ML20082C727

Report to Congress on Abnormal OCCURRENCES.January-March 1991

ML20082C727
Person / Time
Issue date:	06/30/1991
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V14-N01, NUREG-90, NUREG-90-V14-N1, NUDOCS 9107220285
Download: ML20082C727 (21)

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NU REG-0090 Vol.14, No.1 Reaor: :o Congress on n

AJnOr1 EEL UCCurrenCes January - March 1991

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U.S. Nuclear Regulatory Commission Of fice for Analysis and Evaluation of Operational Data

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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 copics of this publication are available from National Technical Informatien Service, Spnngfield, VA 22161

NUlmG-0090 Vol.14, No.1 Report to Congress on Abnormal Occurrences January - March 1991 Date l'ublished: June 1991 OfUce for Analysis and Evaluation of Operational Data U.S. Nuclear llegulatory Commission Washington, DC 20555 o

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Previous Reports in Series NUREO 75/(m, January 4une 1975, NURE04KM1, Vol 6, No 2 Aprildune 1983, publu,hed October 1975 pubinhed November 1983 NURE04fxb1. July-September 1975, NUREO4pM, Vol 6, Na 3, July September 1983 pubinhed March 1976 publu.hed Apnl 1984 NURE04KfxL2, October December 1975, NURE04f>0, Vol 6. Na 4 October Decemler 1983 published March 1976 publahed May 1984 NURE04KML3, January March 1976, NUREG4FM, Vol 7. Na 1, January March 1984, publahed July 1976 publahed July 1984 NUREG-(KfAl-4, Aprildune 1976, NURE04f>0, Vol 7. No 2. Aprildune 1984, pubbsted March 1977 pubhshed Octoter 19S4 NURE04f45, July-September 1976, gggnoay;0, Vol. 7, Na 3. July Septemter 1984, publahed March 1977 publahed April 1985 NURE04Kf0-6, October December 1976, NUREG-(K41 Vol. 7. Na 4, October December 1984, publahed June 1977 publahed May 1985 NURE04fXL7, January March 1977' NURE04KfM, Vol 8. No 1 January March 1985, publahed June 1977 NURE04KW-8, April June 1977 NURb Lhsl985 P h

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N WGh m pubhshed Scptember 1977 publahed November 1985 NURE04f49, July September 1977, NURE04fM, Vot 8, Na 3. July September 1985, published November 1977 NURE04ML10, October December 1977, pubished i ebruary 1986 NURE04fM, Vol 8, Na 4, October December 1985, pubished March 1978 NtlkE04Kr>0, Vol 1 Na 1, January March 1978, pubhshed May 1980 pubhshed June 1978 NUKE 04fXI, Vol 9, No 1. January-March 1986, NURE04f>0, Vol 1, No 2. Aprildune 1976, pubhshed September 1986 publahed Se NURE04f>0, Vot 9, Na 2 Aprildune 1986, NURE04Kr>0, \\ptember 1978 of 1 No. 3, July-September 1978, pubbshed January 1987 pubhshed December 1978 NURE04f>0, Vol. 9, No. 3, July-September 1966 NURE04M1, Vol 1, No 4, October Decemler 1978, pubbshed April 1987 pubbshed March 1979 NURE04KfM, Vol 9, Na 4, October December 1986, NURE041090, Vol 2, Na 1 January-March 1979, published July 1987 published July 1979 NURE04pM, Vol 10, Na 1. January-March 1987 NURE04f>0, Vol 2, No.2 Aprildune 1979, pubhshed Octobcr 1987 pubhshed November 1979 NURE04f>0, Vol 10, Na 2. Apnldune 19S7, NURE04F>0, Vol 2, No 3, July-September 1979, pubbshed November 1987 pubhshed February 1980 NURE04u>0, Vot 10 Na 3, July September 1987, NURE04KY>0, Vol 2, Na 4, October December 1979, pubhshed March 1988 pubhshed April 1980 NURE04Kf>0, Vol 10, Na 4, October Deeember 1987, NURE04KM, Vol 3, Na 1, January March 1980, pubbshed March 1988 pubbshed September 1980 NUREG-(KM1, Vol 11, Na 1, January March 1988, NUREG-0090, Vol 3, No. 2, Apnldune 1980, pubbshed July 1988 pubhshed November 1980 NURE04Kf>0, Vol.11, No. 2 Apri14une 19SS.

NUREO-W>0, Vol 3, Na 3. July September 1980, published December 1988 "I "

NUR 04K 1,

o

,N 4 October-December 1980, published January 1989 NUlfi ot 4, a i, January March 19dl, pubhshed April 1989 4

o U,Na,

obert nender MS8, pubhshed July 1981 NURE04F>0, Vol 12, Na 1 January March 1989, NURE042. Vol 4 No. 2 Aprildune 1981, publahed August 1989 publehed October 1981 NURE04KW, Vol 4, Na 3, July-September 1981, NURE04KFM, Vol 12, Na 2, Aprildune 1989, publahed January 1982 putdahed October 1989 NURE04m, Vol 4, Na 4, October December 1981, NURE04%, Vol 12, Na 3, July-September 1969 pubhshed May 1982 pubhshed January IVO NURE04f>0, Vol 12, Na 4, October-Decemter 1989 NURE04eX1, Vol 5 Na 1, January-March 1982.

pubbshed August 1982 pubbshed March 19X)

NURE04m. Vol 5, Na 2, Apn14une 1982, NURE04M1 Vol 13, Na 1, January March 1990, pubbshed December 1982 pubhshed July IV>0 NURE04fM, Vot 5, Na 3. July-September 1982.

