ML18152A558
| ML18152A558 | |
| Person / Time | |
|---|---|
| Site: | 07100958 |
| Issue date: | 05/31/2018 |
| From: | Michael Layton Division of Spent Fuel Management |
| To: | Davis S US Dept of Defense, Defense Threat Reduction Agency |
| Tapp J | |
| References | |
| EA-18-046 IR 2018201 | |
| Download: ML18152A558 (11) | |
See also: IR 07100958/2018201
Text
S. Dav
UNITED STATES
NUCLEAR REGULATORY COMMISSION
WASHINGTON, D.C. 20555-0001
May 31, 2018
Ms. Sherry J. Davis
Director, ESOH Department
Acquisition, Finance, & Logistics
Defense Threat Reduction Agency
8725 John J. Kingman Road, Stop 6201
Fort Belvoir, VA 22060-6201
SUBJECT:
DEFENSE THREAT REDUCTION AGENCY (DTRA) - NRC INSPECTION
REPORT NO. 71-0958/2018-201
Dear Ms. Davis,
This letter refers to the inspection conducted on April 17, 2018, at your Fort Belvoir, Virginia
facility, with continued in office review through April 19, 2018. The purpose of this initial
programmatic inspection was to assess DTRA's compliance to the quality assurance
requirements of Title 10 of the Code of Federal Regulations (CFR) Part 71, Subpart H and its
NRC-approved Part 71 Quality Assurance Program (QAP). The inspection activities focused on
management controls because DTRA is a user only of transportation packagings and does not
design or fabricate them. The inspection consisted of examination of procedures,
representative records, and interviews with personnel.
Based on the results of this inspection, one apparent violation involving the failure to document
and carry out your QAP in accordance with written procedures or instructions, was identified
and is described in the enclosed report. The apparent violation is being considered for
escalated enforcement action in accordance with the NRC Enforcement Policy. The current
Enforcement Policy is included on the NRCs Web site at https://www.nrc.gov/about-
nrc/regulatory/enforcement/enforce-pol.html.
The failure to carry out the QAP in accordance with written procedures throughout the period
you performed shipments per the requirements of 10 CFR 71.22 is significant. This is because
it was a programmatic breakdown that resulted in the shipment of fissile materials in an
improper package that did not ensure adequate safety during transportation activities. This
resulted in a violation and enforcement action under your NRC Part 30 license in February
2018. In addition, since your QAP approval in December 2015, adequate safety during
transportation activities was not assured and the licensed material that has been shipped was at
risk to be inadequately protected from transportation hazards.
The circumstances surrounding this apparent violation, the significance of the issue, and the
need for lasting and effective corrections are described in the enclosed inspection report and
were discussed with you and members of your staff during the inspection exit teleconference on
April 19, 2018. As a result, it may not be necessary to conduct a pre-decisional enforcement
S. Davis
2
conference (PEC) in order to enable the NRC to make an enforcement decision. The NRC
considered whether the February 2018 enforcement action for the Part 30 license should be
considered as history for the current Part 71 apparent violation. Given the related nature of the
two violations, and the fact that this apparent violation was concurrent with the Part 30 violation,
you would not have had the opportunity to correct the Part 30 failure prior to engaging in the
current Part 71 failure. In addition, the inspections were performed by two different
organizations within the NRC, otherwise, the violations would have been identified in the same
inspection, and therefore neither would have constituted history for the other case. Therefore,
based on no prior history and our understanding of your corrective actions, a civil penalty may
not be warranted in accordance with Section 2.3.4 of the Enforcement Policy.
Before the NRC makes its enforcement decision, we are providing you an opportunity to either
(1) respond to the apparent violations in writing, (2) request a PEC, or (3) accept the violations
as characterized in this letter and its enclosure (in which case the NRC will proceed with its
enforcement decision). Please contact Meraj Rahimi, Acting Chief, Inspections and Operations
Branch at (301) 415-6802 within 10 days of the date of this letter to notify the NRC whether you
are interested in providing a written response, attending a PEC, or accepting the violations.
