ML20042E206
| ML20042E206 | |
| Person / Time | |
|---|---|
| Issue date: | 03/23/1990 |
| From: | Chilk S NRC OFFICE OF THE SECRETARY (SECY) |
| To: | Taylor J NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO) |
| References | |
| REF-10CFR9.7 NUDOCS 9004200411 | |
| Download: ML20042E206 (11) | |
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'o, UNITED STATES NUCLEAR REGULATORY.COMMISplON
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RELEASED TO THE PDR, ;
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OFFICE OF THE
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-MEMORANDUM FOR:
James M. Taylor Executive Director for Operations FROM:
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Chilk, Secretary
SUBJECT:
SECY-90 SECTION 208 REPORT TO THE CONGRESS ON ABNORMAL OCCURRENCES.FOR OCTOBER-DECEMBER 1989 This is.to adviso you that the commission has.not objected'to-the proposed report to Congress subject to the' attached editorial corrections.
Accordingly, the report should be puolishe'd and the letters and Federal Register notice should-be forwarded for signature and transmittal.
(EDO)
(SECY SUSPENSE:
4/17/90)
Attachment:
As Stated cc:
Chairman Carr Commissioner Roberts Commissioner Rogers Commissioner Curtiss Commissioner Remick OGC IG i
.90TE:
THE SRM AND THE SUBJECT SECY PAPER WILL BE MADE PUBLICLY
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AVAILABLE WHEN THE FEDERAL REGISTER NOTICE IS PUBLISHED.
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-IDENTICAL LETTERS TO:
The Honorable J. Danforth Quayle The Honorable Thomas S. Foley President of the Senate Speaker of the United States Washington, D.C.
20510 House of Representatives Washington, D.C.
20515
Dear Mr. President:
Dear Mr. Speaker:
I am forwarding the Nuclear Regulatory Commission's (NRC's) report on abnormal occurrences at licensed nuclear facilities for the fourth calendar quarter of 1989. These reports are required by Sectlon 208 of the Energy Recrpanization Act of 1974 (PL 93-438).
In the context of the Act~, an abnormal-occurrence is an unscheduled incident or event that the Commission determines is significant from the standpoint of public health or safety.
For this reporting period, there were three abnormal occurrences one involvina_ a a licensed nuclear power plant.
Two of the abnormal occurrencesIM pWafunder other NRC-issued licenses.
The first involved a medical diagnostic misadmin-istration and the second involved a medical-therapy misadministration. The third abnormal occurrence was reported by an Agreement State (Louisiana) and involved an industrial radiographer overexposure. We also have included in the report information that updates a previously reported abnormal occurrence.
We will contihue to disseminate information on reportable events through various event reports. These are routinel industry, and the general public. y dis,tributed on a timely basis to the Congress, Sincerely, Kenneth M. Carr
Enclosure:
Report to Congress on Abnormal Occurrences (NUREG-0090, Vol. 12, No. 4) 3 i
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ABSTRACT Section.208 of the Energy Reorganization Act of 1974 identifies an abnormal occurrence as an unscheduled incident or event that the Nuclear Regulatory Commission determines to be significant from the standpoint of public. health or safety and requires a quarterly report of such events to be made to Congress.
This report covers the period from October 1 through December 31,. 1989.:
- ggul For this reporting period, there were three abnormal occurrences, none'~involv--
ing a licensed nuclear power plant.
Two of the abnormal occurrences e-The first involved a medical diagn/h::' ;1;;;
under other NRC-issued licenses.
ostic mis-administration end the second involved a medical therapy misadministration. The l
third abnormal occurrence was reported by an Agreement State (Louisiana) and involved an industrial radiographer overexposure.
l The report also contains information that updates some previously reported 4
abnormal occurrences.
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PREFACE.
INTRODUCTION 1
The Nuclear Regulatory Commission reports to the Congress each quarter under provisions of Section 208 of the Energy Reorganization Act of 1974 on any abnor-I mal occurrences involving facilities and activities regulated by the NRC. An abnormal occurrence is defined in Section 208 as an unscheduled incident or event i
that the Commission determines is significe
' rom the standpoint of public health or safety.
Events are currently identified as abnormal:v:cu. aces for this report by the i
NRC using the criteria listed in Appendix A.