NUREOMN, Vol 13, Na 2, Apnldune 1990, pubbshed January 1983 pubhshed October IVM NURE04f>0, Vol 5, Na 4, October December 1982, NUREG-0090, Vol.13. Na 3. July September 1990, pubbshed May 19S3 pubhshed January 1991 NURE04xfM, Vol 6. Na 1, January-March 19S3, NURU04t!90, Vol U, Nu 4. October-December 1990, pubished September 1983 pubhshed March 1991 ii

Abnormal Occurrences,1st Ott CY91 i

AllSTilACT section 20s of the lincery iteorranization Act of The rquit discusses six abnor mai n cun enc es, none 1974 identifies an abnorrnal occurrence as an un-of which involved a nuclear power plant. Iive of the scheduled incident or event that the Nuclear 1(egula-events occurred at Ni(C-licensed facihties: one in-tory Commission determines to be signtficant from volved a significant degradation of plant safety at a the standpoint of public health or safety and requires nuclear iuel eyele facihty, one involved a medical di.

a quarterly ieport of such events to be made to Con.

agnostic misadministration, and Ihr ce involved rnedi-press.'ll'is report covers the period flom January I can therapy rmsultninistrations. An Agreement State through March 31.1991,

( Aritona) eported one abnormal oci r rence Ihat in-volved inedical therapy inisadinmistri. ons.

til b t[N!31 O'fll), '[( l.14 N(t. t

m Abnormal Occurrences, lit Ott CY91 I

CONTENTS race iii Abstract...........................................................

Preface...............................................................................vii intraluenon................

.......................................................vii

................vii

'i t e it e gulatory Syst e m..............................................

vii lt e po rtabl e Occu rr e nces...............................................................

................ viii Agreement States........................

1:o r e ig n I nf o rm a t ion................................................................... viii I

Iteport To Congress On Abnormal Occurrences. January-hiarch 1991.......................

1 N u cl ea r Powe r P la n ts.........................................................

I Puct Cycle l'acilities (Other 'than Nuclear Power Plants)..................................

91-1 Significant Degradation of Plant Safety at Nuclear I uel Se rvices, Inc. in lirwin. Tennessee.......................................

1 Other NltC 1.icensees (Industrial itadiographers, hiedical Institutions. Industrial Users. etc.)...... 2 91-2 hiedical Diagnostic hiisadministration at liuttel llospital in Detroit.

2 hiichigan 91-3 hiedical'lherapy hiisadministration at Washington llospital Center 4

i n Wa sh in g t on, D.C..................................................

91-4 hiedical'lherapy hiisadministration at flahnemann University llospital 4

in Phila.iciphia, Pennsylvania 91-5 Medical' therapy hiisadministration at Clara hiaass hiedical Center in llelleville, N ew J ersey........................................... 5 6

Agre e m e n t Stat e 1. ice nsees..............................................

AS91-1 hiedical'lherapy hiisadministration at Geod Samaritan hiedical Ce nt e r in Phoe nix. Arizo na........................................... 6 9

lt e f e re nces.................................

11 Appendix A-Abnormal Occurrence Criteria l

l 1

N Ult!!G-0090, Vol.14. No.1 v

Abnonnal Nunentes,1st Qir CY91 PREFACE Ittiroduction ensure the safe use of noticar nutettals. 'lhe repulations unlude design and quality aMuratice

'lhe Nuclear 1(crulatory Commiuton reports to the uitena appropnate for the vanous activities hcensed Congreu each quarter under prousions of Section by the N1(C. An inspectum and colorceinent 20% of the linerry l(corgani/ation Act of 1974 on any progiam helps ensure comphance with the abnornud occurrences involving facdities and r egulanons, acuvities reputated by the N1(C. An abnorrnal occurrence is defined in Section 20S as an lleportable ()ccurrences unscheduled incident or event ticit the Conunission determines is signiheant from the standpomt of Attual opuating espencoce is an ewentul input to public health or safety, the regulatory process for assuring that laensed actinues are conducted safely. 1.icensees ate

!! vents are curt ently identihed as abnor mal required to repoit certain mcidents ot esents to the occunences for this repmt by the NI(C usmg the N1(C, 'this reportmp helps to identify deliciencies esiteria listed in Appendix A. 'lhese criteru were early and to ensure ticit conettive atoons are taken pronmigated in an NI(C pohey statement that was to prevent recuricoce.

puhhshed in the l ederalltegater on l'c hruary 24,19T/

l'or imclear power plants dedicated groups have (Vol. 42, No. 37, luges 10950-10952). In arder to been fonned innh by the NI(C and by t e nmlear h

provide wide disseminahon of information to the power industry for the detailed senew of operating public, a l'ederal liegoter notice is inued on e,uh

'esperime to help idenufy safety concerns caily; to abnormal occunente. Copics of the notice are distributed to the NI(C Pubhe I)ocurnent Hoorn und imptove diueniination of suth infornation; and to leed bmL the experiente mto htensing, segulations all I;ncal Pubhe 1)ocument 1(ooms. At a ramimum, cath nonce tr,ust contain the dite and place of the and operations. In adJiuon.the NitC and the nuticar occunence nnd desenhe its nature and probabic power industry base ongoing ciforts to in prove the operational data systems, winth include not only the consequences.

type and quality of reporis requited to be subnutted, but aho the nn:thods used to anah/c the data. In

'the NitC has determined that only those events order to enore ef fettively wilect, collate, store, descobed in this r epor t meet th'c criteria for reu kus and nalnaie opmanonal data, the abnorrnal occutrence icporting. This repoit covers infonnation is m: untamed m computer based data the period trotn January 1 throuph March 31,1991, fdct information icpotted on cah event includes date and place, nature and probable consequences, cause

.I wo pununy somm of. opeiational data aic or causes, and actions taken to prevent tecurrence.

l acensee 1 vent Iteports (1.l~lts) anti unmedute notdications made pursuant to 10 tTit 5032 The llegtilatory Syslern t hept for reemds ewmpt liom public thsclosure by statute and/or tef ulation, infolinanon conceitting

.the s) stem of licensingand tegulation by w hit h Nit (.

