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Category:Letter
MONTHYEARML24184A1132024-07-0202 July 2024 Written Communication as Required by University of Missouri Research Reactor Technical Specification 6.6.c(3) Regarding a Deviation from Technical Specification 3.10.d IR 05000186/20242012024-05-29029 May 2024 the Curators of the University of Missouri - U.S. Nuclear Regulatory Commission Safety Inspection Report No. 05000186/2024201 05000186/LER-2024-001, Written Communication as Required by by LER 2024-001-00 for University of Missouri Research Reactor Technical Specification 6.6.c(3) Re Deviation from Technical Specification 3.1 0.d2024-05-23023 May 2024 Written Communication as Required by by LER 2024-001-00 for University of Missouri Research Reactor Technical Specification 6.6.c(3) Re Deviation from Technical Specification 3.1 0.d ML24081A1332024-04-0202 April 2024 University of Missouri-Columbia (MURR) – Change of Facility Project Manager ML24044A1162024-03-0101 March 2024 Examination Confirmation Letter No. 50-186/OL-24-02, University of Missouri-Columbia ML24064A1922024-03-0101 March 2024 Federal Funding for the Conversion of the University of Missouri-Columbia Research Reactor from Highly-Enriched Uranium Fuel to Low-Enriched Uranium Fuel ML24059A4412024-02-28028 February 2024 Univ. of Missouri - Columbia - Submittal of Annual Operating Report Technical Specification 6.6.e ML24004A1242024-01-12012 January 2024 Revision No. 5 of Certificate of Compliance No. 9338 for the Model No. 3977A Package ML24003A0052024-01-0303 January 2024 Croft Associates Ltd - Request for Renewal of CoC No. 9338 for the 3977A Package IR 05000186/20232022023-12-12012 December 2023 the Curators of the University of Missouri - U.S. Nuclear Regulatory Commission Safety Inspection Report No. 05000186/2023202 ML23198A0222023-08-29029 August 2023 Examination Report Letter No. 50-186/OL-23-02, University of Missouri - Columbia ML23198A0232023-08-29029 August 2023 Examination Result Letter No. 50-186/OL-23-02, University of Missouri-Columbia ML23221A1172023-08-0303 August 2023 Written Communication as Specified by 10 CFR 50.4(b)(4) Regarding the Submittal of the Physical Security Plan for the University of Missouri Research Reactor as a Part of the Process to Renew Amended Facility Operating License R-103 ML23213A0592023-08-0101 August 2023 Written Communication as Specified by University of Missouri Research Reactor Technical Specification 6.6.2(d) Regarding a Permanent Change in the Facility Organization Involving the Executive Director IR 05000186/20232012023-07-31031 July 2023 the Curators of the University of Missouri U.S. Nuclear Regulatory Commission Safety Inspection Report No. 05000186/2023201 ML23186A2132023-07-31031 July 2023 Examination Confirmation Letter No. 50-186/OL-23-03, University of Missouri - Columbia ML23124A0422023-05-0808 May 2023 Examination Confirmation Letter 50-186/OL-23-02, University of Missouri - Columbia ML23103A0742023-04-10010 April 2023 University of Missouri, Columbia Research Reactor, Shipment of Radioactive Material Shipment Identifier MURR 23-01 Highway Route Controlled Quantity ML23024A2772023-04-0707 April 2023 Cover Letter for the Security Inspection Report for the University of Missouri (Public) - October 2022 ML23087A1132023-03-29029 March 2023 Examination Report No. 50-186/OL-23-01, University of Missouri-Columbia ML23087A1142023-03-29029 March 2023 Examination Results Letter No. 50-186/OL-23-01, University of Missouri - Columbia ML23089A3162023-03-29029 March 2023 Letter Notifying Univ. of Missouri That Us Dept. of Energy Funding Will Not Be Available in Fiscal Year 2023 to Complete the Conversion of MURR to LEU Fuel ML23055B1372023-02-24024 February 2023 Submittal of Annual Operating Report for the University of Missouri-Columbia Research Reactor as Required by MURR Technical Specification 6.6.e IR 05000186/20222022023-02-23023 February 2023 the