ML20070T561
| ML20070T561 | |
| Person / Time | |
|---|---|
| Issue date: | 03/31/1991 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| References | |
| NUREG-0090, NUREG-0090-V13-N04, NUREG-90, NUREG-90-V13-N4, NUDOCS 9104040281 | |
| Download: ML20070T561 (24) | |
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N U R EG-0090 Vol.13, No. 4 ReJor: ~:0 Congress on A~3 normal Occurrences October - December 1990 U.S. Nuclear Regulatory Commission Office for Analysis and Evaluation of Operational Data s na p
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l 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 l.
are available from National Technical information Service, Springfield, VA 22161 t.
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N UlmO-0090 Vol.13, No. 4 Reaort to Congress on Abnorma Occurrences October - December 1990 Date Published: March 1991 Omce for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Wusliington, DC 20555 f.a n.%,,
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I'revious Reports in Series NURBO 75AE January 4une 1975, NUREG-0000, Vol 6, No 1, January-March 1983, R
NUREO-0090, \\ptember 1983 published Se published October 1975 ol. 6, No. 2. Aprildune 1983,
- NUREOM&l, July-September 1975, pubhshed March 1976 published November 1983 NUREG-00%2, October-December 1975, NURE04Y>0, Vol 6, No. 3. July-September 1983 published March 1976 published April 1984 NURE041090-3, January-March 1976, NUREG-0090, Vol 6, No. 4,06ober December 1983 published July 1976 pubbshed May 1984 NUREG-00%4, April 4une 1976, NUREO-0090, Vol 7, Na 1, January March 1984, published March 1977 published July 1984 NUREO-00%5, July-September 1976, NUREO-0090, Vol 7, No. 2, Aprildune 1984, published March 1977 published October 1964
- NUREO-00%6, October December 1976, NURE04/J0, Vol 7, No. 3, July-September 1984, published June 1977 published April 1985 MUREO-0090-7, January-March 1977, NURE04WO, Vol 7. No 4, October December 1984, published June 1977 published May 1985 NUREO-0090-8, April 4une 1977, NURE04390, Vol 8, No.1, January Mareh 1985, pubhshed September 1977 -
published August 1985 NURBO-0090-9, July September 1977, NUREO 0090, Vol 8, No. 2, Aprildune 1985, published November 1977 pubbshed November 1985 NUREO-0090-10, October-December 1977, NUREG-0090, Vol 8, No. 3 July-September 1985, published March 1978 published February 1986 NUREO-0090, Vol 1, No.1, January-March 1978.
NUREO-0090, Vol 8, No. 4, October-December 1985, published June 1978 published May 1986 NUREG-0090, Vol.1, No. 2. Apr04une 1978.
NUREO-0090, Vol. 9, No.1. January-March 1986, published SeEtember 1978.
published September 1986 NURBO-0090, \\ ol.1, No. 3. July-September 1978, NURE04F)0, Vol. 9, Na 2, AprilJune 1986, published December 1978 published January 1987 NUREO-0090, Vol.1. No. 4, October-December 1978, NURE04Y)0, Vol 9, No. 3, July-September 1986 published March 1979 published April 1987 NUREO-0090, Vol 2, No.1, January March 1979, NUREO-0090, Vol 9 No. 4. October December 1986, published July 1979 published July 1987 NURE04F)0, Vol. 2, No.2, Aprildune 1979, NURE04M0, Vol 10. No.1, January-March 1987, published Nowmber 1979 published October 1987 NUREO-0090, Vol 2. Na 3, July September 1979, NUREO-0090, Vol 10, No. 2, April 4une 1987, published Febmary 1980 published Nommber 1987 NURE047)0, Vol 2 No.,4, October December 1979, NUREO-0090, Vol 10, No. 3, July-September 1987, published April 1980 -
published March 1988 NUR BO-0090, N 01, 3, No.1, January-March 1980, NUREO-0090, Vol 10, No. 4, October December 1987, published September 1%0 published March 1988 NUREG-0090, Vol. 3, No. 2, April 4une 1980, NUREG-M)0, Vol 11. No.1. January-March 1988, published November 1980 published July 1988 NUREO-0090, Vol 3, No. 3, July-September 1980, NUREO-0090. Vol. I1, No. 2, Aprildune 1988, published February 1981 published December 1988 NUREO-0090, Vol 3.No. 4 October-December 1980, NUREO-0090, Vol. II, No. 3, July-September 1988, published May 1981 published January 1989 NUREG-0090, Vol 4 No.1, January March 1981, NUREO-0090, Vol.11, No. 4, October-December 1988, published July 1981 published April 1989 NUREG-0090, Vol 4, No. 2, Aprildune 1981,-
NUR EO-0090, Vol 12, No.1, January March 1989, l
- published October 1981
- published August 1989 NUREO-0090, Vol 4, No. 3, July-September 1981, NUREO-0090, Vol 12, No. 2, AprilJune 1989, published January 1982 published October 1989
. NUREG-0090, Vol 4, No. 4, October-December 1981.
NUREO-0090, Vol 12, No. 3, July-September 1989 -
published May 1982 published January 1990 NUREO-0090, Vol 5, No.1, January March 1982, NURE04)90, Vol.12 Na 4, October December 1989
' published August 1982 published March 1990 NUREO-0090, Vol 5, No. 2, Aprildune 1982.
NURE04F)0, Vol 13, Na 1, January March 1990, pubbshed December 1982 published July 1990 NUREO-0090, Vol 5, No. 3, July-September 1982, NUREG-0090, Vol 13, No. 2, April 4une 1990, published January 1983 published October 1990
- NURE04F10, Vol 5, No. 4, October. December 1982, NUREO-0090, Vol 13, No. 3, July September 1990, published May 1983 L published January 1991
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Abnormal Occurrences,4th Olr CY90 AllSTitACT Section 208 of the !!nergy ileorganization Act of
'the termrt discuucs five abnormal occurrences, 1974 identifies an abnormal occurrence as an un-aor.e of which invalved a aackar power riant. Two scheduled incident or event that the Nuclear llegula-irvolved significaat merexposures to the hands of tory Commission detennines to be significant from two radiographers, two involved medical therapy the stand [oint of public health or safety and requiret misadministrations, and one involved a medical diag-a quarterly report of such events to be made to Con-nostic misadministration. No abnormal occurrences gress lhis re[mrt covers the period hom Jetober I were reported by the Agreement States, The report through December 31,1990.
also coritains information that updates a previously reported nbnormal occurrence.
iii NilRI G -0090, Vol, ! 3, No. l
CONTENTS Page Ab5 tract...........................
iii Preface.................................................................
Vii vii introduction.............
Th e R eg ula t ory Syst e m............................................................ Vii R epo rtable Occu rr e nces......................................................... vii Agre e m e n t S ta t es............................................................ viii Forcign Information
..............................................................viii Report To Congress On Abnormal Occurrences, October-December 1990.........................
I N te'.ca r Powe r Pl an t s..................................................................
I duel Cycle Facilities (Other Than Nuclear Power Plants)....................................
1 Other NRC Licensees (Industrial Radiographers, Medical Institudons, Industrial Users. etc.)......
I 90-21 Medical Therapy Misad minist ration...........................................
1 90-22 Radiation Overexposure of a Radiographer..................................
2 90-23 Medical Therapy Misadministration........................................... 3 90-24 Radiation Overexposure of a Radiographer..................................... 4 90-25 Medical Diagnostic Misadministration..........................,......
5 Agre em ent Stat e Licensees............................................................
6 References..............................................................................
/
Appendix A-Abnormal Occurrence Criteria............................................,.. 9 Appendix B-Update Of Previously Reported Abnormal Occurrences 11 O t h e r N R C Lice n se es....................................,.......................... 11 90-16 Medical Therapy Midadministration.............
1I 13 Appendix C-Other Events Of Interest 1.
Inadvertent lifting of Two Irradiated Fuel Assemblies at Indian Point Unit 3..............
13 2.
