ML20082K569

Report to Congress on Abnormal OCCURRENCES.July-September 1994

ML20082K569
Person / Time
Issue date:	01/31/1995
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V17-N03, NUREG-90, NUREG-90-V17-N3, NUDOCS 9504190361
Download: ML20082K569 (35)

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NUREG-0090 Vol.17, No. 3

- Report to Congress on Abnormal Occurrences

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July - September 1994

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U.S. Nuclear Regulatory Commission omce for Analysis and Evaluation of Operational Data l

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I AVAILABILITY NOTICE i

Availability of Reference Materials Cited in NRC Publications i

Most document's cited in NRC publications will be available from one of the following sources:

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The NRC Public Document Room 2120 L Street, NW., Lower Level, Washington, DC

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20555-0001 2.

The Superintendent of Documents, U.S. Government Printing Office, P O. Box 37082, a

Washington, DC 20402-9328

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The National Technical information Service, Springfield, VA 22161-0002 Although the listing that follows represents the majority of documents cited in NRC publica-l tions, it is not intended to be exhaustive, y

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Referenced documents available for inspection and copying for a fee from the NRC Public Document Room include NRC correspondence and internal NRC memoranda; NRC bulletins, circulars, information notices, inspection and investigation notices; licensee event reports; 2

vendor reports and correspondence; Commission papers; and applicant and licensee docu-

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ments and correspondence.

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The following documents in the NUREG series are available for purchase from the Government Printing Office: formal NRC staff and contractor reports, NRC-sponsored conference pro-l ceedings, international agreement reports, grantee reports, and NRC booklets and bro-l 4

chures. Also available are regulatory guides, NRC regulations in the Code of Federal Regula-tions, and Nuclear Regulatory Commission Issuances.

i Documents available from the National Technical information Service include NUREG-series reports and technical reports prepared by other Federal agencies and reports prepared by the l

Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission.

Documents available from public and special technical libraries include all open literature items, such as books, journal articles, and transactions. Federal Register notices, Federal and State legislation, and congressional reports can usually be obtained from these libraries.

Documents such as theses, dissertations, foreign reports and translations, and non-NRC con-ference proceedings are available for purchase from the organization sponsoring the publica-tion cited.

Single copies of NRC draft reports are available free, to the extent of supply, upon wntten i

request to the Office of Administration, Printing and Mail Services Section, U.S. Nuclear Regu-latory Commission, Washington, DC 20555-0001.

Copies of industry codes and standards used in a substantive manner in the NRC regulatory process are maintained at the NRC Library, Two White Flint North,11545 Rockville Pike, Rock-ville, MD 20852-2738, for use by the public. Codes and standards are usually copyrighted and may be purchased from the originating organization or, if they are American National Standards, from the American National Standards Institute,1430 Broadway, New York, NY' 10018-3308.

l A year's subscription of this report consists of four quarterly issues.

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NUREG-0090 Vol.17, No. 3 Report to Congress on Abnormal Occurrences July - September 1994 Date Published: January 1995 Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555-0001 f ~ s,,

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l Abnormal Occurrences,3rd Qtr CY94 Previous Reports in Series NUREG 75/090 (January-June 1975), published October 1975.

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

NUREG-0090, Vols.1 through 16 (January-March 1978 through October-December 1993), published June 1978 through March 1994.

I NUREG-0090, Vol.17. No.1 (January-March 1994), published August 1994.

NUREG-0090, Vol.17, No. 2 (April-June 1994), pu'lished October 1994.

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NUREG-0090, Vol.17, No. 3 11 i

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ABSTRACT Section 208 of the Energy Reorganization Act of 1974 management and procedural control of a radioactive identifies an abnormal occurrence (AO) as an unsched-source. (Due to publication schedule con traints, NRC uled incident or event that the Nuclear Itegulatog Com-was unable to include all of the AO information received mission determines to be significant from the standpoint from the Agreement States. Any Agreement Stateinfor-of public health or safety and requires a quarterly report mation that was not included in this report will be pub-l of such events to be made to Congress. This report pro-lished in the next quarterly report.)

vides a description of those events that have been deter-l mined to be abnormal occurrences during the period of j

July 1 through September 30,1994.

The report also contains updates of six AOs previously re-ported by NRC licensees and three AOs previously re-This report addresses five abnormal occurrences (AOs) at ported by Agreement State licensees.TWo "Other Events NRC-licensed facilities. One involved a medical brachy.

of Interest" concerning nuclear power reactors are also therapy misadministration, two involved medical tele-reported. One involved the fracture of a frozen pipe at therapy misadministrations, one involved a medical so-Dresden Unit I with a consequent release of water, and t

l dium iodide misadministration, and one involved a the other involved the possible deliberate exposure of a medical sodium iodide event. One AO report submitted contract laborer 'n rediation at Quad Cities Nuclear Pow-by an Agreement State is included. It involved the loss of er Station.

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lii NUREG-0090, Vol.17, No. 3 l

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Abnorreal Occurrences,3rd Qtr CY94 i

d CONTENTS i

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Abstract............................................................................................

iii vii Preface.............................................................................................

Introduction..................................................................................... vii The Regulatory System........................................................................... vii 5

Reportable Occurrences..........................................................................

vu Vili Agreement States................................... ".. " ~ " "

Viii Foreign Information.............................. ~... ' " " ' ~ ~ ~. " " ' " " " " ' ' " " ' "

viii Reopening of Closed Abnormal Occurrences........................................................

Report Tb Congress On Abnormal Occurrences, July-September 1994.....................................

1 Nuclear Power Plants.............................................................................

1 Fuel Cycle Facilities (Other than Nuclear Pwer Plants)..............................................

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

1 94-15 Sodium Iodcle Event at Welborn Memorial Baptist Hospital in Evansville, Indiana...........

1 94-16 Tbletherapy Misadministration at Medical Center Hospital in Chillicothe, Ohio..............

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94-17 Sodium Iodide Misadministration at St. Joseph Mercy Hospital in Pontiac, Michigan..........

3 94-18 Multiple Tbletherapy Misadministrations at Sinai Hospital in Detroit, MicHgan..............

4 94-19 Brachytherapy Misadministration involving the Use of a Strontium-90 Eye Applicator at the University of Massachusetts Medical Center in Worcester, Massachusetts.............

4 Agreement State License es...........................................................................

5 AS 94-6 loss of Management and Procedural Control of a Radioactive Source Licensed by the State of Illinois to Kay-Ray, Inc., at a Georgia-Pacific Corporation 5

Paper Millin Palatka, Florida References..........................................................................................