Curators of the University of Missouri - U.S. Nuclear Regulatory Commission Routine Inspection Report No. 05000186/2022202 - Cover Letter and Enclosure ML23031A0132023-02-14014 February 2023 Examination Confirmation Letter No. 50-186/OL-23-01, University of Missouri-Columbia ML23010A1972023-01-19019 January 2023 Croft Associates Limited. NRC Acceptance Letter of Croft Response to Inspection Report 71-0939/2022-201 Notice of Violation ML23017A2072023-01-13013 January 2023 Written Communication as Required by University of Missouri Research Reactor Technical Specification 6.6.c(3) Regarding a Deviation from Technical Specification 6.1.f ML22349A0422022-12-0808 December 2022 Written Communication as Specified in 10 CFR 50.54(b)(5) Regarding Changes to the University of Missouri-Columbia Research Reactor Facility Emergency Plan Without Prior Commission Approval Pursuant to 10 CFR 50.54(q)(3) ML22305A6272022-11-0909 November 2022 Croft Associates Limited - NRC Inspection Report No. 710939/2022201 and Notice of Violation ML22314A2102022-11-0909 November 2022 Written Communication as Required by Technical Specification 6.6.d(2), Other Reports, Regarding a Change in University of Missouri-Columbia Research Reactor Organization Involving the Reactor Facility Director ML22304A0042022-10-27027 October 2022 University of Missouri - Columbia, Shipment of Radioactive Material, Highway Route Controlled Quantity ML22291A0322022-10-14014 October 2022 University of Missouri Written Communication as Required by 10 CFR 73, Appendix G Regarding a Deviation from the MURR Physical Security Plan ML22290A0042022-10-12012 October 2022 University of Missouri-Columbia Research Reactor, Reportable Event Report Pursuant to 20.2201(a)(ii) Regarding Loss of Licensed Material During Shipment IR 05000186/20222012022-06-14014 June 2022 the Curators of the University of Missouri - U.S. NRC Routine Inspection Report No. 05000186/2022201 ML22158A0792022-06-0606 June 2022 Submittal of Revised Annual Operating Report for the University of Missouri-Columbia Research Reactor as Required by MURR Technical Specification 6.6.e ML22097A0592022-04-0707 April 2022 Approval for Spent Nuclear Fuel Highway Route Application - NRC Route No. 182D - Docket Number 050-0186 ML22088A0782022-03-25025 March 2022 Univ. of Missouri, Federal Funding for the Conversion of the Columbia Research Reactor from Highly-Enriched Uranium Fuel to Low-Enriched Uranium Fuel IR 05000186/20212032022-03-0202 March 2022 the Curators of the University of Missouri U.S. Nuclear Regulatory Commission Routine Inspection Report No. 05000186/2021203 ML22056A5162022-02-25025 February 2022 Submittal of Annual Operating Report for the University of Missouri-Columbia Research Reactor as Required by MURR Technical Specification 6.6.e ML22038A6012022-02-0808 February 2022 Acceptance for Spent Nuclear Fuel Highway Route Application NRC No. 182D-Docket No. 050-0186 ML22013B1412022-01-21021 January 2022 Examination Confirmation Letter No. 50-186-OL-22-02, University of Missouri-Columbia ML21327A3042021-11-23023 November 2021 Written Communication as Required by University of Missouri Research Reactor Technical Specification 6.6.c(3) Regarding a Deviation from Technical Specification 3.2.f.6 ML21298A1972021-10-25025 October 2021 University of Missouri-Columbia Research Reactor - Written Communication as Required by University of Missouri Research Reactor Technical Specification 6.6.c(3) Regarding a Deviation from Technical Specification 3.2.g.6 ML21253A2482021-09-23023 September 2021 Examination Confirmation Letter No. 50-186/OL-22-01, University of Missouri Columbia ML21221A3252021-08-0909 August 2021 University of Missouri-Columbia Research Reactor, Written Communication as Required by Technical Specification 6.6.c(3) Regarding a Deviation from Technical Specifications 3.2.a ML21217A2982021-08-0505 August 2021 University of Missouri-Columbia Research Reactor - Reportable