ML20154L232

Insp Rept 50-062/88-02 on 880809-11.No Violations Noted. Major Areas Inspected:Emergency Preparedness Program Conducted in Areas of Emergency Facilities & Equipment, Training,Performance of Drills & Offsite Agency Support

ML20154L232
Person / Time
Site:	University of Virginia
Issue date:	09/13/1988
From:	Boland A, Decker T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20154L210	List: ML20154L207 ML20154L224 ML20154L232
References
50-062-88-02, 50-62-88-2, NUDOCS 8809260129
Download: ML20154L232 (7)

See also: IR 05000062/1988002

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SEP 141988  !

Report No.: 50-62/88-02 l

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Licensee: University of Virginia

Charlottesville, VA 22901

i- Docket No.: 50-62 License No.: R-66

Facility Name: University of Virginia '

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Inspection Conducted: August 9-11, 1988

Inspector: &M tj b

A. T. Boland Date Signed

Approved by: ** 7 J[88 ,

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Thomas R. Decker, Section Chief Date Signed

Division of Radiation Safety and Safeguards ,

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1 SUMMARY

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Scope: This routine, announced inspection of the emergency preparedness

program was conducted in the areas of emergency facilities and equipment, ,

training, performance of drills, offsite agency support, and maintenance of the

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Emergency Plan and Implementing Procedures.  ;

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Results: In the areas inspected, three violations (Paragraphs 4, 5 and 6) were

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identified. The licensee's Plan and Implementing Procedures provide a good i

foundation for an effective Emergency Response Program; however, more  !

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i management attention is needed to ensure adequate implementation and

maintenance. i

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REPORT DETAILS

1. Persons Contacted

Licensee Employees

• P. Benneche, Reactor Supervisor / Supervisor of Services

B. Copcutt, Radiation Safety Officer

• J. Farrar, Reactor Administrator / Supervisor Operations

0. Hale, Reactor Health Physicist

A. Jackson, Radiation Safety Specialist

• R. Mulder, Reactor Facility Director

Other Organizations

J. Chance, Emergency Room Services, University of Virginia Medical Center

M. Sheffield, Director, University of Virginia Police

• Attended Exit Interview

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2. Emergency Facilities and Equipment (82745)

The inspector selectively examined emergency kits / equipment. The two

formal kits, one located on the first floor and the other on the ground

floor, included first aid supplies, decontamination supplies, SCBAs,

dosimetry, radiation monitoring instruments and protective clothing.

Additional equipment was available from Environmental Health and Safety

and the Health Physics Lab. The equipment appeared adequate to support a

radiological emergency.

The inspector reviewed the licensee's program for inventorying and

maintaining emergency equipment. Documentation for the period August 1987

to present, indicated that emergency kits were maintained in accordance

w,th Section 8.6 of the Emergency Plan. Other areas examined included eye

wash stations, fire extinguishers, emergency showers, SCBAs, walkie

talkies, and the rauto to the University of Virginia Police. An

operability test of the radio was conducted with no problems observed.

No violations or deviations were identified.

3. Maintenance of Emergency Plan and Procedures (82745)

This area was reviewed to determine whether changes were made to the

program since the last inspection (May 1987), and te note how these

changes affected the overall state of emergency preparedness.

During the period of June 1987 to August 1988, several revisions were made

to the Emergency Plan Implementing Procedures. These revisions were

primarily administrative in nature and were determined not to decrease the

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effectiveness of the Plan. The most significant change was the deletion

of the accountability roster from EPIP-11, "Personnel Accountability."

This roster is now being maintained as a separate document with current

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copies located in the Office of the Reactor Supervisor, Operations, and on

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Headquarters concern that personnel names and telephone numbers should not

be submitted to NRC for placement in the Public Document Room. The new

roster appeared current and well maintained.

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Submittal of changes to the NRC were also evaluated as well as

distribution of changes to appropriate onsite personnel and offsite

agencies. Review of licensee documentation showed that Revisions 7, 8,

and 9 of the EPIPs were transmitted to the NRC within 30 days as required.

Also, examination of several internal copies of the Plan and Procedures

indicated revisions had been distributed as appropriate, No discrepancies

were noted.

The inspector reviewed licensee documentation to determine that the

licensee had performed a bi-annual review of the Energency Plan as

required. This documentation indicated that a review of the Plan had been

conducted on June 28, 1988, by the Reactor Safety Committee. In addition,

on May 14,1986, a review of the Emergency Procedures was conducted;

however, preliminary evaluation indicated that it did not meet the

requirements of Section 10.4 of the Emergency Plan. This failure to

perform a bi-annual audit of the Plan was identified to the licensee as a

potential violation at the exit interview. Af ter further examination,

however, the May 1986 audit does appear to be sufficient in scope to meet

the intent of the bi-annual Reactor Safety Committee review. The licensee

was notified of this on August 29, 1988.