Mislabeling of Diagnostic Raciopharmaceuticals....................................... 14
- 3. Diagnostic Dose of Iodine-131 and Technetium-99m Administered to a 14 Pregnant Pa tien t..........................
References For Appendices........................
17 v
NURl!G-0090, Vol.13, NoA
Abnormal Occurrences,4th Qtr CY90 PREFACE Introduelion through regulations specifying requirements that will ensure the safe use of nuclear rmterials. The The Nuclear Regulatory Commission reports to the regulations include design and quclity assurance Congress each quarter under provisions of Section criteria appropriate for the various at civities licensed 208 of the Energy Reorganization Act of 1974 on any by tue NRC An inspection at d enforcement abnormal occurrences invohing facilities and program helps ensure compliance with the aethities regulated by the NRC. An abnormal regulations.
occurrence is defined in Section 20S as an unscheduled incident or event that the Commisnan determines is significant from the standpoint of Reportable Occurrences public health or safety.
Actual operating experience is t essential input to the regulatory process for assuring that licensed Events are currently identified as abnorm..
aethities are conductcd safely. Licensee; are occurrences for th.- uport by the NRC using tb required to report certam mcidents or events te the criteria listed in A mdix A. *lhese criteria were NRC. This reporting helps to identify deficiencies promulgated in an " AC policy stement that wns carly and to ensure that corrective actions are taken published in the Fede, ' Register on 1 coruary 24.1977 (Vol. 42, No. ~37, pages 10950-10952). In order to to prevent remene.
provide wide dissemination of information to the public, a Federal Reginer notice is issued on each r, r nuclear power plants, dedicated grons have abnormal occurrence. Copies of the notice are been forrnM both by the NRC and g thr. nuclear distributed to the NRC Public Document Ro< m and p wer mdustry for the detailed review of operating all Local Public Document Rooms;. At a minit um, expenence to help identify safety concerns early; to each notice must contain the date and place of she impt ve dissemination of such information; and to ocentrence and describe its nature and probaNe feed back the experience into licensing, rep"N'm.
and operalions. In addition, the NRC and th o
r consequences, power industry have ongomg effort
- to improve tna peratkinal data systems, which include not only the The NRC has determined that caly those events described in 'this repw: racet the criteria for type and quality of reports required to be submitted, but also the methods used to analyze the data, in abnormal occurrence reporting. This report covers rder to more effectively collect, collate, store, the period from October 1 through December 31, 1990. Information reported on each event includes fetrieve, and evaluate operational data, the nf rm ti n is maintamed m computer-based data date and place, nature and probable consequences, Nes.
cause or causes, and actions taken to prevent recurrence.
1\\vo pnmary sources of operational data are Licensee Event Reports (LERs) and immediate The Regulatory System notificatior.s made pursuant to 10 Crn 50.72.
The system of licensing and regulation by which NRC Except for records exempt from public dMelosure by carries out its responsibilities is implemented statute and/or regulation, information concerning through rules and regulations in Title 10 of the Code reportable occurrences at fecilities licensed or of Federal Regulatiorn This includes public otherwise regulated by the NRC is routinely participation ns an element. To accomplish its disseminated by the NRC to the nuclear industry, the objectives, NRC regularly conducts licensing public, and other interested groups as these events proceedings, inspection and enforcement activities, occur.
evaluation of operatin g experience, and confirmatory
- research, while maintaining programs for Dissemination includes special notifications to establishin" standards and issuing technical reviews licensees and other affected or < interested groups, and studies.
and public announcements. In addition, information on reportable events is routinely sent to the NRC's in licensing and regulating nuclear power plants, the more than 100 hical public document rooms NRC follows the philosophy tht the health and throughout the United States and to the NRC public safety of the public nre best ensured through the Document Room in Washington, D.C.The Congress establishment of multipielevehof protection.These is routinely kent informed of reportable events multiple levels can be achi.cd and maintained occurring in licensed facilities.
vii N UREG-0090, Vol.13. No.4
i A'.,am m t
.utences,4th Ott CY90 t
able at the State level. Certain information is Another prirnary source of operational data is reports a
- of reliability data subml; 1'1y licensees under the also pros" E-d to the NitC under exchange of Nuc! car Plant Itcliability ; 'a System (NPitDS).
informatt.. provisions in the agreements.
'Ihc NPit >$ is a vo:.ntary, industry supported system opaa,ed by the Institute of Nuclear Pov cr In early 1977, the Commission deterrnined that Operations (INPOp a nuclear utility organization.
abnorrnal occurrences happening at facilities of Iloth engmt: ring and failure data are submitted by Agreement State licensees should be iacluded in the nuclear power plant licensecs for specified plant quarterly reports to Congress. The abnormal components and systcms.'the Commission considers occurrence criteria included in Appendix A are the NPilDS to be a vital adjunct to the 1J111 system appl ed n uformly to events at NitC and Agreement for the collection, review, and feedback of State licensec facilities. Procedures have been operational experience; therefore, the Commission developed and implementc6 and abnormal periodically monitors the NPilDS reporting occurrences reported by the Agree.nent States to the activitics.
NitC are included in these quarterly reports to Congress.
Agrectnent States Section 274 of the Atornic !!ncrgy Act, m.vded, I,oreign Infortnution auti.arizes the Commission to enter into...ce:nents with States whereby the Commission ret.it.quishes and the States assume regulatory authority over The NitC participates in an exchange of inforw. tion byproduct, source, and special nuclear materials (in with various foreign governments that have nuclear quantities not capable of sustaining a chain reaction).
facilities. %ls foreign information is reviewed and Agreement State prograras rnust be compa*able to considered in the NitC's assessment of operating and compatible with the Commission's program for experience and in its research and regulatory such material, activities. Iteference to foreign information may occasionally be made in these quarterly abnormal Presently, information on reportable occurrences in occurrence reports to Congress; however, only Agreement State licensed activities is publicly domestic abnormal occurrences are reported.
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NUREG-0090. Vol.1 L No.4 viii
i Ahnotmal Occurrences,4th Ott CY90 ItEl'OllT TO CONGitESS ON AllNOllMAls OCCUltitENCES OCTOllElt-DECEMilElt 1990 Nuclear Power I'lants
- Ihc NitC is reviewing events reported at the nuclear NitC has not determined that any events were abnor.
power plants licensed to operate. For this report, the mal occurrences.
Fuel Cycle Facilities (Other Than Nuclear l'ower I'lants)
The NRC is reviewing events reported by these determined that any events were abnormal occur-licensees. For this report, the NitC has not rences.
Other NitC Licensees (Industrial Itadiographers, Medical Institutions, Industrial Users, etc.)
There are u :ntly about 9,000 NRC nuclear mate-yond the pronate gland. As a result, the radiation rial licenses in effect in the United States, principally dose to the prostate was negligible compared to the for use of radioisotopesin the medical, industrial, and prescribed dose of 16,000 rads. The licensee esti-academic fields. Incidents were reported in this cate-mated a dose of l$,000 rads to the tissue beyond the gory from licensees such as radiographers, medical prostate gland, considerably greater than the dose institutions, and byproduct material users.*lhe NRC which would have been received if the seeds had been is reviewing events reported by these licensees. For positioned as intended.
thi5 report, the NitC has determined that five events were abnormal occurrences.
