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U.S. NUCLEAR REGULATORY COMMISSIONREGION I

Report No. 70-687/89-80; 50-54/89-80

Docket No. 70-687; 50-54

License No. SNM-639; R-81 Priority 1 Category. UHBR

Licensee: Cintichem, IncorporatedP.O. Box 816Tuxedo, New. York 10987

Facility Name: Reactor and Hot Laboratory

Inspection At: Tuxedo, New York

Inspection Conducted: October 23-27, 1989

Inspectors:J. Ro hPrloject Engineer, Effluent

Radiav),on Protection Section, Division ofRadiation Safety and Safeguards, Team Leader

1(D. J. 'Collins, Radiation Specialist,Nuclear- Materials Safety Section C, Divisionof Radiation Safety and Safeguards

• G omfort, Project Licensing Manager,Nuclear Material Safety and Safeguards

C. J. Cqnklin Senior Emergedbcy PreparednessSpec-i-a1ist,..Energency Preparedness Section,Division of Radiation Safety and Safeguards

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2' ýt r? s--Ie\ • " /" '/'dat•.e•ry-dcye, Reactor Engineer, Operational dat'gram Section, Division of Reactor Safety

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J. C. Jang] Senior Radiation Specialist,Effluents Radiation Protection Section,Division of Radiation Safety and Safeguards

N. T. McNalara, Laboratory Assistant,Effluents Radiation Protection Section,Division of Radiation Safety and Safeguards

T_.?Aý Moslak, Resident Inspector, TMI-I,Div/ion of Reacto Projects

Approved by: _ __-

J. Bores, thief, Effluents RadiationProtection Section, Division of RadiationSafety and Safeguards

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Inspection Summary: Inspection on October 23-27, 1989 (Combined InspectionReport Nos. 70-687/89-80; 50-54/89-80)

Areas Inspected: Special team inspection by region-based inspectors andHeadquarters personnel of the licensed programs including: hot laboratory andreactor operations, reactor experiments, radiation protection includingcontamination control, effluent and environmental monitoring, confirmatory andlaboratory measurements, management controls, and emergency preparedness.

Results: Six violations and three unresolved items were identified. Inaddition, a number of significant inspector followup items in the areas ofmanagement controls, contamination control, dosimetry, emergency planning,environmental and effluent monitoring were also identified. Violations:failure to provide effective emergency training to management and healthphysics technicians (Paragraph 5.6.4); failure to mark or decontaminate fixedalpha contamination in excess of 200 cpm/i00 cm2 (Paragraph 7.2); failure toperform environmental analyses required, by Technical Specification (TS) 3.10and 3.11 and Table 5.2.1 of the SNM 639 license application (Paragraphs 9.4.1.1.and 9.4.6); failure to perform analyses of liquid and gaseous effluents asrequired by T.S.3.9.2 and 3.9.3 and Section 3.2.4.4 of the SNM-639 licenseapplication (Paragraphs 10.2 and 11.1.4); Discharge of liquid effluents with1-131 concentrations in excess of the limits as specified in T.S.3.9.3(3)

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(Paragraph 11.1.4); failure to analyze pool water for all nuclides present asrequired by T.S.4.8.(2) and 4.8.(3) (Paragraph 11.1.5). Unresolved items:review licensee measurement data and information concerning the definition and,calculations of Sr-90 equivalents (Paragraph 10.1); review applicability ofestablished techniques for the determination of the iodine collectionefficiency of the ventilation system-charcoal beds (Paragraph 10.4); review thelicensee's quantification of effluent iodine releases and conduct of offsitedose calculation (Paragraph 11.1.1).

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DETAILS

1.0 Individuals Contacted

1.1 Cintichem, Inc.

*J. J. McGovern, Plant Manager*T. Vaughn, Manager, Health, Safety and Environmental Affairs*W. G. Ruzicka, Manager, Nuclear Operations*D. D. Grogan, Manager, Radiochemical Production and Material Control*L. C. Thelin, Staff Health Physicist*J. Guenther, Staff Health Physicist*J. Stewart, Supervisor, Health Physics*J. Ditton, Associate Radiation Safety Officer*L. Babcock, Health Physics Technician III*T. B. Rice, Health Physics Technician III

1.2 Hoffmann LaRoche, Inc.

*M. Drzyzga, Radiation Safety Officer

1.3 Amersham International

*T. J. Rogers, Manager, Pharmaceuticals *Business*M. Whiting, Manager, Amersham International (Harwell) Laboratory

1.4 State of New York

*B. K. Kothari, Associate Radiophysicist, Department of Labor,

Division of Safety and Health*W. T. Varcasio, Environmental Radiation Specialist I, Department

of Environmental Conservation, Bureau of Radiation*S. Zobel, Environmental Radiation Specialist II, Department of

Environmental Conservation, Bureau of Radiation

*Indicates those present at the exit interview. The inspectors, also

interviewed other licensee personnel.

2.0 Licensee Actions on Previously Identified Enforcement Items

2.1 (Closed) Violation (687/88-05-01) Failure to maintain the radiationdose rate in an unrestricted area to less than two millirem/hour.The inspector verified that the licensee had constructed a chain linkfence around the waste storage building to restrict access tosurfaces of the building. Measurements made by the inspector at thesurface of the fence indicated a maximum dose rate of less than 0.6millirem/hour.

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2.2 (Closed) UNR (54/88-03-04) No Nuclear Safeguards Committee approvalfor an irradiation experiment. This item was identified during areview of the administrative control of procedures. One procedure,XG-03, "Rabbit Tube Irradiations", was noted to be lacking documenta-tion which certified that the procedure-had been reviewed and-approved by the Nuclear Safeguards Committee (NSC).

The inspector reviewed the requirements for NSC approvals of newreactor experiments and reactor experiment procedures as outlined inProcedures XG-01, '"Isotope and Service Irradiations", and XG-04,"Experiment Review and Approval". The latest revision of ProcedureXG-03 was also reviewed. This procedure had been recently revisedand was submitted to the NSC on June 6, 1989. The inspector notedthat the NSC had reviewed Procedure XG-03 on June 19, 1989 (NSCmeeting minutes. #141) and had approved it on June 26, 1989 forissuance. This was certified by the signature of the NSC Secretaryon the Procedure Review and Approval Sheet, AD-03. Althoughverification of NSC approval of the previous revision to XG-03 wasnot provided, the above actions satisfactorily resolve this item.

2.3 (Closed) Violation (687/87-04)

1. The Emergency Planning Coordinator did not review and update theRadiological Contingency Plan (RCP) and Implementing Procedures(IPs) biennially since 1983.

The inspector noted that the RCP and IPs had been recentlyreviewed and updated as required.

2. Agreements with offsite support groups were either not initiatedor were not updated biennially since 1976.

Letters of agreement were current for all identified offsiteagencies for 1989 and letters had been sent to update theseagreements for 1990.

3. The Emergency Planning Coordinator did not review the emergencyroster and telephone listings and verify each individual's or

organization's telephone numbers annually since 1983.

The emergency roster and telephone listings were updated inJune, 1989.

2.4 (Closed) Violation (54/84-03-06) Failure to complete training ofoffsite support organizations and provide for periodic retraining andparticipation in emergency drills.

Training of offsite organizations was provided by offering tours ofthe facility and participation in annual drills. Tours wereconducted for 1988 and were scheduled for October 28, 1989.

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2.5 (Open) Inspector Followup Item (54/84-03-14)-Develop a formaltraining/retraining program.

*Training consists of a "read and sign" program to be performedbiennially for the emergency plan and implementing procedures. Thisprogram was not found to be effective. See paragraph 5.6.4 foradditional information.

2.6 (Closed) Unresolved Item (54/88-02-01) Revise the RCP to incorporatethe following:

1. There is no guidance in the RCP regarding the issuance ofpotassium iodide.

The licensee has developed Procedure EP-17, "Potassium Iodide(KI)", to assist the Emergency Director (ED) in determining whenKI should be taken.

2. The RCP does not provide for the turnover of the ED or definethe corporate involvement.

The RCP has been revised and clearly delineates a-line ofsuccession for the ED. Additionally, the plan states thatcorporate officers have no role during an emergency.

3. The RCP, Table 5.11 directs the licensee to notify the NRC onlyif the "situation warrants".

The RCP has been revised to direct the licensee to notify theNRC at all emergency classifications.

4. There is no backup method to determine the magnitude of stackreleases if the stack monitor is off scale.

The licensee has installed an RM-16 with a remote probe at thestack. This instrument reads up to 20 R/hr and includes a stripchart recorder. 'The primary use of this instrument is toprovide high range monitoring capability of stack releases incase the primary stack monitor is off scale.- The licensee hasestablished procedures and dosimetry for evaluation of the dataobtained.

2.7 (Closed) Unresolved Item (54/88-02-02) There is no evidence that thelicensee revises the RCP due to issues identified during drills.

A review of several drill critiques and the RCP indicated that thelicensee has addressed areas for improvement identified duringdrills.

2.8 (Closed) Inspector Followup Item (54/88-02-03) Several equipmentproblems were identified including the following.

1. There was no basis for the equipment selected for use in thevarious emergency kits.

The licensee reviewed the kits, upgraded them as necessary andprovided the bases for equipment selected in the implementingprocedures.

2. Some kits did not include an inventory list.

Inventory lists are now stored with each kit.

3. Inventory lists did not reflect all stored equipment.

Procedure HP-C-14 has been revised to reflect all equipment inthe emergency kits and inventory lists are available for eachkit.

4. There was no emergency offsite monitoring kit or method forfield analysis of offsite air samples.

A kit for emergency offsite monitoring has been prepared andincludes equipment and a methodology to perform field airsampling and analyses.

5.- The licensee does not have a predesignated offsite rendezvouslocation.

The licensee has designated two offsiterendezvous locations.Interviews with staff indicated-they were aware of theselocations, but these locations were not described in the RCP.These locations should be included in the RCP.

2.9 (Closed) Unresolved (687/88-06-01) The licensee was unable to providedata to demonstrate that criticality alarm set points were adequate.Additionally, the licensee did not have a method to readily ascertainif personnel had received a dose of 10 rads or more.

The licensee conducted a review of the criticality alarm set pointsand concluded that they were appropriately set. These review dataare contained in a January 10, 1989 letter from R.-Strack toW. Ruzicka entitled "Adequacy of Criticality Alarm System". Theinspector concluded that this review was adequate. Additionally, thelicensee has a procedure, HP-G-11, "Estimating Neutron Dose FromCriticality Using Na-24 'Quick Sort' Method". This procedure allowsthe licensee to quickly estimate personnel neutron. exposure as aresult of criticality incidents, including exposures of 10 rads ormore. Procedure HP-B-16, "Criticality Dosimetry", delineates thecriticality dosimetry in place. The inspector concluded that theseprocedures were adequate.

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2.9.1 (Closed) Violation (687/88-01-04) Failure to analyze wastesolutions to assure they meet the uranium concentration limitspecified in Section 4.2.5.2(a) of the NRC-approved licenseapplication. The inspector verified that the licensee performedanalyses on waste solutions stored in the hot cells anddetermined that the uranium concentration in those solutionswaslessthan the specified limit. The licensee evaluated the wasteprocessing procedures and determined that the uranium concentra-tion will not exceed the specified limit as long as thecurrently used processing procedures were not modified. Thisevaluation was reviewed by the inspector and no furtherquestions were raised. The licensee committed to reanalyzethese waste solutions whenever the processing procedures aremodified.

