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SSINS No.: 6835 IN 84-28 UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D.C. 20555 April 17, 1984 Information Notice No. 84-28: RECENT SERIOUS VIOLATIONS OF NRC REQUIRE- MENTS BY WELL-LOGGING LICENSEES Addressees: All byproduct materials licensees authorized to possess and use byproduct materials in well-logging devices and manufacturers who distribute devices that incorporate sealed sources for such use. Purpose: To bring to the attention of well-logging licensees the large number of re- cent cases involving serious violations of NRC license conditions, to point out the common causes of these violations, and to describe their consequen- ces. Discussion: From January 1 to December 1, 1983 there have been 26 cases in which the NRC has taken escalated enforcement action against byproduct materials licensees. Nineteen of these cases involved a civil penalty, six involved Orders to suspend the license or to show cause why the license should not be revoked, arid one involved both a suspension Order and a civil penalty. These escalated enforcement actions were taken because various serious violations of NRC license requirements occurred. These violations included employees being overexposed to radiation, members of the public being unnecessarily exposed to radiation, and public property being contaminated with radioactive material. In addition, the financial consequences to the affected licensees have been significant because of the loss of income from the payment of civil penalties, the cost of decontaminating property, and the suspension or revocation of the license. An analysis of the causes of these escalated enforcement cases shows that there were three common causes for the serious violations and their con- sequences. These causes were: (1) Failure to read and understand the conditions of the license. (2) Failure to train employees in the conditions of the license including the radiation safety procedures that are incorporated into the license. (3) Failure to control operations including failure of licensee employees to follow approved radiation safety procedures. 8403140277 . IN 84-28 April 17, 1984 Page 2 of 3 Attached are summaries of two well-logging cases. They illustrate the causes and consequences of the serious violations that the NRC has found during inspections of this class of byproduct materials licensees. One of the principal causes of violations is the fact that some licensees are not cognizant of all the conditions of their license. NRC has found during inspections that some licensees have never read the license or have little understanding of its conditions. Conditions and commitments in the license form the basis for the issuance of the license, and are necessary to protect the health and safety of the public. NRC therefore expects licensees to abide with all the conditions and commitments of their license. Licensees are reminded that nonroutine service and maintenance of equipment such as removal of source capsules from source holders, repair, and replacement of seals on source holder/pressure housing, etc., should not be undertaken, unless the licensee has specifically requested this authorization and provided his procedures for performing these services in his license application. Where specific approval has not been granted under the license, the source holder or pressure housing containing the source should be returned to the source or device Manufacturer or other persons specifically licensed to perform the nonroutine servicing. Two other principal causes of violations are the failure to properly train the workforce and the failure to control the radiation-safety aspects of the licensee's operation. Licensee management is responsible for ensuring that employees receive proper training, that the proper radiation monitoring instrumentation and personnel dosimetry is available and used, and that employees comply fully with all the conditions of the license and associated radiation safety procedures. The licensee's responsibility for control of its operations also extends to consultants and contractors. In certain circumstances the NRC encourages licensees to seek qualified assistance when the licensee does not possess the necessary experience, training, equipment, or personnel dosimetry to perform particular activities; e.g., to handle problems arising from an accident or unusual occurrence. However, the responsibility for the safety of the operations and compliance with NRC requirements remains with the licensee. Licensees should review the conditions of their license to ensure that they understand their responsibilities under the license. This should include an examination of the details of their radiation safety program to verify that the program complies with all requirements. As a result, licensees can avoid the serious consequences to their employees and the public and the significant financial costs that can result from failure to follow NRC requirements. . IN 84-28 April 17, 1984 Page 3 of 3 No response to this information notice is required. If you have any questions regarding this matter, please contact the Administrator of the appropriate Regional Office or this office. J. Nelson Grace, Director Division of Quality Assurance, Safeguards, and Inspection Programs Office of Inspection and Enforcement Technical Contacts: J. R. Metzger, IE (301) 492-4947 E. D. Flack, IE (301) 492-9823 Attachments: 1. Selected Cases Involving Serious Violations of NRC Requirements 2. List of Recently Issued IE Information Notices . Attachment 1 IN 84-28 April 17, 1984 Page 1 of 3 CASE A A well-logging licensee attempted to remove a stuck 2 curie cesium-137 source from a source holder using lubricants. When this failed, the, source holder was placed in a lathe and the lathe was turned on. Attempts were made to push the source out of the holder with a drill bit while the source holder was turning on the lathe. The source finally fell out of the holder but it had been ruptured, causing widespread contamination. The licensee did not recognize the seriousness of the incident and the NRC was not notified until almost 24 hours after the incident had occurred. As a result, a fairly minor problem became a major incident. Violations 1. The licensee employees conducted unauthorized operations. 2. Radiation surveys were completely inadequate for the amount of radio- active material that had escaped from the ruptured source. (the instruments went off-scale and licensee employees assumed the instruments were not working properly.) 3. A radiation exposure to an employee exceeded the regulatory limit. 4. Licensee employees were not properly instructed about what to do when a source became stuck in a source holder. Causes 1. Management and employees did not understand the conditions of the license. 2. Employees were inadequately trained; e.g., they did not know how to use radiation monitoring instruments properly or how to control radioactive contamination. Consequences 1. Radioactive contamination was spread to 27 homes, several private autos, six business establishments and the premises of the licensee. 2. Whole-body exposure to one employee was 13.48 rems. Three employees had a body uptake of cesium-137 equal to about 10% of the NRC limit. One employee had a cesium-137 uptake of 51% of the allowable limit. 3. The estimated cost of decontamination was about $250,000. 4. Two employees received calculated extremity exposures of 125 rems and 25 rems, respectively. . Attachment 1 IN 84-28 April 17, 1984 Page 2 of 3 Enforcement NRC issued an Order, effective immediately, that suspended the license and required the licensee to show cause why the license should not be revoked. The licensee's operations were closed down for 53 days. The Order was recinded permitting continuation of well-logging: however, decontamination is continuing at the main facility. . Attachment 1 IN 84-28 April 17, 1984 Page 3 of 3 CASE B A well-logging licensee knowingly disregarded the conditions of its license and the NRCs regulations resulting in 19 violations of NRC requirements. The more significant violations are listed below. Violations 1. The licensee never leak tested the sealed sources since receipt about three years ago. 2. The licensee never purchased any radiation survey instruments to do required surveys. 3. The licensee failed to provide workers with personnel dosimeters. 4. The licensee's radiation safety officer, failed to conduct audits at any time to assure compliance with NRC requirements. 5. The licensee (not having survey instruments) could riot conduct required surveys of areas where licensed materials were stored and could not conduct required surveys at customer well-logging sites. 6. The licensee did not have a storage area for radioactive materials that was described in the application for a license. 7. Radiation levels were found to read as much as 200 millirems per hour in an unrestricted area (the limit is 100 millirems per 7 consecutive days). 8. The licensee did not instruct workers in the fundamentals of basic radiation protection as required. 9. The licensee transported sealed sources in unauthorized containers. 10. The licensee failed to maintain any records of receipt, transfer or disposal of radioactive materials. Causes 1. The licensee did not read the license or regulations to determine its responsibilities. 2. The licensee did not implement its procedures. Consequence 1. The licensee exposed its workers to undetermined radiation levels. Enforcement NRC issued an Order Suspending License and Order to Show Cause why the License Should not be Revoked; the Order is still pending.
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