EA-00-302 - Law Engineering and Environmental Services, Inc.
January 24, 2001
Law Engineering and Environmental Services, Inc.
ATTN: Carlos Solís, Vice President
General Manager, San Juan, PR Office
HC80, Box 6785
Dorado, Puerto Rico 00646
|SUBJECT: ||NOTICE OF VIOLATION (NRC SPECIAL INSPECTION REPORT NO. 52-25461-01/00-03) |
Dear Mr. Solís:
This refers to the Nuclear Regulatory Commission (NRC) special inspection conducted on November 29-30, 2000, at your Dorado, Puerto Rico facility. The purpose of the inspection was to followup on an event that occurred during a radiography source exchange on November 24, 2000. The results of the inspection, including five apparent violations, were discussed with members of your staff on November 30 and December 13, 2000, and formally transmitted to you by letter dated January 5, 2001. Based on the results of the inspection, an open predecisional enforcement conference was conducted at the NRC's Region II office in Atlanta, Georgia, on January 18, 2001, to discuss the apparent violations, the root causes, and your corrective actions. A listing of conference attendees and the materials NRC presented at the conference are enclosed.
Based on the information developed during the inspection and the information that you presented at the conference, the NRC has determined that five violations of NRC requirements occurred. The violations are cited in the enclosed Notice of Violation (Notice), and the circumstances surrounding them are described in detail in the subject inspection report. As the Notice indicates, the violations were separated into two parts. The four violations cited in Part (A) occurred prior to and during the source exchange, while the one violation cited in Part (B) of the Notice involved the emergency procedure that should have been followed after it was discovered that the source had not reached its fully shielded position.
The violations are: (A.1) failure to perform proper surveys, as required by 10 CFR 20.1501; (A.2) failure to follow the manufacturer's instructions while changing a source, as required by Condition 18 of License No. 52-25461-01 and Item 6.11.b of the application; (A.3) failure to provide instructions to the Radiation Safety Officer (RSO) and a radiographer on the proper use of a source changer prior to its use, as required by Condition 18 of License No. 52-25461-01; (A.4) failure to perform a visual and operability check of the source changer prior to its use, as required by 10 CFR 34.31(a); and (B) failure of the RSO and radiographer to immediately withdraw from the area in response to a sounding alarm rate meter, as required by Item 6.12.a of the application. As discussed at the conference, the root and contributing causes of the event included inadequate training provided to the RSO and radiographer on the use of the new source changer, the RSO's and radiographer's overconfidence in their ability to use the new source changer due in part to their believed familiarity with the equipment and their assumption that changing the source, even with a new model changer, would be a routine operation, the failure to perform proper surveys, and the failure of the individuals involved to fully understand and implement emergency procedures after they became aware that the source had not been safely transferred during the source exchange.
The violations that occurred before and during the source exchange represent the failure of multiple barriers which are specifically in place to preclude events such as the one that occurred in November 2000. In addition to our concern regarding the violations which occurred before and during the source exchange, the failure of the RSO and radiographer to withdraw from the area and to assess the situation prior to attempting to rectify the unshielded 6.7 curie Iridium-192 source is of particular concern to us. This error resulted in a doubling of the dose to the radiographer and unnecessary exposure to the RSO, and demonstrated a lack of forethought and preparation regarding the implementation of emergency procedures. Such procedures are integral to the safe handling of licensed by-product material. In this case, the actual dose received by these two individuals involved in the source exchange was less than NRC regulatory limits. However, these individuals received unnecessary radiation exposure, and a substantial potential existed for radiation dose in excess of prescribed limits. The failure to perform adequate surveys alone could be characterized as a Severity Level III violation, in accordance with the "General Statement of Policy and Procedures for NRC Enforcement Actions - May 1, 2000" (Enforcement Policy), NUREG-1600, as amended on November 3, 2000 (65 Federal Register 59274). We have concluded, however, that based on the relationship of the four Part (A) violations in contributing to the event, Violations (A.1-4) have been categorized collectively as a Severity Level III problem. The violation in Part (B) has been categorized separately as a Severity Level III violation, based on our conclusion that this violation in itself resulted in a substantial potential for radiation dose in excess of prescribed limits.
In accordance with the Enforcement Policy, a base civil penalty in the amount of $6,000 is considered for each Severity Level III violation or problem occurring on or after November 4, 2000. Because your company has not been the subject of escalated enforcement action within the last two inspections, the NRC considered whether credit was warranted for Corrective Action in accordance with the civil penalty assessment process described in Section VI.C.2 of the Enforcement Policy. Your corrective actions were detailed in your December 19, 2000, event report and during the conference, and included in part: (1) immediate actions to secure the source and determine the extent of radiation dose received by the individuals involved in the event; (2) the conduct of refresher training to all radiographers in the proper performance of a source exchange for the type and model used during the event; (3) the conduct of radiographer training with emphasis on the importance of conducting appropriate radiation surveys; (4) your plans for all future radiographers to receive training in the use of source exchange equipment and the importance of conducting surveys; (5) discussions between the RSO and Corporate RSO on this event, lessons learned, and activities necessary to preclude and manage similar incidents in the future; (6) the conduct of periodic meetings (via teleconference) between Corporate management and individuals involved in radiography throughout the company to discuss this event and other industry events as necessary; (7) Law Engineering's intent to conduct independent quarterly audits/reviews of activities at the Puerto Rico office. Based on the above, NRC concluded that your actions were prompt and comprehensive, and credit was warranted for the factor of Corrective Action.