3.0 Reviewof Operations

3.1 Reactor Facilities

3.1.1 Reactor Operations

The inspector observed normal steady-state operations andreactivity manipulations conducted for the off-loading andinsertion of fission product molybdenum (FPM) targets.Throughout these evolutions, the control room was appropriatelystaffed and licensed operators exhibited good overall knowledge

-and command of the on-going operation. Logs and operational.data sheets were rigorously maintained.

The inspector noted a good licensee practice. in that controlroom log entries were color coded to provide quick identifi-cation of plant activities. Log entries for FPM targetremoval/insertions were green, normal operations were blue,

.unresolved shutdowns were red, and scheduled shutdowns forrefueling and maintenance activities were black.

The control room environment was generally quiet, controlled andoriented toward safe operation of the plant. Operations wereconducted from memory without rigorous use of writtenprocedures. However, operating procedures were available as aready reference. Reactivity manipulations were carried out inaccordance with approved Procedure RM-04, "Reactor Operation".The inspector observed that throughout steady-state operationand power manipulations, reactor instrumentation showed goodcorrelation between the various panel and console indications,with the following exception.

During a power escalation evolution, the inspector observedthat the power range nitrogen (N-16) recorder did notfunction. Upon informing the control room operator of thisfact, control room personnel stated that the recording penoccasionally hung up. An operator took immediate action tocorrect the problem. Through subsequent discussions with

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the reactor instrumentation technician, the inspector wasinformed that the problem was identified in October 1988,and that a new N-16 recorder has been purchased and is tobe installed in the near future. As a result of thisobservation the inspector stated that the licensee shouldrespond faster to identified problems. One approach is toconsider the establishment of a tracking system to ensurethat identified equipment deficiencies are corrected incamore timely manner.

Through discussions with licensee representatives and review ofrecords, the inspector determined that the licensee maintains alarge experienced operating staff of thirteen (13) seniorreactor operators and two (2) reactor operators. Such depth ofexperienced personnel permits all shifts to be adequatelystaffed with senior operators. Nuclear Operations Departmentstaffing and planning contributed positively to the conduct ofsteady state operations and reactivity manipulations.

3.1.2 Technical Specification Surveillance Program

The inspector reviewed a selective sample of completedsurveillance procedures. Through this review, the inspectordetermined that these surveillances were completed in accordancewith the required frequencies and met the acceptance criteriastated within the Technical Specifications for the reactorfacility. Included in this review, were the followingsurveillance procedures.

Reactor Standard (RS)-30, "Hot Laboratory Filter Bank andEF-2A Test"

RS-31, "Emergency Charcoal Efficiency Test"RS-32, "Control Rod Gauging/Guide Tube Lift Testing"RS-33, "Control Rod Calibration"RS-34, "Emergency Core Spray"RS-35, "'Emergency Exhaust Flow Rate and Filter Efficiency

Test".RS-36, "Evacuation Test"RS-37, "Fission Chamber Calibration"RS-38, "Emergency Generator Load Test"RS-39, "Flow Meter Calibration"RS-40, "Buildings Nos. 1 and 2 Entrance. Alarm Test"RS-42, "Emergency Generator Gasoline Supply Checklist"RS-43, "Emergency Generator Preventive Maintenance"RS-44, "Rod Scram Times"RS-45, "Rod Calibration"RS-46, "Pool Water Level Calibration"RS-47, "Excursion Monitor Calibration"RS-48, "Sump Checks"RS-49, "Criticality Instrument Checks"RS-50, "Pool Temperature Alarm Calibration"

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Through this review, the inspector determined that whileadequately identifying the specific procedure steps to be taken,the procedures lacked depth by failing to identify the limits,precautions, and prerequisites that would be invoked whenperforming the surveillances. Such information would bevaluable in assessing how other plant systems/components couldbe affected by the test or how test systems/components should beconfigured while the test is in progress. In addition,referencing applicable radiological controls/industrial safetypractices within the procedure would assure that such measuresare implemented during performance of the test.

The procedures also did not consistently identify the specificTechnical Specification(s) that was being demonstrated.Consistently specifying the Technical Specification within thebody of the procedure would provide readily auditableinformation to assure that all surveillance requirements werebeing addressed.

The licensee acknowledged the weaknesses identified in thecontent of the procedure, and indicated that actions would betaken to improve procedural quality. Such actions will includeevaluating the inclusion of the aforementioned items in theprocedures and the inclusion of additional measured parametersfor the system/component being tested to better identifyoff-normal trends in performance. Licensee actions indicatedabove will be reexamined during subsequent inspections. Thiswas identified as an Inspector Followup Item (54/89-80-01).

The licensee is presently evaluating methods to upgrade theplanning/scheduling of surveillances by incorporating them*into a site-wide computerized preventive maintenance program.The inspector considers this a positive action by the licenseeto eliminate the manual surveillance tracking program presentlyin place.

3.1.3 Reactor Facility Tour

The inspector accompanied the Chief Reactor Operator on aninspection of the reactor facilities' overall condition andsafety system configuration. As a guide for conducting theinspection, the inspector used the "Process Systems Data Sheet",(RS-IO), that is completed daily by nuclear operations personnelto track plant systems' status. The inspector confirmed thatthe observed conditionswere as recorded on the data sheet.

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Duringthis inspection, the following observations were made.

1. Overall, the plant was clean, equipment was neatly stored,and workareas were organized.

2. Continuous air monitors, general area radiation monitors,and the stack (airborne effluent) monitor were operable andcalibrated.

3. The two emergency generators, (one 45-kilowatt unit and one50-kilowatt unit) were determined to be operable asindicated by supporting preventive maintenance records andsurveillance tests. 'However, lack of attention to detailwas evident in maintaining this equipment in that the 45-kWgenerator was marred by battery acid spills and significantcorrosion build-up was noted on the battery terminals. Thebattery on the 50-kW generator had been replaced with onethat was physically incompatible. Since the battery wouldnot fit in the mounting plate, it was precariously proppedatop the generator. The licensee immediately moved thebattery.

A new 65-kW diesel generator was installed but has not beentied-in to plant systems. The 65-kW generator is scheduledto replace the 50 kW generator in the near future.

4. The entire area of the reactor building and hot laboratorywas recently painted. However, the licensee did notperform an engineering evaluation prior to conducting thepainting to determine if. paint solvent vapors would degradethe charcoal filter absorption efficiency. This oversightis considered a weakness-in the licensee's safety reviewprocess. The licensee acknowledged this weakness andindicated that measures would be taken to upgrade theidentification of weaknesses and indicated that techniqueswould be evaluated to upgrade the identification of thoseplant activities that could impact safety systems. Thiswas identified as an Inspector Followup Item (54/89-80-02).

5. Plant normal and emergency ventilation systems weresatisfactorily- maintained.

3.1.4 Summary of Observations - Reactor Operations

As a result of this review, the inspector determined thatmanagement has not aggressively implemented a maintenanceprogram to expeditious-ly upgrade or repair faultyinstrumentation and equipment. The engineering reviewprocess should include the impact of general painting oncharcoal filter systems. Surveillance procedures should beexpanded in their depth and scope to provide more detail tothe user on how the-procedure should be implemented

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including limits, precautions, prerequisites and possibleimpacts on other components or systems.

3.2 Hot Laboratory Facilities

The inspector reviewed the operations throughout the hotlaboratory for the manufacturing and processing of uraniumtargets. Particular emphasis was placed upon the procedures forpreparing the uranium feed material; preparing the target tubesfor plating; electrolytic plating operations; target tubewelding, pressure testing, and pyrolysis; and final inspectionand survey of targets prior to release to the reactor. Also,SNM and tube accountability procedures were observed, and thehot laboratory criticality monitors were inspected.

3.2.1 Hot Laboratory Tour

During a tour of the hot laboratory facilities, theinspector-observed that all work areas appeared to be cleanand well maintained with the exception of the targetplating laboratories located above the hot cells. Theseareas contained some laboratory equipment which did notfunction or had not been used for years. Strong acids areextensively used in these laboratories and the long-termeffects of a corrosive environment were evident in thegeneral condition of equipment, walls, floors, etc. Mostof the equipment currently needed for the production ofuranium targets appeared to function as necessary; however,laboratory technicians indicated that most of the equipmentwas antiquated and often had to be modified in order tofunction properly or to be adapted to different laboratoryprocess techniques. The hot laboratory supervisorindicated that the plating laboratories are scheduled andhave been funded for a complete refurbishment inDecember 1989. This work will include complete repair ofwalls and floors, and will also provide new processequipment.

3.2.2 Adherence to Procedures in the Hot Laboratory

The inspector reviewed the hot laboratory operations manualand compared written instructions with those practicesdirectly observed in the laboratory. Although mostprocedures in this manual provided step-by-step detailedinstructions for laboratory processes, some provided only ageneral descriptive review. Other procedures appeared toreflect outdated laboratory techniques. Several proceduralinaccuracies were also noted,for example, Procedure HO-1Istated that target tubes are to be fabricated from 347'stainless steel. However, 304 stainless steel was

-currently in use.. Procedure HO-1O also stated that the

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maximum permissible fixed contamination on targets prior toirradiation was 1000 counts per minute (cpm). However, inpractice health physics personnel converted contaminationsurvey results in cpm-to disintegrations per minute (dpm)based upon a daily check of the survey meter countingefficiency. The maximum allowable level permitted by thismethod was 3000 dpm per target tube (tubes with much lowerlevels have been-rejected). These ambiguities did notpresent an immediate safety issue, however, the procedureshould be revised to reflect current laboratory practice.The manual also did not contain or reference detailedoperating procedures for all of the hot laboratoryequipment. Therefore, although hot laboratory operatorswere proficient in the operation of most laboratoryequipment for routine tasks, some tasks were conductedwithout the benefit of written instructions. For example,as discussed below, there were no wri-tten procedure foroperation of the target tube TIG welder and calibration ofthe target tube leak detector. It was noted that the hotlaboratory supervisor was currently revising the proceduresmanual and expected to include these new procedures in therevised manual. Completion of the manual revision wasanticipated by the end of 1989. The inspector reviewed thecurrent draft of the new manual and noted that it appeared*to provide significant improvements over the currentwritten instructions. The licensee expects the revised,procedures to enhance the hot laboratory 'training manual,which was also currently under development. Review of therevised procedures and training manuals when issued wasidentified as an Inspector Followup Item (687/89-80-01).

3.2.3 Target Tube Welding and Leak Testing

The inspector witnessed a'plating laboratory traineeperform the helium leak test of eight target tubes which hehad personally welded. Two of the eight failed the leaktest and had to be rewelded. The inspector questioned theindividual's trainer and found that the trainee haddemonstrated sufficient skill in welding the target tubesand had therefore been released to perform tube weldswithout supervision. The inspector noted that thetrainee's welding skills had been obtained solely throughon-the-job training and that there was no detailed writtenprocedure for accomplishing these welds. Since these weldswere not strictly controlled or inspected, the final leaktest was intended to provide'the necessary quality control.The inspector interviewed the trainee to determine theoverall level and extent of the training he-had receivedfor his work in the plating laboratory. The individualindicated that he had received the normal 90-daycertification, as demonstrated by a certification record.

