Enforcement Actions Against Medical Licensees for Willful Failure to Report MisadministrationsML031250284 |
Person / Time |
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Site: |
Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill |
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Issue date: |
10/03/1986 |
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From: |
Partlow J NRC/IE |
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To: |
|
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References |
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IN-86-085, NUDOCS 8609300125 |
Download: ML031250284 (4) |
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Similar Documents at Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill |
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Category:NRC Information Notice
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Mclaughlin on NRC, Regarding NRC Information Notice 2006-13: Groundwater Contamination 2020-09-03 The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:05000000]] OR [[:Zimmer]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] OR [[:Skagit]] OR [[:Marble Hill]] </code>.
[Table view]The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:05000000]] OR [[:Zimmer]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] OR [[:Skagit]] OR [[:Marble Hill]] </code>. |
SSINS No.: 6835 IN 86-85 UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF INSPECTION AND ENFORCEMENT
WASHINGTON, D.C. 20555 October 3, 1986 IE INFORMATION NOTICE NO. 86-85: ENFORCEMENT ACTIONS AGAINST MEDICAL
LICENSEES FOR WILLFULL FAILURE TO
--- REPORT MISADMINISTRATIONS
Addressees
All NRC medical licensees*
Purpose
This notice is provided totalert all NRC medical licensees of enforcement
actions taken by NRC against medical licensees who willfully failed to report
misadministrations. It is suggested that addressees review this notice and
disseminate it to their-employees. However, suggestions contained in this
information notice do not constitute NRC requirements; therefore, no specific
action or written response is required.
Description of Circumstances
NRC recently has taken escalated enforcement action against two hospitals as
described below.
In the first case, several violations of NRC requirements were identified during
an NRC inspection at a hospital. An Enforcement Conference was conducted with
the licensee to discuss the violations. Subsequent to that conference and as a
result of an investigation conducted by the NRC's Office of Investigations, NRC
established that four diagnostic misadministrations had occurred before the NRC's
inspection and were not reported to the NRC as required by 10 CFR 35.43. Two
hospital employees stated to NRC investigators that the Radiation Safety
Officer (RSO), who also was the Director of the Nuclear Medicine Department, instructed them to inform NRC inspectors that diagnostic misadministrations
had not occurred. It also appeared that the RSO willfully concealed a film
of a nuclear medicine misadministration scan and thus impeded NRC's inspection
into whether mtsadministrations had occurred. As a result, on April 22, 1986, the NRC issued an Order to the hospital (1) to remove the RSO from that position
and from all involvement in the performance or supervision of NRC-licensed nuclear
medicine activities, and (2) to suspend all-licensed activities at the hospital
until the licensee demonstrates that a qualified individual has been appointed
as the RSO and authorized by the NRC.
8609300125
0,
IN 86-85 October 3, 1986 In the second case, an alleger stated that the Chief Nuclear
(CNMT) of a hospital did not report a misadministration Medicine Technologist
to either the'NRC or the
patient's referring physician as required by 10 CFR 35.43.
conducted by the NRC's Office of Investigations, the CNMT During an interview
a diagnostic misadministration and not being truthful with admitted performing
CNMT explained that the hospital RSO, who is also the Medical NRC inspectors. The
logy, instructed hervia a hospital radiologist not to report Director'of Radio- tion. During an interview with an NRC investigator, the the misadministra- although he was aware of the NRC requirement, he did not RSO admitted that
report the misadminis- tration because he did not think the incident was that serious.
