EA-03-158 - G.E. Inspection Services, Inc. (GE-IS)
October 24, 2003
G.E. Inspection Services, Inc. (GE-IS)
(Formerly Liberty Technologies, Inc.)
ATTN: Russell H. Doyle
Corporate Radiation Safety Officer
8550 Dorchester Road
N. Charleston, South Carolina 29420
|SUBJECT:||NOTICE OF VIOLATION (NRC INSPECTION REPORT NO. 39-24888-01/03-02 AND OFFICE OF INVESTIGATIONS REPORT NO. 2-2003-028|
Dear Mr. Doyle:
This refers to the inspection conducted on May 12, 2003, at your facility located in Richmond, Virginia. The purpose of the inspection was to review the circumstances surrounding an April 13, 2003, event during which radiographers failed to maintain control of a Lixi Profiler containing byproduct material. The preliminary findings of the inspection were forwarded to you by our letter dated June 13, 2003. The NRC's Office of Investigations (OI) also conducted an investigation into matters related to the inspection findings. The results of the investigation and additional information regarding the identification of two apparent violations were forwarded to GE-IS by NRC letter dated August 29, 2003.
On September 30, 2003, a closed predecisional enforcement conference was conducted in NRC's Region II Office in Atlanta, Georgia, with you and members of your staff to discuss the apparent violations, their significance, root causes, and your corrective actions. A listing of conference attendees, material presented by the NRC, and material presented by GE-IS are included as Enclosures 2, 3, and 4, respectively.
Based on the information developed during the inspection and investigation, and the information presented at the conference, the NRC has determined that a violation of NRC requirements occurred. The violation is cited in the enclosed Notice of Violation (Notice), and the circumstances surrounding it are described in detail in the subject inspection report. The violation involves a failure to control and maintain constant surveillance of licensed material from unauthorized removal or access, as required by 10 CFR 20.1801 and 10 CFR 20.1802. In this instance, a GE-IS radiographer left a Lixi Profiler containing approximately 550 millicuries of Gadolinium-153 with an employee of a hotel in Chester, Virginia, so that it could be picked up the following morning by another GE-IS representative. GE-IS attributed the root cause of the event to human error, in that the radiographer made a judgement that leaving the Profiler for pick-up at the hotel front desk did not represent an unreasonable risk. With respect to the apparent violation the NRC presented at the conference regarding the failure to verify that a person receiving licensed material was authorized to receive it prior to its transfer as required by 10 CFR 30.41, the NRC has concluded that this issue is more appropriately characterized as a failure to control licensed material; therefore, this issue will not be cited under 10 CFR 30.41.
Although no actual safety consequences occurred as a result of the violation, the potential consequences are of concern to the NRC. The failure to maintain appropriate control of a device containing licensed material created the potential for unauthorized use, misuse, theft, or diversion of licensed material, which could have resulted in unnecessary radiation exposure to members of the public. In addition, the NRC concluded that the possible radiation exposure levels could be more than limited, under different scenarios such as those involving the intentional misuse or use by untrained individuals, or the inadvertent destruction of the Profiler (e.g., smelting). The NRC also concluded that the violation occurred as a result of the willful (i.e., deliberate) actions of a GE-IS employee, as discussed below. Based on the above, and in consideration of the willful aspects of this issue, this violation has been characterized at Severity Level III in accordance with the "General Statement of Policy and Procedures for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600.
At the conference, GE-IS contended that the violation should be characterized at Severity Level IV based, in part, on GE-IS's view of the limited risk of inadvertent over-exposure and its own measurements of the dose rate. GE-IS stated that its measurements indicated a direct beam dose rate (i.e., with the window open) of approximately 80 millirem per hour (mr/h) on contact, and approximately 20-30 mr/h at six inches from the source. GE-IS also stated that because of the design, labeling, and other device attributes, an exposure that exceeded the exposure limit for a member of the public would be unlikely. Based on the above, GE-IS concluded that the violation should be characterized at Severity Level IV.
At the conference, GE-IS also disagreed with the NRC's conclusion that the violation was due to the willful actions of the radiographer. GE-IS's review of the matter led it to conclude that the radiographer exercised poor judgement based on the specific attributes of the device. The licensee also contended that the radiographer's belief that the Profiler was an exempt source (i.e., exempt from certain Department of Transportation requirements), his knowledge that multiple steps were required to expose the source and that the source emitted a very narrow beam, coupled with his specific instructions to the hotel clerk not to open the case, all contributed to his poor judgement.
In response to the information presented by GE-IS at the conference, the NRC reviewed the Registry of Radioactive Sealed Sources and Devices (SS&D) for the device in question (IL-422-DE-101-S, dated August 22, 2000). The SS&D provides measured dose rates at various distances from the Lixi Profiler's source holder, which are significantly greater than those presented by GE-IS at the conference. The NRC confirmed the magnitude of the SS&D dose rates with the instrument vendor. Furthermore, because the device was left with individuals at a hotel, who were neither knowledgeable of nor authorized to provide the required security and control, an increased potential existed for theft, diversion, or intentional misuse of the device. Based on this, the NRC concluded that the risk of over-exposure or unnecessary exposure was more than limited. The NRC also concluded that the violation was deliberate. In this case, the radiographer was properly trained and experienced in the use of NRC-licensed material and the Lixi Profiler in particular, and he was knowledgeable of the proper safeguards required for licensed material. His exercise of poor judgement and his articulation of a basis for concluding that the device could be left with hotel employees does not alter or diminish the deliberate aspects of this issue, or his responsibility to maintain control and constant surveillance of licensed material at all times.
