX.A.1.e., Licensee's Operating and Emergency Procedures Manual, submited with the license application dated February 1, 1983, requires that areas and equipment be surveyed following use and that any areas or items of equipment which indicate any amount of detectable radioactivity, above background, shall be considered contaminated and appropriate measures be taken to remove such contamination.
Contrary to the above, as of the date of the inspection, a survey had not been made nor had decontamination been performed on one injection tool, which was last used on February 12, 1987, and which measured 4mR/h nn contact.
- 3. Section II.A.4, Licensee's Operating and Emergency Procedures Manual, submitted with the license application dated February 1, 1983, states that TLD badges will be returned to the Radiation Safety Officer, or his designated representative, at the end of the control period for the badge.
Contrary to the above, a badge issued to one individual for January 1986 with a control period ending in February 1986 was not returned until June 10, 1986. i 4 Section IX.C.3, Licensee's Operating and Emergency Procedure Manual, submitted with the license application dated February 1, 1983, states that reports of bicassays will be placed with the personnel l exposure records in the licensee's files. NUREG-0940 II.B-3
y 1
- Notice of-Violation - 2'-
r i . Contrary.'to the above, reports of bioassays were not made.and filed with personnel exposure records for thyroid bioassays'. i I- B. '10 CFR 20.401(a) requires in part that each licensee maintain records on i- . Form NRC-5 showing radiation exposures in accordance with-the instructions .
;. contained in that form, or on clear and legible records containing all the i
(_ information required by Form NRC-5.
- Contrary to the above, records were not maintained showing radiation ! . exposures for the periods May 1984 through April 1985, September 1985, !- ' January 1986 through March 1986, and September 1986 to.the time'of the ! inspection.
, [ C. 10CFR30.34(c)requiresinpartthateachlicenseeconfinepossessionand use of byproduct material to the locations authorized by the license. i Condition 10 of the license requires that licensed material be used only at [ 8236 Southwest 5th Street, Oklahoma City, Oklahoma, and at temporary job
<! sites.
i Contrary to the above, the licensee has possessed licensed material at a i new unauthorized business address of 100 N. Rockwell, Building 84, from l !-- October 1, 1986 until the date of the inspection.
-] These violations are categorized in the aggregate as a Severity Level III '! problem. (Supplements IV and VI) y Pursuant to the provisions.of 10 CFR 2.201, Tracer Profiles, Inc. is hereby )
i required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Comission, ATTN:. Document Control l j Desk, Washington, D.C. 20555 with a copy to the Regional Administrator, Region IV within 30 days of the date of the letter transmitting this Notice. J 'This reply skuld be clearly marked as a " Reply to a Notice of Violation"
; and should include for each violation: (1) the reason for the violation if l L admitted, (2) the corrective steps that have been taken and the results j i achieved, (3) the corrective steps that will be taken to avoid further l i violations,.and (4) the date when full compliance will be achieved. If an 1 .i 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, L
suspended, or revoked or why such other action as may be proper should not be ;
, taken. Where good cause is shown, consideration may be given to extending the q responte time, j
- l. FOR T UCLEAR REGULATORY COMMISSION I t
l' ? / / . f?f 4b? Robert D. Martin 4 Regional Administrator Dated at Arlington, Texas',
-(( this pAdayofJune1987, f
j NUREG-0940 II.B-4
U E. NUCLEAM KEGULATOstV COMMestaON I At> ORT NUMBt m umanea sy TsOC. esa vos No , et enys hC PORM 325 Q 545 NUREG 0940 2"3%'- BIBLIOGRAPHIC DATA SHEET Vol. 6, flo, 2 sa .NirauCTicN. ON T i .sv. Tina A~o su. Tau 2 uan .LA~. Enforcement Action - Significant Actions Resolved uarterly Progress port , o ,, ,,,c,, co,,, ,, o j j Q(April - June 1987) l MON T ,, ,
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U.S. Nuclear Regulatory Co ission " Washington, D.C. 20555
- 10. SPONSOMING ORGANt2 AY,0N NAME ANo MAILING ADORE facte,de to Codel 1is OF REPuMT Same as 7 above 'l , ' Technical s
4 6 9tRIOO CovtRto ttncous**e dea al 12 5UPPLEMENT ARY NOTES h V 4 13 A8EYH AC1 (200 words or seul This compilation summarizes signi ' cant e orcement actions that have been resolved during one quarterly peri d (A l copies of letters, Notices, and Ordbs ent.pbyil the- June Nuclear 1987) and includes Regulatory 1 Commission to licensees with respectT these enforcement actions, It is j anticipated that the information in Lis publication will be widely disseminated to managers and emplo elen by the NRC, so that actions can' b <tak$ to improve gaged safety in activities by avoiding licensed future violations similar to tho desce bed in this publication, t 3 1 1 k h 10 oOCUMLNT ANALYlis - e KE vWORLs'DE tiPTOR$ 16 AvaiLAsiLif v STATEMENT Technical Spec ications, Radiographer, Quality A urance, . Unlimited Radiation Saf ;y Program, Safety Evaluations 4 is $fCURITY CLASS'F CATION b trea o ic .~ T,, .. Rs .o i N Noi o , Ms Unclassified
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. _ _ - Ptnuit No. Go OFFICIAL' BUSINESSi
..orNALTY FOR PRIVATE USEl $300
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