Appendix B ALARA Independent Audit Report
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Appendix B ALARA Independent Audit Report

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CALENDAR YEAR 2006APPENDIX BINDEPENDENT ALARA AUDITOF THE RADIOLOGICAL AND ENVIRONMENTAL PROGRAMSAT THECOTTER CORPORATION URANIUM MILL, CANON CITY, COLORADOCANON CITY MILLING FACILITYCanon City, Colorado June 29, 2007FINAL REPORT Independent “As Low As is Reasonably Achievable” (ALARA) Audit of the Radiological and Environmental Programs Cotter Corporation Cañon City Milling Facility Cañon City, Colorado Prepared for Cotter Corporation Cañon City Milling Facility Cañon City, Colorado April 30, 2007 URS 8181 East Tufts Avenue Denver, Colorado 80237 Project Number 22239445 Table of Contents Executive Summary........................................................................................................................ 1 Introduction..................................................................................................................................... 2 Scope............................................................................................................................................... 2 Audit Schedule and Participants ..................................................................................................... 4 Audit Method and Nomenclature.................................................................................................... 4 Findings.................................................................................................................................. ...

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CALENDAR YEAR 2006
APPENDIX B
INDEPENDENT ALARA AUDIT
OF THE RADIOLOGICAL AND ENVIRONMENTAL PROGRAMS
AT THE
COTTER CORPORATION URANIUM MILL,
CANON CITY, COLORADO
CANON CITY MILLING FACILITY
Canon City, Colorado
June 29, 2007FINAL REPORT
Independent “As Low As is Reasonably
Achievable” (ALARA) Audit of the Radiological
and Environmental Programs

Cotter Corporation
Cañon City Milling Facility
Cañon City, Colorado

Prepared for
Cotter Corporation
Cañon City Milling Facility
Cañon City, Colorado
April 30, 2007

URS
8181 East Tufts Avenue
Denver, Colorado 80237



Project Number 22239445

Table of Contents


Executive Summary........................................................................................................................ 1
Introduction..................................................................................................................................... 2
Scope............................................................................................................................................... 2
Audit Schedule and Participants ..................................................................................................... 4
Audit Method and Nomenclature.................................................................................................... 4
Findings........................................................................................................................................... 6
Finding 1: Lack of Documentation of Prompt, Appropriate Correction of Known Deficiencies
(LC 8.7, LC 33.2, Repeat Finding) ............................................................................................. 6
Finding 2: Response Plan Out-of-Date, Missing Elements (LC 9.1) ........................................ 7
Finding 3: Out-of-Date Quality Assurance/Quality Control Program (LC 25.2.1)................... 7
Finding 4: Quality Assurance/Quality Control Program Lacking Laboratory Components (LC
25.2.2, LC 27.2) .......................................................................................................................... 9
Deficiencies................................................................................................................................... 10
Deficiency 1: Lack of Documentation of Written Recommendations to the Mill Manager (LC
10.3.1) ....................................................................................................................................... 10
Deficiency 2: Written Procedures RH-50 and RH-210 Not Updated (LC 13.1) ..................... 10
Deficiency 3: Missing Signatures on RSO Documentation of Employee Training (LC 16.2) 10
Observations ................................................................................................................................. 11
Observation 1: Inconsistencies in Documented Inspections.................................................... 11
Observation 2: Potential for Loss of Annual Dose Data Maintenance.................................... 12
Observation 3: Lack of Daily Calibration of Breathing Zone Air Sampling Pumps............... 12
General Observations and Recommendations .............................................................................. 13
License Modification Recommendations ..................................................................................... 14
Conclusions................................................................................................................................... 15
Attachment A – Audit Checklist................................................................................................... 16


Cotter Corporation Cañon City Milling Facility i June 15, 2007
2007 Independent ALARA Audit Executive Summary

