ML20261H586

Environmental Properties Management LLC - Reply to Notice of Violation

ML20261H586
Person / Time
Site:	07000925
Issue date:	09/17/2020
From:	Halliburton B, Lux J Environmental Properties Management
To:	Document Control Desk, NRC Region 4
References
Download: ML20261H586 (7)

Text

September 17, 2020 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555-0001 Re: Reply to Notice of Violation Docket No. 070-00925; License No. SNM-928

Dear Sir or Madam:

Solely as Trustee for the Cimarron Environmental Response Trust (CERT), Environmental Properties Management LLC (EPM) submits herein a response to a Notice of Violation (NOV) dated August 20, 2020, to the CERT.

The violation was identified by US Nuclear Regulatory Commission (NRC) personnel during an inspection conducted from July 20 - 22, 2020. The inspection was scheduled to occur during the week that personnel were performing the annual environmental sampling program specified in Section 15 of the licensees Radiation Protection Plan (RPP). The violation is related to the failure to maintain complete documentation of training records in accordance with the site-specific RPP and Quality Assurance Program Plan (QAPP).

The Violation The August 20, 2020 inspection report (accession number ML20233B018) described the violation as follows:

License Condition 26 of Radioactive Material License SNM-926, Revision 21, issued February 4, 2011, requires the licensee to conduct a radiation protection program in accordance with Annex A, Radiation Protection Plan (RPP), dated September 20, 1996, as supplemented.

Section 1.2 of the RPP states, in part, the purpose of the RPP is to summarize the regulations andestablish radiation protection policies. From these policies, specific procedures are developed to ensure compliance.

Section 15 of the RPP states, in part, that annual environmental sampling will be conducted. The conduct of surface water and groundwater sampling is detailed in sampling procedures, Sampling Procedure (SAP)-13, Ground Water Sampling, and SAP-14, Surface Water Sampling. Both SAP-13 and SAP-14 require, in part, that individuals be task qualified by the radiation safety officer (RSO) to conduct the required surveys and task qualified by a subject matter expert (SME) to perform the sampling.

Section 2.4 of the RPP states, in part, that training records must be maintained in accordance with the Quality Assurance Program Plan.

9400 Ward Parkway

• Kansas City, MO 64114 Tel: 405-642-5152

• jlux@envpm.com

U.S. Nuclear Regulatory Commission September 17, 2020 Page 2 Contrary to the above, from July 20-22, 2020, the licensee failed to maintain training records as specified in Section 2.4 of the RPP for individuals conducting groundwater and surface water sampling in accordance with SAP-13 and SAP-14. Specifically, the licensee failed to maintain documentation of the task-specific qualification training presented by the RSO and/or SME to the individuals performing the annual environmental sampling.

Reason for Violation Section 4.2 of the QAPP, Activity Specific Approach, states, Quality activities performed on site must be planned and implemented using an Activity Plan (AP) prepared in accordance with QA Procedure QAIP 2.1, Activity Plan Preparation. Section 4.3 of the QAPP, Personnel Training, states, The Activity Leader is responsible to determine that personnel assigned to Quality Activities are qualified to perform their assigned work.

AP 2020-04, 2020 Annual Environmental Monitoring, states, Personnel performing radiation surveys must have current radiation worker training and be task qualified by the Radiation Safety Officer (RSO) or designee to perform these surveys. It also states, Personnel performing groundwater sampling and field parameter measurement must be task qualified by the Hydrogeology Subject Matter Expert (SME) on the Sampling and Analysis Plan (SAP) and the current revisions of the following procedures Sampling and Analysis Plan (SAP) Procedures provide the work instructions required for the collection and analysis of environmental media such as the groundwater and surface water samples collected for the annual environmental monitoring program. NOV references to SAP-13 and SAP-14 actually refer to SAP-103 and SAP-104. Numerous SAP procedures, including SAP-103, Groundwater Sampling and SAP-104, Surface Water Sampling state that a SME must train and/or qualify personnel on the performance of the procedures.

The NOV reference to Section 2.4 of the RPP contains the text that is actually in Section 2.5 of the RPP. Section 2.5 of the RPP, Training Records, does state that training records for all individuals shall be maintained in accordance with the QAPP. However, Section 2.5 addresses training records for Radiological Orientation and Radiation Worker training records, not records of training on radiation protection procedures. Documentation of Radiation Worker and Radiation Protection was not found to be deficient during the inspection.

