ML20044E535

Report to Congress on Abnormal OCCURRENCES.October-December 1992

ML20044E535
Person / Time
Issue date:	03/31/1993
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V15-N04, NUREG-90, NUREG-90-V15-N4, NUDOCS 9305250129
Download: ML20044E535 (32)

Text

--

NUREG-0090 Vol.15, No. 4

-- = - - -. -- - _. _ -.. = =. _

=

- _ =

Report to Congress on A3 norma: L Occurrences 1

October - December 1992 U.S. Nuclear Regulatory Commission Office for Analysis and Evaluation of Operational Data p scoq

,s affg/Qt ;

~

2

sR52?n!; '

0090 R PDR

o Avai!able from Superintendent of Documents U.S. Government Printing Office Post Office Box 37082 Washington, D.C. 20013-7082 A year's subscription consists of 4 issues for this publication.

Single copies of this publication are available from National Technical Information Service, Springfield, VA 22161

c.

e Available from Superintendent of Documents U.S. Government Printing Office Post Office Box 37082 Washington, D.C.. 20013-7082 A year's subscription consists of 4 issues for this publication.

Single copies of this publication are available from National Technical information Service, Springfield, VA 22161'

NUREG-0090 Vol.15, No. 4 Report to Congress on Abnormal Occurrences October - December 1992 Date Published: March 1993 Omce for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555 j'

i J

Previous Reports in Series NUREG 75/090 (January-June 1975), published October 1975.

NUREG-0090-1 through -10 (July-September 1975 through October-December 1977), published March 1976 through March 1978.

NUREG-0090, Vols. I through 14 (January-March 1978 through October-December 1991), published June 1978 through March 1992.

NUREG-0090, Vol.15, Nos, I through 3 (January-March 1992 through July-September 1992), published July 1992 through December 1992.

l l

$5 i

j w

Abnormal Occurrences,4th Otr CY92 ABSTRACT Section 20S of the Energy Reorganization Act of 1974 There are two abnormal occurrences at nuclear power identifies an abnormal occurrence as an unscheduled inci-plants and six abnormal occurrences involving medical dent or event that the Nuclear Regulatory Commission misadministration (all therapeutic) at NRC-licensed determines to be significant from the standpoint of public facilities discussed in this report. Na abnormal occur-health or safety and requires a quarterly report of such rences were reported by the NRC's Agreement States.

events to be made to Congress. This report covers the

'Itc report also contains information updating three pre-period from October 1 through December 31,1992.

viously reported abnormal occurrences.

iii NUREG-0090. Vol.15, No. 4

Abnormal Oxurrences,4th Otr CY92 CONTENTS Pase III Abstract...................."...-.'""""~"'.'"'"""'"""""""""'*"

• II Preface........................".....'"""'"""'""'""""""""""'"

vii Introduction.................................................................................

y;;

ne R egulat ory Syst em.........................................,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

vii Re portable Occurrences.......................................................................

Agreement States............................................................................ viii Foreign Information......................................................................... viii I

Report To Congress On Abnormal Occurrences, October-December 1992................................

I N ucl ear Power Plants.........................................................................

92-12 Operation With Degraded Steam Generator Tubes at Arkansas Nuclear One Unit 2 and McG uire Nuclear Station Units 1 and 2............................................

I 92-13 Engineered Safety Features Actuation System Design Deficiency-Single Failure -

2 Vulnerability at Millstone Power Station Unit 2........................................

4 Fuel Cycle Facilities (Other than Nuclear Power Plants)............................................

4 Other NRC Licensees (Industrial Radiographers, Medical Institutions, Industrial Users, etc.).............

92-14 Medical Therapy Misadministration at Memorial Hospital of Laramie County in Cheyenne, 4

Wyoming.........................................................................

92-15 Medical Herapy Misadministration and Unplanned Exposure at St. Clares Riverside Medical 5

Center in Denvdle, New Jersey......................................................

92-16 Medical nerapy Misadministration at the Lahey Clinic Medical Center in Burlington, 6

M assa ch u se t ts....................................................................

92-17 Medical Therapy Misadministration at Indiana University Medical Center In 7

Indianapolis, India na...............................................................

92-18 less of Iridium-192 Source and Medical Therapy Misadministration at Indiana Regional Cancer 7

Center in Indiana, Pennsyh ania......................................................

92-19 Medical Therapy Misadministration and Temporary loss of Brachytherapy Source at Yale-New Haven Hospital in New Haven, Connecticut.........................

9 10 Agreem ent Stat e License es.......................................................................

II References......................................................................................

13 Appendix A-Abnormal Occurrence Crit eria.........................................................

17 Appendix Il-Update of Previously Reported Abnormal Occurrences...................................

17 N ucl ear Power Plants......................................................................

92--4 loss of High-Head Safety injection Capability at Shearon Harris Nuclear Power Plant....... 17 17 Ot h er NRC Lice nsees........................................................................

92-7 Medical Diagnostic Misadministration at Baystate Medical Center, Incorporated, in 17 Springfield. Massach usetts...........................................................

NUREG-0090. Vol.15, No. 4 l

v i

r f

-i Abnormal Occurrences,4th Qtr CY92 92-11 Medical nerapy Misadmmistration at the Medical Center of Delaware, Incorporated, in Wilmington, Delaware................................................. -............. 18~

I Appendix C-Other Events of Interest............................................. -................. 19 t

6 Oth er N R C Licensees........................................................................ 19 t

i

.i 1.

Medical nerapy Misadministration at St. John's Medical Center in Anderson, Indiana....... - 19

-i e

R eferences for Appendices........................................................................ 21

.[

t P

i i

t i

i t

l 6

!t I

i i

l i

I Y

)

L

'I,

.i i

i t

E t

[

i l

I b

l i

l

.I i

l l

l t

i 5

i I

t

[

NUREG-0090. Vol.15. No. 4 vi t

Abnormal Occurrences,4th Otr CY92 PREFACE Introduction rules and regulations in Title 10 of the Code of Federal Regulations. This includes public participation as an ele-ment. To accomplish its objectives, the NRC regular *y De Nuclear Regulatory Commission reports to the Con-conducts licensing proceedings, inspection and enforce-grest. cach quarter under provisions 01 Section 208 of the ment activities, evaluation of operating experience, and Energy Reorganization Act of 1974 on any abnormal oc-confirmatory research, while maintaining programs for currences involving facilities and activities regulated by establishing standards and issuing technical reviews and the NRC. An abnormal occurrence is defined in Section studies.

208 as an unscheduled incident or event that the Commis-sion determines is significant from the standpoint of pub-In licensing and regulating nuclear power plants and the lic health or safety.

uses of byproduct nuclear materials, the NRC follows the philosophy that the health and safety of the public are Events are currently identified as abnormal occurrences best ensured through the establishment of multiple levels for this report by the NRC using the criteria and accompa-of protection. Dese multiple levels can be achieved and nying examples listed in Appendix A.These criteria were maintained through regulations specifying requirements promulgated m an NRC policy Statement that was pub-that will ensure the safe use of nuclear materials.The lished in the Federal Register on Febmary 24,1977 (Vol.

regulations include design and quality assurance criteria 42, No. 37, pages 10950-10952).

appropriate for the various activities licensed by the NRC. An inspection and enforcement program helps en-De NRC policy statement was published beiore licen-sure comphance with the regulations.

sees were required to report medical misadministrations to the NRC. Few of the examples in the policy statement are applicable to medical misadministrations. Therefore, Reportable Occurrences during 1984, the NRC developed guidelines for selecting such events for abnormal occurrence reporting. These guidelines, which have been used by the NRC since the Actual operating experience is an essential input to the latter pan of 1984, augment the NRC policy statement regulatory process for assuring that licensed activities are examples and are summarized in Table A-1 in Appendix conducted safely. Licensees are required to report certain A. On January 27,1992, new medical misadministration incidents or events to the NRC.This reporting helps to definitions became effective. Therefore, revised guide-identify deficiencies early and to ensure that corrective lir.es for identifying medical misadministrations as abnor-actions are taken to prevent recurrence.

mal occurrences are currently being developed. De re-For nuclear power plants, dedicated groups have been 1

vised guidelines will be published for coniment in the formed both by the NRC and by the nucicar power m, dus-EcdcralRegister' try for the detailed review of operating experience to help In order to providt wide dissemination of information to identify safety concerns early; to improve dissemination the public, a federal Register notice is issued on each ab-of such information; and to feed back the experience into normal occurrence. Copies of the notice are distributed to licensing, regulations, and operations. In addition, the the NRC Public Document Room and all Iml Public NRC and the nuclear power industry have ongoing efforts Document Rooms. At a minimum, each notice must con-to improve the operational data systems, which include tain the date and place of the occurrence and describe its not only the type and quality of reports required to be sub-nature and probable consequences.

mitted, but also the methods used to analyze the data. In order to more effectively collect, collate, store, retrieve, De NRC has determined that only those events de-and evaluate operational data, the information is main-scribed m this repon meet the cnteria for abnormal oc-tained in computer-based data files.

currence reponing. This report covers the period from October 1 through December 30,1992. Information re-Three primary sources of operational data are Licensee ported on each event includes date and place, nature and Event Reports (LERs), immediate notifications made probable consequences, cause er causes, and actions pursuant to 30 CFR 50.72 and medical misadministration taken to prevent recurrence.

reports made pursuant to 10 CFR 35.33.

Except for records exempt from public disclosure by stat-ute and/ r regulation,information concerning reportable The Regulatory System occurrences at facilities licensed or otherwise regulated l

by the NRC is routinely disseminated by the NRC to the The system of licensing and regulation by which the NRC nuclear industry, the public, and other interested groups carries out its responsibilities is implemented through as these events occur.

vii NUREG--0090, Vol. 5, No. 4

m m.