'lhe licensec does not anticipate any significant ef-fccts to the patient as a result of the misadministra-tion. Further treatment,14 cluding a repeat of the im-90-21 Medical Therapy Misadministra-plant procedure, was planned.
tion Cause or Causes 'the iodine-125 sced implant pro-
'ihe fullowing information pertaining to this event is cedur e was relatively new for the licensec, although it also being reported concurt ently in the federal Regis-had been used 13 times previously.The attending ra-ter. Appendix A(see the overall criterion)of this re-diation oncologist is an authorized. user who is certi-port notes that an event involving a moderate or fled in therapeutic radiology by the American Board more severe impact on public health or safety can be of lladiology. The primary cause of the misad-considered an abnormal occurrence.
ministmtion appears to be the difficulty in viewing the prostate area using the ultrasonic probe. Ultra-Date and Place-August 29,1990; University of Cin-sonic imaging is often difficult and inexact, especially einnati; Cincinnati, Ohio, when attempting to visualize a soft tissue organ like Nature and Probable Consequences-On August 29, 1990, 86 iodine-125 seeds (small scaled radiation Actions Taken in Prevent Recurrence sources) were permanently implanted in an 86 year-old patient. 'lhe seeds totaled 27.5 millicuric, of io-Licensee 'fhe licensee has adopted revised procc-dine-125. A dose of 16,000 rads was prescribed for dures to prevent recurrence of the misplacement c.
the prostate gland.The seeds were to be implanted in the iodine-125 seeds in procedures of this nature.
the prostate usingt n ultrasonic probe to view and po-
'the revisions include an improved measuring tech-sition the implants.
nique to ensure proper seed depth placement and improved ultrasonic image analysis. The attending Subsequent review by the licensee determined that radiation oncologist traveled to the research center most of t he seeds had been implanted too deeply and where the implant procedure had been developed to had paned through the prostate into the surrounding evaluate the procedure and to gather further infor-tinue. Many of the seeds wet e 5 to lo centimeters be-mation to improve the ticensce's implant techniques.
1 NUIEG-0090, Vol.13, No A
Abnormal Occurrences,4th Ott CWO NitC-An inspection was conducted in November Itadiographic operations to perform 35 exposures of and December 1990 to review the full scope of NitC.
welds on a waMe water storage tat.k uere planned.
licensed activities at the University of Cincinnati,in-
'ihe source guide tube end. cap and attached collima.
ciuding this misadrtinistration (itef.1). Although un-tor were clamped to a stand that was magnetically related violations and deficiencies in the licensce's mounted to the extenor surface of the taniwdl.'the program were identified, there were no violations as-stand was moved along the weld for each successive sociated with this misadministration. *lhe Mnsee's 45-second exposure.
corrective actions were determined to be acceptabic.
Af ter cranking out the source for the sixth exposure,
'lhis item is considered closed for the purposes of this the radiographer heard a crash and saw that the mag-netically mounted stand, that held the collimator and report.
end-esp, had fallen from the side of the tank and was lying on the c7ncrete pad.'lhe source guiJe tube end-90-22 Ilttdlatiott Overexposure of a lladi-cap with the collimator had been approximately 10 ographer feet above the concrete pad for this exposure.
The following information pertaining to this event is The radiographer atternpted to crank the source back into the camera but found that the drive cable could also being reported ccacurrently in the Federal Regis, fer. Appendix A (see Example 1 of Tor All Licen.
only be retracted a short distance, lie then looked
- es") of this report notes that an exposure of the around the tank and noticed the guide tube was feet, ankles, hands or forearms of any individual to looped. The radiographer then dragged the camem 375 rem or more of radiation can be considered an ab.
back by pulling on the drive cable housing in order to straighten out the guide tube. After straightening the normal occurrence, guide tube, the radiographer was able to fully retract Date and Place-October 5,1990; Western Stress, the cable, and consequently thought that the source Inc.; llouston, Texas; the radiation overexposure oc.
was in the camera. St'bsequently, the radiographer removed the chain from aro,md his neck that held his curred at a temporary jobsite in 11ordentown, New two 200 millitem scif reading pocket dosimeters and
- Jersey, his thermoluminescent dosimeter badge and laid the crain and dosimeters near the crank handleJihe ra.
Nature and Probable Consequences-During the evening of October 5,1990, tbc licensee notified the diographer later admitted that he took thic ction to NRC that an incident had occuired earlier that eve, mnceal the radiation exposure he woulc ater re-cetve.
ning while a radiographer and his assistant were working at a temporary jobsitcJlhe radiographic op-The radbgrapher walked up to the end of the source crationinvelved the use of a radiography device con-guide tube with his sutYey meter in his hand, but did taining an 80.5-cune indium-192 sealed source. (A not refer to the instrument for any indication of ra-radiography device uses a radioactive scaled source diation. At this time he trasped the end of the source to make x ray like images of welds and heavy metal guide tube with his left hand. With his ri.ht hand he objects.The position of the source is control!d by a removed the tape which held the collimator in place dnvc cable that ts used to crank the source out of the and cast the collimator aside. lie then began to un-exposure device and to retract it back to the shicided screw the source guide tube end cap from the source position within the device via an unshielded source guide tube to exchange the end-cap for a lighter end-guide 2e.)
cap assembly. As he removed the cap, the source chain containing the scaled source fell out of the end-The licensee reported that the source became discon-c p assemW onto me mmek pai he n@gm-nected from the drive cable and remrived in the pher then dropped the source guide tube and end-guide tube.The radiographer retracted the dnvc ca cap, au mp@ ft immc&au ma.
ble unaware that the source was no longet attached to it. At this point, the radiographer removed his per-A source recovery team from the camera manufac-sonnel dosimetry and approached the end of the
- urer was an. to the site and safely recovered the guide tube to adjust the guide tube end cap and colli-
- soyce, mator. As he removed the end-cap, the r'urce chain containing the iridium-192 source fell to the ground.
Ilased o iinterviews conducted with the radiographer The radiographer immediately retreated from the and the.?orporate Radiation Safety Of ficer, NRC in-area. The licensee notified the NRC, and two NRC spe, a determined that the radiographer received Region 1 inspectors were sent and arrived on site at exposures in excess of regulatory limits. Dose esti-midnight to investigate the incident. The circum-mates ) erformed by the N RC indicated a whole body stances associated with the radiMion overexposure exposure to the rad:oprapher of about b.9 rem and an are described below.
extrermty exposure of about 1070 rem.The beensee NUREG-0090. Vol.13 NoA 2
Abnnrmal Occurrences, 4th Ott CY90 sent the radiographer to a pbysician for examination tion, the licensee also received a second vial contain, and blood tests. No clinical manifestations of the ing 140 nullieuries of iodme-131.'this vial is a weekly overexposure were evident.
standing-order for the hospital and is used as needed during the week.
Cause or Causes-lhe radiographer failed to con-duct a radiation survey of the exposure device aftcr n.mmials were assayed by a technologist.'the one the exporure. Without a radiation survey, the radiog-vial containea ISO millituries, and this amount was rapher was not aware that the source was discon-later approved by the authorized physician for the pa-nected and had not returned to the shielded position, tient's treatment. The standing order vial contained llis willful removal of dosimetry devices complicated 140 millicuries. After the assay, the technologist subsequent dose calculations.
placed both vials side by side in the fume hood 10-cated in Ihe nuclear pharmacy. Iloth were still in their original leaded shleids and labeled as to their con, Actions Taken in Prevent itecurrence tents.
Licensee-The licensee's proposed corrective ac-tions include temporarily removing the radiographer At 10:30 a.m., the authorized physician user was from radiography dutler, doubling the number of ready to administer the iodine-D1 to the patient, and management audits and safety meetings, revising called for the material. Since the technologist who company policy on the number of hours worked, and had prepared the dosage was not readily available, incteasing safety training Irom 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> peryear to 32 another technologist went to the pharmacy to obtain hours per year, the radiopharmaceutical.1he technologist who had prepared the dosage did not indicate to the admini.
NitC-NRC Region IV transmitted its inspection re.
stering technologist how many vials were to be ad-port on December 9,1990 (Ref. 2). and conducted an mimstered.1hc administering technologist picked Enforcement Cor.ference with the licensee on De-up both vials, assuming they were to be administered cember 7,1990, to discuss the event. Escalated en-to the patiert.The technologist did not t eview the la.
forcement action is pending. NRC issued an immedi.
bels on the containers, assuming they were the ately effective order on January 28,1991 (Ref 3),
proper doses. The technologin also did not consider prohibiting the radiographer from enraging ;n NRC-the administration d more than one vial to be un-licensed activities on behalf of the licensee for a usual since this was a common occurrence at this fa-period of 1 year, cility.