8 Appendix A - Abnormal Occurrence Criteria...........................................................

9 Appendix B - Update Of Previously Reported Abnormal Occurrences.....................................

13 N uclear Power Plants................................................................................ 13 86-9 Boiling Water Reactor Emergency Core Cooling System Design Deficiency.................. 13 3

Oth er NRC Licensees................................................................................ 14 92-18 loss of Iridium-192 Source and Medical Therapy Misadministration at Oncology Services Corporation in Indiana, Pennsylvania............................................ la 93-11 Medical Brachytherapy Misadministration at Washington University Medical School in St. Louis. Missouri.................................................................. 14 NUREG-0090, Vol.17, No. 3 y

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Abnormal Occurrences,3rd Qtr CY94 1

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93-16 Medical Brachytherapy Misadministration at Marquette General Hospital in l

Marquette, Michigan..................................................................

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94-12 Medical Sodium Iodide Misadministration at Stamford Hospital in Stamford, Connecticut..... 15 i

4 94-14 Medical Brachytherapy Misadministration at The William W. Backus Hospital in i

Norwich, Conn ect icut.................................................................

15 Agreemen t State License es........................................................................... 16 r

AS 88-5 Medical Teletherapy Misadministration at Sacred Heart Hospital in

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Cumberland, Maryland..........................................................

16 AS 88-6 Medicallbletherapy Misadministration at Sacred Heart Hospital in j

Cumberland, Matyland...........................................................

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AS 94-3 Radiation Burn of an Industrial Radiographer at Blazer Inspection in ibxas City, Tbxas.................................................................

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Appendix C - Other Events of Interest................................................................. 19 N ucl ear Power Plants................................................................................ 19 1.

Fracture of a Frozen Pipe at Dresden Unit I with a Consequent Release of Water............ 19

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Possible Deliberate Exposure of a Contract Laborer to Radiation at Quad Cities N ucl ear Power Station................................................................. 20 Appendix D - Agreement State Events Being Considered as Abnormal Occurrences........................ 23 References for Appen dices............................................................................ 24

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NUREG-0090, Vol.17, No. 3 vi

Abnormal Occurrences,3rd Qtr CY94 PREFACE hitrOduction and safety. These events are not reportable as AOs but are provided as other events of interest.

The Mar Regulatory Commission reports to Congress Appendix D includes events submitted by Agreement cach quarter, underprovisions of Section 208 of the Ener-g Re. organization Act of 1974, any abnormal occurrences States that are likely to be categorized as AOs. For these events, insufficient information was available in time to (AOs) mvolymg facilities and activities regulated by NRC.

identify them as AOs for this report.

An AO is defined in Section 208 as an unscheduled m, ca-dent or event that the Commission determines to be sig-nificant from the standpoint of public health or safety.

The Regulatory System NRC identifies an AO for the purpose of this report using The system oflicensing and regulation by which NRC car-the criteria in Appendix A. Rese criteria were promul-rics out its responsibilities is implemented through the gated in an NRC policy statement that was published in rules and regulations in Title 100f the Code offedera/ Reg-the FederalRegister on Febniary 24,1977 (Vol. 42, No. 37, ulations. This includes public participation as an element.

Pages 10950-10952).

'Ib accomplish its objectives, NRC regularly conducts li-censing proceedingr., inspection and enforcement activi-The policy statement was published before licensees were ties, evaluation of operating experience, and confirmatory required to report medical misadministrations to NRC.

research, while maintaining programs for establishing Few of the examples in the policy statement are applicable standards and issuing technical reviews and studies.

to medical misadministrations. Therefore, during 1984, NRC developed guidelines for selecting such events for In licensing and regulating nuclear power plants and the AO reporting. These guidelines, which have been used uses of byproduct nuclear materials, NRC follows the phi-since the latter part of 1984, augment the NRC policy losophy that the health and safety of the public are best statement examples and are summarized in 'lhble A-1 in ensured by establishing multiple levels of protection.

Appendix A. On January 27,1992, new medical misadmi-These levels can be achieved and maintained through reg-nistration definitions became effective. He staff is cur-ulations specifying requirements that will ensure the safe rently developing a policy statement to revise the AO cri-use of nuclear materials.The regulations include design teria for medical misadministrations as well as other and quality assurance criteria appropriate for the various events. In addition, guidelines are being developed for activities licensed by NRC. An inspection and enforce-Appendix C items, "Other Events of Interest." After the ment program helps ensure compliance with the regula-Commission's approval, the policy statement will be pub-tions.

lished for comment in the Federal Register.

In order to provide wide dissemination of information to Reportable Occurrences the public, a Federal Register notice is issued on NRC li-censee AOs. Copies of the notice are distributed to the Actual operating experience is an essential input to the NRC Public Document Room and all Local Public Docu-regulatory process foi assuring that licensed activities are ment Rooms. At a minimum, each notice must contain the conducted safely. Licensees are required to report certain date and place of the occurrence and a description ofits incidents or events to NRC. nis reporting helps to identi-nature and probable consequences.

fy deficiencies and to ensure that cc rective actions are NRC has determined that, of the events reviewed for this reporting period, only those that are described in this re-For nuclear power plants, dedicated graups have been port meet the criteria for reporting as AOs. His report formed, both by the NRC and by the nucicar power indus-covers the period from J uly 1 through September 30,1994.

try, for the detailed review of operating experience to help i

Information reported on each event includes date and iden tify safety concerns carly; to improve dissemination of j

place, nature and probable consequences, cause or such information; and to feedback the experience into li-causes, and actions taken to prevent recurrence.

censing, regulations, and operatiota. In addition, NRC and the nuclear power industry have ongoing efforts to Appendix B contains updated information on previously improve the operational data systems, which include not reported AOs.

only the type and quality of reports required to be sub-mitted, but also the methods used to analyze the data. In Appendix C provides descriptions of events that can be order to more effectively collect, collate, store, retrieve, perceived as significant but do not involve a major reduc-and evaluate operational data, the information is main-tion in the level of protection provided for public health tained in computer-based data files.

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Abnormal Occurrences,3rd Qtr CY94 i

Dree primary sources of operational data are Licensee source, and special nuclear materials (in quantities not ca-Event Reports (LERs) submitted pursuant to 10 CFR pable of sustaining a chain reaction). Agreement State 50.73, immediate notifications submitted pursuant to 10 programs must be comparable to and compatible with the CFR 50.72, and medical misadministration reports sub-Commission's program for such material.

mitted pursuant to 10 CFR 35.33.

Presently, information on reportable occurrences in Except for records exempt from public disclosure by stat-Agreement Stat e licensed activities is publicly available at ute and/or regulation, information concerning reportable the State level. For the purpose of developing a nation-occurrences at facilities licensed or otherwise regulated wide database, Agreement States are encouraged to pro-by NRC is routinely disseminated by NRC to the nuclear vide information to NRC on reportable events.

industry, the public, and other interested groups as these events occur.