In accordance with the provisions of the Cotter Corporation's State of Colorado Department of
Public Health and the Environment (CDPHE) Radioactive Material License (RML), URS
Corporation conducted an independent “as low as reasonably achievable” (ALARA) audit of the
facilities and operations of the Cotter Corporation's milling facility located in Cañon City,
Colorado. The audit was conducted to evaluate the radiation safety and environmental effluent
programs implemented at the facility that provide site employees and the public in the vicinity
with assurances that radiological exposures and releases to the environment are minimized.
After a comprehensive review of the Cotter Corporation radiation safety and environmental
program documentation, the on-site portion of the ALARA audit of the Mill was performed on
April 9 through 11, 2007, by the URS Audit Team with the support of the Cotter Corporation
radiation, environmental, safety and management representatives at the facility.

At the time of the audit, the Mill was not receiving or processing ore. General plant activities
were limited to facility maintenance and measures to sustain compliance with the license
requirements.

Several findings, deficiencies, and observations were noted during the audit. These are described
in detail in the audit report. “Findings” are considered to be significant deviations from
established requirements, and are summarized below:

• The Cotter management and Radiation Safety Officer (RSO) failed to take prompt,
appropriate actions to correct known deficiencies. (LC 8.7, LC 33.2 repeat finding)
• The Response Plan is out-of-date and missing required elements. (LC 9.1)
• The Quality Assurance/Quality Control Program (QAPP), as documented in the QAPP, is
out-of-date and non-functional (LC 25.2.1).
• The QAPP is not updated to reflect or provide review and oversight of new methods and
revised analytical procedures for the laboratory, including those for lower limit of
detection (LLD) and minimal detectable activity (MDA) (LC 25.2.2, LC 27.2).

The opportunities to examine personnel exposures to external radiation and internal intakes for
trends in specific areas were limited by the variations in activities and production rates and
materials processed. Although the average and maximum committed effective dose equivalent
(CEDE) and total effective dose equivalent (TEDE) values represent a decrease in 2006
compared to 2005, the variability of operations may be responsible for these decreases. Many
factors influence the decrease in these dose values, and thus, these numbers could not be
normalized based on production rates or inventory.
Cotter Corporation Cañon City Milling Facility 1 June 15, 2007
2007 Independent ALARA Audit Introduction

Cotter Corporation is a nuclear fuel cycle supply company that is authorized by the United States
Atomic Energy Act and licensed by the state of Colorado to engage in activities for the
commercial processing and recovery of uranium, zirconium and vanadium at their Cañon City
Milling Facility (CCMF), located in Cañon City, Colorado. Cotter Corporation is a General
Atomics (GA) affiliate headquartered in Denver, Colorado. Uranium milling is a highly
regulated industry governed by the conditions and requirements specified in the radioactive
material license. In the State of Colorado, the Nuclear Regulatory Commission (NRC) has
discontinued licensing responsibilities, and the Colorado Department of Public Health and
Environmental (CDPHE) has assumed these responsibilities. The CDPHE has the responsibility
for the licensing and use of radioactive materials in Colorado under the Radiation Control Act
(Title 25, Article 11) and the State of Colorado Rules and Regulations pertaining to Radiation
Control (6 CCR 1007-1).

As a condition of the Cotter Radioactive Materials License issued by the CDPHE (License
Number COLO.396-01, Amendment Number 41, Order on Consent 05 08-24-01 and Addendum
No. 1 to Order on Consent 05 08-24-01), License Condition 10.3.2 states, “The licensee shall
annually commission an independent audit, including conclusions and recommendations from
review of all audits, inspections, employee exposure data, effluent release data, and
environmental data to determine if:

• the radiation, hazardous materials, and safety programs related to radioactive materials
and byproduct materials (including chemicals used in the milling process) are adequate,
• the quality assurance program is adequate,
• any upward trend is developing in personnel exposure for an identifiable category of
worker or type of operation or effluent release,
• any exposure or effluent might be lowered under the concept of ‘as low as reasonably
achievable’ (ALARA), and
• equipment for effluent and exposure control is being properly used, maintained, and
inspected.”
Scope