No violations or deviations were identified.

4 Emergency Response Training (82745)

The inspector reviewed Section 10.1 of the Emergency Plan which described

the training program for reactor facility personnel. The training for

these individuals was to include at least two classroom training sessions

and practical drills yearly.

Review of the licensee's training records for the period October 1986 thru

July 1988, and discussions with licensee representatives revealed that

four personnel who have responsibility for implementing the Plan had not

been trained as required. Specifically, these individuals had not

received any specialized Emergency Plan training since October 1986. The

emergency positions filled by these personnel included Emergency Director.

Emergency Coordinator, and Reactor Health Physicist. Interviews conducted

with three of the staff members revealed that they understood their

emergency roles and were cognizant of the areas of the Emergency Plan and

Procedures they would be expected to implement. Although no major

impediments were identified during the walk-through evaluation, the

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failure to provide training to emergency personnel in accordance with the

Emergency Plan wts identified to the licensee as a violation.

Violation 50-62/88-02-01: Failure to provide emergency response training

in accordance with Section 10.1 of the Emergency Plan.

In addition to the training program for emergency responders, the

inspector also review the licensee's general Emergency Plan training for

all personnel granted unescorted access to the reactor facility. A video

tape had been established for this purpose and included instruction on

general responsibilities during an emergency, evacuation, accountability

and emergency contacts. All personnel were required to take a written

examination, and retraining was provided as appropriate.

The inspector reviewed the licensee's program for maintaining an onsite

capability in first aid. At the time of the inspection, only one staff

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member was qualified in Red Cross Multi-media First Aid. Until January

1988, the licensee had maintained two permanent staff members trained in

first aid; however, since departure of one of these qualified individuals,

no training has been initiated to replace this expertise. In the response

to the 1985 Emergency Response Appraisal dated November 7,1985, the

licensee stated that more than one staff member was qualified in first

aid. Contrary to this, the licensee had not maintained at least two

qualified staff members for the period January 1988 to present, l.icensee

representatives indicated that first aid training was being scheduled for

the fall. Although this item is not being cited as a deviation as stated

at the exit interview, followup action on the first aid training program

will be reviewed during a future inspection.

IFI 50-62/88-02-02: Maintaining more than one staff member trained in

first aid measures.

One violation was identified.

5. Emergency Orills and Exercises (82745)

The inspector reviewed the licensee's program for performing periodic

drills and exercises to test the implementation of the Emergency Plan and

Implementing Procedures. This program included the performance of an

annual onsite drill, a bi-annual drill involving coordination with offsite

agencies, and semi-annual evacuation drills.

Discussion with licensee representatives and review of documentation

indicated that the last biannual drill was conducted in October 1986.

This drill included response by the entire emergency organization to a

predetermined scenario with participation by the local fire department,

rescue squad and hospital. The drill was critiqued and corrective action

was taken as appropriate. The next bi-annual exercise is to be conducted

in the fall of 1988.

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Since October 1986, only one other drill had been performed. This drill,

conducted in November 1987, consisted of the sounding of the evacuation

alarm and implementation of the Emergency Plan and Procedures involving

evacuatica and accountability. Documentation showed the drill duration to

be approximately ten (10) minutes. Discussion with licensee

representatives indicated that this drill was conducted to meet the

annual, onsite drill requirements; however, the licensee was informed that

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the annual drill should fully exercise the integrated emergency response

organization including response management, operations, and health physics

such that all emergency functions are tested.

Inspector Followup Item (IFI) 50-62/88-02-03: Upgrade annual drill scope

to include an integrated response by the emergency organization to a

predetermined scenario of ever.ts.

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In addition, the inspector reviewed the licensee's program for conducting

evacuation drills. This program was described in Section 8.4.2.c of the

Emergency Plan which required that the evacuation horn be sounded every

six months to include a check of the facility to ensure that all personnel

had evacuated (accountability). Discussion with licensee representatives

and review of documentation revealed that only two such drills had been

performed since October 1986; one during the October 1986 drill and the

other in November 1987. The licensee further indicated that prior to

October 1986, semi-annual evacuation drills had been performed; however,

the inspector did not review this documentation.