In early 1977, the Commission determined that AOs hap-l l'

Dissemination includes special notifications to licensees be included in the quarterly reports to Congress.The AO pening at facilities of Agreement State licensees should and other affected or interested groups, and public an-criteria included in Appendix A are applied uniformly to nouncements. In addition, information on reportable events at the NRC and the Agreem mt hte licensee faci-events is routinely sent to the NRC's more than 100 Local lities. Procedures have been devele ped and implemented, Public Document Rooms throughout the United States and AOs reported by the Agreement States to NRC are and to the NRC Public Document Room in Washington, included in these quarterly reports to Congress.

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

Another source of operational data is that submitted by licensees to the Nuclear Plant Reliability Data System l

(NPRDS). He NPRDS is a voluntary, mdustry-sup-NRC participates in an exchange of information with vari-ported system maintamed by the Institute of Nuclear ous foreign governments that have nuclear facilities.His Power Oper tions (INPO), a nuclear utility organization.

foreign information is reviewed and considered in the a

l Both engineering and failure data are submitted by nu-NRC's assessment of operating experience and in its re-clear power plant licensees for specified plant compo-search and regulatory activities. Reference to foreign in-nents and systems. The Commission considers the formation may occasionally be made in these quarterly NPRDS to be a useful supplement to the LER system for AO reports to Congress; however, only domestic AOs are the collection, review, and feedback of operational expe-rep rted.

rience.

Reopening of Closed Abnormal Agreement States Occurrences Section 274 of the Atomic Energy Act, as amended, au-NRC reopens previously closed AOs if significant newin-thorizes the Commission to enter into agreements with formation becomes available. Similarly, previously re-States whereby the Commission relinquishes and the ported "Other Events of Interest" are updated if sigrafi-States assume regulatory authority over byproduct, cant new information becomes available.

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NUREG-0090, Vol.17, No. 3 viii

i Abnormal Occurrences,3rd Qtr CY94 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES JULY-SEPTEMBER,1994 Nuclear Power Plants There are 109 operating nuclear power plants in the this report, none of the events reviewed for this reporting United States (U.S.). NRC has reviewed all event reports period was determined to be significant enough to be re-rcceived from these licensees through the third quarter of ported as an abnormal occurrence (AO).

1994. Using the criteria and guidelines in Appendix A of Fuel Cycle Facilities (Other than Nuclear Power Plants)

There are 41 active licenses for the milling, processing, guidelines in Appendix A of this report, none of the and fabrication of nuclear fuel in the U.S. NRC has re-events reviewed for this reporting period was determined viewed all event reports received from these licensees to be significant enough to be reported as an abnormal oc-during the third quarter of 1994. Using the criteria and currence.

l Other NRC Licensees I

(Industrial Radiographers, Medical Institutions, Industrial Users, etc.)

There are approximately 22,000 active material licenses administered 185 megabecquerel (MBq) (5 millicurie l

for the use of byproduct materials in industrial, medical,

[ mci]) of sodium iodide-131 (I-131) on March 9,1994, as j

and academic applications in the U.S. Twenty-nine States, prescribed in the written directive for the treatment of known as Agreement States, have entered into agree-Graves' disease (hyperthyroidism). The licensee did not ments with NRC to assume regulatory authority for the know that the patient was pregnam at the time of the ad-use of byproduct materials. NRC is responsible for regu-ministration. On May 10,1994, the licensee was informed lating approximately 70000f these licensees located in 21 by a private practice physician that the patient was l

States, the District of Columbia, and all U.S. territories.

22-weeks pregnant at the time of treatment. As a result, l

NRC has reviewed all events received from these licens-the patient's fetus received an unintended radiation dose, ces through the third quarter of 1994. Using the criteria and guidelines in Appendix A of this report, the following The patient was referred to the licensee with possible hy-events have been determined to be significant enough to Perthyroidism.1b confirm the suspect condition, the li-i be reported as AOs.

censee administered a 440.3 kilobecquerel (11.9 microcu-l rie) I-131 capsule to the patient on March 7,1994, and l

measured an 82-percent thyroid uptake over the ensuing 94-15 Sodium Iodide Event at~

25 hours2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br />. The licensee stated that prior to administering the I-131 diagnostic capsule on March 7,1994, the patient Welborn Memorial Baptist was questioned and informed both the treating physician Hospital in Evansville, Indiana and the nuclear medicine technologist administering the capsule that she was not pregnant.The licensee diagnosed The following information pertaining to this event is also the patient's condition as Graves' disease and the treating being reported concurrently in the federal Register. Ap-physician prescribed a 185 MBq (5 mci) I-131 therapy treatment. On March 9,1994, a 185 MBq (5 mci) I-131 pendix A (see General Criterion 1) of this report notes I

that a moderate exposure to, or release of, radioactive capsule was orally admmistered by one of the licensee's nuclear medicme technologists, as prescn' bed. Prior to the i

material licensed by or otherwise regulated by the Com-treatment on March 9,1994, the technologist questioned mission can be an abnormal occurrence.

the patient once more and was again informed by the pa-tient that she was not pregnant.

Date and Place-March 9,1994; Welborn Memorial Bap-tist Hospital, Inc.; Evansville, Indiana.

Oak Ridge Institute for Science and Education calculated the fetal whole body and thyroid doses at NRC request.

Nature and Probable Consequences-On May 16,1994, The fetal dose to the thyroid was calculated as the licensee reported to NRC that a pregnant patient was 7,000-12,000 centigray (cGy) (7,000-12,000 rad), and the 1

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Abnormal Occurrences,3rd Otr CY94 i

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fetal whole body dose was calculated as 0.55 cGy (0.55 94-16 Teletherapy Misadministration rad). Based on the calculated fetal dose there are a rang of possible consequences, the most likely being no signifi-at Medical Center Hosp tal in i

cant harm to the fetus. At NRC request, the Radiation Chillicothe, Ohio Emergency Assistance Center / Raining Site in Oak Ridge, Tennessee, contacted the licensee to discuss the The following information pertaining to this event is also dose assessment and potential fetal effects.

being reported concurrently in the federal Register. Ap-pendix A of this report notes that a therapeutic dose that results in any part of the body receiving unscheduled radi-On May 10,1994, a physician specializing in maternal fetal ation can be considered an abnormal occurrence.

medicine, not affiliated with the licensee, discussed the incident with the licensee. The patient was informed of Date and Place-July 21 and 22,1994; Medical Center the exposure and possible consequences to the fetus by Hospital; Chillicothe, Ohio.

1 the maternal fetal specialist.

Nature and Probable Consequences-On July 27,1994, the licensee reported that a patient received a radiation Cause or Causes-The principal cause for the event was dose of approximately 300 centigray (cGy)(300 rad) to an licensee reliance on the patient's assurance of non.

unintended treatment site using a cobalt-60 teletherapy pregnancy. Licensee procedures do not require determi.

unit.

nation of pregnancy status through scrum testing, or other appropriately documented means, for all female pa-A patient was scheduled to receive 1400 cGy (1400 rad)in tients of child beartng age.The patient was apparently un-a series of seven treatments for cancer of the esophagus.