W umnm at hih bcm d m canies out its t esponsibihiics is impleinented othet wise terulated by the NI(C is routmcly through rules and tegulations in I,alle 10 of the ( ode dizenunated by the NltC to the nutlear mdustty, the of l'rdern/ licgulatmna lhis meludes pubhc obk ud Wher mterested pioups as these events participanon as an tlement. Io accomphsh its objectives, NI(C regularly conducts licensmg proceedmgs inspection and enforcement actinues, t hssenunation inc ludes specut notiheations to evaluation of operating taperience, and confit tnatory licensees and other af fectetl or mterested ptoups

rescatch, white maintaimng programs lot and pubhc announcements. In adshtion, inlonnatmn estabhshmp standaids and issuing technical renews on reportable esents is rouanely sent to the N1(C's and studies.

rnote than 100 hical public document r ooms thf ouf out the f }nited States and to the Nitt' Public h

in licensing and regulating nuclear power plants the 1)ocument 1(oom m Washington, I LC Ethe Congress N1(C follows the phdosophy that the health and is toutinely kept mfonned of repottahle events saf ety of the pubhc are best ensured through the occurung m licensed lacihties establishment of inultiple les els of protectionEl hese multiple lescis can ne achieved and nuuntamed Another punury sounc of operatmnal data is teports through t egulat;ons specify mg r equit ements t hat will of tchahthty data subnutted by inensees under the sh NlmlG noun, Vol 11, No. I

Abnorraal Occurrences.1st Otr CY91 Nuclear Plant Reliab;1ity Data System (NPRDS).

available at the State level. Certain information is

'ihe NPRDS is a voluntary, industry-supported also provided to the NRC under exchange of system operated by the Institute of Nuclear Power infonnation provisions in the agreements.

Operations (INPO), a nuclear utility organization.

Iloth engineering and failure data are submitted by In early 1977, the Commission determined that nuclear power plant licensees for specified plant abnormal occurrences happening at facilities of components and systems.'lhe Commission considers Agreement State licensees should be included ir the the NPRDS to be a vital adjunct to the 1.liR system quarterly reports to Congress. 'the abnormal for the collection, review, and feedback of occurrence criteria included in Appendix A are operational experience: therefore, the Commission applied uniformly to events at NRC and Agreement periodically monitors the NPRDS reporting State licensee facilities. Procedures have been activities, developed and implemented, and abnormal occurrences reported by the Agreement States to the NRC are included in these quarterly reports to Agreernent States Congress.

Section 274 of the Atomic IIncrFy Act, as amended, authorlies the Commieion to enter into agreements Foreign irtforination with Siates whereby the Commission relinquishes and the States assume regulatory nuthority over

'ihe NRC participates in an exchanpc of information byproduct, sourec, and special nuclear materials (in with various foreign governments that have nuclear quantitics not capable of sustaining a chain reaction).

facihties. *lhis foreign information is reviewed and Agreemen. State programs must be compatable to considered in the NRC's assessment of operating and compatible with the Commis.sion's program for experience and in its research and regulatory such material, activities. Reference 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 ate reported.

NUREG-D090, Vol.14 No.1 viii l

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Abnormal Occurrences,1st Qtr CY91 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES JANUARY-MARCil 1991 Nuclear Power Plants The NRC is reviewing events reported at t'ae nuclear NRC has not determined that any events were abnor-power plants licensed to operate. For thi', report, the mal occurrences.

Fuel Cycle Facilities (Other Than Nuclear Power Pla

'Ihe NRC is reviewing everus reported by these ties that were more than suffici,:nt to have caused a licensees. For this report, the NRC has determined criticality accident in the unfavorable geometry tank.

that one event was an abnormal occurrence.

The hydrostatic head associated with those highly concentrated solutions would have been sufficient to force those solutions into the unfavorable geometry S,gn,tficant Degradat, ion of Plant tank if the set of normally closed valves were faulty or 91-1 i

Safety at Nuclear Fuel Senices, were not fully closed.The event is briefly described as Inc. in Erwin, Tennessee follows.

The following information pertaining to this event is Filling of storage tanks withliquid waste from the sol-also being reported concurrently in the Federal vent extraction system in the high enriched uranium Rgister. Appendix A (see Example 10 of "For All recovery process began on November 27, 1990.

1.icensecs") of this report notes that a major defi-When the tanks were full, the contents were recircu-ciency in design, construction, or operation having lated prior to sampling. An operator collected two safety implications requiring immediate remedial samples of the liquid and submitted them for action can be considered an abnorn al occurrence.

analpis. The analytical results were received on November 28,1990, and revealed that the uranium Date and Place-Escalated enforcement action pro-concentration in the liquid was well below the posed on March 20,1991, for an event occurring on authorized discard limit, hence, the quantity of U-235 November 28, 1990; Nuclear Fuel Serviies. Inc.;

was below the safety limit of 350 grams. The liquid Erwin, Tennessee, waste was then pumped to another tank where it was mixed again, sampled for material accountability Nature and Probable Consequences-Nuclear Fuel purposes, and then pumped to the Waste Water Services, Inc. is a fuel production facility that pro-Treatment Facility (WWTF).

duces nuclear fuel for the U.S. Navy. On November 30, 1990, licensee personnel (liscovered that on On November 30,1990, the laboratory reported the November 28,1990,395 grams of uranium-235, con-results of the accountability sample to be above the tained in liquid waste, had been processed through authorized discard limit. This higher concentration the waste water treatment system for collection and was confirmed by analysis of another sample which disposal of the uranium.This quantity was above the had been obtained when the liquid was received at administrative criticality safety limit of 350 grams for the WWTF. These analyses confirmed each other, the unfavorable geometry tanks used to hold the and all discharges were halted as a special licensee in-waste. (A fa.vorable geometry tank is one having vestigatic.n team initiated a detailed review to deter-dimensions specifically designed to prevent eriticality mine the causes and needed corrective actions. At of its fissile material contents. An unfavorable about 4:15 p.m., the licensee reported the incident to geometry tank can be used, however, if the amount of the NRC.

fissile material is kept below that needed to achieve criticality.)

The NRC issued written confirmation on November 30,1990, that the licensee would refrain from trans-While the amount of uranium-235 was well below the ferring liquid waste until certain actions had been amount needed for criticality, the circumstances as-completed (Ref.1). An NRC inspector was dis-sociated with the event were particularly safety sig-patched to the site on December 1 and two other nificant. Highly concentrated uranium solutions in an NRC personnel arrived on December T 1990, to per-adjoining part of the pmcess were available in quanti-form a special NRC team inspection (Ref. 2).