If you choose to provide a written response, it should be sent to the NRC within 30 days of the
date of this letter. Your response may reference or include previously docketed
correspondence. It should be clearly marked as a "Response to Apparent Violations in
Inspection Report No. 71-0958/2018-201; EA 18-046 and sent to the U.S. Nuclear Regulatory
Commission, ATTN: Document Control Desk, Washington, DC 20555-0001 with a copy mailed
to Mr. Michael Layton, Director, Division of Spent Fuel Management, Office of Nuclear Material
Safety and Safeguards, 11555 Rockville Pike, Rockville, MD 20852.
If you choose to request a PEC, you must contact Mr. Meraj Rahimi at 301-415-6802 within 10
calendar days of the date of this letter. The PEC will afford you the opportunity to provide your
perspective on the apparent violations and any other information that you believe the NRC
should take into consideration before making an enforcement decision. The topics discussed
during the conference may include the following: information to determine whether the violations
occurred, information to determine the significance of the violations, information related to the
identification of the violations, and information related to any corrective actions taken or planned
to be taken. The guidance in NRC Information Notice 96-28, Suggested Guidance Relating to
Development and Implementation of Corrective Action, is included on the NRCs Web site at:
http://www.nrc.gov/reading-rm/doc-collections/gen-comm/info-notices/1996/in96028.html, may
be helpful. If a PEC is held, it will be open to public observation, and NRC may issue a press
release to announce the time and date of this open conference.
In addition, please be advised that the number and characterization of apparent violations
described in the enclosure may change as a result of further NRC review. You will be advised
by separate correspondence of the results of our deliberations on this matter.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its
enclosure(s), and your response, if you choose to provide one, will be made available
electronically for public inspection in the NRC Public Document Room or from the NRCs
Agencywide Documents Access and Management System (ADAMS), accessible from the NRC
Web site at http://www.nrc.gov/reading-rm/adams.html. To the extent possible, your response
should not include any personal privacy, proprietary, or safeguards information so that it can be
made available to the Public without redaction. Any information forwarded to NRC should be
clearly labeled on the first page with the case reference number: EA-18-046.
S. Davis
3
Should you have any questions, please contact Mr. Jeremy Tapp of my staff at
(301) 415-8047.
Sincerely,
/RA/
Michael Layton, Director
Division of Spent Fuel Management
Office of Nuclear Material Safety
and Safeguards
Docket No. 07100958
Enclosure:
Inspection Report No. 71-0958/2018-201
cc w/Encl:
Brian J. Stroh, RSO
OFC:
DSFM
DSFM
MSST
DSFM
NAME:
JTapp
MRahimi
MBurgess
via email
LSreenivas
via email
MLayton
DATE:
5/18/18
5/24/18
5/24/18
5/31 /18
5/31/18
Enclosure 1
U.S. NUCLEAR REGULATORY COMMISSION
Office of Nuclear Material Safety and Safeguards
Division of Spent Fuel Management
Inspection Report
Docket No.
Report No.
71-0958/2018-201
Part 71 General
Defense Threat Reduction Agency
Licensee:
8725 John J. Kingman Road
Fort Belvoir, VA 22060-6201
Inspection Location: Defense Threat Reduction Agency
8725 John J. Kingman Road
Fort Belvoir, VA 22060-6201
Inspection Dates:
April 17 - 19, 2018
Inspection Team:
Jeremy Tapp, Team Leader, Safety Inspector, DSFM, IOB
Jon Woodfield, Safety Inspector, DSFM, IOB
Approved by:
Meraj Rahimi, Acting Branch Chief
Inspections and Operations Branch
Division of Spent Fuel Management
Office of Nuclear Material Safety and Safeguards
2
U.S. NUCLEAR REGULATORY COMMISSION
Office of Nuclear Material Safety and Safeguards
Division of Spent Fuel Management
EXECUTIVE SUMMARY
Defense Threat Reduction Agency
NRC Inspection Report 71-0958/2018-201
From April 17 through 19, 2018, the U.S. Nuclear Regulatory Commission (NRC) performed an
announced inspection of the Defense Threat Reduction Agency (DTRA), at its office in Fort
Belvoir, Virginia. The team inspected DTRAs activities associated with transportation of
radioactive material to determine if they were executed in accordance with the requirements of
Title 10 of the Code of Federal Regulations (CFR) Part 71, and DTRAs NRC-approved quality
assurance program (QAP). This was the initial inspection of DTRAs QAP following its approval
in December 2015. Therefore, the NRC reviewed DTRAs suite of implementing procedures to
ensure they were adequate to implement the requirements in the approved QAP and 10 CFR
Part 71. Because DTRAs QAP allows only use of transportation packagings, the scope was
limited to DTRAs management and operational controls.