These criteria were promulgated in an NRC policy statement that was-published in the Federal Register on February 24'-
1977 (Vol. 42, No. 37, pages 10950-10952).
In order _to provide wide dissemina-tion of information to the public, a Federal Register notice is issued on each i
-aonormal occurrence. Copies of the notice are distributed to the NRC PLblic Document Room and all Local Public Document Rooms.
At a minimum, each notice must contain the date and place of the occurrence and describe its nature and probable consequences.
The NRC has-determined that only those events; iMdig the;6 d;;;itted4y-th:
"v.m....,.m MP, described in this report /1ifeet the criteria for abnormal occurrence reporting.' This report covers the period from October 1 through.
December 31, 1989.
Informa' tion reported on each event includes date and place, nature and probable consequences, cause or causes, and actions taken to prevent recurrence.
THE REGULATORY SYSTEM The system of licensing and regulation by which NRC carries.out-its-responsibil-ities is implemented through rules _ and regulations in Title 10 of the Code of Federal Regulations. This includes public participation as an element. To ac-4' complish its objectives, NRC regularly conducts licensing proceedings,-inspec-
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tion and enforcement activities, evaluation of operating experience, and con -
firmatory research, while maintaining issuing technical reviews and studies. programs for establishing standards and In licensing and regulating nuclear power plants,jthe NRC follows the philosophy that the health and safety of the public are best astrered through the establish-ment of multiple levels of protection.
These multiple levels can be achieved and maintained through regulations specifying requirements that will siihe9he safe use of nuclear materials. The regulations include design and quality assurance criteria appropriate for the various activities licensed by NRC. An inspection and enforcement program helps geompliance with the regulations.
REPORTABLE OCCURRENCES Actual operating experience is an essential input to the regulatory process for assuring that licensed activities'are conducted safely.
Licensees are re-quired to report certain incidents or events to the NRC. This reporting helps to identify deficiencies early and to assure that corrective actions are taken to prevent recurrence, h
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REPORT TO CONGRESS ON ABNORMAL OCCURkENCES OCTOBER-DECEMBER' 1989 -
J NUCLEAR' POWER PLANTS
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The NRC is reviewing events reported at the nuclear power plants licensed to operate.
For this report,.the NRC has not determined that any events were y
abnormal occurrences, nxx*****
FUEL CYCLE FACILITIES (Other Than Nuclear Power Plants)
The NRC is reviewing events reported by these licensees.
For this report,.the NRC has not determined that any events were abnormal occurrences, q
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- OTHER NRC LICENSEES (Industrial Radiographers, Medical Institutions, Industrial Users, etc.)
F There are currently about 9,000 NRC nuclear material licenses in effect-in the United States, principally.for use of radioisotopes in'the medical, industrial,-
l and academic fields.
Incidents we're reported in this category from licmwes 4
such as radiographers, nedical institutions, and byproduct material use 5.
The NRC is reviewing events reported by these licensees.
For this repor+, thv NRC' has determined that the following events were abnormal occurrences:
89-13 Medical Diagnostic Misadministration The following information' pertaining to this' event is also being reported con-currently in the Federal Register.
Appendix A (see the general criterion) of this report notes that an event involving a' moderate or more.savere impact on
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public health or safety can be considered an abnormal occurrence.
Date and Place - October 18, 1989; Mayo Foundation; Rochester, Minnesota.-
Nature and Probable Consecuences - On October 27, 1989, the licensee reported to NRC Region III tnat on October 18, 1989, a patient received a diagnostic dose of a radioactive iodine compound that was 10 times the intended dose.
The referring physician intended that a patient receive a neck scan using 100 microcuries of iodine-131, but checked the-box on the referral form indicating a scan using 1 millicurie of iodine-131.
The hospital reported that the patient received an additional radiation exposure of about 1200 rem.to the thyroid be-yond that intended by the referring physician.
Had the intended: dose of 100 microcuries been administered, the thyroid would be expected to receive an exposure no more than about 140 rem.
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A medical consultant, retained by the NRC, indicated that the added dose would result in a very slight increase in the risk that the patient could develop hypothyroidism or thyroid cancer.