I l

1 NUREG-0090, Vol.14, No.1

Abnormal Occurrences,1st Otr CY91 Cause er Causen-The licensee identified the prob.

was initiated to identify the nuclear safety features able causes of the November 28 event to be (1)less and controls for each unfavorable geometry vessel. A than adequate piping layout that allowed uranium Nuclear Criticality Safety Performance improve-solutions to flow into the unfavorable geometry tank ment Program (PIP), that had been instituted prior to

- and (2) personnel.related inadequacies in that opera.

the incident, was accelerated and expanded to ad-tors had no knowledge of the potential for crossover dress the root causes. Training was also given to fuel of highly concentrated uraniurn solutions into recovery personnel to make them aware of the prob.

unfavorable tanks as a result of open valves or other lem.

anomatics in the piping systems.

NRC-The special NRC team inspection (Ref,2)

Following a review of the incident, the NRC con' identified two violations dealing with (1) failure to ciuded that there appeared to be other root causes in perform an adequate evaluation of equipment joined addition to those given by the licensee. These root by piping for the possibility of siphoning and (2) fail.

causes include:

ure to adhere to the administrative criticality safety limit of 350 grams of uranium-235 in unfavorable ge-1.

He safety basis for the plant was less than ometty tanks.

adequate because a documented safety analysis was not available.

The NRC inspected the actions taken and, following the licensce's identificatica of the saiety features and 2.

As a result of the lack of a detailed safety analy-controls, issued a letter authonzing resumption of so-sis, equipment important to safety, such as lution transfers on December 18,1990 (Ref. 3). An valves, were not properly identified, protected, Enforcement Conference with the hcensee was held 1

emphasized in plant control documents and n January 18,1991 On March 20,1991, the NRC i

training sessions, tested and maintained appro-orwarded a Notice of Violation (for the violations priate to their safety function, and did not pos-

{dentified during the special NRC team inspection) i sess positive closure indication.

and proposed a civil penalty of $10,000 (Ref. 4). The two yadons wm c{assified as Severity Level 11 on a 3.

The design liasis of the plant was less than scale m which Severity Levels I and V are the most adequate. The system drawings lacked adequate and least significant, respectively. The licensee has detail.

paid the civil penalty.

The licensee missed an opportunity to preclude the problems several years earlier when modifications In early 1991, the NRC prepared an action plan for were made to the piping system. The licensee's the licensee's facility.This plan is updated quarterly reviews of the modifications failed to identify the and tracks the compiction of the licensee's PIP items, significant potential for uranium solutions to flow quarterly NRC and licensee management meetings on the Pil' status, and NRC technical reviews of PIP.

into unfavorable geometry vessels, Other items eddressed in the plan include license re-newat milestones and management meetings on de-Actions Taken to Prevent Rrcurrence commissioning activities. A full-time resident inspec-Licensee-Corrective actions included modtfication tor started at the facility on April 22,1991.

of the piping system to prevent highly concentrated uranium solutions from flowing into the unfavorable This item is considered closed for the purposes of this geometry tanks. A *eview of the fuel recovery facility report.

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

There are currently over 8000 NRC nuclear material 91-2 Medical Diagnostic Misadrnin-licenses in effect in the United States, principally for istration at llutzel llospital in use of radioisotopes in the rnedical, industrial, and Detroit, Michigan academie fields. Ir adents were reported in this cate-gory from licensees such as radiographers, medical institutions, and byproduct material users. The NRC The following information pertaining to this event is is reviewing events reported by these licensees. For also being reported concurrently in the federal this report, the NRC has determined that four events-Register. Appendix A(see the overallcriterion)of this were abnormal occurrences.

report notes that an event involvi. g u moderate or NUREG-0090, Vol.14, No.1 2

Abnormal Occurrences,1st Qtr CY91 l

more t,evere impact on public health or safety can be only a 30-minute period because of the mother's considered an abnormal occurrence.

medical problems. After the misadministration was discovered, contact between the mother and baby Date and Place-January 17,1991t Ilutzel llospital; was restricted for two days to avoid further radiation Detroit, Michigan, exposure to the infant.

The NRC retained a medical consultant to evaluate Nature and Probable Consequences-On January the circumstances of this case. The consultant esti-24,1991, the licensee notified NRC Region 111 that a medical diagnostic misadministration had occurred at mated that the patient rece$ved a dose of approxi-mately 6500 rads to het thyroid. 'lhis exposure weuld its facility on January 17,1991, when a patient was ad-ry a slightly increased risk of developmg hypothy-ministered a dosage of iodine-131 that was 100 times ca[dism or thyroid cancer. Hecause the patient was roi greater than prescribed. A written report was re, lactating, thus concentrating the radioactive iodine in ceived by Region I!! on l'ebruary 1,1991.

the breasts, there would also be an increase in the pa nt's rid of breast cancer.The consultant recom-On January 16,1991, a 37 year-old female patient mended periodic monitoring of the patient for hypo-(who had given birth to a baby 2 days earlier) was hm m an r

ast and %d cana scheduled to have a thyroid scan to determine if she had a substernal goiter (beneath the breastbone).

um w Cue'lhis misadministration was

,lhe licensee's normal procedure for such a thyroid caused by the modification of the intended diagnostic scan usually involves admmistration of a pmcedure as a result of the discussion between the

50. microcurie dosage of iodine 131. this would typi-physician's assistant and the nuclear medicine tech-cally result in a thymid dose in the range of 50-70 nologist. 'this modification, which involved substan-rads. The prescription for the pmcedure was pre-tially increasing tne dosage of radioactive iodine 131, pared by a physician's assistant at the direction of the was not reviewed by or approved by the patient's phy-referring physician. The nuclear medicine technolo-sician.1he physician, in fact, desired the thyroid scan gist subsequently discussed the pmcedure with the procedure using the lower dosage.

physician s assistant and questioned whether or not the thyroid scan was the appropriate procedure.The An NRC inspection to review the circumstances of technologist indicated a whole body scan to identify the misadministration (Ref. 5) also determined that thyroid tissue throughout the body would be the ap-the hospital had not provided training in the proper propriate test. The physician's assistant agreed and ordering and administration of radiopharmaceuticals submitted a new order for the whole body scan. Ihe to individuals working under the supervision of a phy-iodine 131 was administered to the patient on s e an designated on the NHC license.

