ML20066J104

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Report to Congress on Abnormal OCCURRENCES.July-September 1990
ML20066J104
Person / Time
Issue date: 01/31/1991
From:
NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V13-N03, NUREG-90, NUREG-90-V13-N3, NUDOCS 9102250192
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N U REG-0090 Vol.13 No. 3

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n R-eaor: :o congress on A3norn1a1 Occurrences July - September 1990 U.S. Nuclear Regulatory Commission Office for Analysis and Evahiation of Operational Data oe"%

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NUREG-0090 Vol.13, No. 3 Report to Congress on Abno.rmal Occurrences July - September 1990 Date Published: January 1991 Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555 f*"*%,

Previous Reports in Series NUREG 75/090, January-June 1975.

NUREG-0090, Vol.6, No.1, January-March 1983, published October 1075 pu'blished September 1983 NUREG-0090-1, July September 1975, NUREG-0090, Vol.6, No.2, April-June 1983, 1

-published March 1976 published November 1983 NUREG-0090-2, _0ctober-December 1975 NUREG-0090, Vol.6 No.3, July-September 1983, published March 1976 published April 1984 NURZG-0090-3, January-March 1976 NUREG-0090, Vol.6, No.4,-October-December 1983, published JulyL1976 published May 1984 NUREG-0090-4, April-June 1976, NUREG-0090, Vol.7, No. l. January-March 1984, published March 1977 published July 1984

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NUREG-0090-5, July-September 1976, NUREG-0090, Vol.7, No.2, April-June 1984, published March.1977 published October 1984

'NUREG-0090-6, October-December 1976.

NUREG-0090, Vol.7, No.3, July-September 1984, published June 1977 published April 1985 NUREG-0090-7, January-March 1977, NUREG-0090, Vol.7, No.4, October-Dccember 1984, published June 1977-published May 1985

'NUREG-0090-8 April-June 1977 NUREG-0090, Vol.8, No.1, January-March 1985, published September 1977 published August 1985 NUREG-0090-9, July-September 1977 NUREG-0090, Vol.8, No.2. April-Jnne 1985, published November 1977-published November 1985 NUREG-0090-10, October-December 1977, NUREG-0090, Vol.8, No.3, July-September 1985, published March 1978_

published February 1986 NUREG-0090, Vol.1, No.1, January-March 1978, NUREG-0090, Vol.8 No.4, October-December 1985, published l June 1978 published May 1986

- NUREG-0090, - Vol.1, No.2, April-June 1978, NUREG-0090, Vol.9, No.1, January-March 1986, published. September 1978 published September 1986 (NUREG-0090, Vol.1, No.3, July-September 1978, NUREG-0090, Vol.9, No.2, April-June 1936,.

l

. published December 1978 published January 1987 L NUREG-0090, Vol.1, Nc.4, October-December 1978 NUREG-0090, Vol.9 No.3, July-September 1986, i

published March 1979.

published April 1987 NUREG-0090, Vol.2, No.1, January-Mat ch 1979, NUREG-0090, Vol.9, No.4, October-December ~1986, published July 1979 published July 1987-NUREG-0090,- Vol.2, No.2, April-June 1979, NUREG-0090, Vol.10, No.1, January-March 1987,

" published November 1979 published October 1987 NUREG-0090, Vol.2, No.3, July-September 1979, NUREG-0090, Vol.10 No.2, April-June.1987, cpublished February 1980 published November 1987 NUREG-0090, Vol.2,'No.4, October-December 1979, NUREG-0090, Vol.10. No.3, July-Sept, ember 1987,

. published April-1980 published March 1988 NUREG-0090, Vol.3, No.1, January-March 1980, NUREG-0090, Vol.10, No.4, October-December 1987.

published September 19*3 published March 1988-1 NUREG-0090,l Vol.3, No.2, April-June 1980, NUREG-0090, Vol.'ll, No. l. January-March 1988,

> published November 1980.

published July _1988 NUREG-0090, Vol.3, No.3, July-September 1980, NUREG-0090, Vol.11. No.2. April-June 1988, published February 1981 published December 1988 NUREG-0090 Vol.3, No.4, October-December 1980, NUREG-0090, Vol. ll, No.3, July-September '1938, published May 1981 published January 1989 NUREG-0090,;Vol.4, No.1, January-March 1981, NUREG-0090, Vol.11 No.4, October-December 1988, published July 1981-published April 1989

. NUREG-0090,L Vol.4, No.7, April-June 1981, NUREC-0090, Vol.12. No.l. January-March 1989, s

published October 1981-published August 1989 NUREG-0090, Vol.4, No.3.-July-September 1981, NUREG-0090,' Vol.12, No.2, April-June ' 1989, published ~ January 1982 published October 1989 NUREG-0090,- Vol,4, No.4, October-December 1981, NUREG-0090, Vol.12. No.3, July-September 1989. -

published May 1982-published January 1990 NUREG-0090, Vol.5, No.1, January-March 1982, NUREG-0090, Vol.12 No.4, October-December 1989, i

l published August 1982 published March 1990 l

NUREG-0090. Vol.5, No.2, April-June 1982, NUREG-0090, Vol.13, No.1, January-March 1990, l

published December 1982 published July 1990 l

NUREG-0090, _Vol.5, No.3 ' July-September 1982, NUREG-0090, Vol.13, No.2, April-June, 1990, published January 1983 published October 1990 NUREG-0090, Vol.5, No,4, October-December 1982, published May 1983 l

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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 nade to Congress.

This report covers the period from July 1 through September 30, 1990.

The report discusses six abnormal occurrences, none of which involved a nuclear peser plant. There were five abnormal occurrences at NRC-licensed facilities: nne involved a medical therapy misadministration; three involved medical diagnostic misadministrations; and one involved a significant breakdown in management and procedural controls at a medical facility. The sixth abnormal occurrence was reported by an Agreement State (Arizona); the event involved a medical therapy misadministration, iii

i CONTENTS Page ABSTRACT..............................................................

iii PREFACE...............................................................

vii INTRODUCTION....................................................

vii THE REGULATORY SYSTEM...........................................

vii REPORTABLE OCCURRENCES..........................................

vii AGREEMENT STATES................................................

vili FOREIGN INFORMATION.....................

ix REPORT TO CONGRESS ON ABNORMAL' OCCURRENCES, JULY-SEPTEMBER 1990.......

1 NUCLEAR POWER PLANTS............................................

1 FUEL CYCLE FACILITIES (Other than Nuclear Power Plants).........

1 OTHER NRC LICENSEES (Industrial Radiographers, Medical Institutions, Irdustrial Users, etc.)..............

1 90-16 Medical Therapy Misadministration...................