Future reports will be made as appropriate.
After reviewing the dosage record, the authoriud physician instructed the technologist to administer the dose to the patient. The technologist then pro-90-23 Medical Therapy Misadministra-cceded with the administration of both viah contain.
tion ing 320 millituries.The physician did not review the labchng on the containers, believing that since the The following information pertaining to this event is patient's unit dose record was complete and indicated also being reported concurrently in thc I'cdcrolRct.t-a dosage of 180 millicuries, the two vials were the i
fer. Appendix A(see the overah criterion)of this re-proper ones for administration.
port notes that an event involving a moderate or more severe impact on public health or safety can be On October 16, the nucicar pharmacist received a re-considered an abnormal occurrence, quest for 25 millicuries of iodine-131, but could not fmd the standing order vial.1he resulting investiga-Date and Place-October 15, 1990; William tion determined that the vial had been erroneously Ileaumont Hospital; Royal Oak, Michigan.
administered the previous day. The patient and her doctor were subsequently informed of the misad.
Nature and Probable Consequences-On October ministration. The licensce's radiation safety officer 10,1990, a 60-year-old female patient was referred also was notified.
to the nuclear medicine department for iodine-131 thyroid ablation therapy aftcr undergoing a NRC Region III contracted with a inedical consultant thyroidectomy for cancer. After reviewing the clinical to evaluate the potential medical effects on the pa-data on the patient, the authorized physician user tient ns a result of the misadministration.1hc con-prescribed 175 millieuries of iodine-131 to be ad-sultant's evaluation indicated that the misadministra-ministered orally on October 15.
tion should not have any significant medical effects on the patient; the estima' bone marrow dose re-On October 15, the !icer' e received the patient's ceived by the patient was between 40 and 50 rads, oral iodme-131 solution ho.n a distributor. In addi-which should be well tolerated by the patient.
3 NUlmO-0090, Vol.13, No.4
Abnormal Occurunces,4th Qtt CY90 Cause or Causes 'lhe three primary causes were:
tion overexjusure occurred at a temporary job 'te in (1) the stock solution of iodine-131 was stored in the llurns Flat, Oklahoma.
san
- hication as the patient's dose, (2) the admini-Nat 're und probable Consequenm-On November s'. ring technologist was never informed by the tech, 26,1990, the licensee notihed the NitC tFu on No-nologist who actually prepared the dose that only one vial was to be used, and (3) the admini*tering tech.
vember 12,1990, a radiographer's assistant may have
^
hologist and physiciim did not review the labels on the sustained a possiyle radia'an overexposurc to he right hand. 'the beensee stated that it was not 4 container, formed of the incident by the radiopapher until the morning of November 25,1990, because the radiog.
Actions T ken to Prevent itecurrence rapher did not think an overexpsure had occurred a
until the assistant radiographer s right hand became I.lrensee-On October 18. 1990, the hospital re-quested that its NitC license be amended to ine!ude fed and his fingers began to swell. On the day of the me dent, the radiographer and his assistant were per-the following nmdifications to its iodine-131 adrnini.
forming radiographic operations at a temporary job-stration procedures: (1) on all iodine-131 therapy 5!!C 9 th a radiography device that contamed a 49-cu-i doses, the person administering the dose must either ric aridium-192 scaled source. NitC llegion IV sent be present in the radiopharmacy when the dose is as-an inspector to investigate the incident; based on in-sayed, or the person rnust personally assay the dose terwcws with the radiographer, the assis; ant, and the before it is taken out of the radiopharmacy;(2) the owner of the company, the circumstances associated dose shecting must indicate the number of vials that with the radialmn merex[vsure are described below.
comprise the dose;(3)just prior to the administra, tkm, the physician ' vill verify the assay dose activity
.lhe radiographer and his assistant were performing with the prescribed dose and initial the dose shect; radiographic exposures of welds on a 48-inch diam-and (4) the standing order of therapeutic iodine-131 eter tank at a fabrication shop. After the sixth expo-will be stored in the hot locker and will be placed in sure, the radiographer left the immediate area to l
the fume hood only when needed for dispensing. On load film in a belt. While the radiographer was away, October 29,1990, these new procedures were incor-the assistant set up the seventh exposure and cranked potated into the hospital's NitC license via an out the source.*lhe assistant had turned the crank nmendment, about two or three turns when he saw that the mag-netically mounted stand, that held the guide tube Nitt'-NitC Itegion !!! conducted an inspection at near the exterior of the tank, had fallen, the facility on October 17,1990 (itet,4). Although no violations of NitC requirements were identified, con-
"Ihe assistant radiographer's alarming personnel do-cerns were expressed over the storage of stock 10-8imeter (chirper) had alarmed loudly w hen the gu de dine-131 with the patient's intended dose and the tube had fallen, The assistant stated that he froze for lack of communication between the technologist who about 5 seconds, then he cranked the source back to prepared the dose and the technologist who admini-the shielded positionJIhc ast.istant's chirper had quit stored the dose 'lhe NitC medical cor" uttant indi-alarming, so he thought the source was in the cated that the licensce's corrective namn program shielded position in the radiography device. 'Ihc as4 was appropriate. Corrective actions will be examined sistant radiographer then stated that he failed to pick by the NitC llegion !!! during future inspections, up and use his survey instrument to perform a survey of the radiography device and the source guide tute,
'lhis item is considered closed for the purposes of this because his chirpcr was not alarming. (the licensec
-report, later reported that the chirper had been dropped a couple of times that night and upon subsequent test-ing was f und to be malfuncti ning due to a shorted 90-24 Itadiallon Overexposure of a Itadi-ground wirc.)lnstead, he walked over to the tank and ographer repositioned the magnetic stand and source guide tube, After the assistant radiographer correctly posi-
'The following information pertaining to thh event is tioned the guide tube with his right hand, he s etumed l
also being reported concurrendy in thc Fcdcra/ Rn:is-to the crank handle to proceed with the exposure.
ter, Appendix A (see 11xample 1 of Tor All IJcen.
l
>ces") of this report notes that an exposure of the When he performed this exposua, he noted that his Icet, ankles, hands or forearms of any individual to chirper did not alarm when the source was cranked 375 rem or more of radiation can be 'onsidered an ab-out. llecause of this, after the exposure was com-normal occurrence, pleted, he looked at his pocket dosimeter and noticed that it was off scale (greater than 200 millirem). At l
Date and Place-November 12,1990; Tumbleweed about the same time, the radiographer returned arid Litay Company; Greenwood, Arkansas; the radia-the assistant told him what had happened and that his NURI:G-0090, Vol.13, NoA 4
Abnormal Occurrences, 4th Otr CY90 pocket dosimeter had gone off scale.1he assistant llegion IV issued an inspection report to the licensee told the radiographer that he did not think that he on 17ebruary 5,1991 (itef. 6) and plans to conduct an had received an overexposure, but that he thought his enforcement confcrence with the licensee.
pocket dosimeter was off smle because he had bumped it carlier.1he radiographer and his assistant l'uture reports will be made as appropriate.
cantinued to work and did not infortr the itadiation Safety Officer of the incident until after the assis-90-25 Medical Diagnostic Misadmin.
tant's hand showed clinical signs of a radiation injury.
Istration 1hc assistant radiographer stated that he grasped the lhe following information pertaining to this event is guide tube with his right hand just below where the also being reported concurrently in the Federa/ Regh-guide tube was taped to the magnetic stand. The ra.
ter. Appendix A(see the generalcriterion)of this re-diation injuries that the assistant radiographer sus-port notes that an event involving a moderate or tained to his hand indicated that he grasped the guide more severe impact on public health or safety can be tube with the thumb, index, and middle fingers, and considered an abnormal occurrence, that the source had to be directly beneath the point grasped.This information may indicate that the assis.