Each of the treatments was to consist of two radiation ex-aware of her pregnancy status at the time of I-131 admm-istration on March 9,1994.

posures of 100 cGy (100 rad) each delivered from different i

angles. The first treatment was performed on J uly 21. Fol-le ing the first of the two exposures during the second Action Taken To Prevent Recurrence

'reatment on July 22, the technologist found inconsisten-cies in the angles of treatment documented in the written directive and in the patient simulation sheet. Upon fur.

Licensee-The licensee is in the process of developing in-ther review, the licensee determined that the wrong treat-1 ternal policies which will address options for pregnancy ment angles had been used during the first treatment and status determination including scrum pregnancy testing part of the second treatment.

or suitable written proof, such as evidence of a hysterecto-my.The legal implications and options for written proof of As a result of the incorrect angles of exposure, the treat-non-pregnancy are being evaluated by the licensee. Until ment site received onlypart of the prescribed dose and ad-policies have been finalized, the licensee plans to adminis-Jacent tissue received a higher dose than mtended.The h-ter pregnancy tests to all female patients of child bearing censee estimates a dose of 300 cGy (300 rad) to the age, unless a'ppropriate proof of non-pregnancy is avail-unintended site. Under normal conditions, the unm, -

I able as determined by the authorized user. For patients tended site would have received approximately 20-50 cGy j

unwilling to undergo pregnancy testing, radiopharma-(20-50 rad).

ceuticals will not be administered and the a uthorized user will be consulted for the appropriate course of action.

The treatment angles were corrected on the patient's I

chart, and the radiation dose was modified to compensate for the reduced dosage delivered in the initial treatments.

NRC-NRC Region III conducted a safety inspection ne patient was informed and no adverse medical effects

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from May 18 through June 8,1994, to review the circum-are expected.

stances surrounding the event and to evaluate aspects of The patient was notified verbally on July 26,1994 and in the licensee's radiopharmaceutical Quality Management writing as required by 10 CFR 35.33. According to the Program (Ref.1). No regulatory violations associated with i

medical consultant, there will be no medical conse-the event were identified. The licensee's procedure quences as a result of the misadministration.

i appears to have been followed in this specific case. NRC regulations do not include requirements for patient preg-Cause or Causes-The error occurred because the simu-nancy verification prior to administration of radiopharma-lated gantry angles had not been converted to the treat-ceuticals. However, NRC is in the process of developing ment unit gantry angles, and gantry angle conversion fac-regulations which will address the administration of radio-tors were not included in the licensee's treatment chart pharmaceuticals to breast feeding and pregnant patients.

checks conducted by the technologists.

The root causes of the problem were discussed with the This event is closed for the purpose of this report.

licensee on September 1,1994, during an Enforcement i

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Abnormal Occurrences,3rd Otr CY94 4

1 Conference. The causes appeared to be the following:

the normal range of exposures prescribed for the diagnos-(1) written procedures were r.ot developed to address tic procedure can be considered an abnormal occurrence.

gantry angle conversions; (2) the technologists did not have an adequate understanding of the informal gantry Date and Place-July 26,1994; St. Joseph Mercy Hospital; angle conversion procedures; (3) the informal gantry Pontiac, Michigan.

angle conversion procedure was not part of the licensee's annual refresher training program; (4) technologists did Nature and Probable Consequences-On July 27,1994, not iully understand their responsibilities to resolve dis-the licensee reported to NRC that a misadministration oc-crepancies in a treatment plan; and (5) gantry angle con-curred involving a patient receiving the wrong radiophar-version factors were not included in the licensee's treat.

maceutical for a diagnostic procedure.

ment chart checks conducted by the technologists.

The patient's referring physician requested a thyroid scan 4

which involves administration of a standard prescription Action Taken To Prevent Recurrence at St. Joseph Mercy Hospital of a 9.25 megabecquerel (MBq) (0.25 millicurie [ mci]) sodium iodide-123 (I-123)

Licensee-The licensee's corrective actions included:

capsule. However, the licensee admmistered a 92.5 MBq (1) revising the simulation data form to include a specific (2.5 mci) I-131 capsule. The amount of activity that was location to document the converted gantry angles; (2)ini-admimstered is normally used followm, g removal of the tialing all angle conversions by the person performing the thyroid to examine a patient for the spread of cancer from conversion, and having a second individual independently verify the conversions prior to treatment; (3) instructing the thyroid through the body, the technologists to review all treatment information and NRC retamed a medical consultant to review the case.

to resolve any discrepancy prior to continuing treatment; The medical consultant concluded that the resultant un-(4) performing all future gantry angle conversions by the necessary dose to the patient's thyroid would result in a licensee rather than by the licensee's simulation contrac-tor; and (5) conducting a review of past treatment plans l w, but finite, probability of hypothyroidism developing in the future. Also, there is a lifetime probability of devel-back to 1988, with emphasis on those which did not identi-oping radiat,on-mduced thyroid cancer of 10 percent, m-i fy any additional errors.

c19 ding a risk of fatal thyroid carcinoma of approximately 1 percent.The licensee has arranged for the patient to be NRC-NRC Region III conducted an inspection on Av.

seen by a endocrmologist, and for repeat thyroid imaging gust 1,1994, to review the circumstances surrounding G e with I-123 to be performed several months after the mis-misadministration (Ref. 2). NRC also retained a mecical admmistration.

consultant to review the case. An Enforcement Confer-ence was held on.Geptember 1,1994, to discuss the inspec-The patient was notified in person by the Radiation Safety tion findmgs and ac&ns taken by the licensee. On Sep-Officer on July 27,1994. Subsequently, the patient was tember 20, 1994, NRC Region III issued a Notice of also given a written report that was dated August 5,1994.

Violation with a Severity Level III (Seventy Levels I through V range from the most significant to the least sig-Cause or Causes-Part of the cause of the misadministra-mficant) violation with no civil penalty assessed. The li-tion was the lack of the treating physician's involvement in censee's corrective and preventive actions will be re-the patient's examination prior to the I-131 administra-viewed during the next NRC inspection of the licensed tion.The administrative staff and technologists failed to Pmgram.

have the examination clarified by a treating physician with Ris event is closed for the purpose of this report.

13 Ca fa or vent also clu d the fail ure of licensee management to ensure implementation of the licensee's written Quality Management Program.

94-17 Sodium Iodide Contributing factors also appear to mclude deficiencies in Misadministration at St.

training, and a failure to follow through on matters.