Cotter Corporation contracted URS Corporation (URS) to conduct this independent audit in
accordance with the license provisions and provide a detailed report to be included in the Cotter
Corporation Annual Report to be submitted to the CDPHE by June 30, 2007. The scope of the
audit was focused on elements of licensed operations that have potential radiological aspects to
its workers and the environment. After a review of the Cotter Corporation radiation safety and
environmental program documentation, the URS Audit Team, with the support of the Cotter
Corporation radiation, environmental, and safety staff and the site management, performed the
on-site portion of the independent ALARA audit of the CCMF on April 9 through 11, 2007. At
the time of the audit, the Mill was determined to be in a "stand-down" mode, and the plant was
not receiving or processing ore due to decisions based on business and financial objectives.
Cotter Corporation Cañon City Milling Facility 2 June 15, 2007
2007 Independent ALARA Audit General plant activities were limited to facility maintenance and measures to sustain compliance
with the license requirements. The CCMF on-site analytical laboratory has completed most
upgrades for conducting isotopic and quantitative analysis of samples. The laboratory was
recertified through the “Clinical Laboratory Improvement Amendments (CLIA)” process for
bioassay analysis prior to the 2007 audit.

URS assessed CCMF compliance practices with respect to the applicable CDPHE regulations
and the conditions specified in the license. As outlined in the license, URS evaluated the
nominal work practices and evaluated these against the facility license, pertinent CDPHE
regulations, and written operating procedures specified in the CCMF Radiation Protection
Program Procedures Manual, Site Safety Manual, Site Security Manual, Laboratory Procedures
Manual, Site Liquids and Solid Materials Management Plan, and the Quality Assurance
Program Plan. In addition, a number of NRC Regulatory Guides, some which are specified in
the license, were used to evaluate programs with respect to the concepts of ALARA. These were:

• Regulatory Guide 4.14, Radiological Effluent and Environmental Monitoring at Uranium
Mills, Revision 1, April 1980;
• Regulatory Guide 4.15, Quality Assurance For Monitoring Programs - Effluent Streams
and the Environment, Revision 1, February 1979;
• Regulatory Guide 8.10, Operating Philosophy for Maintaining Radiation Exposures As
Low As Reasonably Achievable, Revision 1-R, September 1975;
• Regulatory Guide 8.22, Bioassay at Uranium Mills, Revision 1, August 1988;
• Regulatory Guide 8.30, Health Physics Surveys at Uranium Recovery Facilities, Revision 1
May 2002; and
• Regulatory Guide 8.31, Information Relevant to Ensuring that Occupational Radiation
Exposures at Uranium Recovery Facilities Will Be As Low As Reasonably Achievable,
Revision 1 May 2002.

Audit findings, deficiencies and observations were based on visual observations at the facility,
review of the CCMF files, records and submittals to the State that were made available to the
audit team, and interviews with CCMF employees. No collection or analysis of soil, air, water,
or waste samples was conducted during the audit. Included in the audit report are
recommendations of methods to lower potential exposures to site workers and the general public
and limiting releases from the facility.

During the independent ALARA audit, URS examined each of the license conditions (LC),
except as described below, and utilized an established checklist to identify compliance issues
associated with each license condition. This checklist appears as Attachment A. It includes an
evaluation of the facility (“satisfactory,” “concern” or “unsatisfactory”) with regard to each
license condition.

URS did not examine decommissioning warranty or financial health and assurance items.
CCMF has retained an independent consultant to evaluate License Conditions 29.2 through 29.3,
30.0 through 30.6 and 32.1 through 32.4.1.3. URS did not examine License Condition 29.5, as
this item is on appeal.
Cotter Corporation Cañon City Milling Facility 3 June 15, 2007
2007 Independent ALARA Audit Audit Schedule and Participants

The independent ALARA audit of the CCMF consisted of the sequential activities listed below.