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However, he had not participated in a standardized

qualification program since none currently existed.

3.2.4 External Contamination Controls on TargetTubes

The inspector observed the electrolytic plating of targettubes which was performed inside a water jacket designed tomaintain the process at a constant temperature. It wasnoted that the electrolyte feed rate into the target tubesoften exceeded the electrolyte drain rate. Consequently-,the uranium feed solution often overflowed the top of thetarget tube. As a result, the overflow spilled into thesurrounding cooling water jacket and spread contaminationonto the external surfaces of the tube. After electropla-ting, the target tube ends were dipped into a nitric acidsolution to effect cleaning in preparation for welding.This dip was into an acid solution which contained up to Igm of uranium/lO0 ml as a contaminant. During dipping,uranium in solution could be redeposited as contaminationonto the outside surfaces of the tubes. Some of thisuranium could b-ecc,,le fixed contamination which could thenbe permanently imbedded during welding. The requiredpost-dip rinse was not always sufficient to remove thiscontamination as evidenced by the fact that tubes wererejected for excess contamination after the end-plugs hadbeen welded in place. The final decontamination procedurespecified the use of emery paper on the tube externalsurfaces, followed by a nitric acid wash to remove surfacecontamination. This also was not always effective,however, since some tubes were rejected by the healthphysics group during the final welded target tube survey.The licensee should consider the establishment of aprocedure to ensure the target tube external surfaces arefree from contamination prior to welding in order preventcontamination from becoming imbedded. in the weld-zoneduring welding. This was identified as an InspectorFollowup Item (687/89-80-02).

The inspector also observed the technique used by healthphysics personnel to accomplish the final alpha survey ofprepared target tubes. It was noted that the presentsurvey method may be useful for detecting the presence ofalpha contamination but was inadequate for quantifying thelevels present. The licensee used an Eberline Model PAC-4Salpha survey instrument to conduct this survey. It wasnoted that the licensee did not use the survey instrumentmeter indication for this-survey because the firstincrement on the scale (200 counts per minute) was far toohigh to obtain an accurate count. Instead, audible countsfrom the instrument speaker were noted by the technicianwhile passing the entire target tube surface over theinstrument detector. The counts were then converted to dpm

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using, the measured efficiency of the survey-meter.However, the technique used, passing the target tubesurface over the detector, did not appear to be appropriatesince there was no way to quantify the number of countsnoted at each location on the tube to obtain an integratedtotal for the tube. The inspector stated that theprocedure should be reviewed and modified to obtain aclearly defined survey procedure which produces accurateand quantifiable results to use as a basis for accepting orrejecting targets.

The inspector also noted that based.on the efficiency ofthe instrument and the surface area of the target tube asseen by the detector, 200 counts per minute was equivalentto approximately 9900 dpm of alpha contamination on thetarget tube. The maximum contamination level on the tubeallowed was 3000 dpm. The inspector discussed with thelicensee the appropriateness of the monitoring techniqueand instrument used, in light of the relative insensitivityof the process for this.purpose.

The inspector also stated that the maximum value of 3000dpm alpha on the surface of each tube should be reevaluatedand reduced as much as possible. The surface contaminationof 3000 dpm alpha could amount to as much as 50 nanocuries(0.8 milligrams) of uranium in the reactor core at any onetime and which would be available for fissioning as "trampuranium". This tramp uranium could be the source of airbornecontamination (mostly cesium-138) which had been found onthe clothes of visitors and workers. Licensee actions todefine, measure and reduce the uranium contamination presenton the surface of the target tubes were identified as anInspector Followup Item (687/89-80-03).

4.0 Criticality Safety

The inspector examined all areas of the hot laboratory and reactorfacilities to observe operations and activities in progress; to inspectthe general state of cleanliness, housekeeping, and adherence to fireprotection rules; and, to assure that all areas in which SNM is handled orstored were properly posted with criticality safety signs as required byNRC regulations or license conditions.

4.1 Postings

During examination of the hot laboratory hot cells, the inspectornoted that the posting on cells 2 and.3 authorized two differentmaximum U-235 limits with identified controls established for eachlimit. The limits were either 650 gms or 3000 grams of U-235,respectively. The nuclear criticality safety controls establishedfor these hot cells included the use of either borated glass bottles

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to which the 650 gram limit applied or borated glass bottles filledwith borated glass raschig rings to which the 3000 gram limitapplied. This was discussed with licensee representatives and thepostings were immediately modified to identify which of the specifiedlimits was applicable. The inspector had no further questions onthis observation.

4.2 Inventory Logs

During examination of the reactor facility fresh fuel vault andassociated U-235 log sheets, the inspector determined that thelicensee did not maintain a single-running inventory log of all freshfuel located in the vault. For instance, the quantity of U-235 infission chambers stored in the vault was not included on theinventory log available in the reactor control room. However, thisinformation was available through review of several documents. Thelicensee took immediate steps to consolidate all the availableinformation into one inventory log. The inspector had no furtherquestions on this observation.

4.3 Waste Storage Facility Desc iption

Through discussions with licensee representatives and review oflicensee records, the inspector determined that thedescription ofthe waste storage facility, located at the north end of Building 2 asdescribed in the facility SNM license- renewal application', datedSeptember 15,. 1989, did not correspond to actual practice. Forexample, the four-foot thick cell plugs had been reduced to aboutthree feet, and waste containers were being stacked two high in atleast nine of the 100 cells, instead of being maintained as a planararray, as described. The inspector requested the licensee to reviewthe licensee renewal application to determine if all other facilitydescriptions accurately corresponded to the actual facilityconditions. The -licensee was also requested to resubmit accuratefacility descriptions to NRC-NMSS, as necessary.

4.4 Criticality Safety Alarm System

The inspector reviewed the reactor building/hot laboratory criti-cality safety monitoring system. This review included verificationthat criticality safety postings and SNM quantity records werecurrent. Postings were positioned as required throughout thefacility and those postings identified which areas were not coveredwhen the criticality monitoring system was in "Bypass." The criti-cality monitoring system is routinely placed in a "Bypass" mode ofoperation when waste containers emitting radiation in excess of themonitor trip levels are being moved from one location to another.The inspector found no case in which the licensee allowed movement ofcritical quantities of SNM when the monitoring system was bypassed.The inspector also verified that the criticality monitoring systemdisplay panel in the hot cell work area was operational and that all

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detectors andinstruments were in current calibration. No deficien-cies were noted.

4.5 SNM Inventory

The inspector examined all areas of the plant andassured that thetotal inventory of unirradiated U-235 was not more than thatauthorized by the facility licenses.

5.0 Management Controls

5.1 Organization

Cintichem, Inc., the licensee, is a wholly-owned subsidiary ofMedi-Physics, Inc., which in turn is a wholly-owned subsidiary ofHoffmann-LaRoche, Inc. Cintichem follows the organizationalstructure outlined in the facility licenses. The inspector deter-mined that personnel in all positions met the corresponding qualifi-cations specified in the licenses. No significant personnel changeshave occurred within the last year. However, the licensee announced,just prior to this inspection, that Amersham international andHoffmann-LaRoche had executed an agreement in principle for Amershamto acquire the Medi-Physics radiopharmaceutical. manufacturing andradiopharmacy businesses. This included a commitment to take overownership of the Cintichem reactor operations upon NRC approval. Noadditional details were available during this inspection.

5.2 Safety Committees

The inspectors examined records of the proceedings for the facility'sthree safety committees.

5.2.1 Nuclear Safeguards Committee (NSC)

The NSC met at least semi-annually to discuss unreviewed safetyquestions, procedural changes affecting safety, violations,operating abnormalities, and audit reports. The NSC currentlyhas eight members and has met five times thus far duringcalendar year 1989. The NSC was developing new guidelines forreview of safety related issues. These new guidelines areexpected to increase the quality of the reviews. The NSCminutes were minimally adequate, in that they did not include

-any major points discussed in each review, nor describe thereasons for rejection of any review. The inspector discussedwith the licensee the value of more detailed minutes so that atfuture committee meetings, committee members could easilyascertain whether complete reviews were made, and that anyresubmitted reviews adequately addressed the required areas andreasons for previous rejections.

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5.2.2 Radiation Safety Committee (RSC)

The RSC met at least every two months, as required by licenseconditions, to discuss radiation control and safety for thefacility. This committee met four times, to date duringcalendar year 1989 and was expected to meet again onOctober 31, 1989. No inadequacies were identified.

5.2.3 General Safety Committee'(GSC)

The GSC met to discuss industrial safety issues during thealternate months that the RSC did not meet. The GSC met five*times, to date during 1989, which fulfilled the licensecondition which requires meetings at least every two months. Noinadequacies were identified.

5.3 Procedure Controls

5.3.1 Procedure Review

The licensee has been in 'the process of reviewing and updati,,g'procedures throughout the facility. Updated procedure pages aresent via a 'distribution list to owners of controlled copies of.procedures, while a master copy is maintained under closesupervision. For the health physics procedures, each procedurepage contained the initials of the reviewers, the date approved,.and the dates of previous editions of the procedures. Pro-cedures were reviewed annually and updated when necessary. Anyprocedures which may have safety significance created or updatedwere also reviewed by the NSC before final approval was given.

The inspector performed a review of procedures and manuals andnoted that in general, they were maintained complete and up to*date. Exceptions .were noted, however, e.g., one of the QCmanuals used in the measurements laboratory of the reactorbuilding was found to contain procedure.sections that were out-of-date; and one operations manual in the administrative officeswas found to be incomplete. The inspector noted that thelicensee did not have a procedure tracking system or consis-tently use procedure cover sheets which identified periodicreview dates, NSC/management approval dates, current revisionnumbers, etc., other than the listing of current revision datesin the master procedure index. The inspector discussed variousadvantages of maintaining a tracking system or cover sheetsystem to identify procedure status, and more effective methodsfor confirming that appropriate administrative controls(approvals, reviews, etc.) have been applied to procedures andmanuals at the facil'ity. Such a method would simplify reviewsby persons who actually use the manuals and procedures, and thereview task can be more efficiently performed if a searchthrough historical records were not first required.

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5.3.2 Procedure Adherence-

The inspector observed various operations in, the reactorbuilding and in the hot laboratory which were controlled byprocedure. It was noted that as a general rule, licenseepersonnel did not perform their tasks with "procedure in hand",since most operations have become fairly routine. At therequest of the inspector, qualified personnel were able todemonstrate proficiency in their work tasks and could referdirectly-to procedures which applied to their jobs. Theinspector noted that trainees were also permitted to performtasks without the direct use of written procedures. However,they were required to follow instructions from their supervisorsor trainers until they demonstrated proficiency. This method oftraining appeared to lack formality or standards and was foundto be dependent primarily upon the individual trainee andtrainer in the various departments. See Paragraph 5.6.2 foradditional comments.

