ML20033C530
| ML20033C530 | |
| Person / Time | |
|---|---|
| Issue date: | 11/12/1981 |
| From: | Pang J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20033C519 | List: |
| References | |
| NUDOCS 8112030365 | |
| Download: ML20033C530 (3) | |
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APPENDIX A NOTICE OF VIOLATION r
U. S. Naval Hospital, Guam License No. 04-14869-01 FP0 San Francisco, California 96630 As a result of the inspection conducted September 23, 1981, and in accordance with the Interim Enforcement Policy, 45 FR 66754 (October 7,1980), the following violations were identified:
l A.
10 CFR 20.207 requires that licensed material stored in an unrestricted area shall be secured from unauthorized removal from the place of storage, or be under the constant surveillance and immediate control of the licensee.
Contrary to the above requirement, at the time of the inspection, the door to the Nuclear Medicine storage room containing licensed quantities of Tc-99m and I-125 was propped open and unattended.
This is a Severity Level III Violation (Supplement VII).
B.
Ii cense Condition 17 requires that the licensee shall possess and use licensed naterial in accordance with statements, representations, and procedures contained in app'ication dated September 17, 1976 and letters dated April 3, 1977 and August 22, 1977.
1.
Part IV, Section 0402 b., of the supplement sheet to the letter dated August 22, 1977 requires that TLD ring badges will be worn when engaged ir generator elution, dose and kit preparation, dose administration and assay procedures.
Contrary to the above requirement, TLD ring badges were not used
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by personnel during generator elution, dose and kit preparation, Jose administration and assay orocedures from the period of November 2, 1979 to July 31, 1981.
This is a Severity Level IV Violation (Supplement IV).
2.
The Radiation Safety Manual attached to the letter dated April 8, 1977 describes the responsibilities of the Medical Isotope Committee.
'a)
The Comm'ttee shall meet at least on a quarterly basis.
Contrary to the above requirement, three of the quarterly neetings had not been conducted during the period between January 1, 1980 to July 1, 1981.
(b) The Committee shall review the Radiation Safety Progran annually ei12030365 P11112 N"5 LIC30 04-19869-01 PDR M
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e Contrary to the above requirement, during the inspection records for the period of January 1, 1979 to September 23, 1981, were examined by the inspector.
Only one annual review made by the Committee was identified on '4 arch 12,1980.
(c) Dart IV, Section 0404, of the Radiation Safety Manual, states that refrigerators are not to be used jointly for foods and radioactive materiels.
Contrary to the above requirement, at the time of the inspection, a bottle of club soda was kept in the refrigerator in roon J406 where byproduct oterials are stored for the RIA Laboratory.
The above items constitute a Severity Level IV Violation (Supplement VII).
3.
Iten 11 of the supplement sheet submitted with the letter dated August 22, 1977 requires that survey and monitoring instruments will be calibrated at six month intervals.
Contrary to the above requirement, at the time of the inspection, all three of the radiation survey instruments on hand at the hospital were over due for calibration. The ANPDR-27, Serial No. 2179, and IW 160E/PDR-56, Serial No. E0437, were both calibrated on November 14, 1980 and were due for calibration on May 14, 1991.
The Eberline Model E-1409, Serial 90. 468, was calibrated on February In, 1981 and was due for calibration on August 10, 1981.
The above instruments are in current use in the Nuclear
'ledicine Laboratory.
This is a Soverity Level IV Violation (Sunplement VII).
4 The Nuclear Medicine Procedures 'ianual, dated April 5,1977, provided as supplenent to the application contained in the letter dated anril 3, 1977 reouires that records be maintained of the daily constancy checks made of the dose calibrator.
Contrary to the above requirenent, at the time of the inspection, records of the daily constancy checks made during the period of November ?, 1979 to laiy 19, 1981 were not maintained.
This is a Severity Level V Violation (Suoplement VII).
5.
Dart IX, Section 0903, of the Radiation Safety Manual submitted with the letter dated April 8, 3977 states that individual survey and monitoring survey maps shall be retained as a chronolooical loc of survey.
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. Contrary to the above requirement, records of survey maps were not maintained of radiation or contamination surveys conducted of the laboratory areas during the period of November 2, 1979 to September 23, 1981.
This is a Severity Level VI Violation (Supplement VII).
C.
10 CFR 19.11(c),(d) require that Form NRC-3 "Netice to Employees", shall be posted by each licensee in sufficient number of places to permit individuals engaged in the licensed activities to observe them on the way to or from any particular licensed activity location.
Contrary to the above requirements, at the time of the inspection, a Form NRC-3 was not posted at the hospital.
This is a Severity level V Violation (Supplement VII).
D.
10 CFR 20.401(b) requires that each licensee shall maintain records in the same units used in this part, showing the results of surveys conducted pursuant to 10 CFR 20.303.
Contrary to the above requirement, at the time of the inspection, records of disposal into the sanitary sewerage systen in the RIA Laboratory were not maintained for the period of October 9, 1980 to September 23, 1981.
This is a Severity Level VI Violation (Supplement VII).
Pursuant to the provisions of 10 CFR 2.201, U. S. Naval Hospital, Guam, is hereby required to submit to this office within thirty days of the date of this Notice, a written statement ar explanation in reply, including:
(1) the corrective steps which have been taken '.nd the results achieved; (2) corrective steps which will be taken to avoid further items of noncompliance; and (3) the date when full compliance will be achieved.
Consideration may be given to extending your response tim for good cause shown.
The responses directed by this Notice 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.
dated J. Frank Pang, Radiation Specialist Radiological Safety Eranch I
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