In accordance with the Enforcement Policy, a base civil penalty in the amount of $3,000 is considered for a Severity Level III violation. Because the violation was willful (deliberate), the NRC considered whether credit was warranted for the factors of Identification and Corrective Action in accordance with the civil penalty assessment process described in Section VI.C.2 of the Enforcement Policy. Regarding the factor of identification, the NRC concluded that the violation was promptly identified by GE-IS personnel. Based on this, the NRC concluded that credit was warranted for the factor of Identification. Regarding the factor of Corrective Action, GE-IS immediately dispatched personnel to the hotel to properly secure the device, confirmed that unauthorized personnel did not open the transport box, the corporate Radiation Safety Officer (RSO) promptly notified the NRC of the details of the matter, GE-IS issued an internal bulletin to all radiographers regarding the circumstances of the event with lessons learned, and GE-IS took appropriate disciplinary action. The Corporate RSO also held discussions on this matter with other company division RSOs. Based on this, the NRC concluded that credit was warranted for the factor of Corrective Action.
Therefore, to emphasize the importance of self-identification and correction of violations, I have been authorized, after consultation with the Director, Office of Enforcement, to propose that a civil penalty not be assessed in this case. In addition, issuance of this Notice constitutes escalated enforcement action, that may subject you to increased inspection effort.
The NRC has concluded that information regarding the reason for the violation, the corrective actions taken and planned to correct the violation and prevent recurrence, and the date when full compliance was achieved is adequately addressed on the docket in NRC Inspection Report No. 39-24888-01/03-02, in the information presented at the conference by GE-IS, and in this letter. Therefore, you are not required to respond to this letter unless the description herein does not accurately reflect your corrective actions or your position. In that case, or if you choose to provide additional information, you should follow the instructions specified in the enclosed Notice.
In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter, its enclosures, and any response will be made available electronically for public inspection in the NRC Public Document Room or from the NRC's document system (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html. To the extent possible, responses should not include any personal privacy, proprietary, or safeguards information so that it can be made available to the Public without redaction. The NRC also includes significant enforcement actions on its Web site at www.nrc.gov; select What We Do, Enforcement, then Significant Enforcement Actions.
R. PLISCO FOR
Docket No. 030-29727
License No. 39-24888-01
1. Notice of Violation
2. List of Attendees
3. Information Presented by NRC
4. Information Presented by GE-IS
Commonwealth of Virginia
G.E. Inspection Services, Inc.
7445 White Pine Road
Richmond, Virginia 23237
NOTICE OF VIOLATION
|G.E. Inspection Services, Inc.
N. Charleston, South Carolina
|Docket No. 030-29727
License No. 39-24888-01
During an NRC inspection conducted on May 12, 2003, and an investigation completed by the NRC's Office of Investigations (OI) on July 16, 2003, a violation of NRC requirements was identified. In accordance with the "General Statement of Policy and Procedures for NRC Enforcement Actions," NUREG-1600, the violation is listed below:
|A.||10 CFR 20.1801 requires
that the licensee secure from unauthorized removal or access licensed
materials that are stored in controlled or unrestricted areas.
10 CFR 20.1802 requires that the licensee control and maintain
constant surveillance of licensed material that is in a controlled
or unrestricted area and that is not in storage. As defined in
10 CFR 20.1003, controlled area means an area,
outside of a restricted area but inside the site boundary, access
to which can be limited by the licensee for any reason: and unrestricted
area means an area, access to which is neither limited nor
controlled by the licensee.
Contrary to the above, on April 13, 2003, the licensee did not secure from unauthorized removal or limit access to approximately 550 millicuries of Gadolinium-153 contained in a Lixi Profiler located in a hotel in Chester, Virginia, which is an unrestricted area, nor did the licensee control and maintain constant surveillance of this licensed material.
This is a Severity Level III Violation (Supplement IV).
The NRC has concluded that information regarding the reason for the violation, the corrective actions taken and planned to correct the violation and prevent recurrence, and the date when full compliance was achieved is already adequately addressed on the docket in NRC Inspection Report No. 39-24888-01/03-02, in the information presented at the conference by GE-IS, and in this letter. However, you are required to submit a written statement or explanation pursuant to 10 CFR 2.201 if the description therein does not accurately reflect your corrective actions or your position. In that case, or if you choose to respond, clearly mark your response as a "Reply to a Notice of Violation," and send it to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with a copy to the Regional Administrator, Region II within 30 days of the date of the letter transmitting this Notice.
If you contest this enforcement action, you should also provide a copy of your response with the basis for your denial to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.
Because any response will be made available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be made available to the public without redaction. ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/ADAMS.html (the Public NRC Library). If personal privacy or proprietary information is necessary to provide an acceptable response, then please provide a bracketed copy of your response that identifies the information that should be protected and a redacted copy of your response that deletes such information. If you request withholding of such material, you must specifically identify the portions of your response that you seek to have withheld and provide in detail the bases for your claim of withholding (e.g., explain why the disclosure of information will create an unwarranted invasion of personal privacy or provide the information required by 10 CFR 2.790(b) to support a request for withholding confidential commercial or financial information). If safeguards information is necessary to provide an acceptable response, please provide the level of protection described in 10 CFR 73.21.
In accordance with 10 CFR 19.11, you may be required to post this Notice within two working days.
Dated this 24th day of October 2003