Violation 50-62/88-02-04: Failure to Perform Semi-Annual Evacuation

Drills in Accordance with Section 8.4.2.c of the Emergency Plan.

One violation was identified.

6. Offsite Support Agencies and Training (82745)

The inspector held discussions with licensee representatives regarding the

coordination of emergency planning with offsite agencies. Written Letters

of Agreement existed with the Charlottesville-Albemarle Rescue Squad,

i Albemarle County Police, Charlottesville Fire Department, University of

Virginia Police, University of Virginia Environmental Health and Safety,

i University of Virginia Hospital, Virginia State Police, Virginia

! Department of Emergency Services and Oak Ridge / Department of Energy, as

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obtained in the fall of 1985, and had not been updated to date.

Documentation dated August 4,1988, showed that all support agencies were

contacted and requested to provide current agreement letters. However,

i Section 3 to Appendix 4 of the Emergency Plan states that Letters of

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Agreement will be sought prior to the bi-annual Emergency Plan review.

l This failure to update the agreement letters in accordance with the

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Emergency Pii.n was identified as a violation.

Violation 50-62/88-02-05: Failure to Update Letters of Agreement in

Accordance with the Requirements of the Emergency Plan.

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It should also be noted that in a letter from R. Mulder to D. Verrelli

dated November 7,1985, the licensee stated that Letters of Agreement l

would be updated every two years beginning this fall (1985). This review ,

cycle is inconsistent with that stated in the Plan; however, a 1987 update  !

was not performed either resulting in the Letters of Agreement being three

years old.

The inspector determined through discussions and review of records that ,

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the licensee had provided recent training and/or tours of the facility to

the University of Virginia Police, University of Virginia Hospital, and l

Pegasis Rescue Squad. In addition, numerous invitations had been extended  ;

to the Charlottesville-Albemarle Rescue Squad for training; however, they '

have not accepted. Other than that noted above, no other specific ,

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Emergency Plan training had been provided to offsite groups since

January 1986. It should be noted that the Fire Department, Hospital, and

Rescue Squad participated in the October 1986 full-scale drill. In '

addition, the licensee sent invitations to all support agencies on f

August 4, 1988, requesting that they participate in training. '

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One violation was identified.  :

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7. Action on Previous inspection Findings (92701) l

a. (Closed) Inspector Followup Item (IFI) 50-62/85-02-02: Upgrade the  !

training for rescue squad members to include a description of the  !'

University of Virginia emergency organization. Discussions with

licensee representatives and a review of pertinent documentation  ;

indicated that the rescue squad was requested to participate in '

training and a facility tour on numerous occasions, specifically in p

letters dated September 1985, June 1987, October 1987, and  ;

August 1988. Although the rescue squad has participated in onsite ,

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drills, they have not been responsive to other invitations for

emergency response training. ,

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b. (Closed) IFI 50-62/87-01-01: Completion of formal documentation on I

the emergency response training program. The inspector reviewed l

documentation for a recent training session that was conducted on '

July 22, 1988. A conplete outline of the lecture content was on file l

and available, j

c. (Closed) IFI 50-62/87-01-02: Submittal of changes to the Emergency I

Plan and Implementing Procedures in accordance with 10 CFR 50.4(b)(5)

and Section 10.4 of the Emergency Plan. The inspector reviewed the

documentation for Revisions 7, 8, and 9 to the Emergency Plan

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Implementing Procedures and found that submittals to the NRC were i

made as required,

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8. Exit Interview i

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The inspection scope and results were summarized on August 11, 1988, with i

those persons indicated in Paragraph 1. The inspector described the areas [

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inspected and discussed in detail the inspection findings listed below.

The licensee did not identify as proprietary any of the material provided

to or reviewed by the inspector. Dissenting comments were not received

from the licensee.

Item Number Descriotion and Discussien

50-62/88-22-01 Violation - Failure to provide emergency response

training in accordance with Section 10.1 of the

Emergency Plan, Paragraph 4.

50-62/88-22-02 IFI - Maintaining more than one staff member trained

in first aid measures, Paragraph 4.

50-62/88-22-03 IFI - Upgrade annual drill scope to include an

integrated response by the emergency organization,

Paragraph 5.

50-62/88-22-04 Violation - Failure to perform semiannual evacuation

drills in accordance with Section 8.4.2.c of the Plan,

Paragraph 5.

50-62/88-22-05 Violation - Failure to update Letters of Agreement in

accordance with the Plan requirements, Paragraph 6.

Licensee management was informed that the three IFIs discussed in

Paragraph 7 were considered closed.