1 90-17 Medical Diagnostic Hisadministration................

3 90-18 Significant Breakdown in Management and Procedural Control s at a Medical Facility.....................

4 90-19 Medical Diagnostic Misadministration................

6 90-20 Medical Diagnostic Misadministration................ 7 AGREEMENT STATE LICENSEES.......................................

8 AS90-2 Medical Therapy Misadministration...................

9 REFERENCES............................................................

11 APPENDIX A - ABNORMAL OCCURRENCE CRITERIA.............................

13 APPENDIX B - UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES.......

17 APPENDIX C - OTHER EVENTS OF INTEREST................................

19 1.

Diagnostic Dose of Iodine-131 Administered to a Pregnant Patient..................................................

19 2.

Contaminated Water Seepage at Sc 1oyah Fuels Corporation..

20 REFERENCES (FOR APPENDICES)..............

25 V

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4 PREFACE INTRODUCTION The Nuclear Regulatory Commission reports to the Congress each quarter under-provisions of Section 208 of the. Energy Reorganization Act of 1974 on any abnormal occurrences involving facilities and activities regulated by the NRC.

- An abnormal occurrence is defined in Section 208 as an unscheduled incident or event that the Commission determines is significant from the standpoint of

-public health or safety.

Events are currently identified as abnormal occurrences for this report by the 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 dissemination of information to the public, a Federal Register notice is issued on each' abnormal-occurrence. Copies of the notice are distributed to the NRC Public 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 described in this report meet the criteria.for abnormal occurrence. reporting. This report covers the period from July 1 through September 30, 1990.

Information reported on each event includes date and pl' ace, 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 responsibilities is implemented through rules and regulations in Title 10'of the rode of Federal Regulations.

This includes public participation as an element.

To accomplish its objectives, NRC regularly conducts licensing proceedings, inspection and enforcement activities, evaluation of operating experience, and confirmatory research, while maintaining programs for

establishing standards and-issuing technical reviews and studies.

In. licensing and regulating nuclear power plants, the NRC follows the philosophy that the health and safety of the public are best ensured through the establishment of multiple levels of protection. These multiple levels can

'be achieved and maintained through regulations specifying requirements that' will ensure the safe use of nuclear materials.

The regulations incluce design and quality assurance criteria appropriate for the various_ activities licensed by the NRC. An inspection and enforcement program helps ensure compliance with the regulations.

REPORTABLE OCCURRENCES Actual operating experience is.an essential input to the regulatory orocess for_ assuring that licensed activities are conducted safely.

Licensees are re-vii

l quired to report certain incidents or events to the NRC.

This reporting helps to identify deficiencies early and to ensure that corrective actions are taken to prevent rccurrence.

For nuclear power plants, dedicated groups have been formed both by the NRC and by the nuclear power industry for the detailed review of operating experi-ence to help identify safety concerns early; to improve dissemination of such information; and to feed back the experience into li:ensing, regulations, and operations.

In addition, the NRC and the nuclear power industry have ongoing efforts to improve the operational data systems, which include not only the type and quality of reports required to be submitted, but also the methods used to analyze the data, in order to more effectively collect, collate, store, retrieve, and evaluate operational data, the information is maintained in computer-based data files.

Two primary sources of operational data are Licensee Event Reports (LERs) and immediate notifications made pursuant to 10 CFR 50.72.

Except for records exempt from public discl0sure by statute and/or regulation, information concerning reportable occurrences at facilities licensed or other-wire regulated by the NRC is routinely disseminated by the NRC to the nuclear industry, the public, and other interested groups as these events occur.

Dissemination includes special notifications to licensees and other af fected or interested groups, and public announcements.

In addition, infor ation on reportable events is routinely sent to the NRC's more than 100 local public document rooms throughout the United States and to the NRC Public Document Room in Washington, D.C.

The Congress is routinely kept informed of reportable events occurring in licensed facilities.

Another primary source of operational data is reports of reliability data submitted by licensees under the Nuclear Plant Reliability Data System (NPRDS).

The NPRDS is a voluntary, industry-supported system operated by the Institute of Nuclear Power Operations (INP0), a nuclear utility organization.

Both engineering and failure data are submitted by nuclear power plant licensees for specified plant components and systems. The Commission considers the NPRDS to be a vital adjunct to the LER system for the collection, review, and feedback of operational experience; therefore, the Commission periodically monitors the NPRDS reporting activities.

AGREEMENT STATES Section 274 of the Atomic Energy Act, as amended, authorizes the Commission to enter into agreements with States whereby the Commission relinquishes and the States assume regulatory authority over byproduct, source, and special nuclear materials (in quantities not capable of sustaining a chain reaction).

Agree-ment State programs must be comparable to and compatible with the Commission's program for such material.

Presently, information on reportable occurrences in Agreement State licensed activities is publicly available at the State level.

Certain in ormation is r

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also provided to the NRC under exchange of information provisions in the agreements.

In early 1977, the Commission determined that abnormal occurrences happening at facilities of Agreement State licensees should be included in the quarterly reports to Congress. The abnormal occurrence criteria included in Appendix A are applied uniformly to events at NRC and Agreement State licensee facilities.

Procedures have been developed and implemented, and abnormal occurrences reported by the Agreement States to the NRC are included in these yi quarterly reports to Congress.

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

This foreign information is reviewed and considered in the NRC's assessment of operating experience and.in its research and regulatory activities.

Reference to foreign information may occasionally be made in these quarterly abnormal occurrence reports to Congress; however, only domestic abnormal occurrences are reported.

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REPORT TO CONGRESS ON ABNORMAL OCCURRENCES JULY-SEPTEMBER 1990 NUCLEAR POWER PLANTS 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 abnormal occe'rences.

FUEL CYCLE FACILITlis (Other Than Nuclear Powcr Plants}

The NRC is reviewing events reported by these licensees.

For this report, the NRC has not determined that any events were abnormal occurrences.

OTHER NRC LICENSEES (industrial Radiographers, Medical Institutions, Industrial Users, etc.)

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, and academic fields.

Incidents were reported in this category from licensees such as radiograpners, medical institutions, and byproduct material users.

The NRC is~ reviewing events reported by these licensees.

For this report, the NRC has determined that five events were abnormal cccurrences-.

90-16 Medical-Theraov Misadministration The following information pertaining to this event is also being reported concurrently in the Federal Register. Appendix A (see the overall 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 - February 20 through March 12, 1990; Muskogee Regional Medical Center; Muskogee, Oklahoma.