As a result, on June 17, 1986 the NRC issued an Order to
show cause why the.
license should not be modified to prohibit these individuals
involvement in the performance or supervision of licensed from any further
activities.
ation was given to removing the CNMT from NRC-licensed activities Consider- ately effective Order. However, this was not considered by an immedi- CNMT had already left the hospital. In-addition, although necessary because the
occurred because of the deliberate, irresponsible actions the violations
uals, the NRC was concernedthat hospital management did of the two individ- sue an investigation of the alleged misadministration whennot aggressively pur- the NRC inspection, but rather awaited the initiation of informed of it during
the
Thus, the NRC issued a proposed Imposition of a Civil Penalty NRC investigation.
five thousand dollars ($5000). in the amount of
-.. scusson:
NRC requires the submittal of all misadministrations pursuant
since some misadministrations can have health effects on to 10 CFR 35.43 the
example, IE Information Notice 85-61 describes four diagnostic patient. For
in which the patient received.an unplanned significant dose misadministrations
one of those misadministrationsi.the patient received an of radiation. In
to 9000 rads to the thyroid instead of the 0.7 rads that estimated dose of 6500
would-have resulted
from the planned diagnostic procedure.
Normally, failure to report a medical diagnostic misadministration
characterized as a Severity Level IV violation. However, would be
actions were taken in these two cases because the failure escalated enforcement
istrations was willful and willful material false statements to report the misadmin- inspectors regarding the misadministrations. All licensee were made to NRC
aware of the importance of being truthful with NRC inspectors personnel should be
with NRC regulations. NRC has the authority to order the and of complying
personnel (such as RSOs or technologists) involved in willfulimmediate removal of
statements from NRC-licensed activities if the NRC determines material false
personnel have misled NRC inspectors and/or there is no that licensee
assurance that they can be relied on to comply with NRC longer reasonable
requirements.
- aIN 86-85 October 3, 1986 :No specific-action~or written response is required-by this information notice.
If you have any questionisregarding this matter, please contact the Regional
Administrator of the appropriate NRC regional office or this office.
Jame G. Partlow, Director
Divi ion of Inspection Programs
Office of Inspection and Enforcement
Technical Contact:
H. Karagiannis, IE
(301) 492-9655 Attachment: List of Recently Issued IE Information Notices
- i I a .c .. ..
_ _
__ - t U O. -. w ax _~ _
, . .
K> ltt~nt
IN 86-85 t i . ,
October 3. 1985 LIST OF RECENTLY ISSUED
IE INFORMATION NOTICES
Inforomtron Iare
SU
Notice no. Subh14ec
-~i
fettle Issued to
85-84 Rupture Of A Nominal 9/30/86 All NRC medical
40-Millcurle Iodine-125 Institution licensess
Brachytherapy Seed Causing
Significant Spread Of
Radioactive Contamination
86-83 Underground Pathways Into 9/19186 All power reactor
Protected Areas. Vital Areas. facilities holding
Material Access Areas, And an OL or CU fuel
Controlled Access Areas fabrication and
processing facilities
8S-82 Failures Of Scram Discharge 9/16/86 All power reactor
Volua. Vent And Drain Valves facilities holding
an OL or CP
86-81 Broken Inner-External Closure 9/15/86 All power reactor
Springs On Atwood I Morrill facilities holding It
Main Steam Isolation Valves an OL or CP
86-80 UnIt"Startup 1ith'Degraded- -97I2/86 '-Allpower reactor
Nigh Pressure Safety InWection facilities holding
System an OL or CP.