5.4 Supervisory Presence

The inspector observed that all work areas in the reactor buildingand in the hot lab were visited regularly and routinely by departmentsupervisors and managers who were cognizant of their respectiveoperations. This practice appeared to be very effective-in ensuringthat production schedules were maintained and that process relatedwork problems were addressed in a timely manner.

5.5 Audits

The licensee performed internal audits annually as reqbired bylicense conditions and had recently developed an external auditboard. The internal audits were generally executed by seniormanagers who provided their-reports to the appropriate safetycommittees for review. The external audit board consisted'ofapproximately eight individuals,-none of whom was employed full-timeby the licensee. The licensee's charter for this external auditboard required annual audits of compliance with license conditionsand regulations. The auditors were also expected to provide inputconcerning the implementation of industry standards in the facility.As of this inspection, external audits had been accomplished in theareas of radiation protection, criticality safety and nuclearmaterial accountability. Draft audit reports were being reviewed andaddressed by the NSC.

5.6 Training

5.6.1 Initial and Requalification Training

Through discussions with licensee representatives and review oflicensee records; the inspectors verified that the licensee

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-provides all employees with initial trainingwhen they are hiredand annual requalification training is provided as required.The inspectors determined that the initial training covers basicradiation protection and general facility operations and is-provided in accordance with an established lesson plan.Checklists are maintained to ascertain whether an employeereceived the required initial training. The employee mustacknowledge that the training had been received by.signing histraining forms. After initial training, the employee isprovided with job-specific training which may include the use ofaudio tapes or classes, but generally consists of on-the-jobtraining. The-employee's supervisor works closely with the newemployee until the supervisor feels that the employee is capableof conducting an operation on his or her own. At that time thesupervisor will checkoff that particular skill on a check sheet.Occasionally, an oral exam is given before the employee's checksheet is initialed. The licensee also conducts an informalrequalification program to reaffirm skills and proper procedureusage. The inspector discussed the requalification program withthe licensee including an evaluation as to whether the programshould be formalized and .sed to reexamine all skills previouslymarked on check sheets so that supervisors may better determinewhat retraining may be necessary.

5.6.2 Hot Laboratory Technician Training

The inspector noted that there was no current formal trainingprogram or qualification procedure for hot laboratorytechnicians. However, the inspector verified that new employeesundergo a 90-day certification on their job tasks. It was notedthat this was a very informal procedure and was intended only tofamiliarize new individuals with the general requirements oftheir work. The inspector also verified that satisfactorycompletion of initial worker qualification normally takes oneyear but the exact time period is dependent solely upon thesubjective judgement of individual trainers and supervisors. Asa result, department managers do not have the benefit oftraining records of individuals to verify that they havedemonstrated work proficiency in all aspects of their jobs. Asof this inspection, the Hot Laboratory Supervisor was developinga formalized training and requalification program for all hotlaboratory technicians. The licensee stated that this programwill designate work standards and formalize testing andqualification procedures. This program is scheduled for. issueand implementation by the end of 1989. It is designed toenhance technician training and help establish minimum qualitystandards for technical tasks in the hot laboratory.

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5.6.3 Health Physics Technician Training

The inspector reviewed the qualifications and training of twohealth physics technicians, one-new and one experienced.Through interviews and observations, the inspector determinedthat each was capable and trained to adequately perform his orher job. It was determined that the licensee's health physicsstaff training program consisted primarily of a "read,understand and sign" program. New technicians were not allowedto perform independent functions until the proper signoff wasmade.

During interviews of several health physics technicians andtrainees the inspector requested-that they discuss the compre-hensive contamination control document which was applicable tothe entire facility. One technician indicated that thereferenced document did not exist. The inspector was subse-quently informed by the Manager, Health, Safety and Environ-mental Affairs that the contamination controlpolicy/procedures/guidelines handbook had been issued onJune 12, 1989, and distributed to al'l HP technicians. He couldnot explain the lack of awareness of this handbook by the oneinterviewed individual, however, he indicated that he would takemeasures to ensure that all HP technicians were cognizant of itscontents and were implementing its procedures. This exampleraises questions about the effectiveness of the licensee's useof "read and sign" training programs as the mainstay of thehealth physics technician training program.

While this type of program will, over time, produce a competenthealth physics technician, it is unlikely to produce a techni-cian with broad health physics skills in the short term. Inorder to enhance the short-term competence of new health physicstechnicians, the inspector discussed with the licensee theconsideration of establishing a cross-training program with anuclear power plant or of sending these individuals throughanestablished health physics training program.

5.6.4 Emergency Preparedness Training

Training requirements are delineated in the RadiologicalContingency Plan .(RCP) and Emergency Procedure EP-16, "Trainingfor Emergency Preparedness Personnel". Training was conductedbiennially, except that personnel were also required to betrained in changes to the plan within 30 days of the change.Training was provided for specific positions including:Emergency Director; Radiological Assessment Team (RAT); PublicInformation Officer; and the First Aid Squad (FAS). RCPtraining for all groups consisted of a "read and sign" program.

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The RAT personnel were given additional training in technicalareas. The FAS was also trained in first aid methods. Theinspector's review of training since January, 1988 indicatedthat emergency response training was completed for 1988. Due tomany changes in the RCP, a special "read and sign" trainingprogram was completed in July, 1989. There were no lessonplans, outlines or other material in evidence to conducttraining. There was no system in place to provide for initialemergency training of new employees. Therefore, some newemployees had received little or no emergency preparednesstraining, but were included on the on-call list.

In order to determine the effectiveness of training, theinspector conducted several walk-through exercises with licenseepersonnel including: two senior reactor operators (SRO); twohealth physics technicians; three managers designated asEmergency Directors (ED); and one-boilerman. The boilerman wasquestioned regarding his duties for offsite notification. Theboilerman was aware of his duties-and performed all taskscorrectly. The SROs and EDs were given basic scena.rios whichtested their knowledge of their RCP responsibilities and theirability to classify an incident. Most were familiar with theirbasic responsibilities, however, most of them were unaware ofthe many major RCP changes that were provided during theJuly, 1989 "read and sign" training program. Although all EDswere able to identify emergency conditions and the need toclassify them, their classifications were not consistent andoften were not in accordance with the classification tablescontained in the RCP.

The health physics personnel were generally familiar with theirduties and were knowledgeable regarding their technical area.However, the health physics technicians were unfamiliar with theduties and responsibilities of the RAT leader, even though theRCP list of succession specified that they were qualified toperform this function.

The inspector concluded the present training system was notadequate to provide effective training to licensee personnel whomay be called upon to provide assistance in an emergency. Thisconclusion is consistent with observations previously madeduring inspections of emergency preparedness conducted during1984, 1987 and 1988.

Ineffective training of emergency response personnel, includinghealth physics personnel as RAT leaders and Emergency Directors,was identified as an apparent violation of 10 CFR 50..54(q) and70.32(i) (687/89-80-04; 54/89-80-03).

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6.0 Reactor Experiments

The inspector reviewed Procedure XG-01 used by reactor operators to assurethat the target tube samples had been properly designated and properlyplaced in the correct core location for irradiation. Target Tube DataSheets (HS-21), which are computer generated, provide a printout ofpermitted and restricted core locations for each specific target. Thecomputer program matches each target tube's known uranium loading profilewith the calculated core flux distribution in each possible targetlocation. It was noted that the local core flux densities remainrelatively constant through frequent fuel rearrangements. However, theinspector determined that the licensee did not update the core flux map orthe computer program for matching target locations after each fuelrearrangement.. The inspector noted that a complete core flux mapping isrequired to be performed only after a significant change in.coreconfiguration has occurred (ie., when more than 15 fuel elements have beenrearranged at one time, or if a new core fuel or target location has beenadded)- It was also noted that this mapping does not measure local fluxin the target tube stringer locations. The map currently in use byreactor personnel was generated during May 1988. As a result, theinspector stated that the licensee should evaluate the need to performcore flux distribution mapping at a defined frequency or interval andinclude a measure of the local flux in the target stringer locations.Since reactor operations for the past eighteen months had been dedicatedalmost exclusively to irradiation of uranium and iodine targets, and sinceno significant change in core configuration had occurred, no immediatereactor safety issue was postulated. However, the need to update reactorphysics data at regular intervals to provide current input for thecomputer program for target location assignments is prudent for fuel andtarget management. The inspector also noted that the total activity dataentered on the core status board in the control room should also beupdated since these data were last determined in 1985. These items wereidentified as an Inspector Followup Item (54/89-80-04).

The inspector observed operators move new target tubes into the reactorand irradiated targets from the reactor to the hot cell via the transfercanal. The inspector noted that there was some potential for droppinghandling tools used for these transfers along with a target tube, becausewires strung across the pool to support the temporary cover create adirect interference to transfer movements. Operators were observedexercising sufficientprecautions to work around this interference. Theinspector noted, however, there were no written procedures available to,reactor operators for recovering a dropped target. The inspector statedthat the licensee should consider writing such a procedure.

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7.0 Radiation Protection

7.1 Health Physics Staffing

The inspector determined through discussions with licenseerepresentatives that the health physics staff was at its authorizedlevel. The facility Radiation Safety Officer is the Manager, Health,Safety & Environmental Affairs. His staff included a CertifiedHealth Physicist, an Associate Radiation Safety Officer (whose soleresponsibility was special nuclear material accountability), anenvironmental supervisor and environmental technician, the HealthPhysics Supervisor and 6 HP technicians. The newest members of thedepartment were the environmental supervisor and a health physicstechnician, each of whom possessed college degrees. The inspectornoted that the licensee appeared to be committed to improving thequality of the health physics staff.

7.2 Fixed Alpha Contamination Surveys

The inspector reviewed the licensee's program for identifying andcontrolling fixed and removable contamination throughout thefacility. The inspector independently surveyed floor areas withinthe boundaries of the uranium target production facility using alarge surface area gas flow proportional monitor. Section 3.2.4 ofthe license application requires performance of a fixed alphacontamination survey once per year. Those areas found to becontaminated with fixed alpha contamination in excess of 200 cpm/100cm2 (1330 dpm/100 cm2 for the survey instruments used) are requiredto be marked or decontaminated. At four areas in the facility, noneof which were marked identifying the presence of fixed alpha contami-nation as required by the license application, the inspectoridentified fixed contamination levels ranging from 8,000 dpm/100 cm2

to 24,000 dpm/100 cm2 . These areas included: the entrance to theplating laboratory, the entrance to the waste laboratory, theentrance to the' solution laboratory, and the passageway outside thesolution laboratory. Through a review of licensee records, theinspector determined that fixed alpha contamination surveys wereconducted annually as required. However, the hot spots (fixedcontamination in excess of 200 cpm/100 cm2 ) were neither marked norremoved, as required. This was identified as an apparent violationof the requirements of Section 3.2.4 of the license application.(687/89-80-05).

7.3 Dosimetry Program Review

The inspector reviewed the external dosimetry program including wholebody and extremity thermoluminescent dosimetry relative to thecriteria contained in 10 CFR Part 20, and applicable licenseeprocedures.

