ML20031G700
| ML20031G700 | |
| Person / Time | |
|---|---|
| Issue date: | 10/15/1981 |
| From: | Book H, Spencer G, Thomas R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20031G696 | List: |
| References | |
| NUDOCS 8110230488 | |
| Download: ML20031G700 (5) | |
Text
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U. S. ?!UCLEAR REGULATORY COMM!SSI0fl 0FFICE OF INSPECTION AND ENFORCEMENT REGION V Report No.
81-02 Docket No.
License No. 53-00458-05 Priority 4 Catagory G3 Licensee:
Dept of the Army Tripler Army Medical Center Oahu, Hawaii 96819 Facility Name:
Teletherapy Facility Inspection at:
Tripler Hospital Inspection conducted:
September 24, 1981
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Inspectors:
~G. S. Spender, Director, Division of Technical Date Signed
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H. E. Book, Chief, Radiological Safety Branch
/ Date 5igned Approved by:
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R. D. Thomas, Chief, Materials Radiation Ddte Signed Protection Section l
r Approved by:
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Dat'e Sijned H. E. Book, Chief, Radiological-Safety Branch Summary:
.a, An Enforcement Conference was held on September,24,1981. The following matters were discussedi 1.
Noncompliance observed'during the last, insperthi of License No. 53-00458-05 at Tripler Arrny Medical Center.
2.
Enforcementhistor[atTriplerMedicalCent'errelatedtoLicenseNo. 53-00458-05.
3.
NRC Enforcement Policies and Procedures.
4.
NRC actions to be taken in present situation.
5.
Possible future actions by NRC.
i 6.
Other matters of concern to NRC.
f The enforcement conference involved a total of three hours on site by two NRC.
l representatives.
l 81102304BO 811016 NMS LIC30 53-00458-04
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DETAILS 1.
Enforcement Conference Participants Maj. Gen. E. Huycke, Commanding Officer Col. D. Devaris., Acting Deputy Commander Maj. W. Wright, Radiation Protection Officer Col. B. Kennedy, Medical Physicist Maj. A. Chacko, Nuclear Medicine Service Maj. M. Hill, Acting Chief of Radiology Capt. R. Embry, Staff Radiologist G. Spencer, Director, Division of Technical Inspection,flRC H. Book, Chief, Radiological Safety Branch, NRC
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2.
Enforcement Conference s
On September 24, 1981 an enforcement conference was held at the Tripler Army Medical Center on Oahu, with.the individuals listed above participating. The enforcement conference was related to a routine safety inspection of activities authorized by NRC license number 53-00458-05, for the teletherapy program, conducted;on July 24 and 27, 1981. The enforcement conference was announced in a letter to the licensee dated September 9,'1981. A copy of that letter -is attached. A similar conference was held for the nuclear medicine program at the same facility. That conference is 6'
covered in a separate report.
The Notice of Violation dated September" 4,1981 had already been received by the licensee.
A copy of Appendix A of that Notice of Violation is attached. Mr. H. E. Book, Chief, Radiological Safety Branch discussed the violation listed in that letter. The licensee was informed that as far as the inspector could determine, none of
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the stops or interlocks on the teletherapy device were operating at all at the time of the inspection. The licensee was informed that this was considered a serious matter by the NRC because it would permit the beam of radiation to be directed so that radiation levels above limits could occur in unrestricted areas. Two particularly sensitive areas were a lawn area outside the building and the roof of the teletherapy room.
It was noted that the license already authorized higher than normal radiation levels during routine operations on the thinly shielded roof of the teletherapy room. Mr. Book also mentioned that it would be possible to crush a patient with the interlocks and stops out of service.
Additional concern was expressed because statements on maintenance records in the licensee's files should have alerted him to this condition.
. The licensee representatives said the violation had been corrected shortly after the inspection. They seemed to understand the violation and gave assurances of improved performance in the future.
Mr. Book explained that any NRC enforcement action took into account the enforcement history at the facility. A review of NRC files for license number 53-00458-05 revealed no violations during the last inspection made in 1977 or the previous inspection made in 1976.
The Enforcement Policies and Procedures of the NRC, as published in 45 FR 66754, were explained by G. S. Spencer, Director, Division of Technical Inspection.
Particular emphasis was placed on escalated enforcement actions such as civil penalties, orders to modify, suspend or revoke licenses, and orders to cease and desist. The explanation included a discussion of when escalated enforcement was utilized and how it was applied. The relative significance of the different severity levels was explained, and it was pointed out that any violations at this licensee would fall into Supplements IV and VII of the Federal Register Notice.
A copy of the Federal Register Notice (45 FR 66754) was given to the licensee. The licensee was told that the enforcement action to be taken at this time consisted of tL Notice of Violation in conjunction with the Enforcement Conference which was being held. The licensee was told that the NRC still expected a written response to the Notice of Violation.
The licensee was told that the one violation listed on the Notice of Violation was categorized as at Severity IV, and that Severity IV violations were safety related and considered significant by the NRC.
It was explained that if the violation was not corrected satisfactorily, if it was repeated, or if a similar violation occurred, escalated enforcement action would probably be taken by the NRC.
It was explained that this provision would remain in effect for two years or until the next inspection, whichever was longer.
The licensee was also informed that an early reinspection would be conducted by the NRC.
This meeting began at about 2:00 PM and the NRC representatives left the facility at about 4:30 PM. This included time spent related to both licenses at this facility and additional discussions following the formal portion of the meeting.
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Appendix A
& N}l 63~ y)
_ NOTICE OF VIOLATION p;r.
Licens'eY.1 d3E604b{l^2 C
E.
Department of the Army
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Tripler Army Medical Center l
HST - RP Tripler N!C, Hawaii 9c859 i
As a result of the inspection conducted on July 24 and 27,1981, and in accordance with the Interim Enforcement Policy, 45 FR 66754 (October 7, i
1980), the following violation was identified:
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License Condition 25 states that the licensee shall possess and use l
licensed material in accordance with statements, representations, j
and procedures contained in lctter with enclosures dated August 25, 1977 signed by William C. Long, Captain, MSC; letter with enclosures dated April 5, 1978, signed by Vandy L. Miller, Colonel, MSC; and application dated November 1,1979, signed by John R. liohn, Major, MSC.
Item 1(c) of the " Radiation Survey Report" submitted with the - -
letter dated April 5,1978 states, 'at teletherapy head swivel angles of greater than 50, the " BEAM CN" condition is allowed at p
gantry rotation angles less than 1110 CCW and 114 CW,gndis
.e i precluded at gantry rotation angles of 1110 CCW and 114 CW or pT'.*
greater."
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Contrary to these requirements, the " beam on" condition was allowed y#
at teletherapy head' and gantry rotation angles in excess of the operational limits. The " beam on" condition was allowed with a 2,
gantry rotation of 125 CCU and a head swivel angle of 25 CW.
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The " beam on" condition was also allowed with a gantry rotation of 3qw..
2450 0
CW and a head swivel angle of 5.
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This is a Severity Level IV Violation (Supplement.VII).
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Pursuant to the provisions of 10 CFR 2.201. Tripler Army Medical Center,
I is hereby required to submit to this office within thirty days of the date of this Notice, a written statement or explanation in reply, 6
including: (1) the corrective steps which have been taken and the results achieved; (2) corrective steps which will be taken to avoid further t
l items of 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 j
affimation. Consideration may be given to extending your response time l
for good cause shown.
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_2 The responses directed by this flotice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
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B. A. Riedlinger/
Radiation Specialist DESIGt,'ATED ORIGINAL C01'tified By. 0)5(,/) g i,,,.
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