Abnormal Occurrences. 4th Otr CY92 i

l Dissemination includes special notifications to licensees pable of sustaining a chain reaction). Agreement State j

and other affected or interested groups, and public an-programs must be comparable to and compatible with the i

3 nouncements. In addition, information on reportable Commission's program for such material.

events is routinely sent to the NRC's more than 100 local P

inf in a rpNe mes b public document rooms throughout the United States and to the NRC Public Document Room m Washmgton, D.C.

Agreement Sta"e licensed activities is publicly available at

'Ihe Congress is routinely kept informed of reportable the State level. Certam mformation is also provided to events occurring in licensed facilities.

the NRC under exchange of information provisions in the f

agreements.

Another primary source of operational data is reports of In early 1977, the Commission determined that abnormal reliability data submitted by licensees under the Nuclear occurrences happening at facilities of Agreement State !!.

Plant Reliability Data System (NPRDS). The NPRDS is a voluntary, mdustry-supported system operated by the In-censees should be included in the quarterly reports to Congress. ' Die abnormal occurrence criteria included in l

stitute of Nuc1 car Power Operations (INPO), a nuclear Appendix A are applied uniformly to events at NRC and utility organization. Both engineering and failure data are 4

Agreement State licensee facilities. Procedures have l

submitted by nuclear power plant licensees for specified been developed and implemented, and abnormal occur-plant components and systems. The Commission consid-rences reponed by the Agreement States to the NRC are ers the N PRDS to be a vital adjunct to the L ER system for included in these quanerly reports to Congress.

the collection, review, and feedback of operational expe-j i

rience; therefore, the Commission periodically monitors i

the NPRDS reponing activities.

Foreign Information

)

Agreentent States The NRC participates in an exchange of information with various foreign governments that have nuclear facilities.

This foreign information is reviewed and considered in Section 274 of the Atomic Energy Act, as amended, the NRC's assessment of operating experience and in its au thorizes the Commission to enter into agreements with research and regulatory activities. Reference to foreign i

States whereby the Commission relinquishes and the information may occasionally be made in these quaderly

[

States assume regulatory authority over byproduct, abnormal occurrence reports to Ccmgress; however, only j

souree, and special nuc! car materials (in quantities not ca-domestic abnormal occurrences are reported.

4 i

l i

i l

l I

l i

i k

t

[

i s

NURiiG-0090, Vol.15, No. 4 viii I

i

Abnormal Occurrences, 4th Qtr CY92 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES OCTOBER-DECEMBER 1992 NucIcar Power Plants ne NRC is reviewing events reported at the nuclear tubes that failed to satisfy the structural margin criteria of power plants licensed to operate. For this repon, the NRC Regulatory Guide l.121.These SG tubes did not re-NRC has determined that the following events were ab-tain adequate structural margins to ensure their integrity for the full range of normal operating, transient, and pos-normal occurrences.

tulated accident conditions.

92-12 Operation With Degraded Steatn On March 9,1992, Arkansas Nuclear One Unit 2 Generator Tubes at Arkansas Nuclear (ANO-2) shut down upon detecting a primary-to.secon-dary coolant leak of 360 gallons per day, which is approxi-One Unit 2 and McGuire Nuclear mately half of its Technical Specifications limit. Entergy Station Units 1 and 2 Operations, Incorporated, the licensee for ANO-2, con-ducted an eddy current inspection of the SG tubing and The following i:tformation pertaining to this event is also Identified the location of the leak.The licensee reviewed being reported concurrently in the federal Register. Ap-the eddy current test data from the presions inspection pendix A(Example 20f "For Commercial Nuclear Power (A ril 1991), and found that this tube had exhibited a P

Plants") of this report notes that a major degradation of flaw-like mdication at that time. In addition, the licensee fuel integrity, primary coolant pressure boundary, or pri-identified six additional tubes that had been incorrectly mary containment boundary can be considered an abnor-analyzed in 1991.To further characterize the degradation mal occurrence.

mechamsm affectmg this particular location on the SG tubes, the licensee removed several tube sections from Date and Place-March 9,1992; Arkansas Nuclear One the SG for analysis.

Unit 2, a Combustion Engineering-designed pressurized, water reactor (PWR), operated by Entergy Operations, On August 7,1992, the licensee for ANO-2 reponed to incorporated and located near Russelville, Arkansas, and the NRC that for three of the tubes the examination re-January 16,1992; McG uire Nuclear Station Units 1 and 2.

vealed circumferentially oriented intergranular stress Westinghouse-designed PWRs, operated by Duke Power corrosion cracking (IGSCC) beginning on the outer sur-Company, and located in Mecklenburg County, North face of the tubes. ne cracks extended 360 degrees Carolina.

around each of the tubes and had average depths ranging between SS and 94 percent of the tube wall thickness.

Nature and Probable Consequences-De NRC received Due to the extent of this degradation, these SG tubes did notifications from Iwo nuclear power plant licensees indi-not retain adequate otructural margins, consistent with cating that some of their steam generator (SG) tubes have NRC Regulatory Guide 1.121, at the time of the March degraded to a point where they no longer have adequate 1992 shutdown of ANO-2.

margin for structural integrity. SG tubing constitutes more than half of the reactor coolant pressure boundary.

On January 16,1992, McGuire I shut down after the pri-Rus, its integrity is important in minimizing the loss of mary-to-secondary coolant leak rate approached 250 gal-primary coolant and release of radioactive fission prod-lons per day. The licensee subsequently identified the ucts. Requirements for periodic insenice inspection of source and location of the leak using eddy current tech-the SG tubes have been established in the plant Technical niques. The licensee reviewed the eddy current test data Specifications to ensure that the SG tubes retain ade-from the previous inspection (October 1991) for the Icak-quate structural margin as defined in NRC Regulatory ing tube, and found that this tube had exhibited a flaw in-Guide 1.121, " Bases for Plugging Degraded PWR Steam dication at that time. His tube, however, was not re-GeneratorTubes." The structural margins that a SG tube moved from service as required by the plant's Technical must possess at the end of an operating cycle, as described Specifications due to improper classification and adminis-in the NRC Regulatory Guide, take into account inspec-trative handling of the indication. In addition, the licensee tion measurement uncertainty and flaw growth between identified an additional indication on this tube that had not been identified in the previous inspection of October inspections-1991. The licensee, therefcre, reviewed all of the eddy A partial insersice inspection of the SG tubing is typically current data from the 1991 inspection. Since McGuire 2 performed every refueling outage with eddy current was in a scheduled refueling outage at this time, the licen-probes. During the past 3 car, two utilities identified SG see decided to further characterize the degradation 1

NUREG-0090, Vol.15, No. 4

Abnormal Occurrences, 4th Qtr CY92 i

mechanism affecting this particular location of the SG ous refueling outage (October 1991) as required by the tubing by r emoving several tube sections for analysis. The plant's Technical Specifications. The failure to plug the eddy current indications in these sections exhibited simi-tube to remove it from service was due to misclassification lar characteristics to those in the Unit 1 SGs.

of the tube's flaw indication during the data analysis proc-In April 1992, Duke Power reported the preliminary re-ess. Although the tube was reinspected during the proc.

sults from the examination of the SG tube segments from ess with a more sensitive probe, the process still failed to McGuire 2 to the NRC. One tube was found to contain assure that the tube was plugged.

arially oriented IOSCC beginning on the outer surface of Actions Taken To Prevent Recurrence the tube. De crack was approximately 1.4 inches long with ar. average through-wall depth of 72 percent of the Licensee-The licensee for ANO-2 has taken several wall thickness. Furthermore, the burst pressure for this corrective steps to address the causes of the missed eddy I

tube section was lower than specified in NRC Regulatory current flaw indications including: (1) enhancement of Guide 1.121. Both McGuire 1 and 2 were shut down m the eddy current guidelincs; (2) implementation of an May 1992 for further examination cf the SG tubing. At analyst training and performance demonstration pro-this time, several tube sections were removed from the gram; (3) broadenmg of the SG tube inspection scope; Unit 1 SGs, including the tube that had leaked and was and (4) the use of a probe appropriate for the detection of subsequently plugged in January 1992. The destructive circumferential crahgmie licensee planno pedorm a eramination of a segment of the tube that leaked in Janu-mid-cycle inspection of SG tubes beginning at the end of A 'ill993' P

ary 1992 revealed an axially oriented stress corrosion crach initiating from the outer surface of the tube. This As a result of the missed eddy current indications during tube was found not to retain structural integrity consis-the 1991 outage at McGuire 1, Duke Power Company tent with the NRC Regulatory Guide.

took several corrective steps to address the causes of the A previous SG tube failure,in this case a SG tube rup-missed indications including: (1) re-evaluation of eddy ture, occurred at McGuire Unit 1 in March of 1989, and cent data imm h preshs outage using enhanced i

guidelines;(2) rmplementation of admtmstative controls was reported as an abnormal occurrence in NUREG-0090, Vol.12, No.1

• Report to Congress on to address the manner in which information on SG tubes Abnormal Occurrences: January-March 1989.

is conveyed for tube disposition; and (3) reducing the work i

schedule of the eddycurrent data analysts. As a result of Cause or Causes-The licensee for ANO-2 attributed the metallographic examination of the tube sections in

[

the missed eddy current flawindications from the 1991 in.

April 1992, the licensee: (1) further enhanced their eddy spection to:(1) lack of training for the eddy current data current guidelines and reinspected the SGs; (2) per-analysts in guidelines for SG tube damage mechanisms formed additional training; and (3) administratively low-j specific to ANO-2 and similar sites:(2) lack of a perform-cred the allowable amount of primary-to-secondary leak-ance demonstration test by the data analysts using actual age.

site data; and (3) inherent difficulties in analyzing signals at the location where the defect was found caused by m-NRC-NRC Information Notice 92-80 " Operation with i

terference from surrounding structures, the geometry of Steam GeneratorTubes Sericusly Degraded" was issued the tube at this location, and deposits on the SG tubes.

on December 7,1992 to inform licensees of findings from SG tube inspections and investigations at ANO-2 (Ref.

i Although the above may have been contributing factors, 1). As a result, recipients can consider, as appropriate, ac-the NRC staff believes inappropriate test probes were tions to avoid sunilar problems at their facilities. The ge-used for tube locations susceptible to circumferential neric implications of undetected degradation of SG tubes l

cmcking. Circumferential cracks can only be detected sat-will contmue to be actively studied by the NRC.

isfactorily with specialized probes, as discussed in NRC Information Notice 90-49,-Stress Corrosion Cracking in His item is considered closed for the purposes of this re-port.