The consultant recommended that the hospital monitor the patient with annual thyroid function tests.
Cause or causes - This misadministration occurred because the referring physi-cian checkea the wrong box on the nuclear medicine referral sheet. The nuclear medicine physiciah approved the-neck scan procedure, but did not specify that d
7 it should be the neck scan with the lower dose of 100 microcuries (i.e., the nuclear medicine physician did not write the prescription on the order fom). f*c Actions Taken to Prevent Recurrence i
1.icensee - The hospital has revised its procedures to require additional precau-tions for procedures involving greater than 20 microcuries of radioactive iodine.
Under the revised procedures, the nuclear medicine physician is to review the request for the diagnostic test and the patient's chart and not only ~ approve the -
test but also write the prescribed dosage on the referral request form. The hospital's radiopharmacy will not dispense any quantities of iodine greater-a than 20 microcuries without a properly prepared referral request form, which 6f.,44 includes a prescription-by a nuclear medicine physician.
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A special inspection will be conducted at the hospital to review the incident and other 9e y aspects of the licensee's nuclear medicine program.
.y Unless new, significant information becomes available, this item is considered closed for the purposes of this report.
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89-14 Medical Therapy Misadministration The following information pertaining to this event is also being reported con-currently in the Federal Register. Appendix A (see the general-criterion) of this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - November 30, 1989; Kuakini Medical Center; Honolulu, Hawaii.
Nature and Probable Consequences - On November 30, 1989, the licensee reported to the NRC that a m dical therapy misadministration had taken place at its facility earlier that day when a therapeutic dose of 9 millicuries of iodine-131 was inadvertently given to the wrong patient (Patient A rather than Patient B).
Patient A was intended to receive only a 20 millicurie diagnostic dose of technetium-99m MDP.
This dose was administered and the patient wss seated.in the waiting room pending a bone scan. Meanwhile, Patient B arrived; Patient B, who was scheduled to receive an iodine-131 hyperthyroidism treatment, completed-l an interview, signed a consent form, and was seated ih the waiting room pending the iodine treatment.
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The technologist prepared a dose of 9 millicuries of iodine-131 for administra-t, ion and reportedly called Patient B.
However,! Patient A responded..The tech-nologist explained the iodine-131 treatment, scheduled a follow-up appointment, and administered the dose to Patient A.
The patient then questioned the tech-nologist, and it became evident that the wrong patient had been treated.
Patient A was immediately informed of the error, and the patient's stomach was pumped, retrieving 3.2 millicuries of the material. The patient was then given M,
potassium perchlorate and Lugol's solution to release any iodine-131 already trapped in the thyroid ano to block further uptake. The use of Lugol's solution
'4 continued for 14 days.
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D' This misadministration-resulted in an estimated-dose to the thyroid of approxi-mately 820 rem.
This-dosage is not expected to significantly affect the-1 function of the thyroid, nor is it expected to cause any other adverse effects.,}
Cause or causes -.The licensee stated that the misadministration was caused-by human error on the part of the. technologist and by inadequate procedural controls. '.
g The root cause was due to inadequate supervision of activities.
Actions Taken to Prevent Recurrence Y
Licensee - The licensee stated that: (1) a training class has been scheduled for all tecnnologis.ts, (2) a single technologi'st will be required to handle all, aspects of the iodine-131 therapy and must be able to recognize the correct g
f patient prior to the treatment, and (3)-the technologist, physician, and patient are required to concurrently sign the therapy worksheet prior to the administration.
NRC - Region V requested an NRC medical consultant to review the incide Inspection has been scheduled to review this misadministration.
Unless new, significant information becomes available, this item is considered closed for the purposes of this report.
xamaa*aa AGREEMENT STATE LICENSEES Procedures have been developed for the Agreement States to screen unscheduled incidenti, or events using the same criteria as the NRC (see Appendix A) and report the events to the NRC for inclusion in-this report.
For this period, an Agreement State (Louisiana) repcded the following abnormal occurrence to the NRC.
AS89-2 Industrial Radiographer Overexoosure Appendix A (see Example 1 of "For All Licensees") of this report notes that an exposure of the feet, ankles, hands, or forearms of any individual to 375 rem or more of radiation can be considered an abnormal occurrence.