86-79 Degradation Or Loss Of 9/2/86 All power reactor
Charging Systems At PWR facilities holding
Nuclear Power Plants Using an OL or CP
Swing-Pump Designs
86-78 Scram Solenoid Pilot Valve 9/2f86 All DldR facilities
(SSPV) Rebuild Kit Problems holding an OL or CP
86-77 Computer Program Error Report 8/28/88 All - r reactor
Handl ing fa*c111tcs holding
an OL or CP and
nuclear fuel man- utacturing facilities
86-76 Problems Noted tI Control 8/28/86 All power reactor -
faillities helding
Systems an OL or CP
OL
CP
UNITED STATES
NUCLEAR REGULATORY COMMISSION FIASTCLASS MAIL
PFOTAGE I FIESPAIO
WASHINGTON. D.C. 205E USIE C
WASH O C
OFFICIA&
susimiss Pi AII MeSU
PINALTv "o PAIUltI usa *so
120555003956 1 lCO1CY1FB
rUS NRC
AOM-DIV OF TIDC
BRANCH CHIEF
RECORDS SERVICES BR
042 2055S
WASHINGTON DC205
|
---|
|
list | - Information Notice 1986-01, Failure of Main Feedwater Check Valves Causes Loss of Feedwater System Integrity and Water-Hammer Damage (6 January 1986, Topic: Feedwater Heater)
- Information Notice 1986-02, Failure of Valve Operator Motor During Environmental Qualification Testing (6 January 1986)
- Information Notice 1986-03, Potential Deficiencies in Enviromental Qualification of Limitorque Motor Valve Operator Wiring (14 January 1986)
- Information Notice 1986-04, Transient Due to Loss of Power to Intergrated Control System at a Pressurized Water Reactor Designed by Babcock & Wilcox (31 January 1986)
- Information Notice 1986-05, Main Steam Safety Valve Test Failures and Ring Setting Adjustments (31 January 1986)
- Information Notice 1986-06, Failure of Lifting Rig Attachment, While Lifting Upper Guide Structure at St. Lucie Unit 1 (3 February 1986, Topic: Control of Heavy Loads)
- Information Notice 1986-06, Failure of Lifting Rig Attachment, while Lifting Upper Guide Structure at St. Lucie Unit 1 (3 February 1986)
- Information Notice 1986-07, Lack of Detailed Instruction & Inadequate Observance of Precautions During Maintenance & Testing of Diesel Generator Woodward Governors (3 February 1986, Topic: Overspeed trip, Overspeed)
- Information Notice 1986-08, Licensee Event Report (LER) Format Modification (3 February 1986, Topic: GOTHIC)
- Information Notice 1986-09, Failure of Check & Stop Check Valves Subjected to Low Flow Conditions (3 February 1986)
- Information Notice 1986-10, Degradation of Reactor Coolant System Pressure Boundary Resulting From Boric Acid Corrosion. (5 January 1995, Topic: Boric Acid, Stress corrosion cracking)
- Information Notice 1986-10, Feedwater Line Break (10 November 1988, Topic: Coatings, Anchor Darling)
- Information Notice 1986-10, Degradation of Reactor Coolant System Pressure Boundary Resulting from Boric Acid Corrosion. (5 January 1995, Topic: Boric Acid, Stress corrosion cracking)
- Information Notice 1986-11, Anomalous Behavior of Recirculation Loop Flow in Jet Pump BWR Plants (31 December 1986)
- Information Notice 1986-13, Standby Liquid Control System Squib Valves Failure to Fire (21 February 1986, Topic: Squib)
- Information Notice 1986-13, Standby Liquid Control Squib Valves Failure to Fire (5 August 1986, Topic: Squib)
- Information Notice 1986-14, Overspeed Trips of AFW, HPCI & RCIC Turbines (26 August 1991, Topic: Fire Barrier, Overspeed trip, Overspeed, Water hammer)
- Information Notice 1986-14, Overspeed Trips of Afw, HPCI & RCIC Turbines (26 August 1991, Topic: Overspeed trip)
- Information Notice 1986-15, Loss of Offsite Power Caused by Problems in Fiber Optics Systems (10 March 1986, Topic: Squib)
- Information Notice 1986-16, Failures to Identify Containment Leakage Due to Inadequate Local Testing of BWR Vacuum Relief System Valves (11 March 1986, Topic: Squib, Local Leak Rate Testing, Integrated leak rate test)
- Information Notice 1986-17, Update of Failure of Automatic Sprinkler System Valves to Operate (24 March 1986, Topic: Squib)