Event Report Pursuant to 20.2203(a)(2)(iv) ML21215A4982021-07-0707 July 2021 Univ of Missouri, Submittal of Revised Road Transportation Security Plan for the Shipment of Irradiated Reactor Fuel ML21098A1992021-06-10010 June 2021 the Curators of the University of Missouri Issuance of Amendment No. 40 to Renewed Facility Operating License No. R 103 to Amend Technical Specifications 6.2 and 6.4 for the University of Missouri Columbia Research Reactor IR 05000186/20212022021-05-28028 May 2021 the Curators of the University of Missouri - U.S. Nuclear Commission Routine Inspection Report No. 05000186/2021202 IR 05000186/20212012021-05-27027 May 2021 University of Missouri-Columbia U. S. Nuclear Regulatory Commission Security Inspection Report No. 05000186/2021201 - Non-OUO-Sri Cover Letter 2024-07-02
[Table view] Category:Written Event Report (30 or 60 day)
MONTHYEARML24184A1132024-07-0202 July 2024 Written Communication as Required by University of Missouri Research Reactor Technical Specification 6.6.c(3) Regarding a Deviation from Technical Specification 3.10.d ML22314A2102022-11-0909 November 2022 Written Communication as Required by Technical Specification 6.6.d(2), Other Reports, Regarding a Change in University of Missouri-Columbia Research Reactor Organization Involving the Reactor Facility Director ML22290A0042022-10-12012 October 2022 University of Missouri-Columbia Research Reactor, Reportable Event Report Pursuant to 20.2201(a)(ii) Regarding Loss of Licensed Material During Shipment ML21298A1972021-10-25025 October 2021 University of Missouri-Columbia Research Reactor - Written Communication as Required by University of Missouri Research Reactor Technical Specification 6.6.c(3) Regarding a Deviation from Technical Specification 3.2.g.6 ML21217A2982021-08-0505 August 2021 University of Missouri-Columbia Research Reactor - Reportable Event Report Pursuant to 20.2203(a)(2)(iv) ML20287A5432020-10-0909 October 2020 University of Missouri, Columbia Research Reactor - Written Report, in Accordance with IO CFR 71.1, as Required by IO CFR 71. 9 5(b) for NRC Docket 71-9338), Regarding Conditions in the Certificate of Compliance for the Safkeg-HS 3977A, Us ML0320300542003-07-17017 July 2003 Curators of University of Missouri, License No. R-103 LER for Airlock Door Malfunction That Occurred on 06/21/2003 ML0229602722002-10-21021 October 2002 Event Report 02-04, Univ. of Missouri-Columbia Research Reactor Center Re Failure of Containment Airlock Door Control Circuit That Occurred on 09/24/02 ML0228900952002-10-14014 October 2002 Letter Providing the University of Missouri Research Reactor Event Report for a mis-positioned Fuel Element That Was Discovered on 09/18/2002 ML0206503622002-02-12012 February 2002 Event Report 02-01 from University of Missouri Research Reactor Center Re Instrument Malfunction That Resulted in a Deviation from Technical Specifications 3.3.a 2024-07-02
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liJ University of Missouri Research Reactor Center 1513 Research Park Drive Columbia, MO 65211 PHONE 573-882-4211 WEB murr.missouri.edu October 9, 2020 ATTN: Document Control Desk Director, Division of Fuel Management Office of Nuclear Material Safety and Safeguards U.S. Nuclear Regulatory Commission Washington, D.C. 20555-0001
REFERENCE:
Docket No. 50-186 University of Missouri - Columbia Research Reactor Renewed Facility License Operating License No. R-103
SUBJECT:
Written report, in accordance with IO CFR 71.1, as required by IO CFR 71. 9 5(b) [for NRC Docket 71-933 8], regarding conditions in the Certificate of Compliance for the Safkeg-HS 3977A, USA/9338/B(U)- 96, that were not met during shipment
Dear Sir or Madam:
The University of Missouri Research Reactor (MURR) submits this letter to report a condition pursuant to 10 CFR 71.95(b) regarding the use of the Safkeg-HS 3977 A, DOT Competent Authority USA/9338/B(U)-96, Revision 3, NRC Docket No. 71-9338.