January 17, 1991, with the whole body scan per-formed on January 18,1991.The procedure consti-Actions Taken to Present Recurrence tutes a misadministration because the referrmg physician had not intended to perform a whole body Licensee-The hospital adopted new procedures re-scan using iodine-131.

qu ring specific approval by an authorized physician prior to the oral administration of more than 50 The whole body scan involved a dosage of 5 microcuries of iodine-l',1.1his authorization is to be millicuries of iodine-131 instead of 50 microcuries, obtained immediately prior to the planned admini-which would have been used for the diagnostic procc-stration. The hospital also reaffirmed that the tech-dure actually prescribed by the referring physician.

nologist and physician's assistants are not permitted Although the whole body scan is a diagnostic test-to change an order given by an attending physician.

intended for patients who have had their thyroid re-moved-the 5-millicurie dosage is in the range that The hospital recommended that the patient be may be used for treatment of thyroid disorders-placed on a thyroid hormone to inhibit the growth of thyroid m)dules and that she be monitored for possi-Prior to administering the iodine-131, the technoh>-

ble development of hypothyroidism or other compli-gist determincd that the patient was not breast-

cations, feeding her baby and did not intend to breast feed.

(Breast-feeding a baby is a concern because the ra-NRC-A spccial inspection was conducted li hruary c

dioactive iodine can be passed to the baby through 19, 1991, to review the circumstances surrounding the milk.) Some direct radiation exposure was re-the misadministration (Ref. 5).The inspection identi-ceived by the baby due to the presence of the io-fled two apparent violations associated with the inci-dine-131 in the mother's body.1his exposure, how dent: (1) failure to instruct supervised individuals on ever, was minimal (estimated to be approximately 0.5 the principles of radiation safcty, and (2) use of N RC-millirads) because the baby was with the mother for licensed material tw unauthorized individuals.These 3

NUREG-0090. Vol.14, No.1

Abrormal Occurrences,1st Otr CY9) l inspection findings remain under review by the NitC, l.icensee 'Ihe licensee provided additional training and enforcement action is pending.

for the technologist in the proper identification pro-cedures for treatment plan verification.

Future reports will be made as appropriate.

NRC-lhe Region I staff will examine the circum.

stances behind the incident during the next inspec-91-3 Medical 'I,herapy Misadm,tnistra*

tion of the program at the licensee's facility.

tion at Washington llospital Center in Washington, D.C.

Unless new, significant information becomes avail.

uble, this item is considered closed for the purposes The following information pertaining to this event is of this report.

also being reported concurrently in the Federal Register. Appendix A(seetheoverallenterion)of this 91-4 Medical Therapy Misadministra-report notes that an event myolving a moderate or more severe impact on public health or safety can bc tion at llahnemann Uaiversit}' Ilos-considered an abnormal occunence.

pital in Philadelph,ia, Pennsylvania Date and Place-February 1,1991; Washington The following information pertaining to this event is llospital Center; Washington, D.C.

also being reported concurrently in the Federal Register. Appendix A(seetheoverallcriterion)of this Nature and Probable Consequences-On February wp ct notes that an event involving a moderate or I,1991, NitC llegion I was notified by the licensee more severe impact on public health or safety can be considered an abnormal occurrence.

that a therapeutic misadministration intolving a teletherapy unit had occurred at its facility earlier that day.

1) ate and Place-February 14-18,1991;Ilahnemann University Ilospital; Philadelphia, Pennsylvania.

A 74-year-old patient was to have received 250 rads Nature and Probable Consequences-On February to the brain for cancer treatment. 'ihe technologist 22,1991, NRC Region I was notified by the licensee identified the patient; however, the technologist ex-that a therapeutic misadministration had occurred at amined another chart without verifying the name on its facility during the period from Febe ary 14 to 18, the chart or the picture of the patient on the chart.

1991, while a patient was undergoing radiation ther-No patient treatment area markers, such as tatoos, apy for a tumor in the eye, were used. Using the wrong chart, the technologist proceeded to set up a 5.0 centimeters by 6.5 centime-A radiotherapy physician prescribed a therapeutic ters field size and initiated treatment of the patient's dose of 30,000 rads to the base of the tumor and larynx. The thyroid of the patient was not blocked 14,300 rads to the apex of the tumor from an from exposure to the teletherapy beam. While the iodine-125 custom designed eye plaque. 'the staff patient was undergoing treatment to the larynx, the physicist who designed the cyc plaque informed the technologist realized that the wrong organ was bemg radiotherapy physician that based on the eye plaque treated. The technologist immediately terminated design, a dose of 30,000 rads would be delivered to the patient treatment. It was estimated that 57 rads the base of the tumor and 9,025 rads to the apex over werc delivered to the larynx, and about the same to 127.8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />. This treatment plan was found accept-the thyroid. The wrong chart indicated that 100 rads able and agreed upon. While the physicist was design-were to be delivered to the larynx in 1.38 minutes and ing the eye plaque and calculating the anticipated the treatment was terminated after0.79 minutes. Af-dose, he decided to change to an eye plaque with a ter termination of the larynx treatment, the patient different radius of curvature.The physicist changed was given the proper treatment of 150 rads to the the coordinates for placement of each iodine-125 brain.

seed used in the plaque but failed to change the asso-ciated points for calculation of dose to various depths Region I contacted an NRC medical consultant to re-within the eye.

view the event.The consultant noted that there were no acute symptoms and that there should be no long On February 18,1991, the physicist suspected that an term medical implications during the expected life-crror had occurred while planning a treatment for time of the patient.

another patient with a similar tumor. At that point, he retrieved patient data from the computer for the Cause or Causes -The technologist failed to follow treatment started on February 14,1991, reviewed the proper identification procedures-data, and confirmed that an error had been made.