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The licensee obtained dosimetry devices from a National VoluntaryLaboratory Accreditation Program (NAVLAP) certified dosimetry vendor,as required by 10 CFR 20.202. The vendor possessed NAVLAP certifi-cation for the applications used. The inspector noted that severaldosimetry reports indicated significant neutron exposures. Licenseepersonnel stated that there were no neutron exposures at thefacility. This was supported by data provided by a contractor whoperformed a neutron survey of the facility. The licensee indicatedthat the dosimetry vendor uses an algorithm which incorrectly assignsneutron doses. The licensee has identified specific personnel to thedosimetry vendor for whom incorrect neutron exposures were assignedso that those exposures can be corrected and removed from the indivi-duals' records. Through discussions with licensee representativesthe inspector determined that the licensee will resolve thissituation with the vendor and maintain documentation of thatresolution for review by inspectors during a subsequent inspection.This was identified as an Inspector Followup Item (54/89-80-05;687/89-80-06).

7.4 Personnel Contamination Control Program

The licensee recently installed a whole body gas proportionalcounter/frisker system which permits monitoring all. body, extremityand head surfaces. The areas of the body not scanned are theunderarms and the tops of the shoes. These areas are manuallyfrisked with a beta-gamma GM detector. When contamination level.s areabove the whole body frisker setpoints, an alarm alerts theindividual and a printer identifies the specific area of the bodygenerating the alarm.

In addition, all persons who have entered the target production areasare required to frisk hands and feet-with an alpha scintillationdetector at the area exit. They must also use the recently installedgas proportional alpha-beta large surface area detector system(frisker) prior to departing the building.

Because of identified recurrent personnel and clothing contamina-tions, the ,environmental supervisor has been tasked with establishingand monitoring a personnel contamination control program. Thelicensee has also established a procedure which requires visitors,but not employees, to wear disposable paper protective clothing in anattempt to control contamination of personnel clothing.

In order to obtain more information on the type and extent of -

contamination found on clothes or body by workers, the licensee hasinstituted a contamination control study. Workers have beenrequested to record the contamination level and body locationwhenever they identify personnel contamination. However, there did

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not appear to be any interaction between these individuals.and healthphysics personnel. The licensee indicated that, at least during theinitial phases of this study, health physics personnel would berequired to conduct or oversee the decontamination process until theworkers become familiar with the required decontamination procedures.

7.5 Smoke Tests

The inspector requested that a smoke test be performed around thereactor pool area and throughout the reactor building in order toobserve the general flow of air currents with the pool covered.During the week prior to this inspection, the licensee covered thepool. in order to determine the effects of this action on airbornecontamination levels in the reactor building. All areas and levels(floors) of the reactor building were smoke tested by a healthphysics technician. Particular emphasis was placed on observing theair flows around and over the pool. It was noted that the air aboveand around the pool was essentially stagnant. The inspector,therefore, questioned the representativeness of the air samples thatthe reactor pool area Continuous Air Monitor (CAM) was obtaining ofreactor building air with the pool covered. In the absence ofconvective currents directly over the pool and with the notablepresence of dead air spaces around the pool, the effectiveness of thebuilding ventilation system for removing, airborne contamination withthe pool covered was also questionable._ The inspector also deter-mined that health physics personnel did not routinely obtain grab airsamples when the pool cover was removed, and the operators whoremoved the-cover did not know what the immediate airborne levelswere, since the CAM does not provide a rapid response to changes inairborne activity levels. Even though the use of the cover istemporary, the effects upon reactor building air flow should beanalyzed. If necessary, the CAM should be repositioned to obtain airsamples from areas around the pool most frequently occupied bypersonnel. Also, the licensee should assess the need for obtaininggrab air samples during removal of the pool cover.

In any case, the usefulness of the cover in reducing airbornecontamination in the reactor pool area was questioned by theinspector. It was noted by the inspector that the pool area CAMindicated that airborne activity in the pool area was reduced only byabout 20% through the use of the pool cover. The licensee indicatedthat the .effectiveness of the cover and the need for enhanced healthphysics monitoring (e.g., air sampling, repositioning of the CAM,potential for the spread of contamination and potential for increasedexposure to workers) as a result of continued use of the cover wouldalso be reevaluated. This was identified as an Inspector Follow Item(54/89-80-06). .

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8.0 Emergency Preparedness

8.1 Offsite Support Agencies

The Radiological Contingency Plan (RCP) identified all agencies thatmight be called upon to provide support in the event of an emergency.These agencies include: the Good Samaritan Hospital; the SaintAnthony's Community Hospital; the Tuxedo Police; the Tuxedo VolunteerFire Department; Tuxedo Ambulance; Greenwood Lake Ambulance; theIndian Point 3 Nuclear Power Plant; and the New York State Police.Letters of agreement (LOAs) were not contained in the plan but weremaintained under separate cover. The LOAs were current for 1989 andwere in the process of being renewed for 1990. Emergency ProcedureEP-01, contains the telephone numbers for each agency, as well as thenames of prime contacts for some of the agencies. The inspectorcontacted each agency and verified that the telephone nUmbers wherecorrect. Each agency representative contacted was questionedregarding their possible roles in support of the licensee. They wereall aware of their roles and support responsibilities. The localagencies participate annually during the licensee's drill asappropriate. Training tours were conducted in 1988 and u tour wasscheduled for October 28, 1989. Each agency, as well as the general.public, was invited and encouragedto attend. The inspector notedthat the contact individuals listed in Emergency Procedure (EP)-01for the Tuxedo Police and Fire Department and the New York StatePolice were incorrect. Their replacements were aware of theirduties, however. The licensee has agreed to revise EP-01 to reflectthese personnel changes.

Based upon the above review, this area is acceptable.

8.2 Emergency Plans, Procedures, Facilities andEquipment

The RCP was revised and reissued on March 31, 1989. The RCP wasreviewed by the Corporate Radiation Safety Committee and reviewed andapproved by the Nuclear Safety Committee. Comments from thesereviews were adequately addressed. The RCP is complemented byEmergency Procedures (EPs) as required by Technical Specificationsand was current and approved. The inspector noted the followinga,reas of the RCP or EP which should be revised.

EP-01 contains a call list for licensee staff and offsiteagencies. The RCP indicates that the on-call health physicstechnician and the on-call senior reactor operator can becontacted by pager. While this pager notification list wasavailable in the Control Room, it was not part of EP-01.Additionally, this EP directs the user to contact NRC Region I,or the NRC Operations Office if after hours. This should berevised to indicate the primary contact as the NRC Operations.Center for all calls, regardless of the-hour.

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-Neither the RCP nor EP-17 indicate where potassium iodine (KI)is stored.-

The RCP *does not specify where the offsite rendezvous points arelocated.

The licensee agreed-to evaluate these areas and make revisions asappropriate.

The inspector reviewed the Emergency Action. Levels (EALs) used tomake emergencyclassifications. EAL Tables 5.1, 5.2 and 5.3 provideguidance for classification of Unusual Event, Alert and Site AreaEmergency levels, as well as actions to be taken at each level..Tables 7.1 and 7.2 provide a methodology to relate stack releases tothe proper classification. The .inspector noted the following areasin which the EALs should be revised.

Specificsare needed to define "safety systems", and quantify"fuel damage" and "severe fuel failure".

Tables 7.1 and 7.2 should be integated with Tables 5.1, 5.2 and5.3.

Stack release EALs are based upon dose projections for a 24-hourrelease. The wording suggests it is permissible to wait untilthe release actually lasts for 24 hours. to classify the event.This is not appropriate. The EALs may be based upon projected24-hour release averages, but should be declared whenidentified.

The EAL tables should be revised to incorporate these comments. Thiswas identified as an Inspector Followup Item which will be reviewedin a subsequent inspection (54/89-80-07; 687/89-80-07).

The inspector reviewed the emergency facilities and equipmentincluding the Emergency Control Centers (ECCs), emergency kits,respiratory protective equipment, protective clothing and supplies,onsite and offsite rendezvous points, monitoring equipment andmedical facilities.

The facilities were found as described in the RCP. Equipment wasavailable and operable. Inventories were conducted in accordancewith HP-C-14, "Inventory of Emergency Equipment". The inventorieswere current and most of the equipment was operable and incalibration. However, one survey instrument and several dosimeterswere found out-of-calibration. The licensee should ensure that allstorage locations are identified and that equipment listed inHP-G-03, "Calibration of Emergency Equipment", is calibrated. Therewere adequate supplies of protective clothing, decontaminationsupplies and first aid equipment at all locations. First aid kitswere maintained and kept by each First Aid Squad member.

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Supplemental supplies, as well as stretchers, showers and eye washeswere located throughout the facility.

The RCP lists' two locations for the ECC. The primary location is atthe south loading dock between Buildings 1 and 2. The secondarylocation is in the lobby of Building 4. The Building 4 locationcontains adequate communications, backup communications, work spaceand supplies. The south loading dock-location was determined to beinadequate in that there were no work space, tables, chairs,equipment and supplies at that location. Further, there was one wallmounted telephone, with no backup available. The south loading docklocation was determined to be adequate as a primary assembly area butnot as an ECC. The licensee should either upgrade this facility, ordesignate the Building 4 facility as the primary ECC. This area willbe reviewed in a subsequent inspection (54/89-80-08; 687/89-80-08).

The licensee has established a Respiratory Protection Program (RPP).The RPP is defined in a policy statement and Procedure HP-A-20, wasapproved, and current. Safety Standard #3, Respirator ProtectionProgram, delineates the RPP and includes specific guidance in thefollowing areas: medical screening; respirator selection; respiratorissuance; respirator usage; training; fit testing; inspection andmaintenance; and general operating procedures. There are individualforms for the medical screening, training and fit testing. Thelicensee maintained a matrix for all employees which describedtraining and medical results, as well as what types of respiratorsfor which each was qualified. The inspector concluded that thelicensee had corrected the weaknesses.identified in CombinedInspection Report 50-54/88-02 and 70-687/88-06.

The licensee has in place equipment and procedures to perform offsitemonitoring. A monitoring and decontamination kit was located in a'storage area off site. This kit contained the necessary equipment,instrumentation and procedures to perform field sampling andanalyses. TLDs were in place on the stack and procedures were inplace to collect and perform analyses on these TLDs, if necessary.Additionally, the licensee has installed an Eberline RM-16 instrumentwith a remote probe and strip chart at the main stack. The primaryuse of this instrument is to provide high range monitor'ing capabilityof stack releases in case the primary stack monitor is off scale.The licensee had in place procedures and dosimetry for criticalityincidents. See Section 2.8 for additional details.

8.3. Tests and Drills

The RCP requires annual action drills, with the intervals not toexceed 14 months from the date of the last drill. The licensee didnot perform a drill in 1988. However, a drill was conducted onJanuary 10, 1989, within the 14-month window specified in the ,RCP(the previous drill was conducted on December 11, 1987). Accordingto licensee representatives, this drill was not held in calendar year

*9 0 030

1988 primarily due to personnel and schedule conflicts, both on siteand off site. The drill, when conducted, was adequate. Objectiveswere clearly stated, the scenario allowed for the demonstration andobservation of. the objectives, and observations were documented andcorrective actions taken as appropriate. Offsite agencies thatparticipated in the drill included the Tuxedo Police and FireDepartments, the Tuxedo Ambulance Service and Good SamaritanHospital. The licensee was informed that the drills should beconducted within the calendar year in order to-maintain closercontrol of the time intervals between drills. The 14-month intervalprovided in the RCP is provided for exceptions for justifiable cause.