Management and Operational Controls
The team assessed the adequacy of management and operational controls in the following
areas: QAP implementation, indoctrination and training, internal inspections, nonconformance
controls, corrective actions, document controls, record controls, audit program, procurement
controls, control of purchased items and services, identification and control of materials and
components, measuring and test equipment controls, handling, storage, shipping controls, and
operating status controls. The team reviewed DTRAs practices and procedures, including
implementation, to determine their effectiveness.
One apparent violation of NRC regulations in the area of QAP procedures was identified and is
being considered for escalated enforcement action. The team determined that DTRA failed to
document and carry out its NRC-approved QAP by written procedures and then performed
shipments of fissile material under its Part 71 general license. The team concluded that this
failure was a programmatic breakdown and constituted an inadequate QAP, thus not ensuring
adequate safety during transportation activities. DTRA took prompt corrective actions to
suspend shipments of fissile material under its Part 71 general license until the QAP is fully
implemented.
Overall
The team assessed that DTRAs overall implementation of its NRC-approved QAP was
inadequate.
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REPORT DETAILS
1.0
Inspection Scope
The purpose of this initial programmatic inspection was to assess DTRA's compliance to its
NRC approved QAP and the quality assurance (QA) requirements of 10 CFR Part 71, Subpart
H. The inspection activities focused on DTRAs implementing procedures which are limited to
management and operational controls. The team reviewed documentation and interviewed
personnel.
1.1
Inspection Procedures/Guidance Documents Used
IP 86001, Design, Fabrication, Testing, and Maintenance of Transportation Packagings
NUREG/CR-6314, Quality Assurance Inspections for Shipping and Storage Containers
1.2
List of Acronyms Used
American Society of Mechanical Engineers
CFR
Code of Federal Regulations
DTRA
Defense Threat Reduction Agency
ESOH
Environmental, Safety, and Occupational Health
NRC
U.S. Nuclear Regulatory Commission
Quality Assurance
Quality Assurance Program
Radiation Safety Officer
Standard Operating Procedure
1.3
Persons Contacted
The team held an entrance meeting with DTRA on the morning of April 17, 2018, to present the
scope and objectives of the NRC inspection. On the afternoon of April 17, 2018, the team held
an on-site debrief, and continued with in-office inspection until the morning of April 19, 2018,
when the team presented the preliminary results of the inspection during an exit teleconference.
Individuals present at the entrance meeting and exit teleconference are listed in Table 1.
Table 1
Entrance Meeting and Exit Teleconference Attendees
Name
Affiliation
Entrance
Exit
NRC
X
NRC
X
X
NRC
X
X
Sherry J. Davis
DTRA
X
X
Mike Hinton
DTRA
X
X
Brian Stroh
DTRA
X
X
Stephanie Rush
DTRA
X
4
2.0
Management and Operational Controls
2.1
Scope
The team assessed the adequacy of management controls in the areas of DTRAs QAP
implementation, indoctrination and training, internal inspections, nonconformance
controls, corrective actions, document controls, record controls, and audit program. In
addition, the team assessed the adequacy of operational controls in the areas of
procurement controls, control of purchased items and services, identification and control
of materials and components, measuring and test equipment controls, handling, storage,
and shipping controls, and operating status controls. The team reviewed DTRAs
practices and procedures, and their implementation, to determine their effectiveness.
2.2
Observations and Findings
The team requested DTRAs suite of implementing procedures. DTRA provided the team
with one specific standard operating procedure (SOP) for the Part 71 QAP for fissile
materials: ESOH SOP RAD-001, dated May 2, 2017. This procedure described the
responsibilities of DTRAs management personnel responsible for implementation of the
Part 71 QAP. It also described an annual/spot inspection process that implements the
requirements for internal inspection of transportation activities to verify conformance with
the documented procedures for accomplishing the activity. Results of a sample of spot
inspections performed by DTRA were also reviewed by the team. The inspections
primarily focused on the assembly and disassembly of the fissile material packages.