Joseph Mercy Hospital in 3,,,,,7,g,,7,p,,,,,,g,,,,,,,,,

Pontiac, Michigan Licensee-The licensee took the following corrective ac-ne following information pertaining to this event is also tions: (1) held a training session which included the Radi-being reported concurrently in the Federal Register. Ap-ation Safety Officer, treating physicians and technolo-pendix A of this report notes that administering a diagnos-gists; (2) instituted a limit on the number of individuals tic dose of a radiopharmaceutical differing from the pre-who will be involved in the use of I-131; and (3) required a scribed dose by more than 50 percent in which the event written directive to be filled out and signed by a treating results in adverse health effects worse than expected for physician.

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Abnormal Occurrences,3rd Qtr CY94 i

NRC-NRC Region III conducted an inspection on Au-without incident. However, on the 21st treatment on Au-gust 1,1994, to review the misadministration (Ref. 3). A gust 3, the teletherapy unit was positioned using the Confirmatory Action Letter (CAL) was issued to the li-wrong treatment angle. This resulted in a radiation dose censee on August 2,1994, which described the commit-of 100 cGy (100 rad) being received by the right lung area ments made by the licensee as to which actions will be tak-instead of the right shoulder area.

en prior to the administration of I-131. An Enforcement Conference was held on August 24,1994, to discuss the An NRC medical consultant reviewed both cases and con-inspection findings and actions taken by the licensee in re.

cluded that no significant adverse side effects or tissue in-sponse to the CAL Jury are expected.

ause w ause e cause oM mbahnhadom i

In October 1994, NRC proposed an $8.000 fine against the was human errors by several of the licensee's therapists, licensee for violations of NRC requirements involved in a

,Ihe theraptsts failed to verify the collimator angle, the diagnostic procedure using radioactive iodine at the hos-

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pital. The violations involve: (1) failure to have signed ng e

apy se tk pades written directives by an authorized user prior to adminis-tration of I-131 in quantities greater than 1.11 MBq (0.03 Action Taken To Prevent Recurrence mci) on J uly 26, and in two previous instances where the i

I-131 was the intended radiopharmaceutical;(2) failure to Licensee-The corrective actions taken included: (1) sus-have a clinical procedure for the proper administration of pending all teletherapy treatments pending an internal I-131 for whole body scans; and (3) failure to provide investigation, and identification of appropriate corrective proper instruction to the nuclear medicine staff. The li-actions prior to re-start of the teletherapy treatments; censee paid the civil penalty.

(2) developing procedures which require independent verification of proper treatment parameters during pa-This event is closed for the purpose of this report.

tient set-up; and (3) installing a record-and-verify system on the teletherapy unit to ensure that all major treatment parameters are checked prior to a treatment.

94-18 Multiple Teletherapy Misadministrations at Sinai NRC-NRC Region HI conduced an inspecion July 29 through August 12,1994, to review the circumstances sur-Hospital in Detroit, Michigan rounding the two misadministrations (Ref. 4). NRC also retained a medical consultant to review the case. An En-The following information pertaining to this event is also forcement Conference was held on September 8,1994, to being reported concurrently in the Federal Register. Ap-discuss the inspection findings and actions taken by the li-pendix A of this report notes that a therapeutic dose that censee. On September 21,1994, NRC Region III issued a results in any part of the body receiving unscheduled radi-Notice of Violation with a Severity Level III (Severity ation can be considered an abnormal occurrence.

Levels I through V range from the most significant to the least significant) violation with no civil penalty assessed.

Date and Place-July 28 and August 3,1994; Sinai Hospi-The licensee's corrective and preventive actions will be tal; Detroit, Michigan.

reviewed during the next NRC inspection of the licensed program.

Nature and Probable Consequences-On July 28,1994, and August 3,1994, misadministrations occurred on two As required by 10 CFR 35.33(a), the licensee, for each separate patients when the licensee's therapists failed to misadministration, notified the referring physician and verify correct teletherapy machine parameters prior to patient after the discovery of the incident and submitted a treatment.

written report to the patient, including a statement that the report submitted to NRC Region Ill will be made Beginning on July 19,1994, a patient was to receive 4500 available upon request.

]

centigray (cGy)(4500 rad)in a series of 25 treatments t This event is closed for the purpose of this report.

f the left neck area. 'Ihe first seven treatments were com-pleted without incident. However, on the eighth treat-ment on July 28, one fraction was set up using the wrong 94-19 Brachytherapy treatment angle. This resulted in a radiation dose of 90 Misadministration Involving cGy (90 rad) being received by the right shoulder and neck area instead of the left neck area.

the Use of a Strontium-90 Eye Applicator at the University of Beginning July 5,1994, another patient was to receive Massachusetts Medical Center 5000 cGy (5000 rad)in a series of 25 treatments to the right shoulder area. The first 20 treatments were completed in Worcester, Massachusetts NUREG-0090, Vol.17, No. 3 4

Abnormal Occurrences,3rd Otr CY94 The following information pertaining to this event is also inexperienced physicist prepared the source and was un-being reported concurrently in the Federal Register. Ap-aware that the source was equipped with a stainless steel pendix A (see Event Type 5 in Table A-1) of this report mask.

notes that a therapeutic dose that results in an actual dose less than 0.5 times the prescribed dose can be considered Actions Taken to Prevent Recurrence an abnormal occurrence (AO). In addition. Criterion No.

11 under "For All Licensecs"in Appendix A notes that a Licensee-The licensee is reviewing the feasibility of mo-serious deficiency in management or procedural controls in major areas can be considered an AO.

difymg the mask m some manner to make it more eastly distmguished from the unmasked source. In addition, the licensee has employed two new radiation oncology physi-Date and Place-July 29,1994; University of Massachu-cians and a new chief physicist.

setts Medical Center; Worcester, Massachusetts.

NRC-NRC conducted a specialinspection on August 3, 1994. The inspector determined that the physician was as-Nature and Probable Consequences-NRC Region I was sisted by a dosineirbt who had not previously been direct-notified on August 1,1994, by thc licensec of a brachyther-ly involved with the procedure. When the physician re-apy misadministration myolvmg the use of a strontium-90 quested that the dosimetrist provide him with the eye (Sr-90) eye applicator. On July 29,1994, a physician per-applicator source in order to perform the treatment, the formed an ophthalmic treatment on a patient usmg an dosimetrist handed him the source with the stainless steel Sr-90 eye applic. tor without first removmg the stainless mask in place. The dosimetrist stated that she was un-steel mask from the source. Because of this oversight, the aware that the source was equipped with a mask and that licensee estimated that the treatment site received 107 the mask needed to be removed. Re physician and other c:ntigray (cGy)(107 rad) of radiation, rather than the 1250 licensee staff stated that it is the assistant's responsibility, to 2000 cGy (1250 to 2000 rad) that was intended. In add -

in this case the dosimetrist's responsibility, to remove the tion, whereas the beta radiation from the eye applicator stainless steel mask from the source before handing the source only affects the surface of the eye, the bremsstrah-eye appl cator to the physician.The treatment was admin-lung radiation resulting from the mteraction of the beta istered by the physician with the mask in place. While particles on the stainless steel mask is more penetrating.