PWR Steam G enerator Tubes," and in NRC Information Notice 92-80, " Operation with Steam Generator Tubes Seriously Degraded." During the ANO-2 SG tube rn-92--13 Engineered Safety Features spections in 1991, the licensee did not use the type of Actuat.on System Design Deficiency-i probe discussed in Information Notice 90-49. However, Single Failure Vulnerability at during subsequent plant outages in 1992, the licensee did Millstone Power Station Unit 2 use an appropriate probe for the detection of circumfer-ential cracking.

' Die following information pertaining to this event is also being reported concurrently in the Fei~eralRegister. Ap-The primary-to-secondary leakage observed at McGuire pendix A (see the second general criterion)of this report 1 in January 1992 was attributed primarily to a SG tube notes that a major degradation of essential safety-related that had not been removed from service during the previ-equipment can be considered an abnormal occurrence.

NUREG-0090, Vol.15, No. 4 2

+

Abnormal Occurrences,' 4th Otr CY92

- Date and Place-July 6,1992; Millstone Unit 2, a Com-valves, inhibiting flow to all emergency coolant in-bustion Engineering-designed pressurized water reactor jection pumps.

(PWR), operated by Northeast Nuclear Energy Company (3) The loss of allde power to one actuation train would and lomted in New 12mdon County, Connecticut.

cause a power operated relief valve in the other train i

Nature and Probable Consequences-On July 6,1992, to open. In addition, when control power alone is during a planned outage at the Millstone Nuclear Power lost to only the sensor cabinets in a single actuation

-l I

Station, Unit 2, with the fuel removed from the reactor train, spurious high pressurizer pressure signals would cause the relief valves in both trains to open.

pressure vessel and stored in the spent fuel pool, the li-Both cases would result in a loss of primary coolant.

censee, Northeast Nuclear EnerEy Company,was prepar-

~ ing to replace two vital inverters. Millstone Unit 2 uscs ne design deficiency in the on-line testing feature could i

four inverters, two on each vital de bus, to power two have prevented both emergency dicscis from accyting trains of engineered safety fcatures actuation system 0iS.

emergency loads under certain single failure conditions.

FAS), comprised of four sensor cabinets and two actua.

The licensee investigated this event and found several de-l tion cabinets. Operators removed power from one actua.

sign vulnerabilities related to loss of a vital de bus which.

i tion train, which caused a false loss of normal power may apply to ESFAS at other plants. Although the de-

)

signal and a false start signal for the emergency core cool-scribed event resulted from an ATI modification,' the ing system.He effect of this action was similar in conse.

other vulnerabilities are inherent in the ESFAS design -

i quence to the complete loss of one of the two vital de and its power supplies.

buses.

The licensee is planning modifications to correct these One emergency diesel generator (EDG) started and tied P.roblems and is reviewing the design of Unit 2 for other onto the bus. The second EDG did not start because it was Sumlar Problems. The NRC will be reviewing the licen-g out of service for maintenance. After the one EDG sce's corrective actions pr or to plant restart.

i started, the safety loads failed to sequence onto the bus because of a continuous false load shed signal. Operators Cause or Causes-The event was caused by a failure to recovered from the event by stopping the EDG and re-correctly transfer design package requirements into the storing power to one of the sensor cabinets. His action plant modification. He implementation plan identified removed the false loss of power signal and thus the load the proper sequence that the inverters would have to be i

shed signal.

replaced and turned on, but when the work order was pre-pared the planned sequence was not followed.

j The licensee reviewed the event and concluded that an unblocking feature of the automatic test insertion (ATI)

Some plant design vulnerabilities were known to the li-l system had caused the continuous load shedding signal.

censee prior to this event. In 1990, the licensee discov-He ATI systern, a continuous, on-line, logic tester that is cred a long standingTechnical Specifications interpreta-common for both trains, was still energized and permitted tion that had permitted indefinite operation of an the spurious loss of power signal to continue to shed the emergency electrical bus on the non-safety related loads.

backup supply.

In reviewing the event, the licensee determined that the The NRC reviewed the design change, the outage plan, 1

ESFAS could also cause other unintended actions under and the operation implementation procedures. In addi-certain power supply failure conditions. These automatic tion, the NRC interviewed the engineer that was respon- -

t actions are not related to the ATI modification.

sible for the design change, the personnel that prepared.

l the work order, and the operations personnel that re-

[

(1) If powerislost to either one of the two de vitalbuses, leased the work order. The NRC concluded that there both the safety injection actuation signal and sump was ample opportunity for the licensee personnel to iden-i recirculation actuation signal would be simultane-tify the error in the work order that caused the partial loss i

ously initiated. The recirculation actuation signal of nonnat power. The staff considers the subsequently j

would result in tripping all low pressure injection discovered design vulnerabilities in the ESFAS to be sig-l pumps. Also, the spurious sump recirculation actua-nificant because, had the plant been operating at the time tion signal would cause one of the containment of the event, the licensee would have been required to f

sump outlet valves to open.

take immediate remedial action.

}

I (2) If power was lost only to the sensor cabinets in one Actions Taken to Prevent Recurrence actuation tram, both containment sump outlet va:ves would open. If this occurred during a loss of-Licensee-Implementation of the pertinent aspects of coolant accident, high pressure in containment the Performance Enhancement Program will enhance could shut both refueling water storage tank check pre-perfonnance review of design change records and j

3 NUREG-0090, Vol.15, No. 4

=

i I

Abnormal Occurrences. 4th Qtr CY92 help resolve plant requirements to suppon multiple work nese changes are complete. Satisfactory operation of activities in outage planning.

the ESFAS was demonstrated during recent testing per-formed as a part of startup preparations following the An ESFAS analysis has thus far identified three areas in steam generator replacement project.

which design changes were needed. Dese include:

An Independent Review Committee was formed to inves-1.

Eliminate the interaction of the automatic test inser-tigate this event. De recommendations from this Com-tion unit with the load shed actuation module.

mittee have been evaluated and, where appropriate, im-plemented.

2.

Modify the action of the simultaneous safety injec-NRC-ne NRC conducted an inspection to investigate tion actuation signal and the sump recirculation ac-the circumstances of the.iuly 6,1992 event (Ref. 2). On tuation signal to eliminate the low pressure injection February 4,1993, the NRC issued Information Notice pump inp and to prevent premature pump suction No. 93-11, " Single Failure Vulnerability of Engineered shift to the containment sump.

Safety Features Actuation Systems," that described the

~

Millstone 2 event (Ref. 3).

3.

Modify the power operated relief valve control relay logic to prevent inadvertent opening or, loss of con-His item is considered closed for the purposes of this re-trol power.

port.

Fuel Cycle Facilities (Other Than Nuclear Power Plants)

The NRC is reviewing events reported by these licensees.

were abnormal occurrences.

For this report, the NRC has determined that no events 1

Other NRC Licensees (Industrial Radiographers, Medical Institutions, Industrial Users, etc.)

Here are currently over 7,500 NRC miear mau al F-Date and Place - August 19,1992; Memorial Hospital of censesin eHect in the United States, p.. 'cipally far t'se of Laramie County; Cheyenne, Wyoming.

radioisotopes in the medical, industrial, and academic fields. Incidents were reported in this category from licen-Nature and Probable Consequences-On October 22, sees such as radiographers, rnedical institutions, and 1992, the licensee notified NRC Region IV that a byproduct material users. He NRC is reviewing events therapeutic misadministration had occurred on August reported by these licensees. For this report, the NRC has 19, 1992, invohing a brachytherapy implant procedure determined that the following events were abnormal oc.

utilizing iridium-192 as seeds encased in nylon ribbon currences using the criteria and guidelines E ven in Ap.

(small sealed radiation sources utilized for interstitial i

pendix A. As noted in the Preface to this report, the treatment of cancer).ne proposed treatment included a guidelines for identifying medical misadministrations as prescribed dose of 3,258 rads for the patient's prostate abnormal occurrences are currently being revised.

gland.

On October 21,1992, while reviewing the shipping docu-ments associated with the implant performed on August 92-14 Medical Therapy Misadmini-19,1992, the ticensee's dosimetrist noted a discrepancy in stration at Memorial Hospital of the units of measurement between what she had ordered Laramie County in Cheyenne, as opposed to what she had receivcd. He licensee or-W O"*E dered brachytherapy nbbons contammg 0.79 millicuries Y

per ribbon. However, the vendor delivered brachytherapy ribbons containing 0.79 milligrams radium equivalent he following information pertaining to this event is also (1.36 millicuries) per ribbon. When the shipment was re-being reported concurrently in the Federal Reginer.

ceived, the dosimetrist checked the prescription order Appendix A (see Event Type 5 in Table A-1) of tbt.e-against what was received and noted that the quantities pon notes that a therapeutic dose that is greater thaa 1.5 (0.79) matched, but she failed to note that the amount times the prescribed dose can be considered an abnormal received was measured in milligrams radium equivalent orurrence, rather than the requested millicurie units. As a result, the i

NUREG-0090, Vol.15, No. 4 4

Abnormal Occurrences. 4th Qtr CY92 i

radiation dose to the patient's prostate gland was 5,669 scheduled to receive radiation can be considered an ab-rads rather than the prescribed 3,258 rads.

normal occurrence.

I i

The referring physician was notified and chose not to in-Date and Place-October 2,1992; St. Clares Riverside form the patient.

Medical Center; Denville, New Jersey.