Nature and Probable Conseouences - On September 19, 1990, the licensee notified the NRC that a therapeutic misadministration had occurred involving a treatment administered from February 20 through March 12, 1990.

The radiation oncologist had identified the treatment error on September 6,1990, but had not immediately recognized it as a reportable misadministration.

The treatment error involved administration of 2160 rads (from a cobalt-60 1

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teletherapy unit) to the right pr.;terior. neck rather than the left posterior i

neck as~ prescribed.-

The' licensee reported that the nncologist had initially participated in the

.i treatment simulation:and had' approved simulation radiographs prior to 1

treatment; however, the physician failed to notice that the wrong side'of the patient's-neck had been the subject of the simulation.

This error was

. attributed to 1 e fact that the patient treatment' was simulated in the prone Lposition cather than:the routine supine p3sition.

Several of the licensee's staff 1.. embers 41uding'the teletherapy physicist,-therapy oosimetrist,

. technical-stai.

id oncologist, had reviewed-t' e patient's chart and

-participated.it, satmnt and followup observations although none had 1;

recogni/.ed the error.

The oncologist had palpated an enlarged cervical lymph node on the patient's left' side'during the September 6, 1990, physical examinationLwhich prompted his subsequent review of the treatment chart and

~ identification of the c.rror. All treatu.ent records indicated that the right side.of the' patient'.s neck was treated, although the prescription clearly indicated that treatment was to be given to the left side.

The licensee's radiation oncologist has advised the MC that no adverse

effects were observed during routine followup examinations, and that no significant effects' are anticipated as a. result of the misadministration.

.Cause or Causes -- The cause is attributed to human error by the -licensee's

staff and failure to perform independent chart reviews in. sufficient detail to

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detect ;he error. The simulation technologist had prepared -a treatment simulation for, and' had tattooed the right-side of'the patient's neck, because the,oncologist had assisted-in simulating.the patient treatment and fluoroscoped the patient's-right side.

The technologist assumed:that the -

correct treatment field had been ficoroscoped, and transcribed -the treatment:

. plan for..the _right posterior neck.

The. simulation radiographs were approved byf the oncologist although they had not been labeled "right":or "left" at the

-time.

The treatment plan was not reviewed until seven treatment fractions-had been

' administered, although neither the teletherapy; physicist or dosimetrist..

recognized the error during this or subsequent reviews;of the patient's chart.

Additionally, the -technical staff did not Jroutinely-review the physician's.

prescriptior, after the patient' treatment was simulated,- and therefore,.did not recognize that _the prescription indicated treatment for the left side rather

-than the right.

Actions Taken To Prevent Recurrence

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LLicensee - The licensee's corrective actions.as of October 15, 1990, included

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reformatting the? treatment chart to include the-physician's prescription in an l

. area routinely used by the technical staff, making the prescription more readily : accessible for staff review during _the course of treatment. ' The

-teletherapy physicist and dosimetrist:planito provide a more detailed review

- of the treatment. plan, including verification 'of treatment field rather.than -

focusing solely on~ dose calculations.

Further corrective actions will be

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implemented pending the licensee's Radiation Safety Officer's full investigation and review.

-EG - An KRC Region IV inspector conducted a special safety inspection on October 3 and 5,1990, of the circumstances associated with the misadministration, and identified violations of NRC requirements as well as deviations from the licensee's documented procedures (Ref. 1). A Confirmatory Action Letter (CAL) was issued on October 10, 1990, to confirm commitments i

made by the licensee during this inspection (Ref. 2).

These commitments include conducting a retrospective review of patient treatments to determine if similar errors had been made. A decision regarding enforcement action is currently under consideration.

j Future reports will be made as appropriate.

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9017 Medical Diaanostic Misadministration The folitswing information pertaining to this event is also being reported concurrently in the federal Register. Appendix A (see the overall criterion) of this resort notes that an event involving a moderate or more severe impact on public 1ealth or safety can be considered an abnormal occurrence.

Date and Place ~- May 14, 1990; Overlook Hospital; Summit, New Jersey.

- Nature and Probable Conseauences - On June 1,1990, NRC Region I was noti ied by the licensee in writing that a diagnostic misadministration involving

. iodine-131 (I-131) had occurred at the hospital, t

An' outpatient was scheduled for a nu: lear medicine study by the referring

' physician's. office by telephone.

The nuclear medicine department understood

.the doctor's office to request an appointment for an. iodine 131 scan. The patient brought the written prescription to the outpatient department and then proceeded to the nuclear medicine department for the scheduled-study. The

. Written pres Diption was not received by the. nuclear medicine department until

=after the study was completed..When the nuclear medicine department received the written prescription, it was noted that the referring physician's written s

. prescription requested a thyroid scan, not an iodine-131 scali.

(A-thyroid scan typically.means a study using approxiidately 100-500 microcuries of iodine l?3 as the imaging.radionuclide. An iodine-131 scan usually refers to.

a whole body scan, utilizing a dose of approximately 1 to 5 millicuries.)

The satient involved in the misadministration had a benign tumor removed from a loae of the-thyroid in June 1989.

Subsequent thyroid scans of the.

individual (an uptake stud 7was performed in November 1989, after the thyroid

. lobectomy) indicated that the patmc had a normally functioning thyroic.

The intended dose to the patient's thyroid war approximately 4 rads from 300 microcuries of iodine-123. The administered dose to the patient's thyroid, as a' result of the misutiderstanding of the physician's request, was approximately 3

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1820 rads from 1.4 millicuries of iodine 131.

The licensee does not expect any significant consequences to the patient.

[ause or Ca n - The cause of the event is attributed to inadequate procedures.

ine verbal request for the nuclear medicine study had not been verified by a written prascription prior to the study being performed.

Actions Taken to Prevent Recurrq ue Licensee - After a telephone call on September 21, 1990, from NRC Region I staff to the licensee in regard to the incident, the licensee convened a Radiation Safety Committee meeting on October 2, 199J, to review the cause of the misadministration and to determine the corrective actions required to prevent a recurrence. The licensee established a procedure requiring receipt of a written prescription by the nuclear medicine department prior to administering any iodine for studies.

This information was communicated to NRC Region I by telephone on October 3, 1990.

NE - NRC Region I inspectors will review the incident during the next routine inspection at this facility. The timeliness of the licensee's response (reviewing the cause and determining corrective actions following the May 14, 1990 incident) will also be reviewed.