'lhe patient's cyc plaque was then removed. At that Actions Taken to Prevent Recurrence time, a total of 99.25 hours2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br /> had clapsed since the NU REG-0090, Vol.14, No.1 4

Abnormal Occurrences,1st Qtr CY91 l

l beginning of the trcatment, resuhing in a total treat-Nature and Probable Conwquences-On March 28, ment dosc of about 59,000 rads to the basc oi the tu-1991, the licensee infortned NltC llegion I that a mor and 19,500 rads to the apex of the tumor. 'lhe therapeutic misadministration. involving administra-licensee stated that the dose received by the tumor tion of iodme 131 to the wrong patient, had occurred was within acceptable medical treatment protocols earlier that day.

for that typc of tumor,and that im acute effects were observed in the patient.

A mdiotherapy physician prescribed a theiapeutic dosage of 10 rmilicurics of iodine-131 to a patient for NllC llegion I contacted an NltC medical consultant the treatment of hyperthyroidism.'the physician that was fam, liar with the patient was not able to admini-i to review the event.'lhe consultant stated that there was an increased risk of long term adverse efIccts, ster the therapeutic dosage and asked another physi-(e.g., cataract, tissue damage).

c an to administer it. In the meantime, a transporter, while reviewing the patient transport requests, noted that the patient was listed in a bed that she believed Cause or Causesalhe causes are attnbuted to ho man error on the part of the licensee's staff physictst, wamccupied by another patier.t. ihe transporter mw lack of written procedures, and lack of dual senf ca-tified the nuclear medicine secretary to check mu tion of dose calculations prior to administration, the depancy. ihe secretary seferred to a patient list for the patient's name, noted the area of the hos-pital where the patient's room was, and changed the Actions Taken to Present itecurrence requer.t form. The secretary did not know that there were two patients in the hospital with the exact same 1.icensee dl he licensee's planned corrective actions names. (the second patient was in the hospital for a melude establishing written protocol for this proce-long condition.) Also, the secretary did not know the dure, including a second yenfication of the treatment computer program that generated the patient list did calculations pnor to admmistration of dosages to pa' not print duplicate entries. 'lhe patient's name who tients.

was to undergo treatment for hyperthyroidism was NitC-An NItC llegion I inspector conducted a spe-cialinspection of the circumstances surrounding this

'Ihc physician who administered the dose picked up misadministration on 1 chruary 25,1991. The inspec-the request form and the iodine-131 dosage from the tion report was forwarded to the licensee on March Nuclear Medicine Department and went to the nurs-11,1991 (ltef. 6) 'lhe report netes that the inspector ing station on the floor of the patient with the long suggested that the licensee establish a w ritten proto.

problen. 'the physician did not inform the nursing col for the procedure and the licensee agreed. 'lhe staff that he was about to admtmster a therapeutic report also identified one violation of NitC require-dosage to one of their patients and went to the lung ments, i.e., failure to ma.fy the NitC of the therapy patient's room.There, he asked the patient his name misadministration within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of discovery. A and verified the name on the wrist band but did rot management meeting between NitC llegion I and cross check the patient utimber on the wiist band licensee management wTs conducted on March 21, with the patient number on the request form. The 1991, to review the licensee's actions to prevent re.

physician completed the request form and returned currence.

the patient folder to the nurses' station. Within five minutes of the administration of the radiopharmac-

'lhis item is considered closed for the purposes of this eutical, the nurses discovered the error and informed report.

the physician and the Itadiation Safety Officer. 'Ihc heensee decided to administer a thyroid blocking agent of 1000 milligrams of potassium iodide immed -

91-5 Metlical Therapy Misatiministra-ately, with three subsequent doses of 1000 milligrams lion at Clara Maass Metlical Center each given at four hour intervals.

in llelleville, New Jersey lhe licensee determined that the thyroid of the patient received an uptake of between 80 and 100

,the following information pertaining to this event is microcuries of iodine-131 which would give a dose of also bemg reported concurrently in the federal between 112 and 140 rads. An NitC medical consult-Regiater. Appendix A(see theoverallcriterion)of this ant, who reviewed the event, concurred with these report notes that an event mvolving a moderate or figures. The beensee advised the NitC that no ad-more severe impact on public health or safety can be verse effects were anticipated dunng the hfetime of considered an abnormal occurrence.

the patient as a result of the misadministration.

Date and Place-March 28, 1991; Clara Maass Cause or Causes Jihe causes were attnhnted to fail-Medical Cc nier; llelleville, New Jersey.

ure to follow the hospital protocol of checking the 5

N Ul<l!G-0040, Vol.14 No, t

Abnormal Occurrences,1st Qtr CY91 patient identification number, and failure to inform ing radiopharmaceutical therapy. Other actions in-the head nurse of the floor of the therapeutic procc-clude changing the computer program so that all of dure, prior to administration.

the information is printed out on the patient list, and reinstruction to personnel regardirig patient verifica.

Actions Taken to Present Recurrence NRC-On April 1,1991, a Region I inspector con-1.icensee JIhe licensee's planned corrective action ducted a specialinspection of the circumstances sur-includes establishing a check list that must be com-rounding this misadministration.'the inspection re-pleted by individuals administering therapeutic dos-port was forwarded to the licensee on April 17,1991 ages. The check list will require that the person ad-(Ref. 7). No violations of regulatory requirements ministering the dosage to check, as a minimum, the were identified. The licensee's corrective actions are type of radiopharmaceutical to be administered, the considered satisfactory.

activity of the dosage, the name of the patient, and the patient number; it will also require notification of This item is considered closed for the purposes of this the nursing staff that one of their patients is undergo-report.