^

~1he patient was examined during subsequent follow-up Nature and Probable Consequences-On October 2, l

visits and has shown no adverse effects due to the in-1992, the licensee notified the NRC by telephone that a creased radiation exposure.ne licensee does not antici.

therapeutic misadmmistration mvoh'ing the implant of pate any significant effects to the patient as a result of the two indium-192 dbbons had occurred that day at its facil-misadministration.

ity. At 2:30 p.m. on October 1,1992, a patient was im-i P anted with 48.25 millicuries of iridium-192 contained in l

l Cause or Causes-The cause is attributed to human error two nylon nbbons.The ribbons were inserted into cathe-by the licensee's staff resulting in the failure to perform ters that extended from the patient's abdomen into the an adequate verification of source strengths prior to im.

common bile duct. The procedure was scheduled to last planting the brachytherapy sources. He licensee's 20 to 23 hours2.662037e-4 days <br />0.00639 hours <br />3.80291e-5 weeks <br />8.7515e-6 months <br /> dunng which a dose of 1500 to 2,000 rads desimetrist had checked the prescription order against would be delivered to a colon tumor obstructing the com-the receipt records but failed to note the discrepancy in mon bile duct. After unph'nting the indium-192 ribbons units of measurement. Additionally, miscommunication mto the two catheters, the implant site was dressed and between the licensee and the vendor also appears to have Instructions were given to nursing personnel not to contributed to the error.

change the dressing.nese instructions were not detailed on the patient's chart. Due to excessive drainage of bile at Actions Taken To Prevent Recurrence the implant site during the evening and early moming i'

hours, the patient's dressings were changed several times Licensee-Revised procedures have been implemented and then reinforced with additional absorbent. At 4:15 to prevent recurrence of admmistering implants without a.m. on the morning of October 2,1992, the nurse on duty

['

complete verification of brachytherapy source strengths.

noted that the dressing was completely displaced and This meludes an implant checklist that must be completed acted to replace the dressing. The nurse noticed that the and initialed to ensure that units of measurement re-two ribbons were displaced but, not knowing what they l

ceived correspond to that which was ordered. mdition-were, coiled the ribbons in her hand and taped the ribbons ally, the licensee's physictsts will verify source strengths to the patient's abdomen. A routine x-ray identified that i

by direct measurement prior to implantation, the seeds were no longer implanted, and the coiled rib-

[

8**'*'**

fr m the surface of the patient's j

NRC-An NRC Re& on IV inspector conducted a sPecial abdomen by a physictan at approximately 12-00 p.m. on i

safety inspection on November 19-20,1992, to review the October 2,1992.

circumstances associated with the misadministration and l

to review the licensee's corrective actions. He licensee's The licensee estimate. : 2at the patient received 1,145 determination of the cause of the event was considered rads to the targeted turnor site, between 172 and 1,032 accurate based upon interviews of the individuals in.

rads to the skin of the abdomen,19.9 rads to the liver and volved.The inspection revealed violations associated with small bowel,12.7 rads to the kidneys, 50.9 rads to the the failure of the licensee's authorized user to instruct colon, and 6.7 rads to the testes. The licensee estimated f

individuals under his supervision in the licensee's quality that the nurse who coiled the ribbons and taped them to

}

management program (Ref. 4). Enforcement action is the patient'; abdomen received approximately 7.6 rads to i

under consideration.

her hands.ne licensee expects no adverse clinical effects as a result of the reduced dose to the target organ since Future reports will be made as appropriate.

this brachytherapy treatment was a booster to the exter-nal beam dose that was yet to be administered.

j 92-15 Medical Therapy Misadmini-stration and Unplanned Exposure Both the patient and nurse were notified of the misadmi-l nistration.

l at St. Clares Riverside Medical Center in Denville, New Jersey Cause or Causes-The misadministration was caused by:

The following information pertaining to this event is also

1) lack of oversight of the procedure by the licensee's being reported concurrently in the Federal Register. Ap-Radiation Safety Officer (RSO); and 2) inadequate train-pendix A (see Event Type 3 in Table A-1)of this report ing of the nursing staffin that they were unable toidentYy notes that a therapeutic exposure to a part of the body not the brachytherapy source ribbon.

5 NUREG-0090, Vol. I5, No. 4

Abnormal Occurrences. 4th Otr CY92 Actions Taken to Prevent Recurrence Nature and Probable Consequences-On October 19, 1992, the licensee notified the NRC Operations Center Licensee-ne licensee initiated an expanded training of a therapeutic misadministration invohing a high dose program that includes familiarization of personnel with rate remote afterloader (HDR) that occurred at the facil-i the size and appearance of the radioactive sources used in ity on October 14,1992. A patient was scheduled to re-brachyt herapy t reatments at the licensee's facility. %c li.

ceive brachytherapy treatment to the right main stem a

censee stated that a manager will be responsible for en-bronchus in three imetions using a Gamma Med HDR.

suring that personnel on all shifts involved in the care and Each fraction was to deliver 700 rads to the targeted i

treatment of radiation therapy patients receive this train.

tumor site. On October 7,1992, the patient was admini-ing.ne licensee decided to name a new RSO because the stered the first treatment as prescribed. On October 14, j

current RSO was unable to devote sufficient time to the 1992, the therapist made an error during input of the radiation safety program due to his other responsibilities.

offset distance into the treatment computer, entering an.

j

%e licensee's actions also included: 1) committing that a offset distance of 7 millimeters rather than 7 centimeters i

new RSO would be in place before another brachytherapy as required. His error resulted in the second fraction procedure is performed; 2) develeping a nurses' proce-delivering 90 percent of the prescribed fractionated radia-dure manual; 3) conducting formal inservice training in tion dose to unintended tissues away from the tumor site l

radiation safety with all nursing unit workers; and 4) re-and under-dosing the tumor site. De under-dose was quinng a written directive be initiated before ordering ra-made up during the administration of the third fraction on dioactive material.

October 22,1992. He physician stated that he expected

{

no adverse clinical effect on the patient due to underdos-ing the tumor site as the dose was made up in the third and NRC-NRC Region I conducted an inspection on Octo-fin i fr etion.

ber 5,6,7, and 9,1992, and held an Enforcement Confer-ence on November 5,1992, to discuss the inspection find-ings. De licensce's corrective and preventive actions will The referring physician and patient were both notified of be reviewed during the next inspection of the licensed the misadministration.

i program. Several violations of NRC requirernents were l

identified including 1) failure to adequately train nursing Cause or Causes-The licensee followed established pro-

[

personnel to recogmze brachytherapy procedures; 2) fail-cedures; however, the procedure did not include a mecha-ure to tram personnel on potential radiological emergen-nism to verify data entries on the HDR console at the time cies for brachytherapy procedures; and 3) failure to im-d mim I

j plement radiation safety and quality management l

l programs to ensure adequate safety.

l Actions Taken to Prevent Recurrence A civil penalty of $10,000 was proposed in a letter dated January 11,1993 (Ref. 5). The licensee paid the civil Licensee-The licensee instituted a new procedure that penalty on February 5,1993.

requires that a second individual verify the data input on the HDR console prior to administration of the therapy.

t l

His item is considered closed for the purposes of this f

]

report.

NRC-NRC Region I conducted a routine inspection at j

the facility on December 3.1992. nc iaspection result ed in the identification of six apparent violations:(1) failure l

92-16 Medical Therapy Misadmini-to have a quality management program to meet the regu-l stration at the Lahey Clinic latory requirements; (2) failure to make tirnely notifica-Medical Center in Burlington, tion to the NRC; (3) failure to provide radiation safety j

training to workers; (4) failure to perform the required Massachusetts 3

tests of the dose calibrator; (5) failure to perform radia-1 tion surveys; and (6) failure to maintain the prior expo-He following information pertaining to this event is also sure record of a new empkiyee (Ref. 6).

_j being reported concurrently in the Fedcral Register. Ap-pendix A (see Event Type 3 in Table A-1) of this report The licensee stated that there were no adverse effects to notes that a therapeutic exposure to a part of the body not the patient as a result of the misadministration.

scheduled to receive radiation can be considered an ab-l 1

normal occurrence.

i Enforcement action is under consideration.

l Date and Place-October 14,1992; Lahey Clinic Medical l

Center: Hurlington, Massachusetts.

Future reports will be made as appropriate-l E

i-NUREG-0040 Vol.15, No. 4 6

(

h E

Abnormal Occurrences,4th Otr CY92 92-1" Medical Therapy Misadmini-misadministration. NRC Region III conducted a special stration at Indiana University inspection on December 14-15,1992, to review the cir-amstances sumundinE this misadministration. Enforce-Medical Center in Indianapolis' ment action on the inspection findmgs is pending.

Ind.iana Future reports will be made as appropriate.

The following information pertaining to this event is also being reported corcurrently in the Federal Register. Ap-92-18 Loss ofIridium 192 Source and pend x A (see Event Type 5 in Table A-1) of this report Medical Therapy Misadministration notes that a therapeutic dose that is greater than 1.5 times at Ind.tana Regional Cancer Center the prescribed dose can be considered an abnormal occur.

in Indiana, Pennsylvania rence.

Date and Place-November 13-14,1992; Indiana Univer.

De following information pertaining to this event is also sity Medical Center; Indianapolis. Indiana.

being reponed concurrently in the Federal Register. Ap-pendix A (see Event Type 5 in Table A-1) of this report Nature and Probable Consequences-A 31-month old notes that a therapeutic dose that is greater than 1.5 times patient, being treated for a brain tumor, was to receive the prescribed dose can be considered an abnormal occur -

two cobalt-60 teletherapy treatments of 150 rads each for rence. In addition, Appendix A (see example 2 of"For All a total dose of 300 rads to reduce swelling behind the pa.

Ijcensees") notes that an exposure to an individualin an tient's eye.The dosimetrist mistakenly prepared the dose unrestricted area such that the whole body dose received calculations for 300 rads per treatment.ne patient was exceeds 0.5 rem in one calendar year may be considered z

an abnormal occurrence.

treated November 13 and 14,1992, with 300 rads per treatment for a total dose of 600 rads.