Unless new, significant information becomet vailable, this item is considered closed for the purposes of this report.

9018 Sionificant Breakdown in Managtment and Proctiural Controls _ at a Medilal f_ittil it y The following information pertaining to this event is also being reported concurrently in the federal Reg / ster.

Appendix A (see the overall criterion) of this report notes that an event involving a moderate or more severe impact on the public health or safety can be considered an abnormal occurrence.

In addition, the third general criterion in Appendix A notes that major deficiencies in management controls for licensed facilities or ratorial can be-considered an abnormal occurrence.

Date and Plac.g - July 19-27, 1990; North Detroit General Hospital; Detroit, Michigan.

Nature and Probable Consecuences - This event involved the apparent use of fraudulent films from 30 diagnostic nuclear medicine studies that rendered all but one of them invalid.

Such an event could have potentially resulted in significant adverse health effects to patients (e.g., a serious disease may not be diagnosed, or a correct diagnosis could be significantly delayed). The l

details of the event are as follows:

On August 14, 1990, the licensee reported to NRC Region III that films from diagnostic nuclear medicine studies were apparently fraudalent.

The films involved 30 studies performed on 27 patients during the time period July 19-4

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27, 1990. (Some patients had more than one diagnostic procedure.) During this time period, the' licensee's staff nuclear medicine technologist was on leave and a replacement technologist was supplied by a temporary services contractor.

For the diagnostic procedures involved, a radioactive pharmaceutit is introduced into the patients by injection or inhalation.

The movement and deposition of these radioactive pharmaceuticals is then recorded as a film image.

The image is then evaluated by a physician as a diagnostic tool.

The licensee subsequently determined that the films for 29 of the 30 procedures were fraudulent or indeterminate and were, therefore, unreliable for patient diagnosis.

The remaining film is from a procedure performed by the contract technologist undur the supervision of the staff technologist, it appesrs to be accurate.

The films in question show evidence of tampering (i.e., handwritten names and dates which do not match the computer-generated display in the film, and faint underlying and overwritten labels on the films),

in addition, the licensee reported that about 100 old patient films and jackets were discovered to be missing from their file location.

The fraudulent films were discovered by the staff technologist by comparison with later films after the contract technologist had left.

The licensee then reviewed the films from procedures performed by the contract technologist.

The licensee's investigation determined " conclusively that [the individual]

had doctored and provided fraudulent nuclear medicine studies for interpretation.

[The technologist] had submitted nuclear medicine studies on patients who had previously been imaged within the Department during the past 2 years and altered the names on those images and placed the names of the patients he was to have performed studies on in their place."

The licensee was unable to determino, in most cases, whether the diagnostic procedures had actually been performed and whether the patients had been administered the prescribed radiopharmaceutical for the procedures.

The diagnostic procedures, with one exception, were not considered to be valid, and therefore of no use in their intended diagnostic function.

The licensee offered to redo the procedures, although some patients or their physicians elected not to have the studies performed again.

In those instances where a second procedure was performed, the patient received additional radiation exposure as a result of the fraudulent films that rondered the first procedure unusable.

Where the retest was refused, the patients may have received a radiation exposure without benefit of a valid diagnostic procedure.

However, the radiation doses associated with diagnostic procedures are small.

Cauce or Causes - The fraudulent films and resulting invalid studies were the result of the action by-the contract technologist and the failure of the licensee to supervise and train the individual adequately, j

A special NRC inspection, which reviewed the circumstances of the fraudulent films, identified 10 apparent violations of NPC requirements, some of which were directly associated with the work performed by the contract technoirgist.

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These violations were indicative of a breakdown of management control of the licensee's nuclear medicine program.

Actions Taken to Prevent Recurrence Licensee - As a result of this occurrence, the licensee has strengthened its screening procedures for prospective employees, both temporary and permanent.

Training procedures have also been broadened and intensified.

There will be more ongoing supervision and review of work by new employees.

E - The NRC conducted a special inspection August 15 through September 7 1990, to review the circumstances surrounding the fraudulent films. A number of violations were identified. On Di:tober 29, 1990, the NRC issued a Notice of Viciation and proposed a civil penalty of $2,500 (Ref. 3), which was paid by the licensee on November 26, 1990.

This item is considered closed for the purposes of this report.

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I 90-19 Medical Diaanostic Misadministration

.The following information portaining to this event is also being reported concurrently in the Federal Register. Appendix A (see the overall criterion) of this re-) ort notes that an event involving a moderate or more severo. impact on public 1ealth.or safety can be considered an abnormal occurrence.

Qate and Place + August 7,1990; Copley Hospital; Morrisville, Vermont.

Nature'and Probable Cpnseauences - On August 14, 1990, NRC Region I was

notified by the licensee in writing that a diagnostic misadministration involving iodine-131 (1 131) had occurred at the hospital on August 7, 1990.

Further-information was obtained in a follow-up phone call to the licensee on September 24, 1990.- A 63-year old woman patient, undergoing I-131 treatment for primary hypothyroidism, was. administered 112 microcuries instead of a routinely prescribed 10 microcuries.

The dose to the thyroid, based upon the results of.an uptake scan, was calculated at.3.9% uptake, resulting in an estimated actual dose to the thyroid of 29 rads.

The licensee does not expect any adverse consequences to the patient.-

l The hospital reported that a supply of I-131 capsules had been ordered with

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' incorrect: amounts of I-131.

Instead of ordering S capsules with a total activity of 100 microcuries, the' 5 capsules were ordered as 100 microcurles '

.each. On the day of the event, the technologist measured the capsule in the l

dose calibrator prior to administration and incorrectly inter)reted the dose-calibrator reading of 112 microcuries as.11.2 microcuries. T1e error was identified by another technologist measuring the uptake by the patient's -

. thyroid the following day.

Cause or Causes - The causes of the event were attributed to human errors.

R The wrong 1-131 capsules had been ordered, and the technologist incorrectly interpreted the dose calibrator reading.

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Actions Taken to Prevent Recurrence licensee - The lie.ensee reviewed the policies and procedures for assaying doses with all nuclear medicine technologists.

in addition, the licensee's procedure was revised to recuire that only the technologist who orders the iodine capsules is allo..td to administer them to patients.

NRC - NRC Region I inspectors will review the incident during the next routine inspection at this facility.

Unless new, significant information becomes available, this item is considered closed for the purposes of this report.

90-20 tiedical Diaanostic Misadministratun The following information pertaining to this event is also being reported concurrently in the federal Register. Appendix A (see the overall criterion) of this report notes than an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.