9.0 Radiological Environmental Monitoring Program (REMP)

9.1 Assignment of Responsibility

The Environmental/Health Physics Technician has the responsibility tocollect and analyze environmental samples. This individual reportsto the Staff Health Physicist who reports to the Manager of Health,Safety, and Environmental Affairs (HSEA). The Manager of HSEAreports to the Plant Manager.

9.2 Direct Observations

The inspector examined the REMP sampling stations, including iodineand particulate air samplers and TLD stations used for themeasurement of direct radiation. All the air sampling equipment andTLDs were operational at the time of the inspection and were placedat the designated locations.

The inspector also examined the environmental laboratory. The samplepreparation room was equipped with a hood, sink, dryer oven, .hotplate, deionized water maker, and associated laboratory glassware.The counting room was equipped with two gamma spectrometry systems[Ge(Li) and NaIl], a low background gas flow proportional counter, anda Ludlum Model 2200 Scaler. The inspector was informed that theGe(Li) gamma system and proportional counter were not fullyoperational at the time of this inspection because they had recentlybeen delivered and installed. The licensee had initiated conduct ofprocurement tests on, this equipment using the manufacturer'sinstructions during this inspection.

9.3 Environmental Laboratory Quality Assurance/Quality Control (QA/QC)

The inspector reviewed Procedure HP-M-30, "Environmental ProgramQuality Assurance Plan". The purpose of this procedure, as definedin the procedure, was to maintain'and improve the effectiveness ofthe environmental monitoring program and to-ensure the validity ofthe analytical results.

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It was noted that the licensee participated in an EPA cross-checkprogram for iodine-131., gross alpha, and gross beta in water samplesand for gross beta in air particulates. The inspector reviewedselected EPA cross-check comparison results. The cross-checkcomparison results showed that the licensee's measurements weregenerally in agreement with the EPA indicated levels. However, theinspector noted that the licensee had not established writtenacceptance criteria for the intra-laboratory or inter-laboratorycomparisons.

The inspector noted that neither the QA/QC program nor ProcedureHP-M-30 for the environmental laboratory included the followingcontrols to ensure quality analytical results. The followingcontrols were discussed by the inspector with licenseerepresentatives and requested that they be considered for inclusioninto the laboratory QA/QC program.

0Establish a frequency for source and background checks on

counting instruments.

'Establish QC control charts and use them to Verify the

operability of the counting instruments.

'Establish appropriate gamma counting geometries for differentsample types.

'Report all analytical results with associated uncertainties.

'Expand the use of the EPA cross-check program to include gammaisotopic analyses of water, particulates, and milk.

0Add spiked samples to the intra-laboratory and inter-laboratorycomparison program.

"Establish acceptance criteria for inter-laboratory andintra-laboratory comparisons.

'Establish followup actions to resolve discrepancies/anomalies.

This action was identified as an Inspector Followup Item(54/89-80-09; 687/89-80-00).

9.4 Implementation of the Radiological Environmental Monitoring Program

9.4.1 Air Sampling

During the direct examination of the weekly and monthly air

sampling stations, the inspector noted that the licenseedetermined the air sample volumes using Dwyer Rotometer (air

*1

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flow meter) readings. The inspector compared the currentrotometer readings against the annual calibration results andfound that most current readings were within the calibrationrange. Procedure HP-M-02, "Weekly Paperwork for EnvironmentalStations A, D, and E", requires that the sampling volume bedetermined by using an average flow of two cubic feet/minute(cfm), regardless of the rotometer readings at the time ofsample collection. For example, although the rotometer readingat sampling station D was about 2.3 cfm at the time of thisinspection, the sampling volume used was based on the averageflow (2 cfm). Because of this discrepancy in air flow, theinspector determined that the Station D monitoring results for1-131 and gamma isotopic analyses could be approximately 15%lower than the actual airborne activity results. Therefore, theinspector stated that the sample volumes should be determined byusing the actual rotometer readings rather than an assigned''average" reading.

The inspector also noted that the licensee maintained fourmonthly air sampling stations which were not required byTechnical Specifications. The inspector stated that thesemonthly sampling stations should be changed into weekly samplingstations to obtain more meaningful analytical results for1-131, because of the short half-life for 1-131 relative to themonthly sampling interval. The inspector noted that this changewould also reduce uncertainties in results due to improvedstatistics obtained from the additional sample analyses.Through discussions with licensee representatives, the inspectordetermined that the licensee will modify the sampling frequencyat these stations.

In addition, the inspector noted that the licensee installed aprototype air sampling station on site. This air sampler hasthe capability to maintain a constant flow rate by compensatingfor dust loading on the collection media. This prototype airsampler had been in operation for greater than one year and hasoperated in a satisfactory manner. The inspector determinedthrough discussions with the licensee that the licensee intendsto replace the other air samplers with this type of air sampleras soon as possible so that sample volumes can be moreaccurately controlled.

9.4.1.1 Measurement of Air Particulates

The inspector reviewed Procedure HP-M-05, "QuarterlyEnvironmental Particulate Composite", and the quarterlyanalytical results for air particulates. The inspectornoted that the licensee measured gross gamma activity usinga Nal detector. However, Technical Specification 3.10 andTable 3.4, "Radiological Environmental Monitoring Program",

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of the Technical Specifications, and Table 5.2.1 of. LicenseNo. SNM-639 require gamma isotopic analyses on compositeair particulate samples at least once per 92 days. Theinspector determined that only the gross gamma activity ofthe composites samples was measured by the licensee. Theinspector stated that failure to perform gamma isotopicanalyses on the 92-day composite samples as required byTechnical Specification 3.10 and Table 5.2.1 of SNM-639 wasan apparent violation. (54/89-80-10; 687/89-89-10). Alsosee Paragraph 9.4.6..

9.4.1.2 Measurement of Iodine In Air

The inspector reviewed Procedure HP-M-02, "Weekly PaperWork for Environmental Stations A, D, and E", and thelicensee's results of airborne iodine measurements. Thelicensee analyzed iodine (1-131 and 1-125)1 in air using aNal detector. These analyses were as done on charcoalcanisters weekly as required by the Technical Specifica-tions. The inspector had no further questions in thisarea.

9.4.2 Water Analysis

The inspector reviewed the following procedures to determine theextent to which the licensee implemented Technical Specificationrequirements.

'HP-M-10, "Weekly Indian Kill Analysis"0 HP-M-21, "Storm Sewer/French Well Data Sheet"0 HP-M-27, "Portable Water Analysis for Iodine-131"'-'HP-M-33, "Storm Sewer/French Well Analysis"

The inspector also reviewed selected analytical results.. Theinspector determined that the licensee performed gross betaanalyses as required by Technical Specifications. However, theinspector noted that the licensee did not correct for self-absorption during determination of the gross beta activity. Theinspector discussed with the licensee the use of self-absorptioncorrections for these measurements. The licensee stated thatthe self-absorption corrections would be determined and used.

9.4.3 Measurement of Direct Radiation

The inspector determined that the licensee measured directradiation levels using thermoluminescent dosimeters (TLDs). Theinspector reviewed Procedure HP-M-28, "Environmental TLDProgram", and 1989 environmental TLD data. The licensee used acontractor (Teledyne Istopes, Inc.) laboratory to measure thedirect radiation through evaluation of the TLDs. On the basisof this review, the inspector.had no further questions in thisarea.

34

9.4.4 Measurement of Other Pathways.

The inspector noted that the licensee analyzed samples fromother pathways such as benthos, fish, sediment, sewage sludge,and soil. The inspector reviewed Procedure HP-M-26, "PathwayEnvironmental Sampling/Analysis" and the related analytical datafor 1989. All these samples were analyzed by the contractor(Teledyne Isotopes, Inc.) laboratory. On the basis of thisreview, the inspector had no further questions in this area.

9.4.5 Review of Annual Reports

The inspector reviewed the licensee's annual reports for 1985,1986, 1987, and 1988. The inspector also reviewed available1989 data and determined that the licensee met reportingrequirements. The inspector had no further questions in thisarea.

9.4.6 Review of Land Use Census

The inspector reviewed the 1988 and available; 1989 land usecensus data. The inspector noted that.the licensee analyzed onemilk sample in late November, 1988 to implement Section 3.11,"Land Use Census", of the Technical Specification requirements.Through a review of 1989 data, the inspector noted that, thelicensee did not perform 1-131 analysis on milk samples, asrequired by the SNM and reactor licenses even though thelicensee identified milk farms during the 1988 and 1989 censussurveys. As a result, the inspector stated that the failure toperform 1-131 analysis on milk samples during 1989 was anapparent violation of Technical Specification, Section 3 andSNM-639, Table 5.2.1 requirements (54/89-80-10; 687/89-80-10).Also see Paragraph 9.4.1.1.

9.4.7 Meteorological Monitoring Program

The inspector reviewedthe most recent calibration results for

wind speed and wind direction. A contractor (Climatronics)performed the calibration of the meteorological instrumentationand all calibration results were accepted by the licensee. Theinspector noted that all calibration measurements were madeusing NIST (formerly NBS) traceable standards. The inspectorhad no further questions in this area.

9.5 Summary

Based on the above review of selected areas of the licensee'sRadiological Environmental Monitoring Program, the followingconclusions were drawn.

35

Procedures, documentation of the program and evaluation of analyticaldata appeared to need improvement. However, it was noted that thelicensee had initiated improvements in these areas. Implementationof qualitycontrols in the laboratory and environmental air samplingtechniques were below current industry standards. It was noted thatthe licensee recently upgraded laboratory instrumentation and added aStaff Health Physicist in the Health, Safety, and EnvironmentalAffairs Section to review all analytical data and to supervise dailylaboratory activities. This is an indication that management hasinitiated actions to support and improve the REMP.

10.0 Liquid and Gaseous Effluent Controls

10.1 Liquid Effluent Controls

The inspector reviewed the following procedures and analyticalresults to determine the status of the licensee's implementation ofSection 3.9.3 of the Technical Specification requirements.

°HP-M-06, "Monthly Environmental Effluent Discharge From 001"'HP-M-08, "Hold-up Tank Samples"0HP-M-09, "Effluent Activity Discharged to Indian Kill"OHP-M-20, "Environmental Release Limits for Batch Released

Water from Buildings 1, 2, and 4"'HP-M-34, "Hold-up Tank Filtration Procedure"

Liquid effluents are held in hold-up tanks and grab samples areanalyzed from each tank prior to discharge to the Indian KillReservoir outlet creek on the creek side of the reservoir dam.Appropriate sample aliquots were collected from each hold-up tank,composited and analyzed monthly for gross beta-gamma activity. Theinspector reviewed selected liquid discharge records and noted thatthe maximum measured gross beta-gamma activity levels were. less thanTechnical Specification limits. The inspector had no furtherquestions in this area.