Date and Place-November 16,1992; Indiana Regional Cancer Center; Indiana, Pennsyh'ania.

Prior to the treatment, the treatment plan was reviewed by the treating physician. Following the treatments, the Nature and Probable Consequences-On December 1, dose calculations were reviewed by a medical physicist 1992, the licensee. Oncology Services Corporation and approved. The error was discovered by a student (OSC), notified NRC Region I of the loss of an approxi ~

technologist dunng a monthly chart review on December mately 4.3-curie scaled iridium-192 source from their 2,1992.

high dose rate (HDR) remote afterloader unit at their In-diana Regional Cancer Center (IRCC), Indiana, Pennsyl-Both the patient's referring phys 1cian and guardian were vania. The licensee stated that they were notified by a lo-informed of the misadmmtstration. The treatment ac-cal nursing home that a manager from Browning-Ferris complished its intended purpose and the swelling was re-Industries (BFI), a biological and hazardous waste han-duced. The licensee reported that no adverse medical ef-dier, found radioactive materialin the biowaste that was fects were expected because of the additional radiatior' picked up from the nursing home. The licensee per-t exposure.

formed radiological surveys of the HDR and noted that

• "# *** * ** "E' Cause or Causes-The error was caused by the mistaken calculations by the dosimetrist and by the apparent inade-On December 1,1992, Region I dispatched a section chief quate review by the physician before the treatment began-and inspector to the IRCC to ascertain the facts sur-ne doses notTnally used for this type of treatment are rounding the loss of the iridium-192 source and how it was 300 rads per treatment, and this further contributed to transferred to BFI facilities. On December 3,1992, the the failure to identify the error before the treatments oc-NRC upgraded its response to an Incident Investigation curred. Here was also a problem with the legibility and Team (IIT). On February 8,1993, the IIT presented its t

format of the treatment plan.

findings (NUREG-1480) to the Nuclear Regulatory Commission (Ref. 7). De following are synopses of the Actions Taken to Present Recurrence Region I inspection and IIT findings.

Licensee-The licensee has provided additional training On November 16,1992, an elderly patient was treated for i

to treatment personnel to eliminate the types of problems anal carcinoma at the IRCC in Indiana, Pennsylvania, us-that contributed to the misadministration. The licensee ing HDR brachytherapy. The patient died on the evening also intends to revise the treatment form to make it more of November 21,1992, five days after the treatment. Be-understandable.

fore the treatment, five catheters were placed in the tu-mor. Du ring the treatment, an approximate 4.3-curie irid-NRC-The NRC retained a medical consultant to review ium.192 sot.rce was placed at various positions in each the case and to provide clinical assessment of the catheter to irradiate the tumor by use of a remotely con-t 7

NUREG-0090, Vol.15, No. A i

Abnormal Occurrences. 4th Qtr CY92 tmiled Omnitron 2000 afterloader. His treatment was successfully identified a name found with the red-bag the first of a series of three 600-rad treat nents planned by waste in the box, and traced it to the nursing home.

the physician, and the five catheters wer: to remain in the patient for subsequent treatments.

After being notified by BFI, the nursing home called the IRCC on December 1,1992.The cancer center had not On November 16,1992, after a trial run through the five used the HDR afterloader after the single treatment on catheters with a dummy wire, the iridiu Ti source wire was November 16,1992. Upon being informed of the source l

placed in four catheters without difficulty. After several discovery, the medical physicist determmed that no unsuccessful attempts to insert the source wire and the source was present in the HDR afterloader and informed dummy wire into a fifth catheter, the.reatment was ter-the NRC Region I office of this fact. He physician and minated. An area radiation monitor in the treatment area the medical physicist drove to Carnegic and retneved the source.

was observed in an alarm condition at various times when the source should have been retracted during the unsuc-A second Omnitron 2000 source wire broke at the cessful attempts to insert the source wire through the Greater Pittsburgh Cancer Center (GPCC) of OSC on catheter. Although three technologists and the physician December 7,1992.This wire broke in the same approxi-attending the patient ere aware of the alarm condition, mate location as the first wire. He GPCC medical physi-no one conducted a survey for radiaaon levels with the cist who was conducting the treatment w:s aware of the available portable radiation survey instrument. ne only first incident and immediately recognized the problem action taken was to check the control console of the HDR and promptly and appropriately intervened, thereby pre-remote afterloader. Because the console mdicator venting significant dose consequences to the patient or showed " safe," they beheved the source to be fully re-the cancer center staff.

tracted into the lead shield and assumed the area radia.

tion monitor was malfunctioning.n:y were unaware the An NRC medical consultant concluded that an analysis of source wire had broken, leaving the source in one of the the medical records and phpical dosimetry would indi-catheters in the patient. The patient was transported by cate that the massive radiation dose was a probable con-ambulance, with the source, to a local nursing home.

tributing cause of death in this patient. The licensee re-ported the prescribed dose at one centimeter was 1,800 He source remained in the patient's body for almost four rads to be delivered in three treatments and that the de-days. The catheter with the source came loose on the livered dose was 1,600,000 rads to the same point, an fourth day and, eventually, the catheter fell out early on overdose of about three orders of magnitude. ne licen-the moming of November 20,1992. It was placed in a see stated the effect on the patient would be significant medical bichazards bag (red-bag)in a storage room by local tissue damage and possible significant tissue damage nursing home personnel who did not know it contained to organs outside the treatment area, depending upon the the radioactive source. later, on the same day, the cathe-progression of radiation damage with time before the pa-ter containing the source was moved to another stora;c tient expired. He licensee stated the dose was of suffi-hication at the nursing home and placed in a box with cient magnitude that it believed it was highly probable other red bags. From November 16 through November that the radiation exposure was at least a contributing fac-25,1992, numerous residents, employees, and visitors to tor to the patient's subsequent death. In a press release the nursing home were unknowing;y irradiated. De arn-dated January 26, 1993, the Indiana County Coroner bulance staff who retumed the patient to the nursing stated that the cause of death listed in the official autopsy home were irradiated along with employees and patients tw was " Acute Radiation Exposure and Conse-at the IRCC.

quences hereof."

On November 25,1992, a driver from BFI picked up the In addition to the patient, the team evaluated the radia-red-bag biowaste and transported it to a BFI facility in tion doses to 94 persons associated with the IRCC event.

Carnegie, Pennsylvania, and from there, it was trans-Radiation doses received by these m, dividuals ranged be-tween 40 mrem and 22 rem.

ported to a HFI medical waste incinerator in Warren, Ohio.

Of these individuals, nine residents who were involved in recreational activities at the Scenery liill Manor Nursing At the Warren facility, fixed radiation monitors identified 11ome were not notified regarding the exposure they had radiation emanating from the trailer, and, on facility per-received. The llT was unable to determine their identity.

sonnel direction, the trailer was returned to Carnegic rhe ne rest of the individuals were notified either by the same day. It was left over the weekend and on Monday, NRC or were monitored by their employer for occupa-November 30,1992, the ilF1 staff searched the truck for tional dose.

the radUtion source. Bey identif_ed the box with the ra-diation source and looked at indnidual red bags to iden-Cytogenetic studies were also performed on a number of tify the erigin of the waste. On December 1,1992, HF1 these exposed individuals and the results were consistent N UREG-0000, Vol.15, No. 4 8

Abnormal Occurrences, 4th Qtr CY92 with calculated doses within the limits of accuracy of both wear a film badge on both occasions when the techniques.The highest extremity dose was calculated to source was encountered, be between 73 to 160 rem to the hands of one of ;he Certi-4.

Overall regulatory oversight was weak. NRC regula-fied Nursing Assistants.

tions do not directly address HDR brachytherapy to No personnel or property contamination occurred and no the extent that teletherapy and low dose rate bra-occupational worker received a whole body radiation dose chytherapy are addressed. Licensing guidance for above the NRC occupational limit of 1.25 rem. While HDR has been unchanged since 1986 in spite of sig-1 members of the public received radiation doses above ap.

nificant changes in medical regulations and other plicable limits, no one received a dose at which acute ra.

rnedical licensing guidance. Inspection guidance for diation injury or clinical signs are expected to occur.

medical licensees does not specifically address HDR brachytherapy. Although inspected by the NRC Re-Cause or Causes-The flT reponed that the event was gion 1 office within a year of initiallicensing, the in-caused by the following:

spection program does not require,early reinspec-tion in cases where licensees significantly expand the 1.

OSC had weaknesses in their radiation safety pro-scope of their program through license amend-gram that were a major contributing cause of the se-me.ats. The regulatory interaction between the riousness of the event and radiation exposure conse-NRC, the FDA, and the involved Agreement States quences. Some of these were a result of a rapid in the regulation and cuthorization of the Omnitron expansion in their HDR brachytherapy program 2000 HDR afterloader is poorly defined.

from one facility to ten facilities in less than a year.

De Radiation Safety Officer (RSO) failed to ensure Action Taken to Prevent Recurrence that the stail at all facilities received adequate radia-Licensee-Licensee actions to prevent recurrence are tion safety trammg and that all management instruc-still undergoing NRC staff review.

tions relating to HDR were being followed.

NRC-The NRC initiated the IIT. The NRC issued Bul-Informal and unwritten procedures that may ha.e letin 92-03 to users of Omnitron 2000 HDR afterloaders been adequate when the licensee possessed one (Ref. 8), Information Notice 92-84 to all NRC licensees HDR unit under the direct control of the RSO were (Ref. 91 and Confirmatory Action Letters curtailing the ineffective for the expanded program.

use of Omnitron 2000 HDR and providing safety precau-tions.

2.

A number of weaknesses were found in the design and testingof the Omnitron2000.Weaknesseswere On January 20,1993, the NRC issued an Order Suspend-identified in the testing and validation of source-ing License (Effective lmmediat ely) to preclude the licen-wire design, and in the design of certain safety fea-see from performing licensed activities at any of its facili-tures of thc HDR afterloader.These could allow the tiespendingfurtherorder(Ref.10).lssuanceof thisorder undetected retraction and funher use of a broken does not preclude additional enforcement action.

wire with no warning to the user. Although not con-tributing to this event, weaknesses were found in Future reports will be made as appropriate.