Date and Plass - September 22, 1990; West Shore Hospital; Manistee, Michigan Nature and Probabla Conseauences - On September 24, 1990, the licensee's consultant informed Region Ill that an 84-year-old female cancer patient received a 175 millicurie dose of a technetium 99m (Tc 99m) labeled radiopharmaceutical for an imaging scan of her gall bladder instead of the 8 millicurie dose prescribed in the Nuclear Medicine Department's procedures manual.

The misadministration occurred on Saturday, September 22, 1990, when the patient's physician ordered a hepatobiliary (liver and gall bladder) scan.

The radiopharmaceutical was prepared and administered by a part-time technician who was on v ekond call. The technician had received only two weeks of training in Naciear Medici'io Department procedures the previous February and had performed only two nuclear medicine procedures since then (during one procedure, she was directly supervised by the Radiology Manager; during the other, the Radiology Manager " coached" her through the procedure by telephone). After receiving the order on September 22, the technician telephoned the Radiology Manager at home for guidance. She was told to prepare the dose according to the Department's procedures manual, which stated that an 8 millicurie (mci) dose of Tc-99m mebrofenin was needed for hepatobiliary scans. Tc-99m mebrofenin is prepared by adding free Tc-99m to a reagent kit containing the mebrofenin.

According to the technician, she eluted 392 mci from the molybdenum-technetium generator, and then took 4 milliliters of the eluate and injected it into the reagent kit. After mixing, she withdrew I milliliter of the solution, put it on a dose calibrator, which she claimed read 8 mci, and then injected the radiopharmaceutical into the patient.

When she saw a " bright spot" forming on 7

E D e v enning screen where the sharp image of the gall bladder should have b L, she telephoned the Radiology Manager and informed hiai that something was wrong.

A reconstruction of the event by NRC and licensee consultants indicated that the dose to the patient was 175 mci instead of the intended 8 mci.

The amount of Tc-99m mixed with the mobrofenin was probably around 440 mci, instead of the manufacturer's maximum recommendation of 100 mci.

The NRC consultant concluded that the technician misread or misunderstood the activity reading on the dose calibrator prior to injecting the patient.

The medical consultant also evaluated the medical consequences of the incident and concluded that no biological effects should be expected from the misadministration.

It is estimated that the doses to the patient's bladder and upper large intestine were about 36 rads and 26 rads, respectively.

C.ause or Causes - The cause of the event was the licensee's failure to properly train and supervise an inexperienced technician.

The individual either misread or misunderstood instructions, and in some cases used guesswork in carrying out the procedure.

Actions Taken To Prevent Recurrence Licensee - The licensee's corrective action includes more orientation and training of new employees; additions to the :omputerized quality assurance system to remind staff to hold required meetings and perform required tests; and additional oversight of the licensee's program by management and the Radiation Safety Officer.

Also, the technician is no longer employed at the hospital.

ML - NRC Region III conducted a special inspection on Seatember 27, 1990, and identified 10 violations of NRC requirements.

Seven of t1e 10 violations pertained to this incident, including failure to instruct the technician in NRC regulations and license realirements, and failure to prepare the reagent kit in accordance with manufacturer's instructions.

The Region contacted a medical consultant who reviewed the case.

On November 16, 1990, the NRC issued a Notice of Violation and proposed a civil penalty of $4,375 (Ref. 4).

The licensee has paid the civil penalty.

The corrective actions will be further reviewed during a future routine NRC inspection.

This item is considered closed for the purposes of this report.

AGREEMENT STATE LICENSEES Procedures have been developed for the Agreement States to screen unscheduled incidents 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, the Agreement States determined that one of these events was an abnormal oCCurrenCO.

l 8

AS90-2 Medical Thernov Misadministration Appendix A (see the overall criterion) of this report notes that an event involving a moderate or more severe impact on public health and safety can be considered an abnormal occurrence.

Date end Place - April 19, 1990; Yuma Regional Medical Center; Yuma, Arizona.

Nature and probable Conscauences - On April 19, 1990, a patient's uterine tumor was implanted with 224 iridium 192 seeds using 32 trochars*, cach containing 7 seeds on a ribbon. The prescribed dose was about 2000 rads. A problem was noted with snagging of the ribbon in one trochar; five seeds were stripped from the trochar when an attempt was being made to remove both the trochar and the seeds.

The trochar had inadvertently been placed in a necrotic cavity within the tumor, permitting the seeds to ' pay out' into the cavity rather than being stopped by tissue, An unsuccessful attempt was made to remove the five str!pped seeds during removal of the other seeds. When the trochar that had contained the snagged ribbon was removed, it was discovered that the tip of t'ne trochar had been bent, presumably by the stony hardness of sne tumor. The trochar was not bent before it was inserted.

The five seeds were lef t in the necrotic tumor center. These seeds, from the time of emplacement until total decay, would deliver a dose considerably in excess of the prescribed dose. However, a medical consultant stated that the patient's poor prognosis from her illness outweighed any harm from additional radiation.

(The patient subsequently died from her illness.)

The Arizona Radiation Regulatory Agency (ARRA) asked for dose calculations and, in addition, asked the physician to describe the nature of the tumor hardness and to describe the incident to the Drug Product Reporting Program at the United States Pharmacopeia (USP). However, since the physician lef t the state, the ARRA sent a report to the USP.

Cause or Causet - There were several causes for this event:

o The trochar was inadvertently placed inside a cavity within the tumor; o

The trochar, which was flexible and bendable, was bent by the hardness of the tumor;

  • A trochar is a sharp, pointed surgical instrument fitted with a hollow tube.

9 l

o During an attempt to remove the seeds, fluoroscopes failed because there was an inadequate power supply to the operating room; and c

o The length of the ribbons was not controlled, so that ' paying out' of the ribbons was possible.

Actions Taken to Prevent Recurrence Licensee - The physician, no longer practicing in Arizone, stated that he would use only rigid tungsten alloy trochars and pre-measure all ribbons, limiting their length to 21 cm.

Aaency - The agency notified the USP and the Arizona State Board of Medical Examiners.

This item is considered closed for the purposes of this report.

10

REFERENCES 1.

Letter from A. Bill Beach, Director, Division of Radiation Safety and Safeguards, NRC Region IV, to William Kennedy, CEO, Muskogee Regional Medical Center, forwarding Inspection Report No. 30-11571/90-02, Docket No. 30-11571, License No. 35-13157-02, November 30, 1990.*

2.