The following is a description of the event, reported in accordance with 10 CFR 71.95(c):
(1) Brief abstract of the event The conditions contained in the Certificate of Compliance (CoC) for the Safkeg-HS Model 3977 A, DOT Competent Authority USA/9338/B(U)-96 (Safkeg-HS), were not met in their entirety for a shipment of liquid 1-131. Contrary to Section 7(b) of the CoC, the package was not prepared for shipment in accordance with the Package Operations in Section 7.0 of the application. Specifically: A Model No.
3987 shielding insert was used in the package where the serial number of the insert body did not match that of the lid as required by Section 7.1.3 (3) of the Safety Analysis Report (SAR).
~ University of Missouri Research Reactor Center 1513 Research Park Drive Columbia, MO 65211 PHONE 573-882-4211 WEB murr.missouri.edu (2) Narrative description of the event On September 23, 2020, MURR shipping staff began the preparation of a Satkeg-HS shipping package for transport of radioactive iodine-131. For transport, the iodine-13 I is loaded in a Model 3987 shielding insert which is placed in the cavity of the package containment vessel (CV). As per MURR Procedure BP-SH-028 and MURR Control Check Sheet FM-163, the serial number located on the body of insert was compared to the serial number on the lid prior to loading the radioactive material. The shipping staff found that the body Serial Number was 0020 and did not match lid Serial Number 0022. The insert body and lid were immediately removed from service in compliance with MURR shipping program procedures.
A different insert was retrieved from storage, the body and lid serial numbers were verified to match and the shipment was completed without further issue.
Discovery of the mismatched insert body and lid lead to an investigation of the discrepancy and MURR has initiated a Corrective Action Program issue (CAP 20-0096) to document and track root cause and corrective actions. The remaining stock of Model 3987 inserts was examined and all were found to have matching body and lid serial numbers. It was concluded that the corresponding mismatched body and lid had been used in a shipment the previous week, on September 18, 2020. This was confirmed when the package was returned and opened for inspection on September 25, 2020. The returned package contained insert Model 3987, body Serial Number 0022 and lid Serial Number 0020. The insert body and lid were immediately removed from service in compliance with MURR shipping program procedures. There were no abnormal dose rates or contamination levels found on either the exterior or interior of the returned package.
The Satkeg-HS shipment with the mismatched insert contained 1184 GBq (32 Ci) of I-131 (Liquid Sodium Iodide Solution), to be used by the recipient in the manufacture of a radio-pharmaceutical. As a result of the mismatch, the insert was not shipped in the same configuration as it was leak tested. The rest of the package was assembled in compliance with the CoC and SAR. The body and lid of the CV were matched, both having the same serial number. The CV was leak tested as per requirements and passed the test. The package arrived at its destination as scheduled and the recipient did not report any abnormalities when the package was opened.
