ML23006A214

Us Department of Commerce - National Institute of Standards and Technology, NRC Form 591M Part 1, Inspection Report No. 07000398/2021002

ML23006A214
Person / Time
Site:	07000398
Issue date:	09/28/2021
From:	Jonathan Pfingsten NRC Region 1
To:	Mejias M US Dept of Commerce, National Institute of Standards & Technology (NIST)
References
IR 2021002
Download: ML23006A214 (2)

Text

NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION (07-2012) 10 CFR 2.201 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION

1. LICENSEE/LOCATION INSPECTED 2. NRC/REGIONAL OFFICE Department of Commerce - NIST Region 1 100 Bureau Drive, Mailstop 173 475 Allendale Rd Building 301, Room B124 Suite 102 GAITHERSBURG, MD 20899-1731 King of Prussia, PA 19406 REPORT NUMBER(s) 2021002

3. DOCKET NUMBER(S) 4. LICENSE NUMBER(S) 5. DATE(S) OF INSPECTION 070-00398 SNM-362 09/28/2021 - 11/30/2022 LICENSEE:

The inspection was an examination of the activities conducted under your license as they relate to radiation safety and to compliance with the Nuclear Regulatory Commission (NRC ) rules and regulations and the conditions of your license. The inspection consisted of selective examinations of procedures and representative records, interviews with personnel, and observations by the inspector. The inspection findings are as follows:

o 1. Based on the inspection findings, no violations were identified.

2. Previous violation(s) closed.

3.The violations(s), specifically described to you by the inspector as non-cited violations, are not being cited because they were self-identified, non-repetitive, and corrective action was or is being taken, and the remaining criteria in the NRC Enforcement Policy, to exercise discretion, were satisfied.

1 Non-cited violation(s) were discussed involving the following requirement(s):

License Condition 10 of NRC License No. SNM-362 requires, in part, that licensed material be used in accordance with statements, representations, and conditions of the licensees renewal application dated March 23, 2011. Section 10.3 of the application dated March 23, 2011, requires that Health Physics shall maintain inventory records for unsealed licensed sources with activity greater than 10 CFR 20, Appendix C quantities and all sealed sources requiring leak testing. Source Custodians shall maintain inventory records for, and conduct an annual physical inventory of all sealed and unsealed licensed sources under their responsibility that exceed this criteria.

Contrary to the above, between July 2016 and August 2021, Source Custodians failed to properly maintain inventory records for, and conduct an annual physical inventory of all sealed and unsealed licensed sources under their responsibility that exceed this criteria. Specifically, four discrete Pu-239 sources with activity greater than 10 CFR 20, Appendix C quantities were initially registered under a single source number.

Two of the source subcomponents were separated from the original registration, assigned individual source numbers, and transferred to a different Source Custodian. However, the subcomponents were also still inaccurately tracked in the licensees official inventory system as part of the original source registration assigned to a single source custodian, with the two subcomponents and their activities being included in the original sources registration totals. Subsequently, the two individual subcomponents with separate source registration numbers were transferred between Source Custodians for disposal, ultimately being collocated with a third subcomponent of the original source registration, but the inventory system did not reflect the transfer or disposal of the two individual items. While conducting an inventory, the source custodian for the two separate, individual subcomponents identified that while the sources were still assigned to him or her in the system, the individual components were not under his or her control. This led the licensee to believe the materials were lost for a period of time until the individual subcomponents were subsequently identified on August 11, 2021, under their separate source numbers in the licensees waste storage. The sources were stored in secure locations at all times even though the true location was not always accurately recorded in the licensees database.

This is a Severity Level IV violation (Enforcement Policy 6.3)

As corrective action for this violation, the licensee modified their processes to adjust registration information if a parent source or item is split and updated inventory reconciliation instructions and source user trainings to address the identified deficiencies. Additionally, the licensee committed to updating various additional procedures and training materials, as well as upgrading the Radiation Safety Information Management System to automate and streamline the process for generation of a new source number registration where the radioactive materials are already part of an existing registration. These additional items are anticipated to be completed by the end of the first quarter of 2023.

o 4. During this inspection, certain of your activities, as described below and/or attached, were in violation of NRC requirements and are being cited in accordance with the NRC Enforcement Policy. This form is a NOTICE OF VIOLATION, which may be subject to posting in accordance with 10 CFR 19.11. (Violations and Corrective Actions)

NRC FORM 591M PART 1 (07/2012) Page 1 of 2

NRC FORM 591M PART 1 U.S. NUCLEAR REGULATORY COMMISSION (07-2012) 10 CFR 2.201 SAFETY INSPECTION REPORT AND COMPLIANCE INSPECTION

1. LICENSEE/LOCATION INSPECTED 2. NRC/REGIONAL OFFICE Department of Commerce - NIST Region 1 100 Bureau Drive, Mailstop 173 475 Allendale Rd Building 301, Room B124 Suite 102 GAITHERSBURG, MD 20899-1731 King of Prussia, PA 19406 REPORT NUMBER(s) 2021002

3. DOCKET NUMBER(S) 4. LICENSE NUMBER(S) 5. DATE(S) OF INSPECTION 070-00398 SNM-362 09/28/2021 - 11/30/2022 Statement of Corrective Actions I hereby state that, within 30 days, the actions described by me to the Inspector will be taken to correct the violations identified. This statement of corrective actions is made in accordance with the requirements of 10 CFR 2.201 (corrective steps already taken, corrective steps which will be taken, date when full compliance will be achieved). I understand that no further written response to NRC will be required, unless specifically requested.

TITLE PRINTED NAME SIGNATURE DATE LICENSEE'S Manuel (Manny) Mejias Digitally signed by MANUEL REPRESENTATIVE MANUEL MEJIAS MEJIAS Date: 2022.12.15 10:03:37 -05'00' NRC INSPECTOR Jonathan Pfingsten Jonathan B. Digitally signed by Jonathan B.

Pfingsten Pfingsten Date: 2022.12.12 16:29:09 -05'00' BRANCH CHIEF Christopher Cahill Christopher G. Cahill Digitally signed by Christopher G.

Cahill Date: 2022.12.15 09:15:24 -05'00' NRC FORM 591M PART 1 (07/2012) Page 2 of 2