Confirmatory Action Letter from Robert D. Martin, Regional Administrator, NRC Region IV, to William Kennedy, CEO, Muskogee Regional Medical Center, Docket No. 3C-11571, License No. 35-13157-02, October 10, 1990.*

3.

Letter from A. Bert Davis, NRC Region 111 Regional Administrator, to Jerry Frohlich, President, North Detroit General Hospital, forwarding a Notice of Violation and Proposed imposition of Civil Penalty ($2,500),

Docket No. 030-12467, license No. 21-10578 02, October 29, 1990.*

4.

Letter from A. Bert Davis, NRC Region 111 Regional Administrator, to Burton Parks, Administrator, West Shore Hospital, forwarding a Notice of Violation and Proposed imposition of a Civil Penalty ($4,375), Docket No. 030-10713, license No. 21-16277 01, November 16, 1990.*

  • Available in NRC Public Document Room, 2120 L Street, NW, (Lower Level)

Washington, D.C., for public inspection and copying.

11

_=

APPENDIX A ABNORMAL OCCURRENCE CRITERIA The following criteria for this report's abnormal occurrence determinations were set forth in an NRC policy statement published in the Federal Reaister on February 24, 1977 (Vol. 42, No. 37, pages 10950-10952).

An event will be considered an abnormal occurrence if it involves a major reduction in the degree of protection of the public health or safety.

Such an event would involve a moderate or more severe impact on the public health or safety and could include but need not be limited to:

1.

Moderate exposure to, or release of, radioactive material licensed by or otherwise regulated by the Commission; 2.

Major degradation of essential safety-related equipment; or 3.

Major deficiencies in design, construction, use of, or management controls for licensed facilities or material.

Examples of the typer, of events that are evaluated in detail using these criteria are:

For All Licensees 1.

Exposure of the whob body of any individual to 25 rem or more of radia-tion; exposure of the skin of the whole body of any individual to 150 rem or more of radiation; or exposure of the feet, ankles, hands or forearms of any individual to 375 rem or more of radiation (10 CFR 20.403(a)(1)], or equivalent exposures from internal sources.

2.

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

3.

The release of radioactive material to an unrestricted area in concentrations which, if averaged 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 regulatory limit of Appendix B, Table II,10 CFR Part 20 (CFR 20.403(b)(2)].

4.

Radiation or contamination levels in excess of design values on packages, or loss of confinement of radioactive material such as (a) a radiation dose rate of 1000 mrem per hour three feet from the surface of a package containing the radioactive material, or (b) release of radioactive material from a package in amounts greater than the regulatory limit.

5.

Any loss of licensed material in such quantities and under such circum-stances that substantial hazard may result to persons in unrestricted

areas, l

1 l

13

6.

A substantiated case of actual or attempted theft or diversion of licensed material or sabotage of a facility.

7.

Any substantiated loss of special nuclear material or any substantiated inventory discrepancy that is judged to be significant relative to normally expected performance and that is judged to be caused by theft or diversion or by substantial breakdown of the accountability system.

8.

Any substantial breakdown of physical security or material control (i.e., access control, containment, or accountability systems) that significantly weakened the protection against theft, diversion, or sabotage.

9.

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

10.

A major deficiency in design, construction, or operation having safety implications requiring immediate remedial action.

11.

Serious deficiency in management or procedural controls in major areas.

12.-

Series of events (where individual events are not of major importance),

recurring incidents, and incidents with implications for similar facilities _(generic incidents) that create major safety concern.

For Commercial Nuclear Power Plants 1.

Exceeding a safety limit of license technical specifications [10 CFR 50.36',c)].

2.

Major degradation of fuel integrity, primary coolant pressure boundary, or primary containment boundary.

3.

Loss of plant capability to perform essential safety functions such that a potential release of radioactivity in excess of 10 CFR Part 100 guidelines could result from a postulated transient or accident (e.g.,

. loss of emergency core cooling system,. loss of control rod system).

=4.

Discovery of a major condition not specifically considered in the safety analysis report (SAR) or technical specifications that requires immediate remedial action.

5.

Personnel error or procedural deficiencies that result in loss of plant capability to perform essential safety functions such that a potential release of radioactivity in excess of 10 CFR Part 100 guidelines could result from a postulated transient or accident (e.g., loss of emergency core cooling system, loss of control rod system).

For Fuel Cycle licensees 1.

A safety limit of license technical specifications is exceeded and a plant shutdown is required [10 CFR 50.36(c)].

14

__.-_ _. _ _. _ _ _ _ _. _ ~ _ _. - _.. _ _ _ _ _ _ _ _ _ _ _

2.

A major condition not specifically considered in the safety analysis report or technical specifications that requires immediate remedial action.

3.

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

P v

7 A

15 l

APPENDIX B UPDATE Of PREVIOUSLY REPORTED ABNORMAL OCCURRENCES During the July through Septerber 1990 period, NRC licer sees, Agreement States, Agreement State licensees, and other involved parties, such as reactor vendors and architect-engineering firms, continued with the implementation of actions necessary to prevent recurrence of previously reported abnormal occurrences.

For this reporting period, there was no significant updating information to report.

1 i,

17

APPENDJX C OTHER EVENTS Of INTEREST The following items are described because they may possibly be perceived by the public to be of public health or safety significance.

The items did not involve major reductions in the level of protection provided for public health or safety; therefore, they are not reportable as abnormal occurrences.

1. Diacnostic Do e of Iodine-131 Administered to a Preanant Patient On July 13, 1990, North Country Hospital and Health Center, Inc., in Newport, Vermont reported to NRC Region I that a pregnant patient had received an oral administration of 15 microcuries of iodine-131.

The patient was administered the prescribed diagnostic dose on July 10, 1990, for a thyroid uptake study.

The patient, while waiting for the procedure, was carrying an infant.

This led the technologist to believe that the infant belonged to the patient and, therefore, the technologist did not ask the patient whether she was pregnant before administering the iodine dose.

immediately after administering the dose, during a discussion with the technologist, the patient informed the technologist that she was pregnant in her 4th or 5th week. The technologist immediately called the referring physician, who instructed the technologist to perform a pregnancy confirmation test.

The test was performed and one and half hours later, confirmed the pregnancy.

The technologist informed the referring physician and, later the same day, informed the radiologist (a visiting authorized user).

Neither physician recommended any medical intervention.

On July 16, 1990, the NRC performed an inspection at the licensee's facility to review the circumstances of the reported incident.

As a result of the inspection, the NRC issued a Notice of Violation to the licensee for failing to instruct the technologist to ask female patients if they were pregnant, prior to administering radioactive material for nuclear medicine studies (Ref.