cleaning the eye applicator later that same day, the licens-The patient returned on August 2,1994, for the comple-ee determined that the treatment had been performed tion of the therapy to brmg the total dose dehvered withm with the mask in place. The licensee stated that the pa-the ongmally prescribed range. The licensee expects that tient and the patient's physician were notified that there the cimical outcome of the misadministration will be m-had been an underdose and the patient returned on Au-consequential for the patient.

gust 2,1994, for the completion of the therapy. The pa-i tient was given a written report of the misadministration Cause or Causes-According to the licensee a combina-on August 9,1994.He licensee submitted a report for the l

tion of factors led to the misadministration: (1) infrequent misadministration on August 10,1994. NRC Region I has use of the ophthalmic applicator and the fact that its ap-enlisted the services of a medical consultant to e, valuate pearance with the mask is similar to its appearance with the cimical consequences of this mtsadmmistration and l

the mask removed; (2) the event occurred on a Friday af, awaits his report.

(

ternoon and the stress of the week's work affected the l

alertness of the individuals involved; and (3) the most ex-This event will be updated when additional information perienced physicists were not available, and a relatively becomes available.

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l Agreement State Licensees He 29 Agreement States have approumately 15,000 ac-AS 94-6 Loss of Management and tive material licenses for the use of byproduct materials in g

g mdustrial, medical, and academic applications. Proce-dures have been developed for Agreement States to Radioactive Source Licensed screen events using the same criteria an:1 guidelines as b the State ofIllinois to I

NRC, and to report those events that have been deter-mined to be significant enough to be considered as abnor-Kay-Ray, Inc., at a Georgia-mal occurrences (AOs).

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NUREG-0090, Vol.17, No. 3

Abnormal Occurrences,3rd Qtr CY94 i'

i I

Pacific Corporation Paper holder cssembly consists of a 6.4-centimeter (2.5-inch) i n8 alunu,num tube crimped at one end to contain the Mill in Palatka* Florida source,with the opposite open end of the tube attached to i

an aluminum plate which is secured to the housing by Appendix A (see item No.12 of "For All Licensees") of three screws. Internal corrosion of one of the gauges this report notes that a senes of events (where individual caused the manufacturer's service technician to experi-events are not of major importance), recurring incidena, ence difficulty removing it, and in the process the source 1

and incidents with implications for similar facilitiec (ge.

holder assembly was broken and the scaled source be-neric incidcras) that create major safety concern shouso came detached. The source holder and plate were in-i be considered an abnormal occurrence (AO).

stalled into the new source housing as two separate pieces while the scaled source remained in the old housing. The I

ne State of Florida's decision to select the stated AO cri-new housing was installed and the old housing, with its teria is based on its belief that the violations committed by broken shutter left in the open position, was stored with j

the gauge manufacturer's representatives, who perfonn the three empty source housings.The manufacturer's ser-licensed activities nationwide, has implications for similar vice technician failed to perform, or improperly per-i facilities.ne State of Florida stated that its decision ap-formed, required surveys and failed to verify the proper pears to be supported by the occurrence of another gauge operation of the reinstalled gauge.

J incident in Cedar Springs, Georgia.The State of Florida has discussed the incident at Palatka, Florida, with the Following the telephone report of the incident, an ORC State of Georgia.

inspector went to the licensee's facility to investigate the

[

cause and assure that immediate corrective actions were 1

Aao, since the gauge manufacturer is Kay-Ray, Inc.,

taken.The ORC inspector confirmed the presence of the which is licensed by the State of Illinois, the State of Flori-source, measuring the radiation level at 30.5 centimeters da worked closely with the Illinois Department of Nuclear (12 inches) from the open shutter at 151 microcoulomb Safety (IDNS)duringitsinvestigationof thisincident.nc per kilogram (585 milliroentgen) per hour. (The ORC in-l State of Florida received copies of the Kay-Ray license spector also found that Kay-Ray, Inc., which is an IDNS and procedures from IDNS, which facilitated the investi-licensee, had not filed for reciprocity and was operating gation.

illegally in the State of Florida.)

l Date and Place-Between January and April 1993; A consultant hired by the licensee performed wipe tests Georgia-Pacific Corporation; 1%latka, Florida.

which found no leakage from the source. All personnel handling or working in the vicinity of the source were in-1 Nature and Probable Consequences-On April 1,1993, terviewed to calculate their exposures. Beed on the con-the State of Florida, Office of Radiation Control (ORC) sultant's calculations, the highest dose received was 700 l

was notified by phone that a Kay-Ray, Inc., Mode 17063P microsievert (70 millirem). No physical effects were ob-fixed gauge tMt was presumed to be empty had been served or expected.

j found to still contain its 7400 gigabecquerel (200 millicu-Cause or Causes-The primary cause of the m.cident was rie) cesium-137 sealed source. The licensee's radiation the failure of the manufacturer s service techm,etan to safety officer (RSO) reported that the gauge was one of l6 transfer the source to its new housing and subsequent fail-i damaged devices removed from service between March ure to follow procedures which would have identified the 10 and 19,1993, for repair or replacement. Following the I cation of the source. A contributing factor was the fail-removal and reloading of their source holders into new ure of both plant personnel and the service technician to housings by a manufacturer's factory service technician, n te the deterioratmg condition of the gauges and take four of the damaged gauges were stored on-site pending c rrective measures.,The State of Florida ORC licensec the disposal as scrap metal. Twenty-one days later, a radi-failed to perform annual physical inventories as required, ation survey of the housings revealed the presence of a and the manufacturer s service techm,cians contracted,to i

source in one of the gauges.

perform annual leak tests of the gauges failed to inform its client of the safety hazard created by the corroded gauges.

The RSO reported that the cause of the incident was the fsfere of the Kay-Ray service technician to successfully Actions Taken to Prevent Recurrence transfer the gauge's sealed source from its damaged source housing to a replacement housing. The gauges op-Licensees-The fixed gauge licensce's corrective actions erate as levelindicators in the corrosive environment of a included hiring a consultant to assist in the resolution of paper mill. Extensive corrosion of four of the 16 gauges the gauge incident and in its assessment of the exposures j

that were removed from service had left their source hold-received by its personnel, and to evaluate and implement ers as the only salvageable components.The manufactur-revisions to its radiation protection program to ensure er was contracted to load the source holdea into new compliance. A meeung was held with the gauge manufac-housings and reinstall them. The Model 7063P source turer's management to ensum that all required safety pre-NUREG-0090, Vol.17, No. 3 6

Abnormal Occurrences,3rd Qtr CY94

/

cautions are taken when the manufacturer's service tech-(NOV)(annual inventory requirements) was issued to the nicians are on-site. Additional radiation safety training fixed gauge licensee on October 7,1993. Due to the licens-was provided to all of the licensee's personnel.

ee's identification and immediate notification of its viola-tion ard its immediate corrective actions to prevent recur-IDNS indicated that the manufacturer's corrective ac-rence, no Civil Penalty was imposed.

tions included providing immediate assistance in resolv-A NOV and Proposed Imposition of Administrative Fine ing the incident and cooperating with its client,s manage-in the amount of $3,000 was issued to the manufacturer on ment to enact corrective measures to prevent recurrence.

