EA-98-100 - Wisconsin-Oshkosh University

March 27, 1998

EA 98-100

John Kerrigan, Ph.D.
Chancellor
University of Wisconsin-Oshkosh
800 Algoma Blvd.
Oshkosh, WI 54901

SUBJECT:

NOTICE OF VIOLATION (NRC Inspection Report 030-01171/98001(DNMS); 030-07111/98001(DNMS))

Dear Dr. Kerrigan:

This refers to the inspection conducted on February 11 and 12, 1998, at University of Wisconsin in Oshkosh, Wisconsin. The purpose of the inspection was to determine whether activities authorized by the licenses were conducted safely and in accordance with NRC requirements. During the inspection, apparent violations of NRC requirements were identified. A copy of the NRC inspection report was sent to you by a letter dated March 6, 1998. You were given the option of participating in a predecisional enforcement conference or addressing the apparent violations in writing. You chose to submit a written response dated March 23, 1998.

Based on the information developed during the inspection and the information provided in your March 23 response to the inspection report, the NRC has determined that violations of NRC requirements occurred. These violations are cited in the enclosed Notice of Violation (Notice) and the circumstances surrounding them are described in detail in the subject inspection report.

Seven violations were identified during the inspection and together they demonstrate a programmatic breakdown of control over licensed activities. The root cause of this breakdown stems from the lack of program oversight by the Radiation Safety Office and university management. In addition, the radiation safety program personnel changes which occurred in September 1997, directly affected the continuity of program activities. Individually, the safety significance of the violations is low because of the small quantity of radioactive materials currently being used. However, collectively, the violations are of significant regulatory concern to the NRC because they cover the breath of your program. Incumbent upon each NRC licensee is the responsibility to ensure that all requirements of the NRC license are met and any potential violations of NRC requirements are identified and corrected expeditiously. Therefore, these violations are classified in the aggregate in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600, as a Severity Level III problem.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $2,750 is considered for a Severity Level III problem. Because your facility has not been the subject of escalated enforcement actions within the last two inspections, the NRC considered whether credit was warranted for Corrective Action in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. Based upon the corrective actions taken following the inspection and those actions identified in your letter dated March 23, 1998, credit for Corrective Action was warranted. Beside addressing each of the individual violations, the corrective actions planned or taken to address the root causes include: (1) scheduled training on your license commitments and pertinent NRC regulations for all individuals who work with licensed material or work in restricted areas; (2) performance of an annual program audit by management with the assistance of the Radiation Safety Committee; (3) increased management oversight of the radiation safety program to ensure compliance with NRC requirements and to review program needs and resources.

Therefore, to encourage prompt and comprehensive correction of violations and in recognition of the absence of previous escalated enforcement action, I have been authorized not to propose a civil penalty in this case. However, significant violations in the future could result in a civil penalty. In addition, issuance of the Severity Level III problem constitutes escalated enforcement actions that may subject you to increased inspection effort.

The NRC has concluded that information regarding the reasons for the violation, and the corrective actions taken and planned to correct the violation and prevent recurrence are already adequately addressed in your letter dated March 23, 1998. Therefore, you are not required to respond to this letter unless the description therein 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, the enclosed Notice, and your response if you choose to respond, will be placed in the NRC Public Document Room.

Sincerely, Original Signed by James L. Caldwell for A. Bill Beach Regional Administrator

Docket No. 030-01171
License No. 48-13250-02

Enclosure: Notice of Violation

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NOTICE OF VIOLATION

University of Wisconsin Oshkosh, Wisconsin

Docket No. 030-01171 License No. 48-13250-02 EA 98-100

During an NRC inspection conducted on February 11 and 12, 1998, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the violations are listed below:

A. License Condition 12.B of License No. 48-13250-02, names a specific individual to act as the Assistant Radiation Safety Officer.