Omnitron's quality assurance / quality control (QAl QC) program.The cause of the wire failure is not 92-19 Medical Therapy Misadmini-known with certainty at this time. The vender be-stration and Temporary Loss of lieves it has evidence to show that stomge of the Brachytherapy Source at Yale-source wire in teflon, if moisture is present, causes New Haven Hosp.tal.in New Haven, i

degradation of the teflon with release of fluorine or hydrogen fluoride that causes degradation of the Connecticut Nitinol (nickel-titanium alloy) wire. The NRC and De follewing information pertaining to this event is also its consultant are still evaluating this hypothesis and being reported concurrently in the Federal Register. Ap-conducting further studies pendix A (see Event Type 3 in Table A-1) of this report notes that a therapeutic exposure to a part of the body not 3.

He safety culture at IRCC contributed significantly scheduled to receive radiation can be considerm! an ab-to the event. Technologists routinely ignored the n rmal ecurrence.

PrimAlert-10 alarm. Its problems were worked around and not fixed. Technologists did not survey Date and Place-December 2,1992; Yale-New Haven patients, the afterloadct, or the treatment room fol-Hospital; New Haven, Connecticut.

lowing HDR treatments. No one was sure who was responsible for radiation safety training or the radia-Nature and Probable Consequences-On December 2, tion safety program. The authorized user failed to 1992, the NRC was notified by the licensee that it had re-9 NUREG-0090. Vol.15, No. 4

\\

J

Abnormal Occurrences. 4th Qtr CY92 covered a 35 millicurie brachytherapy source that was dis-had not been checked for the presence of a brachytherapy covered to be missing earlier that day. On December 3, source.

1992, NRC Region I was notified that the source had probably been lost before or during a brachytherapy Actions Taken to Prevent Recurrence treatment, resulting in a therapeutic misadministration.

A female patient, approximately 39 years old, was to re-Licensee-ne licensee has taken the following steps:

ceive 1,848 rads to the cervix for cancer treatment. One of the sources that was prescribed was either neverinserted 1.

Physicians have been instructed to visually confirm or was removed from the applicator during treatment. As-that sources are properly loaded into applicators.

suming manmum deviation from the planned treatment, 2.

Dosimetrists have been instructed to observe the the actual dose to the patient was only 1,235 rads.The li-7 censee stated that a source was also misplaced and was in loading process and confirm that applicators are cor-contact v i h one of the patient's legs for a period of time, rectly loaded.

t resulting in an estimated dose to the leg of 260 rads. He 3.

A linen hamper will be placed in each brachytherapy l

physicians responsible for the treatment, after reviewing the dose estimates, decided no additional treatments patient's room so that Imen wzil not, generally, be removed until after the final room survey to confi:m were necessary.

that no sources have been lost.

The misplaced source was inadvertently put with hospital 4.

Soiled linen that annot be left in the room until the a

linen. ne linen with the brachytherapy source was taken end of treatment will be surveyed to ensure that no to an off-site laundry facility, from which it was subse.

sources are in the linen prior to its removal from the.

quently recovered.

patient's room.

5.

Physicians have been instructed to visually check for i

The referring physician Lnd patient were notified of the the presence of sources at the time they are removed misadministration.

from the patients.

NRC-The NRC retained a medical consultant to review Cause or Causes-He licensee failed to recognize the the case to provide clinical assessment of this misadmi-significance to radiation safety of a procedural change nistration. NRC Region I conducted a special inspection i

that eliminated the use of disposable pads in favor of on December 3-4,1992, and three violations of NRC re-reusable linen pads. Previously, the licensee disposed quirements were identified: 1) failure to survey soiled pads by putting them in infectious waste, which stayed in linen pads prior to removing them from a patient's room; tbc room unti' after the final radiation survey was per-2)lws of contrel of the radioactive source; and 3) exis-formed, after removal of the radiation sources.The reus-tence of radiation levels above the regulatory limit in un-able pads, when changed, were placed in laundry bags in restricted areas. Enforcement action is under considera-the hallway, w hich were taken to the laundry facility daily.

tion.

The nursing staff failed to follow the procedure that pro-hibited removing anything from the patient's room that Futare reports will made as appropriate.

Agreement State Licensees Procedures have been developed for the Agreement events to the NRC for inclusion in these quarterly reports Stat es to screen unscheduled incidents or events using the to Congress. For this period, the Agreement States re-same crit eria as the NRC (see Appendix A) and report the ported no events as abnormal occurrences.

NUREG-0090 Vol.15, No. 4 10

Abnormal Occurrences, 4th Qtr CY92 REFERENCES 1.

U.S. Nuclear Regulatory Commission, NRC Infor-6.

Letter from Richard W. Cooper, II, Director, Divi-mation Notice 92-60, " Operation with Steam Gen-sion of Radiation Safety and Safeguards, NRC Re-erator Tubes Seriously Degraded," December 7, gion I, to Douglas Harding, Senior Vice President, 1992.*

Lahey Clinic Foundation, forwarding Inspection Re-port No. 030-01879/92-001, Docket No. 03041879, 2.

Ixtter from Marvin W. Hodges, Director, Division January 12,1993.*

of Reactor Safety, NRC Region I, toJohn F. Opeka, Executive Vice President, Nuclear, Northeast Nu-7.

U.S. Nuclear Regulatory Commission, NUREG-c! car Energy Company, forwarding Inspection Re-1480,"Ioss of an Iridium-192 Source and Herapy port ho. 50-336/92-22 and Notice of Violation, Misadministration at Indiana Regional Cancer Cen-Docket No. 50-336, License No. DPR-65, January ter, Indiana, Pennsyhania, on November 16,1992,"

11, 1993.*

February 1993.*

3.

U.S. Nuclear Regulatory Commission, NRC Infor-8.

U.S. Nuclear Regulatory Commission NRC Bulletin mation Notice 93-11," Single Failure Vulnerability 92-03," Release of Patients after Brachytherapy",

of Engineered Safety Features Actuation Systems,"

December 8,1992.*

February 4,1993.*

9.

U.S. Nuclear Regulatory Commission, NRC Infor-4.

Ixtter from L J. Callan, Director, Division of Ra-mation Notice 92-84,

• Release of PatientsTreated diation Safety and Safeguaals. NRC Region IV, to with Temporary Implants", December 17,1992.*

Jon M. Gates, Administrator, Memorial Hospital of Iaramie County, forwarding NRC Inspection Re-

10. 12tter from Hugh L Thompson,Jr., Deputy Execu-port No.

030-03496/92-02, License No, tive Director for Nuclear Materials Safety, Safe-49-01380-01, Docket No. 030-03496, February 2, guards and Operations Support, NRC, to Oncology 1993.*

Services Corporation, forwarding Order Suspending License (Effective Immediately), License No.

5.

lxtter from Thomas T. Martin, Regional Adminis-37-28540-01, Docket No. 030-31765, January 20, trator, NRC Region I, to Stanley Sebastian, Vice 1993.*

President of Operations St. Clares Riverside Medi-o,1 Center, forwarding Notice of Violation and Pro-is adable for inspection or i for a fx in the NRC

.A @ Document Room. 2120 LStreet

. (Iower tevel), Wash-posed imposition of Civil Penalties, Docket No.

Pu 030-09606, January 11,1993 ington, oc 20555.

l l

l l

l l

11 NUREG-0090, Vol.15, No. 4

Abnormal Occurrences, 4th Otr CY92 I

APPENDIX A ABNORMAL OCCURRENCE CRITERIA The following criteria for this report's abnormal occur-release of radioactive material from a package in rence (AO) determinations were set fonh in an NRC pol-amounts greater than the regulatory limit.

j icy statement published in the FederalRegister on Febru-ary 24,1977 (Vol. 42, No. 37, pages 10950-10952).

5.

Any loss of licensed material in such quantities and under such circumstances that substantial hazard An event will be considered an AO if it involves a major may result to persons in unrestricted areas.

reduction in the degree of protection of the public health 6.

A substantiated case of actual or attempted theft or or safety. Such an event would involve a moderate or diversion of licensed material or sabotage of a facil-more severe impact on the public health or safety and could include but need not be limited to:

ity.

t 7.

Any substantiated loss of special nuclear material or 1.

Moderate exposure to, or release of, radioactive ma-any substantiated inventory discrepancy that is terial hcensed by or otherwise regulated by the Com-judged Io be significant relative to normally ex-mission; pected performance and that is judged to be caused by theft or diversior or by substantial breakdowntf 2.

Major degradation of essential safety-related equi -

the accountability system.

P ment; or 8.

Any substantial breakdown of physical security or 3.

Major deficiencies in design, construction, use of, or material control (i.e., access control, containment, management controls for licensed facilities or mate-or accountability systems) that significantly weak-rial.

ened the protection against theft, diversion, or sabo-

[

tage.

Examples of the types of events that are evaluated in de-9.

An accidental criticality [10 CFR 70.52(a)].

tail using these criteria are:

10. A major deficiency in design, construction, or opera-For All Licensees tion having safety implications requiring immediate remedial action.

1.

Exposure of the whole body of any individual to 25 remormoreof radiation;exposureof theskinof the

11. Serious deficiency in management or procedural

[

whole lxx!y of any individual to 150 rem or more of controls in major areas.

radiation; or exposure of the feet, ankles, hands or forearms of any individual to 375 rem or more of ra-

12. Series of events (where individual events are not of diation [10 CFR 20.403(a)(1)], or equivalent expo-major imponance), recurdng incidents, and inci-sures from internal sources.

dents with implications for similar facilities (generic incidents) that create major safety concern, 2.

An exposure to an individual in an unrestricted area such that the whole body dose received exceeds 0.5 For Commercial Nuclear Power Plants rem in one calendar year [10 CFR 20.105(a)].