Date and Place-November 26,1990; Vetcrans Ad.
tant radiographer mistakenly cranked the source out, ministration Medical Cenwr; San Diego, California.
instead of in, when the incident first occurred. From Nature and Probable Consequences-On November reenactments, clinical observations, and calculations, 26,1990, a patient schedulcd for the administration the dose to the assistant radiographer s hand was esti-of 5 millicuries of indium-111 labeled anti.Cl!A mated oy the NitC to be between 1500 to 3000 rem.
rnonoclonal antibody for diagnostic imaging of Ihc whole body dose to the assistant, as measured by colorectal cancer was mistakenly admitistered 168 his thermo!uminescent dosimeter, was 365 millirem.
rnillicuries of technetium-99tn pertechnctate.
I?lood samples were taken from the assistant for cytogenetic tests; the results indicated an equivalent Prior to the administration, a nuclear medicine physi-whole body exposure of less than 10 rem.
cian instructed his technical assistant to obtain the in-dium-lit from the Nuclear Medicine Preparation On November 29,1990, the NRC inspector noted 1.ab. llowever, the assistant erroneously picked up a that the assistant's thumb, index, and middle fingers syringe mntaining the technetium-99m pertech-were severely blistered and swollen. On this date the netate. IN physician failed to positively identify the assistant was admitted to a burn center in Oklahoma label on the syringe before injecting the contents of City, Oklahoma, for medical carc.1hc assistant re-the syringe into the patient, mained in the hospital for approximately two weeks, and during that period had a skin graft performed on The error was discovered by the licensec within min-his index finger. On January 22,1991, the physician utes after the misadministration and the patient was contacted NRC and stated that the assistant's middle administered 10 drops of iodide and i gram of finger and thumb appeared to be healing and that the perchlorate to block and flush the thyroid gland re-index finger was grafted due to lesions that were not spectively, healing.1hc physician also stated that the assistant would remain under his care, and he would supply 1hc patient was placed in an isolated room normally NRC with periodic reports.
used for therapy for two days. The patient was scanned approximately thirty hours after the misad-
. Cause or Causes-lhe radiographer failed to super, ministration and the thyroid gland showed no cle-vise the assistant properly, and the assistant failed to vated radioactivity. A small recidual amount of tech-netium-99m was detceted in the bladder. Following conduct a radiation survey of the exposure device, the scar, the patient was noted to be clinically un-changec and was discharged from the licensec's Actions Taken to Prevent Recurrence medical center.
Licensee-lhe assistant rac'iographer is no longer llad the blocking and flushing tsgents not been ad.
employed by the beensee. Aditional actions to be ministered, the organ receiving the highest exposure taken by the licensee will be discussed at an upcoming would have been the stomach wall, receiving an esti-enforcement conference with the NRC.
mated 42 rem comparco to about 5 rem for in-dium-ll t. Administration of th bhicking and flush.
NRC-During the investigation of this event, an Or-ing agents reduced the radiatien exposure to all der modifying the license was issued on December 4, organs cxcept the bladder wall. It is estimsted the 1990, prohibiting the radiographer and the assistant bladder wall received about 17 rem from the technc-from participating in licensed activities (Ref. 5). NRC tium-99m compared to about 3 rem for indium-11 L 5
NUREO-0090, Vol.13, No.4
Abnormal Occurrences,4th Olr CY90 Cause or Causes 'the main cause of the tions of a licensee internal q Jality assurance investi-misadministration war. the failure of the nuclear pation board are currently being considered.
medicine physician and his technical assistant to read the label on the technetlurn-99m syringe at the time NitC-A special NitC team inspection was con-of the injection. A contributing camse of the ducted at the licensec's facility following the misad.
misadministration wm inadequate training of the ministration. An inspection report was issued on physician's technical assistant who was provided a de-January 3,1991 (llef. 7) and an linforcement Confer-scription of the radiopharmaceutictd based only on ence was held with the licensee on J anuary 10,1991, the color and shape of a container and not the label.
On March 13,1991, a Notice of Violation was issued to the licensec for violations identified during the in-spection ef. 8). None ai tht, violations pertained to n
the misadmiristration and no civil penalty was pro-Actions Taken to Prevent Itecurrence posed.
Licensee 'the physician's privilege toinject patients Unless new, significant inh,,mtion becomes avail-has been temporarily revoked. Additional training of able, this item is considered cloed for the purposes the nuclear medicine staff is planned. Itecommenda-of this report.
Agreement State Licensees Procedures have been developed for the Agreement and report the events to the NitC for inclusion in this States to screen unscheduled incidents or events us-report. For this perkid, the Agreement States re-ing the same criteria as the NitC (see Appendix A) ported no events as abnormal occun ences, I
i Nt 'RfiG-0090. Vol.13. No.4 6
l l
Abnormal Occurrences 4th Otr CY90 llEFEltENCES 1.
letter from Charles li, Norelius, Director, Di-Safety, Safeguards, and Operations Support, sision of Itadiation Safety and Safeguards, NitC, to Olho G. Jones, Owner Tumbleweed NRC llegion lit, to Donald llarrison, M.D.,
X-Itay Company, forwarding Order Modify.
Senior Vice President and l'rovost for llealth ing IJcense (Ilflective immediately), Docket Affairs, University of Cincinnati, forwarding No. 30-28741, l.icense No. 03-23185-01, inspection lleport No. 30-02764/90001 December 4,1990.*
(DitSS), Dccket No. 30-2764,1Jcense No.
6.
lenr from A INI thN Dimon Div@
34-06903-05, dated January 23,1991,,
of Radiation Safety and Safeguards, NitC Re.
2.
I.ctter from A.11111licach, Director, Division gion IV, to Otho G. Jones, Owner, Tumble-ofItadiation Safetyand Safeguards,NRClle-weed X Itay Company, forwarding Inspection gion IV, to Paul Abat, President, Western Iteport No. 30-28741/90-02, Docket No.
Stress, Inc., forwarding Inspection Report No.
30-28741, IJcense No. 03-23185-01, Febru-30-30175/90-04, Docket 30-30175, l.icense ary 5,1991.*
No. 42-26900-01, December 9,1990.
7.
letter from Itoss A. Scarvno, Director, Divi-3.
Letter from ilugh I. ' thompson, Jr., Deputy sion of Itadiation Safety and Safeguards, NRC thecutive Director for Nuclear Materials Region V, to'thomasTrujillo, Medical Center Safety, Safeguards, and Operations Support, Director, Veterans Administration Medical NRC, to Paul Abat, President, Western S'ress, Center, forwarding inspection iteport No.
Inc., forwarding Order Modifying IJcense (im-30-08456/90-03, Docket No. 30-08456, mediately Effective), Docket 30-30175, Li-ljcense No. 04-15030-01, January 3,1991, cense No. 42-26900-01, January 28,1991.'
8.
Letter from Itoss A. Scarano, Director, Divi.
4.
letter from John A. Grobe, Chief, Nuclear sion of Radiation Salety and Safegeards, NRC Materials Safety firanch, NRC Region 111, to Region V, to'thomasTrujillo, Medical Center larry Randolph, Associate llospital Director, Dirtctor, Veterans Administration Medical William lleaumont ilospital, forwarding Center, forwarding a Notice of Violation, inspection Report No. 30-02006/90-001 Docket No.
30-08456, IJecnse No, (DRSS), Docket No. 30-02006, IJcenst., No.
04-15030-01, March 13,1991.*
21-01333-01, November 8,1990.*
- Amilable in NRC Pubhc Dwu.nent Room,21:01. Street. NW 5.
letter from ilugh I.,Ihompson, Jr., Deputy (twer tweh, hhint. ton. on, for pubhe inspecuon mi Executive Director for Nucl:ar Materials cr ;yint 7
N URdG-0090, Vol.13, No.4
1 Abnormal Occurre t.ces, 4th Ott CY90 APPENDIX A AllNOllM AL OCCUltitENCE ClllTElll A The following criteria for this report's abnormal oc-dioactive material from a package in amounts currence determinations were $ct forth in an NitC greater than the regulatory limit.
policy statement published in the Federal Regirter on 5.