August 12,1993. This action was based on six violations A consultant was hired to (1) study the regulatory require-related to the incident: (1) repeated failures to provide re-ments of all State and Federal agencies to ensure com-quired notification of entries into the State by the licens-phance with reciprocity and other regulatory require-ces' employees in which licensed activities were con-ments, (2) teview the manufacturer's procedures and ducted (reciprocity), (2) failure to make surveys to recommend revisions, and (3) ensure that all of the man-cvaluate the extent of radiation hazards, (3) failure to take ufacturer's personnel understood the requirements and reasonable measures to maintain radiation exposures as procedures. Increased management oversight of its field low as reasonably achievable, (4) and (5) failures to comply semce personnel was also implemented. Additional in-with required procedures for safe performance of li-struction on radiation safety and procedures was provided to all field semce personnel, and an annual recertifica-censed activities, and (6) failure to '.ake precautions suffi-tion program was implemented.

cient to prevent loss of a source of radiation. Each viola-tion was categorized at Severity Level III on a scale in which Severity Levels I through V are the most significant State Agency-The ORC reviewed the circumstances as-and least significant, respectively. Each violation was as-sociated with the incident and the licensee's and manufac-sessed a proposed administradve fine of $500. The fine turer's immediate and follow-up corrective actions during was paid on January 24,1994.

(1)a reactive inspection on April 4,1993, (2) evaluation of the report compiled by the licensee, and (3) a follow-up He State of Florida's ORC provided information pack-inspection on September 9,1993. An Enforcement Con-ages on this event to the states of Georgia and Illinois.

ference with representatives of the manufacturer was conducted on January 24,1994. A Notice of Violation This event is closed for the purpose of this report.

7 NUREG-0090, Vol.17, No. 3

Abnormal Occurrences,3rd Qtr CY94 REFERENCES 1.

Letter from W.L Axelson, Director, Division of Ra-Executive Offices. St. Joseph Mercy Hospital, for-diation Safety and Safeguards, to Steven Kern, Se-warded Inspection Peport No. 030-02104/94001, Li-nior Vice President, Welborn Memorial Baptist Hos-cense No. 21-11651-OL dated August 19, 1994.*

pital, forwarded Inspection Repoit No. 030-01598/

94001, Docket No. 030-01598, License No.13-01674-4.

Letter from W.L Axelson, Director, Division of Ra-01, dated July 6,1994.*

diation Safety and Safeguards, to Robert Reed, M.D.,

Executive Vice President, Sinai Hospital, forwarded 2.

Letter from W.L Axelson, Director, Division of Ra-Inspection Report No. 030-00252/94001, Docket No.

i diation Safety and Safeguards, to Allen Rupiper, 030-00252, License No. 21-00299-Go, dated Septera.

Chief Executive Officer, Medical Center Hospital, ber 2,1994.*

forwarded Inspection Report No. 030-10543/94001, Docket No. 030-10543, License No. 34-11852-02, dated August 23,1994.*

' A copyis available for inspection.or copying for a fee,in the NRC Pub-3.

Letter from W.L Axelson, Director, Division of Ra*

lic Document Room,2120 t. Street NW. (Inver level), Washington, diation Safety and Safeguards, to Jack Cullen, Chief nc.

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I NUREG-0090, Vol.17, No. 3 8

4 Abnormal Occurrences,3rd Qtr CY94 l

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APPENDIX A ABNORMAL OCCURRENCE CRITERIAI

'Ihe following criteria used to determine abnormal occur-5.

Any loss of licensed material in such quantities and rence (AO) were set forth in an NRC policy statement under such circumstances that substantial hazard published in the federa! Register on February 24,1977 (Vol.

may result to persons in unrestricted areas.

42, No. 37, pages 1095G.10952).

6.

A substantiated case of actual or attempted theft or An event will be considered an AO if it involves a major diversion of licensed material or sabotage of a facil-reduction in the degree of protection of the public health ity.

or safety. Such an event would involve a moderate or more severe impact on the public health or safety and 7.

Any substantiated ioss of special nuclear material or could include but need not be limited to:

any substantiated inventory discrepancy that is judged to be significant relative to normally expected 1.

Moderate exposure to, or release of, radioactive ma-Performance and that is judged to be caused by theft terial licensed by or otherwise regulated by the Com.

or diversion or by substantial breakdown of the ac-mission; countability system.

8.

Any substantial breakdown of physical security or 2.

Major degradation of essential safety-related equip-material control (i.e., access control, contamment, ment; or or accountability systems) that significantly weak-3.

Major deficiencies in design, constructior,, use of, or ened the protection against theft, diversion, or sabo-me.nagement controls for licensed facilibes or mate-tage.

'I"I' 9.

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

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

10. A major deficiency in design, construction, or opera-tail using these criteria are:

tion having safety implications requiring immediate remedial action.

For All Licensees

11. Serious deficiency in management or procedural 1.

Exposure of the whole body of any individual to 25 controls in major areas.

rem or more of radiation; exposure of the skin of the whole body of any individual to 150 rem or more of

12. Series of events (where individual events are not of radiation; or exposure of the feet, ankles, hands or major importance), recurring incidents, and inci-forearms of any individual to 375 rem or more of ra-dents with implications for similar facilities (generic diation [10 CFR 20.403(a)(1)], or equivalent expo-incidents) that create major safety concern.

sures from internal sources.

For Commercial Nuclear Power Plants 2.

An exposure to an individualin an unrestricted area such that the whole body dose received exceeds 0.5 1.

Exceeding a safety limit of license 'Ibchnical Specifi-rem in one calendar year [10 CFR 20.W5(a)].

cations [10 CFR 50.36(c)].

3.

The release of radioactive material to an unre.

2.

Major degradation of fuel integrity, primary coolant stricted area in concentrations which, if averaged Pressure boundary, or primaty containment bound-over a period of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, exceed 500 times the regu.

ary.

latory limit of Appendix B,'Ihble II,10 CFR Part 20 3-LOSS of lant capability to perform essential safety

?

P

[CFR 20.403(bX2)].

functions such that a potential release of 4.

Radiation or contamination levels in excess of design radioactivity in excess of 10 CFR Part 100 guidelines values on packages, or loss of confinement of radio-active material such as (a) a radiation dose rate of

'On January 1,1994, changes to'ntle 10 of the Code offederalRegula.