U.S. Nuclear Regulatory Commission September 17, 2020 Page 3 Regardless, Radiation Protection Procedure RP-39, Performance of Radiation, Contamination, and Airborne Radioactivity Surveys, states that the RSO is responsible to ensure that only trained and qualified personnel perform surveys and authorize the unconditional release of material and equipment.

A process to task qualify individuals to perform radiation and contamination surveys was implemented at the Cimarron Site several years ago through the issuance of Desk Instructions (DIs). RP-DI-01 addresses initial qualification of individuals, and RP-DI-02 addresses annual refresher training for these individuals. Both DIs state, Successful completion of this Task Qualification demonstrates an adequate working knowledge of these instruments that allows the Task Qualified Individual to perform job coverage surveys for radiation levels (dose rate) and contamination levels within specified limits.

RP-DI-01 provides a Task Qualification Checklist and RP-DI-02 provides a Task Re-Qualification Checklist. According to the DIs, the instructor is responsible for completing the checklist. The RSO is the responsible for reviewing the checklists and identifying those personnel who are qualified and for which tasks they are qualified.

The last re-qualification training (prior to the inspection) was performed on May 29, 2019.

Objective evidence available to document completion of this training was limited to an attendance roster indicating the refresher training for the five procedures that address radiological survey instrument operation and use (RP-101, RP-102, RP-103, RP-104, and RP-105). The RSO was notified of completion of this training by the Instructor. Approval of the individuals re-qualification was verbally communicated to the QAC and the QAC updated the Sites training qualification matrix to reflect completion of annual refresher training for task qualified individuals. However, the checklist provided in RP-DI-02 was not completed.

The findings of the inspection are strictly administrative; forms had not been filled out in accordance with the RSO-approved desk instructions. The inspection did not identify any issue regarding the adequacy of training, the identification of personnel who had been trained, or decisions made based on surveys performed. Review of survey results indicated that no contaminated material was released for unrestricted use, personnel exposures did not exceed any dose limits or dose goals, and the handling, packaging, and shipping of materials did not present any radiological risk to workers or the public

U.S. Nuclear Regulatory Commission September 17, 2020 Page 4 Corrective action is required so that procedures, desk instructions, and documentation complies with the requirements of the Radiation Protection and Quality Assurance Programs.

Similarly, the task qualification matrix had been updated as SAP procedures were revised based upon verbal communication by SMEs. However, as with the RP training, there was no supporting documentation from SMEs. There is no procedure or desk instruction that addressed documentation of training on SAP procedures, but it is acknowledged that reliance upon verbal communication does not provide the supporting documentation needed so that individuals perform work in accordance with SAP procedures are qualified to do the work. Corrective action is required so that proper documentation is maintained verifying the training of personnel.

Corrective Actions That Have Been Taken The RSO determined that task qualified personnel had completed the 2020 annual Radiation Worker Training refresher but not instrument re-qualification. The instrument re-qualification had been delayed due to precautions taken in response to the coronavirus pandemic. Personnel who are qualified to perform radiation and contamination surveys and use radiation protection instruments are identified in RP-DI-03, Radiation Safety Officer Designees. RP-DI-03 is reviewed and updated annually by the RSO. The RSO confirmed that the individual who had been performing and documenting surveys was so designated in RP-DI-03, Rev. 3 (the revision which was in effect at the time).

In accordance with the corrective action program described in Section 14 of the QAPP, Corrective Action Program), a Notice of Deficiency (NOD) was generated for each of the deficiencies identified by the NRC Inspector.

NOD 2020-05 was initiated to correct the lack of documentation of training and qualification for the implementation of radiation protection procedures and the use of radiation protection instruments. NOD 2020-06 was initiated to correct the lack of documentation of training and qualification for implementation of sampling and analysis procedures.