Any loss of licensed material in such quantities February 24, 1977 (Vol. 42 No. 37, pages and under such circurnstances that substantial 10950-10952).
hazard may result to persons in unrestricted areas.
An event will be considered an abnormal occurrence if it involves a major reduction in the degree of pro.
6.
A substantiated case of actual or attempted tection of the public health or safety. Such an event thef t or diversion of licensed rnalerial or sabo.
would involve a moderate or more severe impact on tape of a facility, the public health or safety and could include but need 7.
Any substantiated loss of special nuc! car rnate.
not be limited to:
rialoranysubstantiated inventorydiscrepancy that is judged to be significant relative to not.
1.
Moderate exposure to, or release of, radioac-mally expected performance t.nd that is judged tive materiat 'icensed by or otherwise regu-to be caused by theft or liversion or by sub-lated by the Commission; Stantial breakdown of the accountability sytr 2.
Major degradation of essential safety related equipment; or 8.
Any substantial breakdown of physical t.ecurity or material control (i.e., access control, con.
3.
Major deficiencies in design, construction, use tainment, or accountability systems) that sig-of, or management coutrols for licensed facili-nificantly weakened the protection against ties or rnaterial.
thef t, dwersion, or sabotage, Examples of the types cf events that are evaluated in 9.
An accidental criticality (10 CFil 70.52(a)).
detail using these criteria are:
10.
A major deficiency in desi,;n, construction, or operation having safety implications requiring for All Licensees immediate remedial action.
1.
Exposure of the whole body of any individual 11.
Serious deficiency in management or proce-1025 rem or more of radiation: exposure of the dural controls in major areas.
skin of the whole body of any individual to 150 rem or more of radiation; or exposure of the 12.
Series of events (where individual events are icet, ankles, hands or forearms of any individ.
not of majorimportance), recurringincidents, 10 C Rt and incidents with implications for similar fa.
ual to 375 rem or more of radiation [fromin.
cilities (generic incidents) that create major 20.403(a)(1)] or cquivalent exposures ternal sources.
safety concern.
2.
An exposure to en individual in an unrestricted ror Commercial Nuclear Power Plants area such that the whole body dose received exceeds 0.5 rem in one calendar year [10 CFit 1.
Exceeding a safety hmit of license technical 20.105(a)].
specifications [10 CFR 50.36(c)].
2.
Major degradation of fuel integrity, primary 3.
The rclease of radioactive matcrial to an unre.
stricted area in concentrations whkh,if aver.
emlant presme boundary, or primary con.
l aged 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 tainment boundary.
l times the regulatory limit of Appendir 11, Ta-3.
Iass of plant capability to perform essential l
ble II,10 CFR Part 20 (CFR 20.403(b)(2)].
safety functions such that a potential release 4.
Radiation or contamination levels in excess of of yadyactivity in excess of 10 CFR Part 100 m em mu m a postulated tmm design values on packages, or loss of confine.
nt or nddM i sg, is of emgency a ment of radioactive material such as (a) a ra-cmling system, ioss of control rod system).
diation dose rate of 1000 mrem per hour three feet from the surface of a package containing 4.
Discovery of a major condition not specifically the radioactive material, or (b) release of ra.
considered in the safety analysis report (SAR) l l
9 NUIWO-0090, Vol.13, No.4
Abnormal Occurrences,4th Qtt CY90 or techn.:al specifications that sequires imme-l'or l'uti Cyle I.lansas diate remedial action.
1.
A safety limit of license technical specifica-tion' is exceeded and a plant shutdown is re-5.
Personnel error or procedural deficiencies quired [10 C1115036(c)l.
that result in loss of plant capabihty to per-2.
A major condition not specifically considered l
forrn essential safety functions such that a po-i:4 the safety analysis report or technical speci-i tential release of radioactivity in excess of 10 fications tt'at requi*cs immediate remedial ac.
j CI'It Part 100 guiJelines could result from a tion.
i postulated transient or accident (e.g., loss of 3.
An event that seriously cornpromised the abil-ernergency core cooling system, loss of control ity of a confinement system to perform its des-rod Fystem),
ignated function.
f C
N L.'P,I!G-0090, Vol.13, No 4 in
Abnormal Occurrences, 4th Qtt CY90 Al'I'ENI)lX 11 UI'DATE OF l'ItEVIOUSIX llEl'OllTED AllNOllM AL OCCUltitENCES During the October through December 1990 period, during this period tevealed no further misad:rinistra.
NilClicensees Aprcement States, Agreement State lions, although a few documentation erro 3 had been licensees, and other involved parties, such as reactor identified and corrected. On December 13,1990, an vendors and architect engineering firms, continued enforcement conference was conduct ed with licensee with the implementation of actions necessary to pre-representatives to review the circumstances which vent recurrence of previously reported abnormal oc-centributed to the misadministration, the vio?.itions curtences. Ihe referenced Congressional abnormal identified during NilC's investigation of the incident, occurrence report below provides the initial and any and the licensee's correctiv' actions taken in re-subsequent updating information on the abnormal sponse to NI(C's findings. The licensee had imple-occurrence discussed. (Ihe updating provided gener-mented corrective actions for each of the violations ally covers events that took place during the report identified during the inspection and had addressed period; some updating, however,is rnore current as other concerns related to licensed activities as docu-indicated by the associated event dates.) Open items mented in NitC Inspection Report 30- 11571/90-02 will be discussed in subsequent repons in the series.
(itef,11-1).
On December 20,1990, the NitC 1:ued a Notice of i
Otller NltC I'leenses Vi"l"ti """d P' P 5*d l*P Siti " ICi"I' P'""I'Y "
the amount of $1.250 for two violations associated with the therapy misadministration (Itef, Il-3).'Ihese included: (1) a failure by the licensee to require its 90-16 Medical Therapy Misadministra*
staff to follow the instructions of the supervising phy-tion sician, and (2) a failure on the part of the licensee, throegh its Itadiation Safety Officer, to ensure that
'lhis abnormal occurrence, which occurred at Mus-radiation safety activities were being performed in ac-Logee llegional Medical Center in Muskogee, Okla-cordance with approved procedures and regulatory homa, involved radiation therapy to the wrong side of requiremnts in the daily operations of its byproduct a patient's neck.'lhe event was originally reported in material program. 'these violations were jointly cate-N UREG-0090, Vol.13, No. 3, " Report to Congress gorized a., a Severity lxvel 111 problem (on a scale in on Abnormal Occurrences: July-September 1990."
which Severity levels I and V are the most and least As previously reported, an NRC Region IV inspector significant, respectively) and assessed a civil penalty conducted a special safety inspection on October 3 of $1,250. A third violation, involving the failure to and 5,1990, of the circumstances associated with the notify NRC of the therapy misadministration within misadministration, and identified violations of NRC the time allotted by NRC regulations, wac catego-requirements as well as deviations from the licensee's ri7ed as a Severity level IV violation and was not as.
documented procedures (Ref B-1). On October 10, sessed a civil penalty, 1990, the NRC issued a Confirmation of Action let-ter confirming a committnent made by the licensee to
'Ihe licensee has paid the civil penalty and has re-conduct a review of patient treatments completed sponded to the Notice, acknowledging each of the during the previous 12 months to determine if similar violations. NRC will review the effectiveness of the treatment errors had o;cmred and gone unrecog-licensee's corrective actions during future, routine nized (Ref.11-2).
inspections.
'lhe licensee reported on November 5,1990, that the
'Ihis item is considered cicsed for the purposes of this investigation of treatmentF initiated of completed report.
I1 NtiREG-0090, Vol.13, No.4
Abnorrnal Occurrences 4th Olr CY90 Al'I'ICNDIX C OTillCit EVI:NTS Olt INTElli ST
'the following items are described because they may found bent and not engaged into the fuel assembly possiWy be perceived by the public to be of public upper flow noule hole; the other locating pin was health or safety significance. 'the items did not in-bent and suspended the assembly at an angle of ap-volve major reductions in the level of protection pro-proximately 7 degrees.
sided for public health or safety; therefore, they are not reportable as abnormal occurretices.