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Date and Place - August 26, 1989; Mobil-Lab, Inc. (the licensee) of Harvey, J
Louisiana, while performing industrial radiography at Shell Oil Refinery in-
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Morco, Louisiana.
Nature and Probable Consequences - On August 26, 1989, the licensee notified the Louisiana Department of Environment Qualit
.that earlier that day one of the licensee'y, Nuclear Energy Division (" Agency")
s radiographers had apparently received a significant exposure to his lef t hand while performing radiograhy Hth_ a SPEC 2-T exnosure 4uw containino an 82 curie iridium-192 sourre JThe radiographerM 1and may have contacted the source while it was unshielded.- The original calcu-lated exposure was 3000 to 3500 rem.
As discussed below, this was later revised j
l downward to about 1400 rem, based on the Agency's investigation.
The whole-body exposure was about 12.9 rem, based on the reading of the radiographer's_.thermo-l luminescent dosimeter (TLD).
The Agency: advised the licensee to provide immed-iate medical attention, including a doctor's examination of the hand and obtain-7 (ingbloodtests.
l The Agency performed an investigation on August _ 29, 1989,.to determine the-circumstances associated with the incident.= This involved. interviews with the.
radiographer and the. licensee, and a reenactment of'the incident using a dummy source. The incident is briefly described below.
After performing an exposure, the radiographer cranked in the source; however, the source was not fully retracted into the exposure device. The radiographer then performed an inadequate radiation survey that failed to detect the exposed k
source.
He locked the exposure device, took it to a piperack, and set the device r
into a rack. While preparing for the next exposure, he was located approximately i
e 2 feet.from the front of the exposure device in a squatting position, with his back to the device. After an estimated 8 minutes, he reached back, without turning around, and disconnected the source tube with his left hand.
He pulled
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the tube away and may have trazed the source capsule with his left palm.
1 Within a couple of seconds, he noticed that the source was protruding from the
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nipple about 4 inches. He immediately left the area and notified the lead radi-
,b ographer. The lead radiographer saw the exposed source, cranked itLfully-into i
the exposure device, and then surveyed and locked the device. Af ter. directing the radiographer to return to Mobil-Lab to turn in his TLD badge, he carried the exposure device to SPEC Inc., in Kenner, Louisiana, for inspection. The exposure
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device appeared to be working properly.
Though the calculated exposure of the radiographer's hand may have been as high as 1400 rem, as estimated from an reenactment of the incident, the hand showed no indications of injury. Blood tests taken shortly after the incident, and again 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> later, were normal.
Cause or Causes - The Agency investigator concluded that the primary cause was the radiographer's failure to perform a proper radiation survey to determine if the source was in the safe position following a radiographic exposure.
No train-ing or significant
'agement deficiencies were identified.
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.q Actions Taken to Prevent Recurrence 1
1 Licensee - The licensee circulated a notice to its employees with their pay-d checks; the notice describ'ed the incident and stated the cause was due to the radiographer not performing a pro r radiption survey.
In addition, the li-censee c..:.;t:d :- - ;':,:_ ^7 nereasethe number of field audits of radiog-kd-raphy work being performed at job sites. ^
j Agency - The itcensee was cited for three violations: (1) failure of the radiog-rapher to perform a proper survey following an exposure, (b) permitting an indi-vidual to receive an exposure in excess of specified limits, and (c) permitting the individual to act as a radiographer prior to the licensee's submission of proper forms to the Agency.
This item is considered closed for the purposes of this report.
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...PENDIX C
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OTHER EVENTS OF INTEREST The following item is described because it may possibly be perceived by the pub-The-item did not involve a lic to be of public health or safety significance.
major reduction in the level of protection provided for public health or safety; therefore, it is not reportable as an abnormal occurrence.
Significant Degradation of' Reactor Fuel Rod Cladding at Haddam Neck 1.
On September 3,1989, the Haddam Neck Plant (a Westinghouse-designed pr f l water reactor located in Middlesex County, Connecticut) was shut down for re ue -
Because fission product concentra-ing af ter 461 days of continuous operation.
tions in the reactor coolant were higher than normal during the operating cycle, the licensee (Connecticut Yankee Atomic Power Company) conducted extensiveTh examinations of the reactor fuel assemblies.