1. URS provided written notification as to the purpose, scope, schedule, and regulatory
basis for the independent audit to Cotter Corporation Cañon City Milling Facility.
Included in the notification document were auditors’ names, background, pre-audit
checklists, audited personnel needed for interviews, and health and safety requirements
for facility access.
2. Opening audit meeting was conducted with key Cotter Corporation Cañon City Milling
Facility personnel on April 9, 2007.
3. Tours of CCMF, interviews, record reviews and examination, discussions, etc., were
conducted on April 9 through 11, 2007.
4. Final exit meeting with key personnel was conducted on April 11, 2007.
5. The draft audit report for CCMF review and response was submitted to CCMF on April
30, 2007.
6. URS will prepare and submit the final audit report to CCMF following receipt of CCMF
review comments.

Key personnel participating in the Annual Independent Audit included:

Auditors: URS Audit Team
Sally K. Miller, CIH (Project Manager, Auditor)
Lisa S. Berta (Auditor)

Auditees: Cotter Corporation Cañon City Milling Facility Personnel
John Hamrick, Mill Manager
James Cain, Environmental Coordinator/Radiation Safety Officer
Mark Currey, Assistant Radiation Safety Officer
Richard Wooten, Health and Safety Supervisor
Mitch Abbate, Laboratory Manager
Frank W. Adamic, Quality Assurance Coordinator
Kristy Usnick, Radiation Safety Clerk
Audit Method and Nomenclature

The annual independent audit for 2007 of CCMF was conducted by the URS Audit Team using
American Society of Mining Engineers (ASME) Standard NQA-1 as the quality assurance (QA)
standard for audit nomenclature and assessment standards. The independent audit (as defined by
ASME NQA-1) was designed and conducted as “a planned and documented activity performed
to determine by investigation, examination, or evaluation of objective evidence the adequacy of
compliance with established procedures, instructions, drawings, and other applicable documents,
and the effectiveness of implementation.”

Cotter Corporation Cañon City Milling Facility 4 June 15, 2007
2007 Independent ALARA Audit The findings, deficiencies, observations and recommendations included in this report are based
on the results determined from the audit. Audit results are categorized into four types per the
ASME NQA-1 and are defined as follows:

• Findings are considered significant deviations from established requirements (e.g.,
license requirements, radiation regulations, ALARA principals, etc.) and are supported by
the identification and assessment of related or repeating deficiencies and observations.
• Deficiencies are considered to be potential or actual isolated infraction(s) of established
requirements that pose a potential for significant violation if not adequately addressed
and ameliorated.
• Observations reflect both positive and negative observations of physical and personnel
interview evidence.
• Recommendations are proposals by the audit team for addressing findings, deficiencies,
and observations and are meant to provide useful information and suggestions only. The
Licensee has the final responsibility for addressing the findings and deficiencies to the
satisfaction of the appropriate licensing authority.

Cotter Corporation Cañon City Milling Facility 5 June 15, 2007
2007 Independent ALARA Audit Findings
Finding 1: Lack of Documentation of Prompt, Appropriate Correction of Known
Deficiencies (LC 8.7, LC 33.2, Repeat Finding)

Documentation that the CCMF management and RSO took prompt, appropriate actions to
correct known deficiencies was not readily available at the time of the audit. (LC 8.7, LC
33.2, Repeat Finding)

Basis for finding: A review and subsequent investigation of the deficiencies and the
recommendations outlined in the 2005 and 2006 Independent ALARA Audit Reports and
the Notice of Violation (NOV) issued by CDPHE dated November 23, 2006, indicated
that CCMF failed to formally address each finding or deficiency and sufficiently track the
progress of potential corrective efforts. While it was apparent that elements outlined in
the report and NOV were reviewed and, for some deficiencies, action was taken or
considered, no formal and documented process was established to universally track the
progress for violations, findings, deficiencies and observations.

CCMF does maintain spreadsheets for previous Independent ALARA Audit Reports.
These summarize reported items, action assignments, tentative due dates and outcomes.
Many of the items from the 2005 and 2006 Independent ALARA Audit Reports are not
yet noted as completed on the spreadsheets.