'!he licensce's fuel assembly retrieval scheme in-cluded: a static lift of the UIP until the fuel assem-1.
Inadvertent 1,1fting of Two Irratllated bHes wne appnnimately 1 foot abm the veml flange, rotating the Ull'in order to move the fuel as.
Fuel Assentblics at Indian l'olnt semblics outside of the vessel flange (one at a time),
Unit 3 and positioning the assemblies such that they could be lowered into fabricated steel baskets that were 10-On October 4,1990, the licensee (Power Authority of cated in the deep end of the reactor cavity. One of the State of New York) for Indian Point Unit 3 was the assemblics dropped into its basket when the attempting to remove the upper core support strue.
brakes to the overhead crane were applied and be-ture (upper internals package-UIP) from the reac.
lore the assemblics could be lowered into the bas-tot ves;el in preparation for refueling the core. (In.
kets. 'the licensee lowered and freed the remait,ing dian Point Unit 3 is a Westinghouse-designed assembly withou t incident. 'l he dropped assembly re-pressurized water reactor located in Westchester sulted in no radiological release or breach of fuelin-County, New York.) After fint raising the UIP out of tegrity. 'these efforts were monitored by the NPC the reactor vessel, lateral movement of the UIP was Special inspection Team, commenced and then stopped when the licensee dis-l'ollowing recovery of the fuel assemblics, an NRC covered that two peripheral fuel assembhes were sus-Augmented insPcetion Team (AIT) was scnt to d*<
pended from the bottom of the upper core plate site imm O.ctobu 24 01mugh November 16,19 <0 which is part of the UIP, llecause of poor lighting,
,this inspection focused on ascertaining the rel.' ant water clarity, and camera kication, the two suspended facts and probable cause(s), and evaluating the licen-fuel assernblics were not recognized earlier during see's analyses and proposed corrective acuans for the the underwater video inspection.The licensee imme-October 4,1990 event (Ref. C-2). !n parallel with the diately suspended the manipulation of the UIP and Art efforts, on October 22,1990, the licensee organ-notified the NRC of the event.
12ed a Root Cause I cam (RCT) to m, vestigate the cir-cumstances associated with the event and to deter-A C,onfirmatory Action Letter (CAL) was issued to m ne its causes. 'lhe RCI', as well as the AIT, confirm the licensee s commitments to develop a safe concluded that the damage to the guide pins occurred and controlled retrieval of the two fuel assembhes during previous refueling operations on May 27.
and to obtam NRC agreement prior to: (1) moving 1989, when the UIP inaAertently bumped into the the upper core internals with two assemblics at-stomge stand. Subsequent mspections of the fuel as-tached; and,(2) degrading the containment integnty sembly that had ? ' been dropped during the recov.
and degrading vital safety systems. The cal, a'so cry process rf ad sustained mechanical deforma-confirmed the ticensee s commitment to restrict con-tion of portions of its fuel rods, attributed to tainment access to personnel required to monitor in' proper guide pin insertion and bending of the fuel and recover the fuel. An NRC Special Inspectmn assembly upper flow noule.This outwardly bent fuel l
,l'eam was sent to the site from October 5 to October rod deformation was also the apparent cause of fuel 19,1990, to provide an mdependent assessment of rod mechanical deformation in an adjacent fuel as-l the licensec,8 acuons for recovery of the fuel assem-sembly.The damaged guide pins were not discovered bh,es, including pmcedures and safety analyses (Ref.
during the May 1989 refueling which realted in the C-1).
fuel assemblies being used during the subsequent
'lhe two assemblics were attached to the UIP by bent fuel assembly kicating pins (guide pins).The kicating Once the mechanism of the guide pin bending was pins extend downward from the upper core plate and determined, tne licensee began preparations for insert into the fuel assembly upper nonle puide pin rehiadingof the reactorcore and reinstallation of the holes when the upper core internal structure is prop-UIP.The AIT then became imimately involved in re-erly aligned over the top of the core. On caeh of the viewing the various aspects of licensee readiness to j
suspended fuel assemblics, one kicating pin was take these steps. This review included an assessment 13 NU REG-0090. Vol.13. No.4
Abnormal Occurrences,4th Otr CY90 i
of such factors as: the acceptabitity of reactor opera-
'the doses were distributed to 8 Akron arca hospitals tion with some fuel atsemblics having missing guide and 8 were used for diagi.ostic tests on patients.'lhe pins, the adequacy of training and procedures, and error was discovered when the hospitals reponed review of the core reload analysis, that the test results were different than those antici.
pated.
From its review of the 1989 refuctingoutage ahitics
.lhe error was attributed to conflicting markings on as well as activities observed while on site during the the bulk quantity of the radiopharmaceutical. 'lhe 1990 outage, the AIT identified the following as the outer vial shield wat incorrectly mai ked *M DP_. 'ihc principal contributing factors to this fuel assembly inner vial label, which was difficult to read through event: inadequate overvic.y ty the lleensee of safety I C ti cd glass shield, was correctly rnarked as related work performed by a contractor, and deficien.
,. g.,,,
cies in the level of detail embodied in refueling pro-cedures for the purpose of ensuring that the UIP
.lhe radiation doses associated with the misad-guide pins are preclu mJ from being damaged during ministrations are within the normal range for diag-transit and storage of the UIP outside of the reactor nostic tests of the kidney (i.e., about 2 rern). Ilow-nssel' ever,6 order to obtain valid test results, the studies would have to be repeated using the correct form of On January 31,1991, an enforcement conicrence was the radiopharmaceutical.
conducted with the lleensee at the NitC llegion 1 Of-fice to discuss issuce associated with the event. On As wrrective actions, the licensec has revised the la-February 22,1991, the NitC issued to the licensec a bel on both the inner vial containing the radioactive copy of the enforcement conference report together pharmaceutical and the outer vial shield to better de-with n Noticc of Violation (Itef. C-3). No civil penalty scribe the contents. Personnel have also been in-wes praposed for the violation. 'lhe violation con-structed to double check the labels of each radiophar.
sisted of four exa.nples of either the failure to follow maceutical vial and the outer shield.
procedures, or the failure to provide adequate guld-ance or cisteria in procedures, ccmccrning the re-An NitC inspection was conducted on December 18 moval and reinstallation of the up;)er internals.
and 20,1990, to review the circumstances of the mis-labeling as wcll as other aspects of the licensec's ae.
On December 12,1990, the NitC issued Information tivities. On January 15,1991, a Notice of Violation Notin No.90-77("InadvertentIternovalof Fuel As.
was issued to the licensee for one viuation involving semblics from the Itcactor Cc"") m all holders of the incorrect labeling of the radiopharmaceutical operating licenses or construct..,..mits for pres.
(l<cf. C-6) suriicd water reactors (llef. C-4). 'ihe notice de-
'the item is of interest because it illustrates how a f.in-scribed the event at Indian Point Unit 3, as well as events of a similar nature that have occurred at other gle egor can result in mtltiple misadmmistrations, ny h mg multiple hospitals,in addition, s nec the di-pints. In addition, the notice offered suggestions on avoiding future such incidents. Additionalinforma, agnostic test results were invalid, the patients re-ceived unnecessary crposure to radiation; however, tion regarding the Indian Point Unit 3 event was is, the radiation doses associated with such diagnostic sued on February 4,1991 in Supplement I to NltC procedures are small.
Information Notice No. 90-77 (itet C45).
3.
Diagnostic Dose of lodine-131 und 2.