Therefore, to encourage prompt and comprehensive correction of violations and in recognition of the absence of previous escalated enforcement action, I have been authorized to propose that no civil penalty be assessed in this case. However, similar violations in the future could result in further escalated enforcement action. 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 already adequately addressed on the docket in this letter and in Law Engineering's report of the incident dated December 19, 2000. 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 enclosure, and your response, should you provide one, 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). ADAMS is accessible from the NRC Web site at the Public NRC Library.
If you have any questions regarding this matter, please contact Douglas M. Collins, Director, Division of Nuclear Materials Safety, at 404-562-4700.
| ||Sincerely, |
|Luis A. Reyes |
Docket No. 030-34909
License No. 52-25461-01
Enclosure: Notice of Violation
Law Engineering and Environmental Services, Inc.
Richard P. Garrison, Senior Vice President
1105 Sanctuary Parkway, Suite 300
Alpharetta, GA 30004
email distribution (firstname.lastname@example.org)
Law Engineering and Environmental Services, Inc.
David A. Rumrill, Assistant Vice President and
Quality Assurance Manager
1105 Sanctuary Parkway, Suite 300
Alpharetta, GA 30004
email distribution (email@example.com)
Commonwealth of Puerto Rico
NOTICE OF VIOLATION
|Law Engineering and Environmental Services, Inc. |
Dorado, Puerto Rico
| ||Docket No.: 030-34909 |
License No.: 52-25461-01
During an NRC inspection conducted on November 29-30, 2000, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedures for NRC Enforcement Actions - May 1, 2000," NUREG-1600, as amended on November 3, 2000 (65 Federal Register 59274), the violations are listed below:
|A. ||(1) ||10 CFR 20.1501 requires that each licensee make, or cause to be made, surveys that may be necessary for the licensee to comply with the regulations in Part 20 and that are reasonable under the circumstances to evaluate the extent of radiation levels, concentrations or quantities of radioactive materials, and the potential radiological hazards that could be present. |
| ||Pursuant to 10 CFR 20.1003, survey means an evaluation of the radiological conditions and potential hazards incident to the production, use, transfer, release, disposal, or presence of radioactive material or other sources of radiation. |
Contrary to the above, on November 24, 2000, a licensee radiographer failed to perform the proper surveys to assure compliance with 10 CFR 20.1201(a), which limits occupational exposure to the extremities and the whole body. Specifically, the radiographer failed to perform an adequate radiation survey which would have revealed that a 6.7 curie iridium-192 sealed source was not in the proper shielded position and could have caused an overexposure of the extremities and whole body. The survey meter used during the activity was located behind the radiographer and was not in a position to measure the radiation levels to which the radiographer was exposed. In addition, the alarming ratemeter worn by the radiographer was shielded by his body and not capable of detecting the radiological hazard present. (01013)
|(2) ||Condition 18 of License No. 52-25461-01 requires, in part, that the licensee conduct its program in accordance with the procedures contained in the license application dated December 31, 1998. |
Item 6.11.b of the application (Source Exchange Procedures) requires that the manufacturer's attached instructions for each model source changer be followed explicitly during the source exchange.
Contrary to the above, on November 24, 2000, the radiographer failed to open a newly added lock on the source changer as specified in the manufacturer's instructions. This prevented the source from entering the source changer, which stayed in an exposed position in the immediate vicinity of the radiographer. (01023)
|(3) ||Condition 18 of License No. 52-25461-01 requires, in part, that the licensee conduct its program in accordance with the procedures contained in the license application dated December 31, 1998. Item 8.4.e.2 of the application (Training) requires, in part, that experienced radiographers hired by the licensee receive instructions in the use of radiography equipment to the extent necessary to supplement their previous training and experience. |
Contrary to the above, as of November 24, 2000, the licensee's Radiation Safety Officer (RSO) and a radiographer had not received any instructions in the use of the model of the source changer prior to its use that day. (01033)
|(4) ||10 CFR 34.31(a) requires the license to perform a visual and operability check of source changers on the day of use to ensure the source changer is in good working condition and that the sources are adequately shielded. |
Contrary to the above, on November 24, 2000, the radiographer failed to perform the required visual and operability check prior to using the source changer. (01043)
|This is a Severity Level III problem (Supplements IV and VI). |
|B. ||Item 6.12.a of the application (Emergency Procedures – Alarm Ratemeter Warning) requires that, at any time the alarm ratemeter sounds, radiography personnel immediately withdraw to an area where it is silent and read the survey meter. |
Contrary to the above, on November 24, 2000, both the radiographer and the RSO failed to stop, withdraw to a silent area, and confirm being in the presence of low radiation levels when an alarm ratemeter sounded. (02013)
This is a Severity Level III violation (Supplements IV and VI).
The NRC has concluded that information regarding the reason for the violations, 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 the letter transmitting this Notice of Violation (Notice) and in Law Engineering's report of the incident dated December 19, 2000. 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 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, United States 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 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 January 2001
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