- Information Notice 1986-18, NRC On-Scene Response During a Major Emergency (26 March 1986, Topic: Squib, Backfit)
- Information Notice 1986-19, Reactor Coolant Pump Shaft Failure at Crystal River (21 March 1986, Topic: Squib)
- Information Notice 1986-20, Low-Level Radioactive Waste Scaling Factors, 10 CFR Part 61 (28 March 1986, Topic: Squib)
- Information Notice 1986-21, Recognition of American Society of Mechanical Engineers Accreditation Program for N Stamp Holders (31 March 1986, Topic: Squib)
- Information Notice 1986-22, Underresponse of Radiation Survey Instrument to High Radiation Fields (31 March 1986, Topic: High Radiation Area, Squib)
- Information Notice 1986-23, Excessive Skin Exposures Due to Contamination with Hot Particles (9 April 1986)
- Information Notice 1986-23, Excessive Skin Exposures due to Contamination with Hot Particles (9 April 1986)
- Information Notice 1986-24, Respirator Users Notice: Increased Inspection Frequency for Certain Self-Contained Breathing Apparatus Air Cylinders (11 April 1986, Topic: Hydrostatic)
- Information Notice 1986-25, Traceability and Material Control of Material and Equipment, Particularly Fasteners (11 April 1986)
- Information Notice 1986-26, Potential Problems in Generators Manufactured by Electrical Products Incorporated (17 April 1986)
- Information Notice 1986-27, Access Control at Nuclear Facilities (21 April 1986, Topic: Contraband)
- Information Notice 1986-28, Telephone Numbers to the NRC Operations Center and Regional Offices (24 April 1986)
- Information Notice 1986-29, Effects of Changing Valve Moter-Operator Switch Settings (25 April 1986)
- Information Notice 1986-30, Design Limitations of Gaseous Effluent Monitoring Systems (29 April 1986)
- Information Notice 1986-31, Unauthorized Transfer and Loss of Control of Industrial Nuclear Gauges (14 July 1986)
- Information Notice 1986-32, Request for Collection of Licensee Radioactivity Measurements Attributed to Chernobyl Nuclear Plant Accident (2 May 1986, Topic: Chernobyl, Potassium iodide)
- Information Notice 1986-33, Information for Licensee Regarding the Chernobyl Nuclear Plant Accident (6 May 1986, Topic: Chernobyl, Potassium iodide)
- Information Notice 1986-34, Improper Assembly, Material Selection, & Test of Valves & Their Actuators (13 May 1986)
- Information Notice 1986-34, Improper Assembly, Material Selection, & Test of Valves & their Actuators (13 May 1986)
- Information Notice 1986-35, Fire in Compressible Material at Dresden Unit 3 (15 May 1986, Topic: Chernobyl)
- Information Notice 1986-36, Change in NRC Practice Regarding Issuance of Confirming Letters to Principal Contractors (16 May 1986, Topic: Chernobyl)
- Information Notice 1986-37, Degradation of Station Batteries (16 May 1986, Topic: Chernobyl)
- Information Notice 1986-38, Deficient Operator Actions Following Dual Function Valve Failures (20 May 1986, Topic: Chernobyl)
- Information Notice 1986-39, Failures of RHR Pump Motors and Pump Internals (20 May 1986, Topic: Chernobyl)
- Information Notice 1986-40, Degraded Ability to Isolate the Reactor Coolant System from Low-Pressure Coolant Systems in Bwrs (5 June 1986, Topic: Chernobyl)
- Information Notice 1986-40, Degraded Ability to Isolate the Reactor Coolant System from Low-Pressure Coolant Systems in BWRs (5 June 1986, Topic: Chernobyl)
- Information Notice 1986-41, Evaluation of Questionable Exposure Readings of Licensee Personnel Dosimeters (9 June 1986, Topic: Chernobyl)
- Information Notice 1986-42, Improper Maintenance of Radiation Monitoring Systems (9 June 1986, Topic: Temporary Modification, Chernobyl)
- Information Notice 1986-43, Problems with Silver Zeolite Sampling of Airborne Radioiodine (10 June 1986, Topic: Chernobyl)
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