Section 3.9.3.(4) of the Technical Specifications states that totalradioactivity released in liquid effluents shall not exceed 0.01 Ci(Sr-90 equivalent) in a year. The inspector discussed the definitionand calculation of Sr-90 equivalent with the licensee. However,.since the licensee was unable to retrieve historical measurement datain terms of Sr-90 equivalent, and neither the specific definition ofSr-90 equivalent, nor the calculational methodology during thisinspection, the inspector stated that this item will be consideredunresolved, pending review of this information by the NRC.(54/89-80-11)

36

10.2 Gaseous Effluent Controls

The inspector reviewed the licensee's gaseous effluent controlprogram to determine implementation of the following TechnicalSpecification (TS) requirements.

°TS 3.9.1, "Airborne Stack Release Limit"ITS 3.9.2, "Dose in Unrestricted Areas"

*The inspector reviewed the following procedures and selected recordsto determine compliance with the above requirements.

°HP-M-14, "Determination of MPC for Eight-Hour Mixture of NobleFission Gases Produced in Fission Product MolybdenumTarget Irradiations"

°HP-M-15, "Determination of Stack Noble Gas Concentration LimitBased on Environmental Data"

'HP-M-18, "Evaluation of MPC for Particulate Isotope Releasefrom Stack of June 12, 1981"

OHP-M-12, "R-81 License"0 HP-M-13, "Dos- in Unrestricted Areas-Calendar Quarter

Calculation"°HP-M-16, "Summary of Dose Inhalation Factors for 1-125 and

1-131"0 HP-M-17, "Dose Factors for Noble Gas Cloud"0 HP-F-25, "Counting Weekly Stack Filters"

The inspector determined that the licensee quantified the totalamount of gross noble gas releases using stack monitoring results.The licensee then determined isotopic noble gas dose factors for usein offsite dose calculations using Procedures HP-M-14 and HP-M-17calculations. It was noted that these isotopic noble gas dosefactors were obtained by theoretical calculation rather than by usingactual measurements. Section 3.9.2.(2) of the Technical Specifi-cations requires isotopic measurement to quantify isotopic releasesfor offsite dose calculations. Section 3.2.4.4 of the SNM-639license requires weekly stack noble gas analyses. The inspectordetermined that the licensee did not analyze stack gas samples.Failure to perform the stack gas sample analyses as required consti-tutes an apparent violation of Section 3.9.2.(2) of the TechnicalSpecifications (54/89-80-12) and Section 3.2.4.4 of SNM-639(687/89-80-11). Also see Paragraphs 11.1.2 and 11.1.4.

The inspector reviewed selected weekly analytical results for stackiodines and particulates. The inspector noted that the licenseequantified 1-125 and 1-131 for offsite dose calculations. Theinspector also noted that the licensee performed gross gammameasurements from the weekly particulate samples, and thencalculated, using Procedure HP-M-18, the activities of fivepredominant gamma isotopes for the offsite dose calculation using.

-e

37

gamma fractional abundances determined on June 12, 1981 for Cs-136,Cs-137, Ru-103, Zr-95, and Nb-95. The inspector discusseduncertainties in the validity of these fractional abundances with thelicensee. The licensee stated that production operations had notbeen changed since 1981, therefore, the fractional abundances shouldbe the same. The inspector indicated that the licensee's justifi-cation could not be verified because the licensee had not performedisotopic gamma measurements on the weekly particulate samples sinceJune 1981. The inspector also stated that the licensee shouldperiodically verify the fractional isotopic abundances of theparticulate releases. These analyses should.be used to determine thevariability of these abundances and.be the bases for the frequency ofverifying these values. The inspector stated that this area would bereexamined during a subsequent inspection. This was identified as anInspector Followup Item (54/89-80-13).

The inspector was able to verify through independent measurementsthat activity levels on the weekly particulate samples were belowTechnical Specification limits, during the time of the inspection.No violations were identified in this area.

10.3 Calibration of Stack Gas Monitor

The inspector reviewed Procedure HP-D-10, "Procedure for CalibratingGas Stack Monitor", and calibration results for 1982, 1984, 1985,1987, 1988, and -1989. Through the review of calibration results anddiscussions with the licensee, the inspector identified the followingweaknesses.

.Electronic calibration of the stack ratemeter was not performedas part of the gas monitor calibration.'Calibration gas source (Xe-133) was not traceable to National

Institute of Sciences and Technology (NIST) standards.

The inspector stated that the calibration of the stack gas monitorwas questionable due to the above weaknesses. The licensee stated

that new stack monitors and a new effluent sampling system will beinstalled in the near future. Subsequent to this inspection, onNovember 14, 1989, the inspector was informed by the licensee thatthe new effluent sampling system was expected to be installed by thevendor by April 1, 1990. The inspector stated that the calibrationtechnique for the new system will be evaluated during a subsequentinspection. This was identified as an Inspector Followup Item(54/89-80-14; 687/89-80-12).

10.4 Ventilation System

The inspectorexamined the main ventilation system whic-h containedHEPA filters and charcoal beds to collect particulates and iodines.During a tour of the facility, the inspector noted that the licensee

38

was painting extensive areas of the hot laboratory and the reactorbuildings. The inspector was informed that the painting would be acontinuing activity. Through discussions with licenseerepresentatives the inspector determined that the licensee was notaware that the paint vapors or other solvents might affect the iodinecollection efficiency of the charcoal filter beds.

The licensee used charcoal canisters to collect iodines in order todetermine the iodine collection efficiency of the charcoal bedsmonthly as required by Section 3.2.2 of SNM-639. Independentsampling lines were inserted into the main ventilation enclosure atdesignated locations, one before the charcoal beds (up stream) andthe other after the charcoal beds (down stream). The licensee thencollected iodines for two hours and counted each charcoal, canister todetermine 1-131 activity. The iodine collection efficiency of thecharcoal beds was then calculated by using the ratio of iodineactivity of the downstream and upstream charcoal canisters. Theinspector reviewed iodine collection efficiencies of the charcoalbeds for 1989 and found that they exceeded the license requirement(99.5%). The inspector, noted, however, that because of the nearproximity of the upstream and downstream sampling points to thefilter bed and the absence of information relative to isokineticsampling, the representativeness of these measurements was question-able. Methodology for obtaining representative filter collectionefficiencies was discussed with the licensee representatives whostated that this methodology would be reevaluated subsequent to thisinspection.

The inspector also discussed-maintenance of the ventilation systemwith the licensee and noted that the licensee was unfamiliar withcommon industry standards concerned with ventilation systems (e.g.,ANSI/ASME N509-1976, ANSI/ASME N150-1980, and NRC Regulatory Guides1.52 and 1.140). The inspector also discussed with the licensee theuse of air flow capacity tests, in-place tests, visual inspections,and laboratory testing criteria for iodine collection efficiency.

Based on the above review, the inspector stated that thedetermination of iodine collection efficiency for the charcoal bedswas an unresolved item because insufficient information was availableat the time of this inspection (687/89-80-13).

11.0 Confirmatory Measurements

11.1 Confirmatory Measurements Sampling

During this inspection, liquid, airborne particulate (filter), iodine(charcoal cartridge), and gas samples were split between the licenseeand the NRC for the purpose of intercomparison. Where possible, thesamples obtained were actual effluent or inplant samples which werein the same geometry as that used by the licensee for sampleanalyses. The samples were analyzed by the licensee using routine

39

methods and equipment and by the NRC Region I Mobile RadiologicalMeasurements Laboratory. The analyseswere used to verify thelicensee's capability to measure radioactivity in effluent samples asrequired by Technical Specification and other regulatoryrequirements.

In addition, a liquid sample (hold-up tank) was-sent to theDepartment of Energy, Radiological and Environmental SciencesLaboratory (RESL), the NRC reference laboratory, for analysis. Theanalyses to be performed on the sample are: gross alpha, gross beta,gamma isotopes, Sr-89, Sr-90, and uranium isotopes. The results willbe compared with the licensee's results, when received, and will bedocumented in a subsequent inspection report.

11.1.1 Iodine Measurements in Charcoal Cartridge

The licensee uses Mine Safety Appliance Company (MSA) charcoalcartridges to quantify the amount of iodine released from thestack. Weekly measurements of 1-131 and 1-125 were performed bythe licensee using these MSA cartridges to implement TechnicalSpecification requirements. It was noted, however, that thelicensee recently installed a new sampling device; which uses aCP-200 charcoal cartridge, to study the iodine collectionefficiency at the same sampling location as the MSA cartridge.The licensee stated that if the iodine collection efficiency ofthe CP-200 charcoal cartridge, manufactured by ScienceApplications International Corporation (SAIC), is better thanfor the MSA cartridge, then the MSA cartridges will be replacedwith the CP-200 cartridges. Both types'of cartridges wereanalyzed by the licensee and the NRC for iodine during thisinspection. The analytical results are listed in Table 1. -

A review of the analytical results indicated that the licenseeand NRC measurements on charcoal cartridges for the hotlaboratory were in disagreement for 1-131. There was agreementon the reactor facility charcoal cartridges only because of thehigh counting uncertainties which were associated with themeasurements. The NRC result for the measurement of 1-133 inthe CP-200 charcoal cartridge was not compared because thelicensee did not analyze this cartridge for 1-133. The NRCresults of 1-125 measurements were not reported because ofcounting geometry problems related to iodine breakthrough forthese cartridges.

During this inspection, the inspector noted that the iodineswere distributed' fairly uniformly through the MSA and CP-200charcoal cartridges from the air inlet to outlet sides,indicating iodine breakthrough. The inspector discussed withthe licensee that improper quantification of effluents and dosecalculations may have occurred. The improper quantificationwould occur as a result of the breakthrough of iodines duringthe sampling period, resulting in less iodines in the cartridge

40

than were in the sampled air stream. Based on this finding, anunresolved item was identified pending licensee resolution ofthe following (54/89-80-15; 687/89-80-14).

(1) Re-evaluation of effluent charcoal cartridge resultsin consideration of iodine breakthrough for 1-131 and1-125 considering both apparent collectionefficiencies (i.e., based on time of breakthrough inthe sampling period) and calibration/geometry factorsfor analysis.

(2) If results of (1) indicate past effluents have beenreported incorrectly, re-evaluate dose assessments andprovide revisions to the Annual Reports.

11.1.2 Measurement of Stack Gas Sample

Even though the licensee has not analyzed stack gas samples aspreviously discussed in Paragraph 10.2, the inspector split astack gas sample to verify the licensee's analytical capability,an~d implementation of Procedures HP M-14 and HP-M-17. TwoMarinelli beakers (licensee's and NRC's) were connected inseries at the stack gas monitoring station and the stack gas wascirculated through the beakers for 15 minutes to obtainrepresentative samples. The licensee counted the gas sampleusing a Nal detector and analyzed the results only for Xe-133.The NRC performed an isotopic analysis using the GeLi detectorin the NRC Mobile Laboratory. The ana-lytical results are listedin Table 2.

Results of the licensee and NRC analyses of the stack gassamples indicated disagreement for Xe-133. The NRC analyticalresults indicated that the theoretical fractional abundance fornoble gases as specified in Procedures HP-M-14 and HP-M-17 maynot be useful for dose assessments since the fractionalabundance is not a fixed value. This should be evaluated by thelicensee and will be reviewed during a subsequent inspection.This was identified as an Inspector Followup Item (54/89-80-16;687/89-80-15).