C-1).

The licensee's Radiation Safety Officer (RS0) submitted a written account of the licensee's actions as well as an estimate of exposure to the fetus.

The RSO concluded that the fetus could have received 2.25 millirad to the whole fetal body and no thyroid dose, based on a fetal age of 1.5 to 6 weeks.

Consequently, adverse impacts on the fetus are not anticipated as a result of the exposure.

The NRC staff and NRC consulting physician confirmed these potential dose values to the fetus, in the cover letter that transmitted the Notice of Violation and Inspection Report to the licensee, the NRC acknowledged the low dose to the fetus, for this specific incident, but stated that it was fortuitous.

Had the fetus been more developed (greater than 12 weeks), the dose and its potential consequences would have been significantly greater.

19

i

2. Contaminated Water Seeraae at Seouoyah fuels Corporation i

On August 22, 1990, Sequoyah fuels Corporation (SFC) in Gore, Oklahoma, reported to NRC Region IV that uranium contaminated water had been discovered seeping into an excavation near the solvent extraction (SX) building.

The uranium concentration in the seepage ranged up to 8 grams per liter, which was substantially above SFC's environmental action level of.000225 grams per liter for uranium in water. On August 23, 1990, an NRC inspector was dispatched by Region IV to the site to review the circumstances of the report.

Following this review, and because of the apparent lack of awareness by SFC of the potential significance of the elevated concentrations, Region IV dispatched an Augmented Inspection Team (AIT) to the site on August 27, 1990.

During the August 27-29, 1990, inspection, the four person AIT reviewed the circumstances surrounding the contamination found in the excavation near the SX building, evaluated the licensee's actions, and determined, to the extent possible, the impact of this event on the safety and health of the workers and the public in general.

The AIT reached the following findings of fact (Ref.

C-2):

1.

During the excavation for the vault around hexane tanks near the SX building, uranium contaminated waters and uranium salts were discovered in the pit.

Measurements of water samples showed uranium levels as high as 8.1 grams per liter.

2.

Surveys of personnel and equipment entering and leaving the site indicated that no contamination related to the excavation was allowed offsite.

3.

Initial investigations of groundwater in the vicinity of the SX building indicate that contamination apparently has not migrated offsite or come in contact with any aquifers that may be used by members of the public.

4.

Backfill around pipelines and utility lines in the vicinity of the SX building has apparently served as conduits for the migration of liquids.

The licensee has effectively eliminated these pathways by construction of barriers around the lines and installation of upgradient sumps to collect any liquid.

5.

Uranium contaminated water also exists in the aggregate fill under and in the vicinity of the SX building.

Some of this water will probably remain relatively immobile.

The remainder is proWuly moving at a very slow rate toward the North Ditch or the sewage iagoon.

6.

The sources of the contamination were apparently solutions that had seeped over the years through the floor of the SX building, leakage from the old evaporator pad that was located adjacent to the SX building, and overflow from the solvent dump tank.

These sources have been eliminated f

by: constructing a new floor and sump in the SX building and changing procedures to eliminate running contaminated, corrosive liquids over the l

floor; removing the old evaporator; constructing a new evaporator pad 20

=.-

_--~_-.- -..

b and sump system; and constructing a vault with a sump to capture spillage from the solvent dump tank.

7.

Af ter August 22, upon discovery of the high levels of uranium in the water in the excavation, the licensee proceeded to survey and sample the area and require daily urinalyses of all personnel associated with the construction.

Two workers, who apparently did not enter the excavation but worked above ground, did record slightly elevated levels.

They were placed on work restrictions and had lowered urinalyses results upon retesting.

8.

The soil removed from the excavation has been partially barreled with the remainder moved to the "yellowcake pad" where it was placed on a Hypalon liner and covered with plastic.

9.

Environmental data from monitoring stations around the site were reviewed and uranium and other contaminants have been detected, although at levels below the maximum permissable concentrations specified in 10CFR Part 20.

The amount that may have been contributed by the seepage is unknown at this time.

10.

Licensee managers were aware of this situation as early as August 7, 1990, but no further investigation or evaluation was performed to determine the potential hazard to workers until about two weeks later, 11.

The plans by the licensee to characterize further the extent of contamination and develop remediation actions were determined to be sufficient as an initial effort, future, more detailed plans are to be reviewed as they are made available by the licensee.

During the period of the AIT follow-up and daily onsite inspections, the NRC inspectors observed licensee activities and noted that they had located and stopped process solution leakage to the ground around the solvent extraction building.

The licensee drilled bore holes and monitoring wells in selected locations to characterize the soil beneath and around the building, and dug trenches in selected locations to identify leakage paths away from the building.

Although there _is evidence of some horizontal migration of the liquid along underground pipes and other utilities, there is no evidence to date that the liquid migrated offsite or reached the water table.

The licensee will monitor the environment closely to characterize the problem.

The inspectors determined that much of the leakage probably occurred before the current licensee's ownership of the facility.

The solvent extraction building was constructed in 1969 and operations began in 1970.

The floor of each half of the building is sloped to a center curb, with a sump on each side of the curb.

Both the floor and sumps were constructed of unprotected concrete, as was the center curb.

During early operations of the building, process solutions were routinely discharged onto the floor when they did not meet specifications. These corrosive acidic solutions, which also contained uranium, traveled across the floor to the sumps.

This practice resulted in extensive degradation of the concrete floor, particularly in the vicinity of the sumps.

l 21 1

As a result, proct:ss solutions seeped through the degraded floor and into the bas.. fill underneath the building over a period of several years.

Most of these fleids remained in the backfill because there was no significant driving force to cause them to move, particularly after the floor was replaced in 1983 and 1984.

Excavation near the building in August 1990 provided a migration pathway.

Two additional sources of contamination in the vicinity of the solvent extraction building were identified. One was un antiquated evaporator located on an unprotected concrete pad adjacent to the north wall of the solvent extraction building. When the evaporator was used to increase the concentration of uranium in the solution, it routinely leaked onto the pad, degrading the unprotected concrete and allowing solutions to enter the backfill. Although the evaporator was replaced by a new one in 1980, it was used as an auxiliary unit until 1985.

The degraded pad was rebuilt in 1985.

The other source of contamination was one of the two storage tanks being excavated so that a reinforced vault could be constructed to contain them.

One tank is used to store hexane and the other is the solvent dump tank, used for emergency storage for all solvent extraction building solutions. Although the solution level in the solvent dump tank can be measured by a differential pressure gauge, it is not reliable.