DTRA also provided the team with the Radiation Safety Program Guide; DTRA I-6055.8,
Radiation Safety Program, dated September 28, 2017; the Radiation Safety Standard
Operating Procedure, dated February 11, 2015; and DTRA/SCC SOP J4E-001,
Environmental, Safety, and Occupational Health (ESOH) Inspection Program, dated
October 16, 2013. The Radiation Safety Program Guide is the overall programmatic
document for radiation safety. The document briefly states that transportation packaging
assembly vendor instructions be followed, components inspected, and issues identified
be reported to the appropriate personnel. The team found that these items pertain to the
process for performing transportation shipping activities but do not describe nor
implement the management or operational controls required by the QAP. This document
also does not reference the Part 71 QAP as an applicable reference document that it
implements. In addition, the team found that the Radiation Safety Standard Operating
Procedure described the procedures for use of radioactive sources, material
accountability, shipment of sources, receipt of sources, recordkeeping, and special
nuclear material security, receipt, and storage; but did not implement any of the required
Part 71 QAP controls. The ESOH Inspection Program SOP was also silent to Part 71
QAP controls and had not been updated since the Part 71 QAP was approved in
December 2015.
The team noted that DTRA performed an assessment of the Part 71 QAP before the
team performed the inspection. DTRA identified some deficiencies but the results were
not yet finalized and no formal corrective actions had been documented as of the time of
the inspection. In addition, DTRA stated that a few additional procedures specific to the
5
Part 71 QAP were being drafted at the time of the inspection but were not yet approved
for use. Therefore, the team did not review this information as it was still in draft form.
Based on the above information, the team found that DTRA did not have implementing
procedures for all applicable areas of the Part 71 QAP except in the area of internal
inspection, which was being controlled by ESOH SOP RAD-001. In addition, the required
implementing procedures have not been in place since the Part 71 QAP was approved by
the NRC in December 2015. The team requested shipment documentation since
December 2015 to determine if shipments had been performed under DTRAs Part 71
general license and therefore, the procedures were required to be in place. DTRA could
not find records of shipments performed except in one case, but verbally stated that more
shipments occurred. Therefore, the implementing procedures were required to perform
the shipment activities. The team noted the one shipment that was documented was also
described in detail in a Notice of Violation to DTRA, dated February 15, 2018.
The team determined that an apparent violation of NRC requirements occurred. 10 CFR
71.105(a) states, in part, that [t]he licenseeshall document the quality assurance
program by written procedures or instructions and shall carry out the program in
accordance with those procedures throughout the period during which the packaging is
used. Contrary to the above, DTRA did not document nor carry out the QAP by
procedures for the applicable criteria of its program, except in the area of internal
inspection. Specifically, since the first transportation activities were performed from
December 2015 through April 2018, under the provisions of 10 CFR 71.22 for fissile
material, DTRA performed shipments without quality assurance procedures in place.
This failure was a programmatic breakdown and constituted an inadequate QAP in order
to ensure adequate safety during transportation activities.
DTRA took prompt corrective action after identification of the issue and suspended
shipments of fissile material performed under DTRAs Part 71 general license until the
following actions have been taken:
Draft the required implementing procedures for each applicable criteria of the
QAP,
Quality Assurance Manager, who is also the Radiation Safety Officer (RSO), to
attend American Society of Mechanical Engineers (ASME) Lead Auditor Training
in May 2018,
Perform QAP training for all users of the Part 71 QAP, and
Implement a robust internal audit schedule to ensure QAP compliance
2.3
Conclusions
One apparent violation of NRC regulations in the area of QAP procedures was identified
and is being considered for escalated enforcement action. The team determined that
DTRA failed to document and carry out its NRC-approved QAP by written procedures
and then performed shipments of fissile material under the Part 71 general license. The
team concluded that this failure was a programmatic breakdown and constituted an
inadequate QAP thus not ensuring adequate safety during transportation activities.
DTRA took prompt corrective actions to suspend shipments of fissile material under the
Part 71 general license until full implementation of the QAP is achieved.