A Radiological Protection Supervisor issued a Problem Report indicating that there were issues with radiation protection instruments failing daily background or source checks and being marked as satisfactory and then put back into service for use. An internal review and confirmed that there were instances of daily instrument function checks where records indicated that instruments failing the daily checks had been marked as satisfactory and returned to service. Independent surveillance of the Radiation Protection department records management and document control confirmed the potential of problems in the accuracy of instrument background check records. It was not readily apparent if the instruments were actually used or if the record keeping failures would have resulted in improperly functioning instruments being placed in service. Additional information obtained indicated that the initial concern of instruments failing background and source checks and being marked satisfactory was supplemented by another concern that there was evidence of intentional and improper record alteration. Record reviews confirmed that records had been altered without following prescribed procedures.
Lessons Learned: The Radiation Protection department had been ineffective in creating an organization that operated in accordance with established procedures and protocols, organizational and programmatic weaknesses that undermined the barriers designed to prevent such an environment from developing.
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