ML20010B700
| ML20010B700 | |
| Person / Time | |
|---|---|
| Issue date: | 08/06/1981 |
| From: | Sreniawski D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20010B696 | List: |
| References | |
| NUDOCS 8108170420 | |
| Download: ML20010B700 (4) | |
Text
,
Appendix A NOTICE OF VIOLATION Otto C. Epp Memorial Hospital License No. 34-18868-01 As a result of the inspection conducted on July 17, 1981, and in accordance with the Interim Enforcement Policy, 45 FR 66754 (October 7, 1980), the following violations were identified:
1.
Condition No. 15 of your license requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in the referenced application and letter.
The referenced application dated January 4, 1981, states in Item No.
7, that the Radiation Safety Committee will meet quarterly.
Contrary to the above, the Radiation Safety Committee has not met from September 26, 1980, to the date of this inspection.
This is a Severity Level V violation (Supplement VII).
2.
Condition No. 15 of your license requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in the referenced application and letter.
The referenced application dated January 4, 1980, states in Iten No.
10, that procedures for the dose calibrator contained in Regulatory Guide 10.8, Appendix D, will be followed. Appendix D requires that the dose calibrator be calibrated quarterly for linearity and at installation and each year thereafter for accuracy.
Contrary to the above, a linearity test was not performed during the first quarter of 1981.
In addition, an accuracy test has not been performed since the instrument was installed in approximately December 1980.
This is a Severity Level V violation (Supplement VII).
3.
Condition No. 15 of your license requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in the referenced application and letter.
The re ferenced application dated January 4,1980, states in Item No.
14, procedures for opening packages described in Regulatory Guide 10.8, Appendix F, will be followed. Appendix F requires that all packages be surveyed, on receipt, at three feet and the surface.
In addition, a smear survey of the final source container is required.
8108170420 810806 NMS LIC30 PDR.
34-18868-01
Appendix A 3 Contrary to the above, G-M surveys and wipe tests of packages con-taining radioactive materials have not been,'rformed since the date of license issuance on April 11, 1980.
This is a Severity Level V violation (Supplement VII).
4.
Condition No. 15 of your license requires that licensed material be possessed and Cred in accordance with the statements, representations, and procedures contained in the referenced application and letter.
The referent'd application dated January 4, 1980, states in Item No.
17, that procedures for area surveys contained in Regulatory Guide 10.8, Appendix I will be followed. Appendix I requires that elution, injection, and preparation areas be curveys daily with a survey meter.
Contrary to the above, areas used for preparation and injection of radio pharm? euticals have not been surveyed daily since the date of license issuance on April 11, 1980.
I This is a Severity Level V violation (Supplement VII).
5.
Condition No. 15 of your license requires that licensed material be l
possessed and used in accordance with the statements, representations, and procedures contained in the referenced application and letter.
j The referenced application dated January 4, 1980, states in Item No.
18.3 that solid waste is held for decay until levels as determined l
with a survey meter reach background levels.
Contrary to the above, contaminated solid waste such as gloves and paper have not been surveyed to determine radiation levels prior to disposal since the date of license issuance on April 11, 1980.
This is a Severity Level V violation (Supplement VII).
l 6.
Condition No. 15 of your license requires.that licensed material be l
possessed and used in accordance with the statements, representations, and procedures contained in t'te referenced application and letter.
1 The referenced letter dated March 24, 1980, states in Item No. 6, that syringe shields for injection will be used for injection of all patients.
Contrary to the above, on the day of the inspection, syringe shields were not available to the individual performing injections.
This is a Severity Level V' violation (Supplement VII).
l 7.
Condition No. 15 of your license requires that licensed material be possessed and used in accordance with the statements, representations, and procedures contained in the referenced application and letter.
l t
I
Appendix A The referenced letter dated March 24, 1980, states in Item No. 6, that eating, drinking, or smoking will not be allowed iv4 any area where radioactive materials are used or stored.
Contrary to the above, the inspector observed or4 the day of the inspection, that bread, peaches, end a drink were stored in a refrig-erator located in the radioisotope camera room where radioactive j
materials are used.
4 This is a Severity Level V violation (Supplement VII).
Pursuant to the provisions of 10 CFR 2.201, you are required to submit to this office within thirty days of the date of this Notice a written statement or explanation in reply, including for each item of noncompliance:
(1) cor-rective action taken and the results achieved; (2) corrective action to be taken to avoid further noncompliance; and (3) the date when full compliance will be achieved. Under the authority of Section 182 of the Atomic Energy Act of 1954, as amended, this response shall be submitted under oath or 1
affirmation.
Consideration may be given to extending your response time i
for good cause shown.
f I
Dated
/
~
D. J. Sre twski, Chief f
Materials idiation Protection Section i
l i
i e
i I
1
_,-,-,-.--,y,....
~,,,,, - -
,-,.a
,,,,4,,,
,,n n.-
,,.~,. - -
Appendix B NANAGEMENT CONTROL In order to provide you with some guidance in assessing the adequacy of your management control program, the NRC Region III office provides 4
the following as the acceptance criteria for adequate management control for materials licensees.
" Management Control" is a system instituted by management to assure that licensed activities are performed safely and in accordance with regulatory requirements (license conditions and applicable rmyulations).
This will include:
a.
Delineation of duties and responsibilities of all persons involved in licensed activities.
b.
Providing for indoctrination and training of all personnel performing i
licensed activities, specifically in those areas directly affecting compliance with NRC regulations and license conditions.
{-
Verification, as by checking, auditing and inspecting, that activi-c.
ties affecting safety related functions have been correctly performed.
The verifying process should be performed by individuals or groups other than those performing the safety related procedures.
I d.
Insuring continued compliance of licensed activities throughout periods during which routine activities may be interrupted, such j
as changes in equipment, personnel or facilities.
i Because of the many variables involved, such as the number of personnel, type of activity being performed and the location or locations where activities are performed, the organizational structure for executing the management control program may take various forms; however, irrespective i
of the o ganizational structure, the individual or group responsible for this control should have the flexibility and authority to institute changes or corre tions as required to maintain compliance with NRC regulations and license conditions.
t G
.+r-y__
y y,.,_,.-,
i...-,-.-w
,,.m e
,,,.,.. r e.,,p, r
,,.n,,