Contrary to the above, from June 1997 until February 11, 1998, the specifically named individual no longer acted in the capacity of Assistant Radiation Safety Officer. Another individual not designated by the license was acting in the position of Assistant Radiation Safety Officer. (01013)

B. License Condition 11.F of License No. 48-13250-02, authorizes a specified individual to use only iodine-125.

Contrary to the above, prior to November 25, 1997, phosphorus-32 and tritium, radioactive materials other than iodine-125, were used by the above referenced individual in laboratory Room HS-244. (01023)

C. License Condition 17.B of License No. 48-13250-02, requires the licensee to conduct its program in accordance with the statements, representations and procedures contained in the modified license application received October 5, 1995.

Section VI of the application received October 5, 1995, states, in part, that survey instruments are calibrated twice a year.

Contrary to the above, survey instruments have not been calibrated twice a year. Specifically, the Nuclear Chicago survey instrument, Serial No. 23009 was calibrated on November 6, 1995 and again on November 18, 1996. The Victoreen Model 495-5 survey instrument, Serial No. 578 was last calibrated on October 14, 1996. (01033)

D. License Condition 17.B of License No. 48-13250-02, requires the licensee to conduct its program in accordance with the statements, representations and procedures contained in the modified license application received October 5, 1995.

Item 8 of the application received October 5, 1995, requires, in part, that individuals working under the supervision of an authorized user yearly receive training in accordance with the model training program in Appendix A of Regulatory Guide 10.8, Revision 2. Records of this training will be documented on a Radiation Safety Training Form.

Contrary to the above, between October 1996 and February 11, 1998, all individuals working under the supervision of an authorized user did not receive yearly training as required. Specifically, one individual who worked under the supervision of an authorized user during the above time period and was responsible for the receipt of packages containing radioactive materials, did not receive radiation safety training in accordance with the model program in Appendix A of Regulatory Guide 10.8, Revision 2. (01043)

E. License Condition 17.B of License No. 48-13250-02, requires the licensee to conduct its program in accordance with the statements, representations and procedures contained in the modified license application received October 5, 1995.

Section XII of the application received October 5, 1995, requires, in part, that upon receipt of a package containing radioactive material, the receiving department at 846 Warren Road will check the package with a calibrated survey meter at the receiving point.

Contrary to the above, between October 1995 and February 11, 1998, packages containing radioactive material were not checked with a survey instrument upon receipt in the receiving department at 846 Warren Road. (01053)

F. License Condition 17.B of License No. 48-13250-02, requires the licensee to conduct its program in accordance with the statements, representations and procedures contained in the modified license application received October 5, 1995.

Section XIV, Item 14 of the application received October 5, 1995, states that waste containers for solid waste are designated with signs which include the standard "Radiation Symbol."

Contrary to the above, on November 25, 1997, solid radioactive waste was not stored in properly labeled containers. Specifically, in Room HS-244 solid radioactive waste was stored in plastic bags and was not labeled with the standard radiation symbol. (01063)

G. License Condition 17.B of License No. 48-13250-02, requires the licensee to conduct its program in accordance with the statements, representations and procedures contained in the modified license application received October 5, 1995.

Section 7.C entitled "Personnel Monitoring," of the application received October 5, 1995, states, in part, that the RSO (Radiation Safety Officer) keeps records of isotope users, film badge numbers and film badge exposure records.

Contrary to the above, in September 1997, the RSO did not keep the records of isotope users, film badge numbers and film badge exposure records of eight students who were assigned film badges while working with isotopes. (01073)

This is a Severity Level III problem (Supplement VI).

The NRC has concluded that information regarding the reasons for the violation, and the corrective actions taken and planned to correct the violation and prevent recurrence is already adequately addressed in a letter from University of Wisconsin-Oshkosh dated March 23, 1998. However, you are required to respond to the provisions of 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, D.C. 20555, with a copy to the Regional Administrator, Region III, 801 Warrenville Road, Lisle, Illinois 60532-4351, within 30 days of the date of the letter transmitting this Notice of Violation.

If you contest this enforcement action, you should also provide a copy of your response to the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001.

If you choose to respond your response will be placed in the NRC Public Document Room (PDR). Therefore, to the extent possible, it should not include any personal, privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction. Under the authority of Section 182 of Act 42 U.S.C. 2232, any response shall be submitted under oath or affirmation.

Dated at Lisle, Illinois
this 27th day of March 1998