1.

Exceeding a safety limit of license Technical Specifi-cations [10 CFR 50.36(c)].

3.

'lhe release of radioactive material to an unre-stricted area in concentrations which, if averaged 2.

Major degradation of fuel integrity, primary cool-k over a period of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, exceed 500 times the regu-ant pressure boundary, or primary containment latory limit of Appendix II, Table II,10 CFR Part 20 boundary.

[CFR 20.403(b)(2)].

3.

Irss of plant capability to perform essential safety 4.

Radiation or contamination levels in excess of design functions such that a potential release of radioactiv-values on packages, or loss of confinement of radio-ity in excess of 10 CFR Pan 100 guidelines could re-active material such as (a) a radiation dose rate of sult from a postulated transient or accident (e.g., loss 1,000 mrem per hour three feet from the surface of a of emergency core cooling system, loss of control rod package containing the radioactive material, or (b) system).

13 NUREG-0090, Vol.15, No. 4

_m Abnormal Occurrences. 4th Ott CY92 i

i

+

r 4.

Discovery of a major condition not specifically con-2.

A major condition not specifically considered in the l

sidered in the Safety Analysis Report (SAR) or safety analysis report or Technical Specifications Technical Specifications that requires immediate re-that requires immediate remedial action.

medial action.

3.

An event that seriously compromised the ability of a confinement system to perform its designated func-5.

Personnel error or procedural deficiencies that re-tion.

sult in loss of plant capability to perform essential l

safety functions such that a potential release of ra-Medical Misadministrations dioactivity in excess of 10 CFR Part 100 guidelines could result from a postulated transient or accident As discussed in t he Preface to this report, the NRC policy (e.g., loss of emergency core cooling system, loss of statement on AOs was published before licensees were control rod system).

required to report medical misadministrations to the i

NRC.Therefore, during 1984,the NRC developed guide- '

lines for selecting such events for AO reponing. These guidelines, which are summarized in Table A-1, augment I'or Fuel Cycle Licensees the NRC policy statement.

l 1.

A safety limit of license Technical Specifications is As noted in the Preface, revised guidelines are currently exceeded and a plant shutdown is required [10 CFR being developed because new medical misadministration 50.36(c)].

definitions became effective on January 27,1992.

I i

i I

i l

l t

i I

l i

i l.

1 t

t t

I

.i t

i NURliG-0090, V' l.15, No. 4 14 l

o i

Abnormal Occurrences, 4th Qtr CY92 Table A.1 NRC Guidelines for Selecting Medical Misadministration Events for Abnormal Occurrence (AO) Reporting AO Reporting Threshold Event Type Diagnostic Exposure Therapeutic Exposure (1) Administering a radiopharma-If theimproperadministration If theimproperadministration ceutical or radiation from a results in any part of the results in any part of the body sealed source other than the body receiving unscheduled receiving unscheduled radiation, an one intended.

radiation, an AO report should AO report should be proposed for be proposed if:

any such event.

(a) the actual dose to the If the parts of the body wrong body part is receiving radiation greater than five times improperly would have the upper limit of the received radiation anyway, normal range of had the proper administration exposures prescribed been used, an AO report for diagnostic procedures should be proposed if:

invoh'ing that body part, or (b) there are clinical (a) the actual dose is greater indications of any than 1.5 times that intended adverse health effects to the above described body to the wrong body part.

parts, or, If the parts of the body (b) the actual dose is less than receiving radiation 0.5 times that intended to the improperly would have above described body parts, or, received radiation anyway, had the proper administration (c) the above described body parts been used, an AO report should show signs of adverse health be proposed if:

effects greater than expected had the proper administration been used, or (a) the actual dose is greater (d) the event (regardless of any than five times that intended health effects)affects two or to the above described body more patients at the same parts. or, facility.

(b) the above described body parts show signs of adverse health effects greater than expected had the proper administration been used.

(2) Administering a radio-An AO report should be An AO report should be pharmaceutical or radiation proposed if:

proposed for any such event.

to the wrong patient.

(a) the actual dose to the wrong patient exceeds five times the prescribed dose for the intended patient, or (b) the event results in any adverse health effects.

(3) Administering a radiophar-Same guidelines as for Same guidelines as for maceutical or radiation by a Event 'lype 1.

Event Type 1.

15 NUREG-0090, Vol.15, No. 4

Abnormal Occurrences, 4th Otr CY92 6

Table A.1 (Continued)-

AO ReportingThreshold Event Type Diagnostic Exposure Therapeutie Exposure route of administration other than that intended by the pre-scribing physician.

(4) Administering a diagnostic An AO report should be Not applicable.

dose of a radiopharma-proposed if:

ceutical differing from the prescribed dose by more (a) the actual dose is than 50 percent.

greater than five times the prescribed dose, or, (b) the event results in adverse health effects worse than expected for the normal range of exposures prescribed for the diagnostic procedure.

(5) Administering a Not applicable.

An AO report should be therapeutic dose of proposed if:

a radiopharmaceutical differing from the prescribed (a) the actual dose is greater dose by more than 10 percent; than 1.5 times the prescribed or administering a therapeutic dose,or, radiation dose from a sealed source such that errors in the (b) the actual dose is less than source calibration, time of 0.5 times the prescribed dose,or exposure, and treatment geometry result in a calculated total treatment dose differing (c) the event results in adverse health effects worse than from the final prescribed total treatment dose by more would be expected for the than 10 percent.

normal range of exposures prescribed for the therapeutic procedure,or, (d) the event (regardless of any health effects)affects two or more patients at the same facility.

(6) Recurring or series For either diagnostic or therapeutic exposures, an AO report of events (regardless should be proposed for recurring events or a series of events of the number of (in which each individual misadministration is not of major patients or facilities importance) that create a significant public health Or Safety

. involved).

Concern.

(7) Generic events.

For either diagnostic or therapeutic exposures, an AO report should be proposed for misadministrations with generic implications that create a significant public health or safety concern.

- NUREG-0090, Vol.15. No. 4.

16

Abnormal Occurrences. 4th Qtr CY92 APPENDIX B UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES During the October through December 1992 period, the initial and any subsequent updating information on NRC licensees, Agreement States, Agreement State li-the abnormal occurrences discussed. (he updating pro-censce::, and other involved parties, such as reactor ven-vided generally covers events that took place during the dors and architect-engineering firms, continued with the report period; some updating, however, may be more cur-implementation of actions necessary to prevent recur-rent as indicated by the associated event dates.) Open rence of previously reported abnormal occurrences.Ee items will be discussed in subsequent reports in the series.

referenced Abnormal Occurrence Reports below provide Nuclear Power Plants 92-4 Loss ofIligh-Head Safety Injection Ca-and system modifications to prevent recurrence of the pability at Shearon Harris Nuclear problem.De NRC staff conducted an inspection to re-view the facts and circumstances regarding the reported Power Plant loss of the high-head safety injection system, and the re-his abnormal occurrence was originally reported in sults of the inspection were reported in a special team in-NUREG-0090, Vol. IS, No. 2, " Report to Congress on spection report (Ref. B-1). In letters dated October 9,12, Abnormal Occurrences: April-June 1992." ne eventin_

and 28, and November 5,1992, the licensee submitted de-tails of the modification and stated that the modified al-volved degradation of piping and relief valves used in the recirculating flow paths of the high-head safety injection ternate miniflow system design will eliminate previously system.The abnormal occurrence is updated and closed identified weaknesses. During refueling outage 4, the re-out as follows:

lief valves were removed and orifices installed to regulate the recirculation flow.ne NRC staff reviewed the modi-As previously mentioned, the event involved degradation fication and found it acceptable on November 27,1992 of piping and relief valves used in the high-head safety in.

(Ref. B-2).This resolves'the event at Shearon Harris.

jection system at the Shearon Harris Nuclear Power Plant, Unit 1. nis degradation was reported initially on On November 6,1992, the NRC issued Information No-April 3,1991, by the licensee as adversely impacting the tice 92-61, Supplement 1, to alert all holders of operating performance of the system during the previous operating licenses or construction permits for nuctcar power reac-cycle, should it have been required to operate and deliver tors to additional developments relating to this event water to the reactor coolant system.

(Ref. B-3).

In a supplement to Licensee Event Report 91-08, the li-nis item is considered closed for the purposes of this re-censee documented additional testing done on the system port.

Other NRC Licensees 92-7 Medical Diagnostic Misadmi-occurred at the licensee's facility on May 18,1992. A diag-nostic dose of 16 microcuries was intended; however, a nistration at Baystate Medical Ih*' P*"*I' d 5*

I 4'I *iIII*"'i*8 **8 "d**, 'S**'*d-Center, Incorporated, in Springfield, Massachusetts ne NRC inspection identified two apparent violations of NRC requirements: (1) failure of authorized user to pre-His abnormal occurrence was originally reported in pare a written directive, and (2) failure to follow proce-dures. An enforcement conference was held on June 23, NUREG-0090, Vol.15, No. 2,

• Report to Congress on 1992. As a result, the NRC issued a Notice of Violation Abnormal Occurrences: April-June 1992." The abnor.

mal occurrence is updated and closed out as follows.

and Proposed Imposition of Civil Penalty in the amount of $2,000. He licensee responded to the notice by re-questing mitigation of the civil penalty amount and deny-As previously mentioned, on May 20,1992, the licensee, ing part of one violation.

Daystate Medical Center, in Springfiehl, Massachusetts, notified the NRC by telephone that a medical misadmi-De NRC considered the licensce's request for full miti-nistration involving iodine-131 radiopharTnaceuticals had pation of the $2000 Civil Penalty that was proposed on 17 NUREG-0090, Vol.15, No. 4

Abnormal Occurrences, 4th Qtr CY92 August 21,1992, and concluded that an adequate basis nelicensee's corrective and preventive actions included:

was not provided for mitigation. An Order Imposing a (1) training for all Radiation Herapy staff on August 12, 1992, to review standard operating procedures for exter-Civil Monetary Penalty in the amount of $2000 was issued nal beam therapy; (2) increased supervisory review and on January 6,1993 (Ref. B-4). He licensee paid the civil evaluation of existing procedures to ensure comprehen-penalty on January 21,1993.

sion and implementation; and (3) strengthening of other existing procedures to ensure that periodic reviews of the his item is considered closed for the purposes of this re-Radiation herapy Technologist's activities are con-port.

ducted.