In the operation and handling of the Model 3987 insert, the only situation where more than one unit has the body and lid separated at the same time is during the drying stage following a leak test. It was concluded that the mismatching of the bodies and lids occurred at this time. Section 7(a) of the CoC requires the installation new O-ring seals on the Model 3987 insert prior to each shipment and Section 8.2.2.2 of the SAR requires a bubble leak test after the replacement of the insert seal. The leak test requires the inserts to be submerged in liquid and the length of time required for the test makes it more efficient to do them in batches rather than one at a time. After the leak test, the body and lid of the insert must be separated to look for moisture in the interior and to allow thorough drying in a vacuum chamber prior to retuning them to service. The cause of the mismatch was a human performance error. The root cause was determined to be a weakness in leak test procedure BPB-SH-031, "Bubble Testing Acceptance October 09, 2020 Page 2 of 4
I!) University of Missouri Research Reactor Center 1513 Research Park Drive Columbia, MO 65211 PHONE 573-882-4211 WEB murr.missouri.edu for Croft SAFKEG-HS Insert Model No. 3987". The procedure does not instruct the performer to match body/lid serial numbers as the inserts are reassembled.
MURR shipping staff missed an opportunity to identify the error while assembling the package for transport. Procedure BP-SH-028 and MURR Control Check Sheet FM-163, require the performer to record the insert serial number on the check sheet and verify that the body and lid numbers match. The performer must initial the check sheet verifying that these actions have been completed. In this instance the performer initialed the check sheet but failed to identify the mismatched serial numbers. This lack of attention to detail is classified as a human performance error.
(3) Assessment of safety consequences of the event While the insert was not shipped in the same configuration as it was leak tested, there were no apparent safety consequences of the event.
The containment boundary of the Safkeg-HS package consists of the Containment Vessel flange/cavity wall, the CV lid and the inner O-ring. The inserts are not part of the containment boundary. The various inserts provide different degrees of shielding and confinement under normal conditions of transport.
They also prevent the contamination of internal containment surfaces in the event the radioactive material container is breached.
The CV was assembled correctly and passed the pressure decay leak test prior to transport.
The recipient of the incorrectly configured package did not report any abnormal dose rates or contamination levels. In addition, when the package was surveyed on its return to MURR, there were no indications that any of the contents escaped from the insert.
(4) Description of corrective actions
- MURR procedure BPB-SH-031, "Bubble Testing Acceptance for Croft Safkeg-HS Insert Model No. 3987" has been revised to include a step requiring the performer to match the body and lid serial numbers as the insert is reassembled after the drying stage.
- MURR Form FM-163, "Control CheckSheet for Packaging of Type B Radioactive Material Using USA/9337/B(U)-96 (Safkeg-LS) and USA/938/B(U)-96 (Safkeg-HS)" has been revised to include a second individual review and initials for more individual steps on the sheet. This is in addition to the already existing initials by the Performer. Steps 5 and 6 already require the serial number of both the CV and the insert to be entered on the checksheet. The revision now requires entry of the serial numbers of both the body and the lid.
October 09, 2020 Page 3 of 4
m universi ty of Missouri Research Reactor Center 1513 Research Park Drive Columbia, MO 65211 PHONE 573-882-4211 WEB murr.missouri.edu
- All members of the radioactive material shipping staff were retrained prior to the next shipment using the Model 3987 insert. The retraining emphasized the following items:
o A discussion of the performance error and the potential safety consequences.
o Importance of carefully following instructions contained in procedures and completing each line item on checksheets.
o Taking the time to pay attention to detail when packaging material for transport.
o Review of the procedure revisions.
(5) Reference to similar events MURR is not aware of any similar events.
(6) Licensee contact For further discussion of this incident, please contact Daniel Doenges, Manager, Health Physics and Safety, at 573-882-5204 or danieldoenges@missouri.edu.
(7) Extent of exposure of individuals There was no exposure to individuals as a result of this event.
Sincerely,
\~
J David Robertson, Ph.D.
Executive Director xc: Geoffrey Wertz, NRC Project Manager Craig Basset, NRC Inspector Croft, Certificate Holder Reactor Advisory Committee Reactor Safety Subcommittee October 09, 2020 Page 4 of 4