11.1.3 Analysis of In-Plant Smear Samples

The inspector took smear samples in the facility during thisinspection. These smear samples were counted by the licenseeusing the licensee's normal method and by the NRC using theMobile Laboratory. The analytical results are listed inTable 3.

The results of the gross beta measurement were in agreement forthe waste laboratory doorway and the plating laboratory doorway.However, the inspector noted that the NRC measured only gross

'4

41

beta and the licensee measured gross beta-gamma. The results ofgross alpha measurements were in disagreement. The inspectorstated that because of the identified disagreement, thelicensee's analytical capability for the measurement of grossalpha would be reviewed during a subsequent inspection. Theinspector also noted that the licensee did not have anestablished QA/QC program for the in-plant health physicslaboratory counting equipment (for additional information, SeeParagraph. 9.3).

11.1.4 Analysis of Environmental Soil and Water Samples

A soil sample obtained from the site storm drain was collectedand sent to the NRC reference laboratory (RESL). The analysesto be performed on that soil sample included gamma isotopes,gross alpha, gross beta, Sr-89, Sr-90, and uranium isotopes.The results will be documented in a subsequent inspectionreport.

Two grass samples, taken from onsite and offsite areas, werean&lyzed in the NRC Mobile. Laboratory during this inspection.These samples were not contaminated by either fission oractivated radionuclides and showed only background activity.

Water samples were obtained and analyzed from three locationsincluding at the storm drain (002 Outfall), in the creek at apoint 150 feet below the Indian Kill Reservoir Outfall, and atthe 001 Outfall pipe. The samples were analyzed in the NRCRegion I laboratory rather than the Mobile Laboratory becausethey required.more sophisticated analytical treatment to meetthe appropriate sensitivity requirements. The storm draincatches runoff from the site (parking lots and building roofs)and discharges directly into the Indian Kill Reservoir.Processed water discharges through the 001 Outfall pipe into thecreek just below the Indian Kill Reservoir outfall. Theanalytical results of the storm drain and the Indian KillReservoir Outfall indicated that only naturally occurringradionuclides were present; It was noted, however, that the 001Outfall water samples contained (6.7 +/-0.3)E-7 uCi/ml of 1-131.This value was about twice the 10 CFR 20, Appendix B, Table II,Column 2 limit of 3E-7 uCi/ml for 1-131. The inspector notedthat at the time of this inspection the licensee was processingand releasing process water from onsite storage tanks which is aperiodic rather than a continuous operation. Technical Specifica-tion 3.9.3.(3) states that liquid waste shall not be releasedfrom the site unless its activity concentration is below thatspecified in 10 CFR 20, Appendix B, Table II, Column 2. Failureto meet the Technical Specification 3.9.3(3) limit was identifiedas an apparent violation (54/89-80-17). Also See Paragraph 10.2.

The inspector reviewed the licensee's analytical methods for thegross beta analyses of process water prior to release from thesite through the 001 Outfall. It was noted that the watersamples were evaporated for the gross beta analysis. Since the

0 042

samples were evaporated during preparation, any iodine presentwould have been driven off. The analytical method employed doesnot appear to be appropriate to determine the content of allradionuclides, including iodine in the process water. Use of aninadequate analytical method to determine the content of allradionuclides in water samples was identified as an apparentviolation of T.S. 3.9.3(3) (54/89-80-12; 687/89-80-11). SeeParagraph 10.2.

11.1.5 Analysis of the Reactor Pool Water

The licensee measures radioactivity.of the reactor pool water toimplement Sections 4.8.(2) and 4.8.(3) of Technical Specifica-tion requirements. The inspector reviewed the licensee'sanalytical procedure for the reactor pool water-analysis.- Thereactor group supplies one gallon of pool water for analysiseach month. The sample is held for one week before the analysisis performed. The gallon of pool water is then boiled down to30 milliliters and counted for identification of the radioactiveisotopes required by Section 4.8.(2) of the TechnicalSpecifications. In addition, the licensee takes a daily grabsample (10 ml) of the reactor pool water to meet the Section4.8.(3) requirement. That sample is boiled down to dryness on aplanchet and measured for gross beta-gamma activity. Theinspector stated that entrained noble gases, iodines, and anyother volatile nuclides (if present) would be driven off byevaporation during sample preparation. In addition, theone-week delay prior to the analysis would allow all of theshort-live nuclides to decay~prior to analysis. Therefore, theinspector stated that the licensee's method for the analyses ofthe reactor pool water did not meet Technical Specificationrequirements since the analytical techniques used were notappropriate to identify all nuclides present. Additionally, theinspector noted that the techniques employed are notsufficiently sensitive to measure leaking fuel elements ortarget tubes, aside from total failures. This was identified asan apparent violation of Technical Specification 4.8.(2) and4.8.(3) ( 5 4 / 8 9 - 8 0 - 1 8 ).

One reactor pool water sample was analyzed in the NRC MobileLaboratory in order to determine which radionuclides werepresent. Twenty milliliters of the reactor pool water werediluted to 50 milliliters and analyzed. The NRC analyticalresults are reported in the following table.

Through discussions with licensee representatives, the inspectordetermined that the licensee's typical analytical results onreactor pool water following the evaporation procedure indicatedthe presence of about 1.0 E-7 uCi/ml total gross beta/gammaactivity.

43

Reactor Pool WaterNuclide Activity (uCi/ml)

Ar-41 (2.6 + 0- 0.2)E-4Xe-135 (1.25 +/- 0.04)E-4Na-24 (6.67 +/- 0.03)E-31-131 (3.1+/- 0.4)E-51-132 (1.12 +/- 0:12)E-41-133 - (2.16 + 0- 0.05)E-41-134 (4.4 +/- 0.6)E-41-135 (2.8 +/- 0.4)E-4

TOTAL* (8.1 +/- 0.6)E-3

*Total gamma emitter nuclides of energy greater than 60 keVs

.11.2 Summary

Based on the above review of selected areas of the licensee's liquidand gaseous effluent control and measurement programs,-the followingconclusions were made.

Procedures, documentation, measurement techniques and evaluation ofanalytical data appeared to be inadequate in a number of specificidentified areas. Implementation of quality controls in thelaboratory was inadequate and effluent sampling and measurementtechniques were below industry standards. The inspector determined,however, that the licensee had initiated actions to improve thestack monitoring and sampling programs. Installation of new stackmonitoring devices is expected to be completed by April 1, 1990.

12.0 Unresolved Items

Unresolved items are matters about which more information is required inorder to ascertain whether they are acceptable items, violations ordeviations. Three unresolved items with respect to review of licenseesupplied information concerning the definition and calculation of Sr-90equivalents (Paragraph 10.1); review of methods used to determine theiodine collection efficiency of the charcoal beds (paragraph 10.4);reevaluation of the measurement of effluent iodine releases and conductoffsite dose calculations (paragraph 11.1.1) were identified.

13.0 Exit Interview

The inspectors met with the licensee representatives (denoted in Paragraph1) at the conclusion of the inspection on October 27, 1989. Theinspectors summarized the scope and findings of the inspection.Subsequent to the inspection, the licensee informed the team leader thatinstallation of appropriate sampling and monitoring equipment on the plantstack was expected to be completed by April 1, 1990.

I ." .

0D.

Table 1, Comparison of Charcoal Cartridge Analytical Results

Results (uCi/cc)NRC Results Licensee ResultSample Isotope Comparison

MSA( 1)

Hot Lab

MSA(')Reactor

CP-200(2 )

Hot LabStack Monitor

1-1311-125

1-1311-125

1-1311-133-I-125

(1.208+/-0.009)E-8

(2.9+/-0.4)E-11

(5.75+/-0.02)E-9(1.62+/-0.02)E-9

2. 54E-.9

1.37E-11

6. OE-9

1.46E-8

DisagreementNo Comparison

DisagreementNo Comparison

AgreementNo ComparisonNo Comparison

(1) MSA Charcoal Sampling Period: 10-13-89 to 10-20-89Sample Date: 10-18-89

(2) CP-200 Charcoal Sampling Period: 10-20-89 to 10-26-89Sample Date: 10-25-89

Gamma Analytical. Systems NRC: Ge(Li)Licensee: NaI, except 1-131 in MSA-ReactorMSA-Reactor Charcoal: Ge(Li)

Note 1 See Attachment I for Comparison Criteria

. 41

0

Table 2, Comparisonof Stack Gas Sample Analytical Results

Results (uCi/cc)NRC Results Licensee ResultSample Isotope Compari son( ')

Stack Gas( 2 ) Xe-133m (8.0+/-0.9)E-6 Not Measured No Comparison10/26/89 Xe-133 (1.646+/-0.007)E-4 2.69E-4 Disagreement10:28 a.m. Xe-135m (1.504+/-0.013)E-4 Not Measured No ComparisonGrab Sample Xe-135 (1.024+/-0.004)E-4 Not Measured No Comparison

Ar-41 .(1.66+/-0.12)E-6 Not Measured No Comparison

Gamma Analytical Systems NRC: Ge(Li)Licensee: Nal

Notes: 1. See Attachment 1 for Comparison Criteria- 2. Licensee does not routinely analyze gas stack sample

0 0I

Table 3, Comparisons of In Plant Smear Samples

Gross Alpha Results (dpm/smear)NRC Results Licensee ResultSample ID Comparison

Waste Lab DoorwayMakeup Lab DoorwayMakeup Lab-Crack in FloorPlating Lab Doorway

473+/- 10692 +/- 12

48 +/- 6467 +/- 10

181371

less than 11221

DisagreementDisagreement

No ComparisonDisagreement

Beta (1) Results (dpm/smear)

NRC-Gross Beta Licensee-Gross Beta/Gamma

Waste Lab DoorwayMakeup Lab DoorwayMakeup Lab-Crack in FloorPlating Lab Doorway

218 +/- 8313 +/- 9

4 +1- 1203 +/- 8

165 Agreementless than 127 No Comparisonless than 127 No Comparison-278 Agreement -

-(1) Counting Instruments NRC: Windowless Proportional CounterLicensee alpha; Eberline SAC-2

Zinc Sulfide detectorbeta-gamma; Mini Scaler II

HP-210 GM Counter

Note: See Attachment 1 for ComparisonCriteria

-P ,, b.%

ATTACHMENT 1

CRITERIA FOR-COMPARING ANALYTICAL MEASUREMENTS

This attachment provides criteria for comparing results of capability tests andverification measurements. The criteria are based on an empirical relationshipwhich combines prior experience and the accuracy needs of this program.

In these criteria, the judgement limits are variable in relation to thecomparison of the NRC Reference Laboratory's value to its associateduncertainty. As the ratio, referred to in this program as "Resolution",increases the acceptability of a licensee's-measurement should be moreselective. Conversely, poorer agreement must be considered acceptable as theresolution decreases.

Resolution' Ratio for Agreement'

<3 0.4 - 2.54 - 7 0.5 - 2.08 - 15 0.6 - 1.66

16 - 50 0.75' - 1.3351 - 200 0.80 - 1.25>200 0.85 - 1.18

'Resolution = (NRC Reference Value/Reference Value Uncertainty)2 Ratio = (License Value/NRC Reference Value)