Based on the available resources, it appeared that no action was taken in the case of some
deficiencies identified through independent audits and the NOVs. This is an infraction of
License Condition 8.7, which states that the licensee's management and RSO shall take
prompt and appropriate action to correct known deficiencies in the facility's procedures,
processes, equipment, and site conditions.

Recommendation: Ensure that the RSO and/or the ALARA Committee implement a
mechanism to address audit findings and track corrective actions. URS recommends
placing all audit findings, weekly management inspections observations, and related self-
reported items, including those specified in the 2005 and 2006 ALARA Audits, into a
single tracking system. The Corrective Action and Improvement Request (CAIR) system
described in Chapter 12 of the QAPP could be expanded to address a wider scope of
items.

Many of the items from the 2005 and 2006 ALARA Audits are not part of the successful
hazard reduction program and are administrative in nature. Currently, there is no unified
method to track progress for procedure revisions, housekeeping and maintenance items,
or inspection or audit findings. Multiple tracking spreadsheets based on the source of the
items are not an efficient process improvement method. Tracking all actions through
completion in one system will improve management performance, and will provide
documentation that Cotter’s corrective actions are “prompt and appropriate.”

Cotter Corporation Cañon City Milling Facility 6 June 15, 2007
2007 Independent ALARA Audit Finding 2: Response Plan Out-of-Date, Missing Elements (LC 9.1)

Although Response Plan re-training using a tabletop drill was conducted in December of
2006, the Plan itself was out of date, and did not include some of the required elements,
e.g., “detailed listing of, and location of dedicated emergency supplies and equipment
available at the site.” Although knowledgeable of the proper response procedures, the
RSO was not familiar with the contents of the Response Plan. (LC 9.1)

Basis for finding: LC 9.1 states, “The licensee shall use written plans and procedures
approved by the Division to respond to any incident, accident, or emergency at the
milling facility and in transportation of radioactive material,” and requires certain
elements to be included in the Response Plan. The current plan contains out-of-date
(2004) information with regard to phone numbers and dedicated emergency supplies and
equipment and its locations, and does not appear to address the current status of the
facility, as evidenced by the RSO’s unfamiliarity with the Plan.

Recommendation: Provide for management to annually review and update the
Response Plan content and train all facility personnel to the current Plan.

Finding 3: Out-of-Date Quality Assurance/Quality Control Program (LC 25.2.1)

The Quality Assurance/Quality Control Program, as documented in the QAPP is out-of-
date. (LC 25.2.1)

Basis for finding: The QAPP was last revised in 1999. The document does not have a
firm schedule for revision and resubmission to CDPHE. The current revision of the plan
does not address quality control of some current site activities, upgrades of radiation
safety department since 1999 or upgrades laboratory equipment since 1999. The quality
assurance officer has performed field observations, but in many cases, the reports were
not closed nor were the recommendations acknowledged or implemented. An example of
this is the August 2006 EV-120 field observation. In this case, the recommendation was
to revise the procedure to provide a sufficient level of detail similar to EV-120, Revision
2, dated 2004. Evaluation #8-2006-1 was prepared for file with the recommendation, but
was not forwarded for documentation of a management acknowledgement of the audit
and either a concurrence or rejection of the recommendation. A formal Corrective Action
and Improvement Request (CAIR) were not generated from Evaluation #8-2006-1.

Recommendation: CCFM developed CAIR 250 following the auditors’ site visit to
develop a timetable for revision of the QAPP. This revision of the QAPP is to consider
upgrades to the RPP procedures and the analytical laboratory. The Quality Assurance
(QA) Manager requires additional assistance to revise the QAPP and bring QA records
up to date. Using one staff member consistently as an assistant to the QA Manager
would be beneficial. The QA Manager has compiled a binder with collected
recommendations for the QAPP update that provides a solid starting position. The
laboratory will need to be closely involved to ensure the QAPP will adequately and
correctly provide quality guidance for their operations, and the Laboratory Manager will
Cotter Corporation Cañon City Milling Facility 7 June 15, 2007
2007 Independent ALARA Audit