Mislabel.tng of Diagnostle Techneflum-99m Administered to a Radiopharmuccuticals Pregnant Patient On November 23.1990,12 individual dosages of a On December 7,1990, St. John Medical Center, of radiopharmaceutical containing technetium-99m Tulsa, Oklahoma, reported that a pregnant patient were mislabeled and uributed to area hospitals by had received oral administration of 30 microcuries of the Syncor Corporation radiopharmacy in Akron, iodine-131 in combination with an intravenous dose Ohio. The individual dose labels indicated that the of 14 millicuries of technetium-99m,The patient was material was technetium-99m-M DP, a bone imaging administered the prescribed diagnostic radiophar-agent. In fact, the material was technetium-99tn-maceutical doses on September 7,1990, for a thyroid DTPA, a kidney imaging radiopharmaceutical. flhe uptake and scan. 'lhe licensec's staff was unaware radioactive element, technetium, is the same in both that the patient was pregnant at that time, forms; the other chemicals in the pharmaceutical, however, determine which organ the pharmaceutical The referrmg phpician had examined the patient on tends to be deposited in.)
August 28,1990, and had referred her for a thyroid Nt!!WG-0090, Vol.13, No.4 14 i
_ _ _ _ _., _ _ _ _ _ _ _ _ _ _ _. _ - - - ~, _ _ _.. _ _
Abnortnal Occuuenas, 4th Ott CY90 examination with a suspected diagnosts of Grave's The licenwe reported th;.t the fetal are was deter-disease, in preparation for the exarnination, the phy.
mined to have been 11 weeks at the time that the thy-tacian questioned the patient r eparding the possibihty toiJ test was performeJ. 'the hcensee's raJiation of pregnancy, and was informed by the p.stient that s.af ety of fice,- (RM )) rnade an milial dose anessment she was not pregnant.1.ikewise, the licensee's stalf on 1)ccember 10,1990 !)ue to the diffeulty in accu-l also conbrmed that the patient did not believe she rately determning the dose to the fetal tt.yroid, and l
was pregnant prior to administering the radiophar-because of une :rtainties involving fetal ape, percent-I maceuticals.
are uptake of ladioiodine by fetal thyroiJ tissue, and the concurrent :ffeets of maternal thyroid hormones, j
'lhe patient was seen in the hospital emergency room a lanpc of dose estimates was made.'lhe best case as-one month later by the physician for other medical sumes a non functioning fetal thyroid resulting in no concerns, and the physician observed that she was dose to the thyroid and IM millirem whole body ab-4 pregnant. At this time, the patient's complete ruedi-sorbed dose. 'lhe worst case assurnes a functioning cad history was unavailable and the physician ques-thyroid resultmg in a thyroid dose of 21 rem anJ 160 tioned the patient as to whether the thyroid examina-milkrern whole body absorbed dose.'lhe N1(C is con-tion had been performed.'lhe patient misunderstood tinuing to evaluate the estimated absorbed fetal dose, the physician's question (she does not speak linghsh Tbc llSO plans to consult with a pediatric endocri-fluently), and replied that it had not been performed.
nologist for further guidance in monitoring the infant During a later examination on December 7,1990, the through follow up evaluations.
physician discovered tht.t tbc examination had been completed on September 7,1990, and that due to a The event remains under review by both the licensee clerical error at the physician's office, the results had and the NilC. NitC staff has determined that the li-not been brought to the physician's attention. 'the censee did follow procedures concernir.g precautions phy esan notified the licensee of the problem and re-necewary to determine whether female patients of d
quested assistance in evaloating the potential extant child bearing are are pregnant prior to administering of fetal thyroid damage resuhing froni the radiophat-radiopharmaceutical doses and will review the licen.
maceutical dosages.
see's evaluation during a future inspect on.
1 15 N I.1:1 'i-0M Vol 13. No t
_ ~, -
Abnottual Occurrences, 4th Ott CY90 itEFEltENCES 17011 Al'I'ENDICES 11-1 Letter from A.11i11 lleach, Director, Division Power Authority, forwarding NRC Region I of Radiation Safety and Safeguards, NRC lle.
Augmented inspection Team inspection Re-pion IV, to William Kennedy, CEO, hiuskogcc port No. 50-286/90-80, Docket No. 50-286, a
Regional hiedical Center, forwarding inspec-January 8,1991.'
tion Report No. 30-11571/90-02, Docket No.
C-3 letter from Thomas,1 hiartin, Regional Ad-30-11571, License No. 35-13157-02, Novem-mmistrator, N RC R egion 1, te J. Ilrons,11xccu-ber 30,1990 tive Vice President-Nuclear Generation, 11-2 Confirmatory Action letter from Robert D.
New York Power Authority, forwarding No-h1artin, Regional Administrator, NRC Region tice of Violation and Enforcement Conference IV, to William Kennedy, CEO, hiuskogee Re-lleport, Docket No. 50-286, February 22, gional Medical Center, Docket No. 30-11571, 1991,'
License No. 35-13157-02,0ctober 10,1990.'
C-4 U.S. Nuclear Regulatory Commission, NRC 11-3 letter from Robert D. Martin, Regional Ad.
Information Notice No. 90-77, "!nadvertent ministrator, NRC Region IV, to William Ken.
Removal of Fuel Assemblics from the Reactor Core " December 12,1990.'
nedy, CEO, Muskogcc Regional Medical Cen.
ter, forwarding a Notice of Violation nnd C-5 U ". Nuclear Regulatory Commission, NRC Proposed hnposition of Civil Penalty, Docket liuormation Notice No. 90-77, Supplement 1:
No. 30-11571, IJecnse No. 35-13157-02, De-
" Inadvertent Removal of Fuel Assemides cember 20,1990.'
from the Reactor Core," February 4,1951.*
C-1 letter from Marvin W, llodges, Director, Di-C-6 letter from William 11. Schultz, Chief, vision of Reactor Safety, NRC Region I, to Nuclear Materials Safety Section J. NRC Joseph Russell, Resident Manager, New York Region 111, to Steven Shipper, Manager, Power Authority, forwarding NRC Inspection Eyncot Corporation, forwarding a Notice of Report No. 50-286/90-19, Docket No.
Violation, Docket No. 30-15203 License 50-286, December 13,1990.'
No. 34-1900S-01 MD, January 15,1991.'
C-2 letter from Marvin W, Ilodges, Director, Di-
. g,Mable in NitC Pubhc Document floom,2120 t. Street. NW vision of Reactor Safety, NRC Region 1, to cower inco, whington D,c., for pubhc ins;<ction and Joseph Russell, Resident Manager, New York colV"'8-1 I7 NUIWG-0090. Vol. t 3, No, l
t,';OH 3 p
U $ NUCH AH hl0VL AlohV COMMabiON L
ge eow m EE BIBLIOGRAPHIC DATA SHEET
<3.,,mur...,,,,, me.,i NUREG-0090 L flif AND tiv6 fir a Vol.13, No. 4 Report to Congress on Abnormal Occurrences 3
oait stPeat Pueusm o October - December 1990 w.-
l March 1991 a FIN OR GIANT Nuvet k 6 QUTHoRap 61 TPL 08 ht PUHi Quarterly
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.e,*,or, comw.ie a, 9 $P,ONsORING OR, G ant 2 A110N - N AME AND A DDR o$b fi, Nac. erce Tene ss ew. e roa,rer eer,,pr* haC 0**a.
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- 10. SUPPLLMENT ARY NOf ts
- 11. AB5t h ACI troo woe e< *n, Section 208 of the Energy Reorgani7ation Act of 1974 identifies an obncm) 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 October 1 through December 31, i990. The report discusses five abnormal occurrences, none of which involved a nuclear power pl ant.
Two involved significant overexposures to the hands of two radiographers, two involved medical therapy misadministrations, and one involved a medical diagnostic mi: administration.
No abnormal occurrences v:ere reported by the Agreement States.
The report also contains information that updates a previously reported abnormal occurrence.
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u t v wOa vs ot se mn os s io.... -,....~.,,., - -. a. -- a Unlimited Medical Therapy Misadministrations; Medical Diagnuic
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Misadministration; Diagnostic Dose of I-131 r.) Te-99m 3,,,,,,,
Administered to a Pregnant Patient; Mislatei.ng of Unclassified Radiopharmaceuticals; Inadvertent Lifting of Fuel Assemblies.
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