U.S. Nuclear Regulatory Commission September 17, 2020 Page 5 The following corrective actions identified in NOD-2020-05 have been completed:

1. RP-DI-02 was revised to update the content of the Task Re-Qualification Checklist as follows:

a. As stated above, circumstances beyond the control of the RSO (such as the COVID-19 pandemic in 2020) may necessitate providing relief from a strict within 12 months time period for annual refresher training. The DI will provide for extension of the annual period (a grace period) for completing annual refresher training if determined necessary by the RSO.

b. The DI will allow the RSO to determine the need to fully re-qualify under RP-DI-01 if the grace period has been exceeded.

c. The DI will provide content for annual re-qualification training.

2. The RSO and the Health Physics Specialist conducted a virtual training session with all task qualified individuals and candidates to review performance and documentation of surveys as well as the operation and proper use of radiological instrumentation (except for air sampling, which will require separate training when needed in preparation for site activities). The training was documented consistent with RP-DI-02, Rev. 5.

The following corrective actions identified in NOD-2020-06 have been completed:

1. The QAC developed a Task Qualification Checklist for sampling and analysis procedures.

2. A SME documented the qualification of individuals to implement sampling and analysis procedures on the Task Qualification Checklist.

3. The Quality Assurance Coordinator reviewed the qualifications of all current SMEs against the requirements for a Cimarron Project SME in the current version of the QAPP (Rev. 3).

The QAC identified issues associated with documentation of initial SME qualification. The QAC documented the results of this qualifications review and recommendations for SME approval to Site management.

U.S. Nuclear Regulatory Commission September 17, 2020 Page 6 Corrective Actions That Will Be Taken The following corrective actions related to NOD 2020-05 have been scheduled for completion:

1. During the annual independent audit of the radiation protection program, the Quality Assurance Coordinator will ensure that documentation of training for task qualifications is properly maintained and available at the Site. The annual independent audit of the radiation protection is scheduled to be completed by December 31, 2020.

2. Qualifications of individuals for the implementation of radiation protection procedures and the use of radiation protection instruments will be a topic on the agenda of future ALARA Committee meetings. The next ALARA Committee meeting is currently scheduled to be conducted November 19, 2020.

The following corrective actions related to NOD 2020-06 have been scheduled for completion:

1. A new Quality Assurance Implementing Procedure (QAIP) will be developed to document qualification to perform work in accordance with both SAP and QA procedures. This corrective action is scheduled for completion by December 18, 2020.

2. Reference to the Task Qualification Checklist for the documentation of training will be added to Section 4 of the next revision of the QAPP. This corrective action is scheduled for completion by December 18, 2020.

3. QAIP 2.1 will be revised to clarify that the QAC is responsible for reviewing the training matrix and communicating personnel qualification status to the Activity Leader during pre-job briefs. This corrective action is scheduled for completion by December 18, 2020. The next revision of the QAPP will also include this clarification.

4. Qualifications of individuals for the implementation of radiation protection procedures and the use of radiation protection instruments will be a topic on the agenda of future ALARA Committee meetings. The next ALARA Committee meeting is currently scheduled to be conducted November 19, 2020.

Note: The QAPP and associated procedures will be reviewed and revised both in performing these corrective actions and as part of the preparation of Facility Decommissioning Plan - Rev 2.

U.S. Nuclear Regulatory Commission September 17, 2020 Page 7 Rather than review and revise the QAPP and associated procedures twice, EPM has directed the QAC to complete the review and revision of the QAPP for both purposes in one effort. The current schedule for revision of these documents for the revised decommissioning plan is December 18, 2020.

Achieving Full Compliance Full compliance with corrective actions related to NOD 2020-05 will be achieved by December 31, 2020. Full compliance with corrective actions related to NOD 2020-06 will be achieved by December 18, 2020. CERT believes that these corrective actions address the NRC violation and will prevent recurrence. If you have any questions regarding this submittal or require additional information, please contact Jeff Lux, EPM Project Manager at (405) 642-5152 or jlux@envpm.com.

Sincerely, Jeff Lux Project Manager Bill Halliburton Trust Administrator cc: Hard Copies:

Regional Administrator, NRC Region IV Robert Evans, NRC Region IV Electronic Copies:

James Smith, NRC Project Manager for the Cimarron Decommissioning Project Michael Broderick, Oklahoma Department of Environmental Quality Jeff Lux, Project Manager for the CERT Jay Maisler, Radiation Safety Officer for the CERT Charles Beatty, Quality Assurance Coordinator for the CERT NRC Public Document Room