Therefore, the level in the tank was visually checked and solution spilled out of the tank when it was overfilled.

A concrete floor and curb were placed around the pipe in 1988 to contain spilled solutions.

During the period September 10 13, 1990, the AIT performed a follow-up inspection to review the findings of the AIT.

In addition, the AIT reviewed the actions taken by the licensee in accordance with commitments made to the NRC in an August 30 letter as prerequisites for restart of the solvent extraction process.

The inspectors determined that the licensee's actions were appropriate to satisfy those commitments, and on September 13, 1990, the licensee was given verbal concurrence by NRC to restart the solvent extraction process. At the same time, NRC initiated daily onsite inspector coverage as a result of the concerns identified by the AIT and the AIT follow-up inspection.

(Ref. C-3).

As indicated above, the licensee began a significant effort to identify the cause(s) of the problem and to initiate corrective actions.

Actions adopted include better procedures, better training of employees, and better communication within the licensee organization and with NRC. On September 14, 1990, SFC reported by telephone the discovery of uranium contaminated water under the main process building.

On September 20, an Order Modifying License was issued that requires Sequoyah fuels characterize the site, take actions to prevent furnice releases of contaminated water, and appropriately monitor ground water (kef. C-4). An NRC Relaxation of Order, dated October 23, 1990, was provided to enable the licensee to conduct proper environmental monitoring at the plant site (Ref.

22

)

C-5).

The licensee is continuing its environmental investigation to characterize the extent of contamination at the SFC facility and its environs.

On November 5, 1990, the NRC issued a Demand for Information to determine whether the NRC should renew or modify SFC's license (Ref. C 6).

On November 13, 1990, a meeting was held between senior NRC and licensee managers at NRC headquarters in Rockville, Maryland, to discuss the NRC's concerns. On December 7, 1990, the licensee submitted its formal response to the NRC's Demand for Informatiou (Ref. C 7). The licensee's response is under review.

In addition, the NRC will continue to review tie licensee's corrective actions to assure that safety concerns are satisfactorily resolved.

Because evidence to date indicates that the contaminated water did not migrate offsite or reach the water table, there was no impact on public health and safety. Therefore, the event is below the threshold for abnormal occurrence reporting.

23

REFERENCES FOR APPENDICES C-1 Letter from Mohamed M. Shanbaky, Chief, Nuclear Materials Safety Section A. Division of Radiation Safety and Safeguards, NRC Region I, to Larry Labor, Vice President of Professional Services, North Country Hospital and Health Center, Inc., forwarding Inspection Report No. 030-17817/90-002 and Notice of Violation, Docket No. 030-17817, License No. 44-19518-01, September 18, 1990.*

i C-2 Letter from A. Bill Beach, Director, Division of Radiation Safety and Safeguards, NRC Region IV, to Reau Graves, Jr., President, Sequoyah fuels Corporation, forwarding NRC Augmented Inspection Tean. (AIT)

Inspection Report No. 40 8027/90-04, Docket No. 40 8027, License No.

SUB-1010, October 11, 1990.* The findings may be found in paragraph 7 of the inspection report.

C-3 Letter from A. Bill Beach, Director, Division of Radiation Safety and Safeguards, NRC Region IV, to Reau Graves, Jr., President, Sequoyah Fuels Corporation, Docket No. 40-8027, License No. SUB-1010, November 20, 1990.*

C-4 Letter from James M. Taylor, Executive Director for Operations, NRC, to Reau Graves, Jr., President, Sequoyah Fuels Corporation, forwarding l

Order Modifying License, Docket No. 40-8027, license No. SUB-1010, September 20, 1990.*

C-5 Letter from Robert D. Martin, Regional Administrator, NRC Region IV, to Reau Graves, Jr., President, Sequoyah Fuels Corporation, relaxing Order Modifying License, Docket No. 40-8027, license No. SUB-1010, Octnber 23, 1990.*

C6 Letter from Hugh L. Thompson, Jr., Deputy Executive Director for Nuclear Material Safety, Safeguards, and Operational Support, NRC, to Reau Graves, Jr., President, Sequoyah Fuels Corporation, transmitting Demand for Information, Docket No. 40-8027, License No. SUB-1010, Novcmber 5, 1990."

C-7 Letter from Lee Lacey, Vice President, Regulatory Affairs, Sequoyah Fuels Corporation, to William Brown, Regional Counsel, NRC Region IV, Docket No. 40-8027, License No. SUB-1010, December 7, 1990.*

i pf

  • Available in NRC Public Document Room, 2120 L Street, NW (Lower level),

Washington, D.C., for public inspection and copving.

25

80mu 335 U S. NUCLE AA Mt0VL ATOMY COMMISSION 1.

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NUREG-0090 ne.,,,,,,, r e..,,4,,..m, Vol. 13 No. 3 t mtt AND suemot Report to Congress on Abnormal Occurrences:

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January 1991 4 FIN OR GR ANT NUVBE R

6. AUTHQRt5) 6 T YPE OF ht POR T Quarterly L Pt RIOD Covi R E D tmcruse perw July - September 1990
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- ena mes., eami Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555

9. SPONSORING ORG ANIZ ATION - N AME AND ADOR ESS (sf eac. tree W*e se swee". s' eeatrarw. a'e** **C Deva *. O"ar* *' 88'*a. U S Sue"*' ***** f*****-

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10. SUPPLEMENT ARY NOTES
11. A BST R AC T (200 *e,m a, em Section 208 of the Energy Reorganization Act of 1974 identifies an abnormal occurrence as an unscheduled incident or event which 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 July 1 through September 30. 1990.

The report discusses six abnormal occurrences, none of which involved a nuclear power plant.

There were five abnormal occurrences at NRC-licensed facilities:

one involved a medical therapy misadministration; three involved medical diagnostic misadministrations; and one involved a significant breakdown in management and procedural controls at a medical facility. The sixth abnormal occurrence was reported by an Agreement State (Arizona);

the event involved a medical therapy misadministration.

12. KEY WORD 5'DESCR:P10R$ ttar = eros onparem mer ew s sesr evsewaeri m weeme ene reaore, s u Avas6Assut y stattutNi Medical Therapy Misadministrations; Medical Diagnostic

[,If,{ted m

Misadministrations; Breakdown in Management and Procedural Controls; Diagnostic Dose of I-131 Administered to a Pregnant ssified Patient; Contaminated Water Seepage.

Uncl assi fied Ib. NUM86 R OF PAGkb 16 PRICL NHC FORM 335 0 498

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