Agreement State Licensees Procedures have been developed for the Agreement consulting physicist and being told that a wedge fac-States to screen unscheduled incidents or events us-tor would be required.

ing the same criteria as the NRC (see Appenuix A) and report the events to the NRC for inclusion in this While preparing to treat a fifth patient assigned the report. The Agreement State of Arizona reported same treatment protocol, a point hand calculation in-the following event as an abnormal occurrence. The dicated a wide discrepancy when compared to the writeup is based on information provided to the N RC computer generated treatment time. This discrep-during late 1990.

ancy led to a comprehensive search of past cases which revealed the three overexposures out of four AS91-1 Medical Therapy Misad ninistra-tion at Good Sarnaritan Medical All three patients showed signs of skin crythema Center in Phoenix, Arizona (reddcning) and the first two patients (who had re-ceived radiation to the larynx reg,on) reported i

Appendix A (see the overall criterion)of this report hoarseness and pain on swsdlowiag. The licensee notes that an event involving a moderate or more se-stated that these symptoms are not unusual for pa.

vere impact on public health or safety can be consid.

tients undergomg radiotherapy, and m f,.ct, these ered an abnormal occurrence, same symptoms were mennoned to the patients as possible side effects of the treatment.

Date and Place-Februaryyune 1989; Good Samari.

Cause or Causes-A consultmg physicist was re-tan Medical Center; Phoemx, Arizona' tained to review patient records and the hospital's Nature and Probable Consequences-On July 26, 1989, the licensee reported to the Arizona Radiation a.

The hospital staffing level was inadequate for the Regulatory Agency (State Agency) a series of three patient load.

misadministrations involving the use of a cobalt-60 b.

'lhere was a loss of continuity in physics services teletherapy unit in the licensce's Radiation Oncology Department.

with the departure of one physicist and the hiring of another physicist.

The three patients received exposures of approxi' c.

There was poor communication (documenta-mately 14% 11%, and 12% greater than the pre-tion) regarding the use of the computer gener-scribed doses of 6200 rads,6480 rads, and 5000 rads, ated treatment plans.

respevively, from an AEL1/Fheratren-80 unit con.

tainirg 5529 curies of cobalt-60 assayed on Septem-Actions Taken to Present Recurrence ber 16,1988. A beam correcting wedge had been used along with a treatment planning computer, Although 1.icensee Jfhe licensee has hired a full time ouali-the computer already contamed a wedge correction fied therapy physicist and a technical administrator.

factor, the technologist and dosimetrist added a sec-These individuals will not have responsibilities out-ond wedge correction factor after checking with the side of the therapy department.

NUREG-0090, Vol.14, No.1 6

Abnormal Occurrences,1st Ott CY91 All computer pencrated treatment plans will have basis was centered on the ltadiation Safety Commit-point hand c:deulations to verify the computer read-tee's failure to adequately conduct its activities and ings. Procedures for use of this computer to generate supervise the use of therapy sources, patient treattnent plans have been revised, l.itigation continues on this event and not all records State Agency-A civil penalty of $3,000 was proposed have been received by the State Agency at this time, on January 19,1990, after a thorough review of the llowever, unless new, significant information be-licensee's 1(adiation Safety Committee's activities comes available, this item is considered closed for the was conducted on December 22,1989. The violation purposes of this report.

7 NUREG-0090, Vol.14, No.1

enormal Occurrences,1st Otr CY91 l

l REFERENCES 1.

I ctter from J, l'hilip Stohr, Director, Division Docket No.70-143,1Jcense No. SNht-124, of Itadiation Safety and Safeguards, NitC h1 arch 20,1991.'

Itegion 11 to Charles 11. Johnson, President, 5.

Icuer Imrn John A. Grobe, Chief, Nuclear Nuclear l'uct Senices, Inc., forwarding a Con, firmation of Action lxtter, Docket No.

hiaterials Safety liranch, NItC llegion III, to 70-143, l.icense No. SNM-124, November 30, Sus a lirickson,Vice President, Professional 1990'.

Senices, llutrel llospital, forwarding Inspet-tion lleport No. 30-0202451-001 (DitSS),

Docket No.

30-02024, l.icense No.

2.

letter from J. Philip atohr, Director, Division 21-03001-01, h1 arch 13,1991,*

of Itadiation Safety and Safeguards, NitC llegion 11, to Charles it. Johnson, President, h-Ittter from Malcolm 11. Knapp, Director, Di-Nuclear l'uct Services, Inc., forwarding NllC vision of Itadiation Safety and Safeguards.

Inspection Iteport No. 70-143/90-30, Docket NitC llegion I, to Jeseph I Mintrer, Vice No.70-143, l.icense No. SNM-124. January President for Clinical Senices, llahnemann 14, 1991.*

University llospital, forwardmg Inspection lleport No. 30-02959/91-001 Docket No.

30-02959, license No. 37-00467-34, March 3.

letter from Stewart D. libneter, llegional II' I99I' Adminir.trator, NitC llegion it, to Charles it.

Johnson, President, Nuclear I uct Senices, 7.

lxtter from Mohamed M. Shanhaky, Chief, Inc., forwarding a letter of Authoritation to Nuclear Materials Safety Section A, Division resume operations in the itecovery 1 acility, of iladiation Safety and Safeguards, NitC ite.

Docket No.70-143, l.icense No. SNM-124, gion I, to Itobert S. Curtis, President, Clara December 18, 1990.*

Maass Medical Center, forwarding Special in-spection lleport No.

30-02467/91-001, 4.

lxtter from Stewart D. Iibneter, llegional Ad.

Docket No. 30-02467, l.icense No. 29-03163-ministrator, NitC llegion II, to Charles 11.

03, April 17,1991.*

Johnson, President, Nuclear I uct Serdees,

• w>m'it Pubhc Ihicumen t itoom. 212u l. Street. NW Inc., forwarding Notice of Violation and Pro-Omer incl) wnhington. n c., for public inspecuon and posed Imposition of Civil Penalty-$10,000, copying.

9 NUREG-0040, Vol.14, No. I

I-j Abnormal Occurrences,1st Otr CY91 APPENDIX A AllNORMAL OCCUllllENCE CillTERIA The following criteria for this report's abnormal oc-dioactive material from a package in amounts currence determinations were set forth in an NitC greater than the regulatory limit.

polig staternent published in the Federal Register on 5.