While there was stainless steel cladding of a significant number of fuel rods event is of particular inttrest because:
i lly was involved; (2) the unusual nature of the damage; and (3) the damage part a compromised one of the three fission product barriers com containmentboundary).
The details of the event 4re as follows.
The Haddam Neck reactor : ore is 10 feet long and consi The stainless steel fuel clad is rod thimbles and one incore instrument sheath.
Iodine concentration in 16.5 mils thick with an outer diameter of 0.422 inch.
the reactor coolant, which is typically used to monitor fuel rod integrity during operation, indicated that a limited number of fuel rods (about six to twelve)
The iodine levels had failed during the first few months of the operating cycle. stab averaged 0.025 microcurie per milliliter, about a f actor of four higher tha previous operating cycles.
During the subsequent cooldown and to about 0.8 microcurie per milliliter.depressurization, the iodine-131 sp Ultrasonic examinations of the fuel identified a total of ab Of these failures, 343 were in 95 fuel assemblies intended fu reuse in That number of failures far exceeded the anticipateo failures.
rods.
the next cycle.
Rod clad failure was confirmed with eddy current tests; the failure rate was The defects were generally pinhole about 1.5% of the rods within the core.
sized, and primarily cencentrated in the bottom 1.2 inches of the fuel rods.
d The f ailures were caused by small fingerna11-sized metal chips or. shavings that had accumulated in the region between the fuel assembly lower noz:le 3
first fuel rod spacer grid. Long-term fretting between the debris and the following cleaning efforts.
adjacent fuel rods resulted in penetration of the fuel cladding.
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Although the source of the debris has not been absolutely icentified, it is be-lieved to be stainless steel chips which escaped the controls to capture them during inachining operations associated with modifications to the reactor vessel thermal shield supports which were performed during the last refueling, During the work, which was all performed remotely and under water, mechanical devices such as' dams, trays, and water suction probes were used to catch tailings from j
end mill machines. Although extensive cleanup efforts were conducted, the licen-see did not flush the reactor coolant system to remove hidden debris prior to l
reactor coolant pump operation with an assembled reactor.
At present, eddy current inspections are being made of fuel rods believed to be defective following ultrasonic examination, along with rods at debris sites, rods adjacent to damaged rods and rods selected randomly.
A rod is rejected if found l
with a defect greater than 20% of wall thickness.
Rejections are occurring at the rate of about 11% for known debris.and failure sites, and about 4% for the i
randomly selected rods.. The core also contained four test fuel assemblies of ds clad with Zircaloy rather than stainless-steel.
(The licensee fuel ores with all-fuel rods, clad in Zircaloy sometime in the future.) plans to There we
.no nacceptable defeckb found in the fuel rod cladding in these test as-se les. The Zircaloy cladding-is considerably thicker than the cladding of the Ac p s
sta nl s steel assemblies (i.e., 27 mils vs.16.5 mils).
Seventy-five percent of t e damaged rods have been-located in the outer two peripheral rows of the stainless steel clad fuel.
The licensee is replacing rejected rods with acceptable fuel. rods from once-and.twice-used fuel assemblies.
Each rod is insp?cted to be free of defects and has an accumulated power history similar to that of the damaged rod being replacad. The licensee is currently evalually programs for the cleaning and flushing of reactor components and the reactor coolant system.
The fuel asses-blies have been mechanically cleaned of all visible debris. Since donor fuel 1
rods are being obtained from assemblies which would have been reused, the li-censee has crdered additional new assemblies.
Prior to plant startup, it will be necessary for the licensee to reevaluate the modified reload reactor core to verify that safety analyses inputs remain valid.
The NRC will closely monitor the actions taken by the licensee.
As previously mentioned, there was no effect from the event on public health or safety. Although many fuel rods were affected, the release of radioactivity to the coolant was not very large, i.e., the coolant activity remained within the technical specification limitations. Because of the location and the failure-i mode (pin-hole failures), damage to the fuel rods only partially compromised the fuel rod cladding barrier. At all times,- the releases offsite remained within the technical specification limits. Based on these considerations, the event was considered below the threshold for an abnormal occurrence.
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