He NRC Region I staff conducted an inspection on No-92-11 Medical Therapy M.isadm,inistrat. ion vember 19,1992 and held an enforcement conference at the Medical Center of Delaware, with the licensee on Dcccmber 17,1992, to discuss the in-Incorporated,in Wilmington, SPection findings (Ref. B-5). As a result, three violations of NRC requirements that related to the ticensee' simple-Delaware mentation of its Quality Management Program and that contributed to the misadministration were identified.ne His abnormal occurrence was originally reported m.

violations were classified in the aggregate as a Severity NUREG-0090, Vol.15, No. 3, " Report to Congress on level III problem (on a scale in which Severity Ixvels I Abnormal Occurrences: July-September 1992." De ab-through V are the most and least significant, respec-normal occurrence is updated as follows:

tively). No fine was proposed for the violations (Ref.

B-6). The licensee's corrective and preventive actions As previously mentioned, on August 12,1992, NRC Re-will be reviewed during the next inspection of the licen-gion I was notified by telephone by the licensee's radia-see's program.

tion safety officer that a therapeutic misadministration in-volving a cobalt-60 teletherapy unit had occurred at the Unless new, significant information I ecomes available, Medical Center of Delaware's Christiana llospital on the the item is considered closed for the purposes of this re-previous day.

port.

a

Abnormal Occurrences, 4th Otr CY92 APPENDIX C OTHER EVENTS OF INTEREST ne following item is described because it may possibly be the level of protection provided for public health or perceived by the public to be of public health or safety sig-safety; therefore, it is not reportable as an abnormal oc-nificance. He item did not involve a major reduction in currence.

Other NRC Licensees 1.

Medical Therapy Misadministration at ment time, the dosimetrist used the total head thickness of 16 centimeters instead of the midline measurement of St. John's MedicalCenterin Anderson, 8 centrmeters.

Indiana The oncologist who prescribed the treatments reviewed On November 6-12,1992, a patient was to be treated for cancer that had spread to the brain. The treatment plan the patient's chart, but did not verify that the parameters used in the treatment calculations were correct. Two called for a total dose of 3,000 rads to be delivered to the teletherapy technologists who were assigned the case brain in 10 individual treatments using a cobalt-60 questioned the uausually long treatment time among teletherapy device. He whole brain treatments were to themselves, but did not raise the question with the on-be followed by a series of localized treatments. Each whole brain treatment was to consist of two 150 rad treat.

cologist or the dosimetrist.

ments, one from each side, for a total of 300 rads per day.

De error was found during a weekly chart check by the De daily treatments began on November o,1992.

medical physicist on November 12. On November 13 the Because of a calculational error, the patient received ap.

senior medical physicist, who had been absent from the proximately ~10 percent more than the prescribed dose in hospital during the treatment series, returned and veri-fied the error.

the first five daily treattnents. After the fifth treatment on November 12,1992, the error was discovered.The whole brain treatment procedure was terminated, and further The attending physician and patient were notified of the localized treatments were carried out as originally misadministration.

planned.De intended dose in the five treatments given was 1,500 rads. De dose actually delivered was 2,550 rads The licensee has revised its procedures to require a re-for the fis c treatments.

view of dose calculations within two working days of the first treatment in a series of three or more treatments.

The NRC retained a medical consultant to review the cir-The checks will be made by both a physician and a medical cumstances of the case. He consultant determined that physicist, neither of whom made the original calculations.

the actual dose received by the patient represents the Other qualified personnel will make the checks if the pri-peak tolerance of the brain for radiation, carrying a 5 per-mary personnel are not available. For series of three cent risk of radiation necrosis in 4 to 12 months.The licen-treatments or less, the rechecks will be made before the see, however, reponed that the patient's physician did not treatments begin.

cxpect any adverse effects from the misadministmtion.

NRC Region Ill conducted a special inspection on No-The misadministration war the result af a calculational er-vember 24,1992, to review the circumstances surround-ror by the dosimetrist. He dosimetrist measured the ing the misadministration (Ref. C-1). A medical consult-thickness of the patient's head to be 16 centimeters with a ant was also retained to review the case. Enforcement midline point of 8 centimeters. In calculating the treat-action on the inspection findings is pending_

19 NUREG-0090, Vol.15 No. 4

Abnormal Occurrences, 4th Otr CY92 REFERENCES FOR APPENDICES B-1 12tter from Steven A. Varga, Director, Division of Region I, to Raymond Seigfried, Vice President, Reactor Projects, NRC to R. N Watson, SeniorVice Clinical and Material Management Services, The President, Nuclear Generation, Carolina Power &

Medical Center of Delaware, Inc., forwarding In-Light Company, forwarding Inspection Report No.

spection Report No. 030-17578/9242, Docket No.

50-400/92-201, Docket No. 50-400, September 1, 030-17578, License No. 07-12153-03, December 4, 1992.*

1992.*

B-2 12tter from Ngoc B. Le, Project Manager, Division B-6 letter from Thomas T. Martin, Regional Adminis-of Reactor Projects, NRC to R. A. Watson, Senior trator, NRC Region I, to Raymond Seigfried, Vice Vice President, Nuclear Gercration, Carolina President, Clinical and Material Management Serv-Power & Light Company, forwarding Safety Evalu-ices, The Medical Center of Delaware, Inc., for-ation, November 27,1992.*

warding Notice of Violation, Docket No. 030-17578, License No. 07-1215343, January 20,1993.*

B-3 U.S. Nuclear Regulatory Commission, NRC Infor-mation Notice 92-61, Supplement 1," Loss of High C-1 letter from Charles E. Norelius, Director, Division Head Safety Injection," November 6,1992.*

of Radiation Safety and Safeguards, NRC Region III, to James Moore, Vice President, Clinical B-4 Letter from James lieberman, Director, NRC Of-Services, St. John's Medical Center, Anderson, fice of Enforcement, to Joseph Tye, Acting Execu-Indiana, forwarding Inspection Report No.

tive Vice President, Chief Operating Officer, Bays-030-19555/92001, License No. 13-17793-02, tate Medical Center, Incorporated, forwarding Docket No. 030-19555, December 24,1992.*

Order Imposing Civil Monetary Penalty, Docket No.

030-09946, License No. 20-01412-05, January 6, 1993*

B-5 Ixtter from Richard W. Cooper II, Director, Divi-

'hcNE*nS*No'.i"N s"EcNM (NN[).SaSin 2

sion of Radiation Safety and Safeguards, NRC son. DC 20555.

21 NUREG-0090, Vol.15, No. 4 i

__m NRC FORM 335 U.S. NUCLEAR REGULATORY COMM!SSION

1. REPORT NUMBER j

supp.oned try fac, Ads voi..

fAni c24o1

, Rav., and Addendurn Num-NROM 1102, 3201. 3202 BIBLIOGRAPHIC DATA SHEET bars. " *av-) -

(See instructions on the reverse)

NUREG-0090 Vol.15, No. 4

2. mLE Ato SUBMLE

• ' ^ ' ' " ' " " ' " " " " * * "

Report to Congress on Abnormal Occurrences:

l October-December 1992 MONN YEAR j

March 1993

4. FIN OR GRANT NUMBER

6. AU1 Nom 6)

6. TYPE OF REPORT Ouarterly

7. PERIDD COVERED (inclusive Dates) l October - December 1992

8. PERFORMING ORGAN!ZATION - NAME AND ADDRESS (If NRC, provide DMston, Offeco or Region, U.S. Nuclear Regulatory Commission, and matting address; if contractor, provide name and malling address.)

Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555 l

S. SPONSORING ORGAF4ZAT60N - NAME AND ADDRESS (tf NRC, type *Same as above"; if contractor, provide NRC DMs6an, Offtos or Region, U.S. Nuclear Regulatory Commission, and malilnD address.)

Same as 8., above t

10. SUPPLEMENTARY NOTES

11. ABSTRACT (200 words or less)

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 and safety and requires a quarterly report of such events to be made to Congress. This report covers the period October through December 1992.There were two abnormal occurrences at nuclear powe.r plants. Six abnormal oc-currences involving medical midadministrations (all therapeutic) at NRC-licensed facilities are discussed in this re-port. No abnormal occurrences were reported by NRC's Agreement States. The report also contains information updating prcviously reported abnormal occurrences.

l i

i i

I

12. KEY WORDS/DESCRIPTORS (List words or pewsses that will assist researchers in locattnD the ep.)

13. AVAILABluTY STATEMENT Unlimited -

14. SECURrrY CLASSIFleATION Abnormal OccurTence, Nuclear Power Plant, Report to Congress, AEOD (This rsse)

Medical'Iterapy Misadministrations Unclassified Degradation, Steam Generator, Engineered Safety Feature, Design Deficiency

<This neport)

Unclassified is. NuuBER OF PAGEs

16. PRICE NRC FORM 335 (249)

i i

1 i

r l

'f t

I i

Printed on recycled paper Federal Recycling Program 1

,1

M;kto-oo99, Vol 15. N:,4 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES MARCII 1993 UNITED STATES NUCLEAR REGULATORY' COMMISSION FIRST CLASS Mall WASH!NGTON, D.C. 20555-0001 FO5TAGE AND FEES PAID UsNnc FERMIT NO. G 67 OFTICIAl. BUSINESS f-NJ T '

PENAt.TY FOR PRIVATE USE, 5300

• • • I s n..

4 estr. i )

I 3

1 ~;q n

., e. si

^,

gg, r ^ y_ m m e' L ',,

p. T r.

l g ; !: & ' '

t