Any loss of licensed material in such quantities I eb a 24, 1977 (Vol. 42, No. 37, pages and under such circumstances that substantial hazard may result to persons in unrestricted 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 lection of the public health or safety. Such an event theft or diversion of licensed rnaterial or sabo-would involve a moderate or more severe impact on tage of a facility.

the public health or safety and could include but need 7.

Anv substantiated loss of special nuclear mate-not be limited to:

rialorany substantiated inventorydiscrepang that is judged to be significant relative to nor-1.

hioderate exposure to, or release of, radioac-mally expected performance and that is judged tive material licensed by or otherwise regu-to be caused by theft or diversion or by sub-lated by the Commission; stantial breakdown of the accountabiliiy sys-2.

hiajor degradation of essential safety-related equipment; or 8.

Any substantial breakdown of physical security or material control (i.e., access control, con-3.

hiajor deficiencies in design, construction, use tainment, or accountability systems) that sig-of. or management controls for licensed facili-nificantly weakened.the protection against ties or material, theft, diversion, or sabotege.

lixamples of the types of events that are evaluated in 9.

An accidental criticality [10 CFit 70.52(a)l.

detail using these criteria are:

10.

A major deficiency in design, construction, or operation having safety implications requiring For All 1.icensees immediate remedial action.

1, lixposure of the whole body of any individual 11.

Serious deficiency in management or proce-to 25 rem or more of radiation; exposure of the dural controls in major creas, 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 feet, ankles, hands or forearms of any individ.

not of major importance), recurring incidents, ual to 375 rem or more of radiation [10 CI'It and incidents with implications for similar fa-20.403(a)(1)], or equivalent exposures from in.

cilities (generic incidents) that create major ternal sources.

safety concern.

2.

An exposure to an individual in an unrestricted For Commercial Nuclear Power Plants area such that the whole body dose received exceeds 0.5 rem in one calendar year [10 CFit 1.

I!xceeding a safety limit of license technical 20.105(a)].

specifications (10 CFil 50.36(c)).

3.

The release of radioactive material to an unre.

2.

h1ajor degradation of fuel integrity, primary stricted area in concentrations which, if aver-coolant pressure boundary, or primary con-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 tamment boundary.

times the regulatory limit of Appendix 11,Ta*

3.

loss of plant capability to perform essential b'c 11,10 CFR Part 20 [CFR 20.403(b)(2)).

safety functions such that a potential release 4.

Radiation or contamination levels in excess of of radioactivity in excess of 10 CFit Part 100 design values on packages, or loss of confine' guidelines could result from a postulated tran-ment of radioactive material such as (a) a ra-s ent or accident (e.g., loss of emergency core diation dose rate of 1000 mrem per hour three cooling system, loss of control rod system).

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 (SAll) 1I NUREG-0090, Vol.14, No. I

l Abnormal Occurrences,1st Otr CY91 or technical specifications that requires irme-For Fuel Cycle Licensees diate remedial action.

1, A safety limit of license technical specifica.

tions is exceeded and a plant shutdown is re-5.

Personnel error or procedural deficiencies quired [10 CFR 50.36(c)].

that result in loss of plant capability to per-2.

A major condition not specifically considered form essential safety functions such that a po-in the safety analysis report or technical <.peci-tential release of radioactivity in excess of 10 fications that requires immediate remedial ac-Cf'R Part 100 guidelines could result from a tion.

postulated transient or accident (e.g., loss of 3.

An event that seriouly compromised the abil-emergency core cooling system, loss of control ity of a confinement system to perform its des-rod system).

ignated function.

i NUREG-0090, Vol.14. No.1 12

NRC FCAM 335 U.S. NUCLEAR REGULATORY COMMISSION

1. 7E POR T NUMBE R l

( Assigned by t#tC, Aod Vol.,

{

(2-89)

Supp, Rev., and Addendum Num-NRCM 1102, 32ot. 3202 BIBLIOGRAPHIC DATA SHEET

'*- " *"vl (see instruenons on the reversei NUREG-0090 Vol.14, No.1

2. uitE AND ouemtE

3. DATE REPOHT PUBLISHlO Report to Congress on Abnormal Occurrences:

yoy7g l

ygin i

January - March 1991 June 1991

4. FIN OR GRANT NUMBER

6. AUT HOR (6)

6. TYPE OF RtPORT Quarterly

7. PERCO COVERED (inclustve Dates)

January - March 1991

8. PERFORMING ORGANt2AllON - NAME AND ADDRESS (if N14C, provios Division, Othce or Region, U. S. Nuclear Regulatary Commission, arid malung address; if contractor, pre-v6de name and malling address,)

Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, L)C 20555

9. 6PONSOHNG OHGANIZATION - NAME AND ADDRESS (if NRC, type

• bame as above'; if contractor, provios NRC "evision, Othce o Reg 6cn.

U.S. Nuclear Regulatory CommissW), and meiltng address.)

Same as 8., above

10. SUPPLEMENT *RY NOTES

11. ABSTRAC r (200 words or less)

Section 208 of the Energy Reorganization Act of 1974 identifies an abnormal occurrence as an unscheduled incident or event that the Nuclear Regulatory Commission determines to be significant from the standpoint of public health and safety and requires a quarterly report of such events to be made to Congress. This report covers the period January through March 1991. The report discusses six abnormal occurrences, none of which involved a nuclear luwer plant. Five of the events occurred at NRC-licensed facilities: one involved a significant degradation of plant safety at a nuclear fuel cycle facility, one involved a medical diagnostic misadministration, and three involved medi-cal therapy misadministrations. An Agreement State (Arizona) reported one abnormal occurrence that involved medical therapy misadministrations.

13 AVAILABILITY STATEMENT

12. KEY WORDS/DESCRFTORS (Ll2+ words or phrases that wn) assist researchers in locating the report.)

Unlimited

14. SECURITY CLASSIFICATION Degraded Plant Safety at Fuel Cycle Facility; Medical Diagnostic Misadministration; (1,,,,,,,,

MedicalTherapy Misadministrations Unclassified (This Report)

Unclassified Ib. NUM8tR OF PAGES

16. PRICE

)

PC4C FORM 335 (2-60)

(

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