1,000 mrem per hour three feet from the surface of a tions Part 20 were promulgated. At the Commission's directive, the package containing the radioactive material, or (b) staffiscurrentgdevelgeg a policy statement revising criteria for vari-ous types of A The n es pertinent to the 10 CFR 20 revisions will release of radioactive material from a package in also be included in that draft policy statement. upon commission's amounts greater than the regulatory limit.

proval, the appropriate changes to this Appendix will be published.

9 NUREG-0090, Vol.17, No. 3 e

Abnormal Occurrences,3rd Otr CY94 could result from a postulated transient or accident 1.

A major condition not specifically considered in the (e.g., loss of emergency core cooling system, loss of safety analysis report orlbchnical Specifications that control rod system).

requires immediate remedial action.

l 4.

Discovery of a major condition not specifically con-3.

An event that seriously compromised the ability of a sidered in the Safety Analysis Report (SAR) oribch-confinement system to perform its designated func-nical Specifications that requires immediate reme-tion.

dial action.

Medical Misadministrations i

5.

Personnel error or procedural deficiencies that re-sult in loss of plant capability to perform essential safety functions such that a potential release of ra-As discussed in the Preface to this report, the NRC policy dioactivity in excess of 10 CFR Part 100 guidelines statement on AOs was published before licensees were could result from a postulated transient or accident required to report medical misadministrations to the (e.g., loss of emergency core cooling system, loss of NRC. Therefore, during 1984, NRC developed guidelines j

control rod system).

for selecting such events for AO reporting.nese guide-lines, which are summarized in Thble A-1, augment the For Fuel Cycle Licensees NRC policy statement.

i 1.

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

definitions became effective on January 27,1992.

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l NUREG-0090, Vol.17, No. 3 10

l Abnormal Occurrences,3rd Qtr CY94 Table A.1 NRC Guidelines for Selecting Medical Misadministration Events for Abnormal Occurrence (AO) Reporting AO Reporting Threshold Event Type Diagnostic Exposure Therapeutic Exposure (1) Administering a radiopharma-If the improper administration If theimproperadministration i

ceutical or radiation from a results in any part of the results in any part of the body l

sealed source other than the body receiving unscheduled receiving unscheduled radiation, an one intended.

radiation, an AO report should AO report should be proposed for l

be proposed if:

any such event.

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

involving that body part, or (b) there are clinical (a) the actual dose is greater indicationsof any than 1.5 times that intended I

adverse health effects to the above described body to the wrong body part.

parts, or, l

If the parts of the body (b) the actual dose is less than I

receiving radiation 0.5 times that intended to the j

improperly would have above described body parts, or, received radiation anyway, l

had the proper administration (c) the above described body parts been used, an AO report should show signs of adverse health be proposed if:

effects greater than expected had the proper administration l

been used, or (a) the actual dose is greater (d) the event (regardless of any than five times that intended health effects) affects two or l

to the above described body more patients at the same parts, or, facility.

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

been used.

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

proposed for any such event.

to. the wrong patient.

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

(3) Administering a radiophar.

Same guidelines as for Same guidelines as for maceutical or radiation by a Event 'I}pe 1.

Event 'l}pe 1.

l 11 NUREG4)090, Vol.17, No. 3 l

Abnormal Occurrenccs,3rd Otr CY94 Table A.1 (Continued)

A0 Reporting Threshold Event Type Diagnostic Exposure Therapeutic Exposure route of administration other l

than that intended by the pre-1 scribing physician.

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

dose of a radiopharma-proposed if:

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

greater than five times the prescribed dose, or, l

(b) the event results in adverse 1

health effects worse than expected for the normal range i

of exposures prescribed for the diagnostic procedure.

(5) Administering a Not applicable.

An AO report should be cherapeutic dose of proposed if:

i a radiopharmaceutical differing from the prescribed (a) the actual dose is greater dose by more than 10 percent; than 1.5 times the prescribed j

or administering a therapeutic dose,or, radiation dose from a sealed source such that errors in the (b) the actual dose is less than I

source calibration, time of 0.5 times the presenbed 3

3 exposure, and treatment dose,or geometry result in a calculated total treatment dose differing (c) the event results in adverse i

from the final prescribed health effects worse than total treatment dose by more would be expected for the than 10 percent.

normal range of exposures prescribed for the therapeutic procedure, or, (d) the event (regardless of any 1

health effects)affects two i

or more patients at the same facility.

(6) Recuning or series of For either diagnostic or therapeutic exposures, an AO report should be events (regardlessof the proposed for recurring events or a series of events (in which each individual number of patients or misadministration is not of major importance) that create a significant i

facilities involved).

public health or safety concern.

i (7) Generic events.

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

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NUREG-0090, Vol.17, No. 3 12

Abnormal Occarrcnces,3rd Otr CY94 APPENDIX B UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES During July through September 1994, NRC licensees, discussed below contain a summary of information pres-Agreement States, Agreement State licensees, and other ented in previous reports and any subsequent updated in-involved parties, such as reactor vendors and architect-formation provided during the reporting period. Those engineering firms, continued with the implementation of updated events which still require additional information actions necessary to prevent recurrence of previously re-will be discussed in future reports.

ported abnormal occurrences. The abnormal occurrences Nuclear Power Plants 86-9 Boiling Water Reactor Protection logic design deficiency. (The notification was required by the U.S. Code of Federal Regulations,"Re-Emergency Core Cooling porting of Defects and Noncompliance," Part 21, Wie 10, l

System Design Deficiency

" Energy.")

His abnormal occurrence (AO) was originally reported in NRC issued Bulletin 86-01, " Minimum Flow Logic Prob-NUREG-0090, Vol. 9, No. 2, " Report to Congress on Ab-lems Hat Could Disable RHR Pumps," on May 23,1986, normal Occurrences," April-June 1986.

to all BWR licensees.The Bulletin requested that licens-ees: (1) respond to NRC, if problems c:ist or not; (2)in-He AO criteria used were:

struct operators immediately if a proUem exists; and (3) identify short-term and long-term corective actions (1) General Criterion, No. 3-Major deficiencies in de-and provide a schedule for completion.

sign, construction, use of, or management controls for licensed facilities or material; In response to Bulletin 86-01, BECo's wrrective actions consisted of:

(2) For All Licensees, No.10- A major deficiency in de-sign, construction, or operation having safety impli-cations requiring immediate attention; and (1) Changing the normal position of the RHR pump minimum flow bypass valve from closed to open; (3) For All Licensees, No.12-Series of events (where individual events are not of major importance), re-(2) Removing the automatic valve closure signal to en-curring incidents, and incidents with implications for sure a continuous flow path; similar facilities (generic incidents) that create major safety concern.

(3) Removing restricting orifices from the RHR mini-mum flow lines to increase the flow rate from 1135.6 At the time it was reported that on May 19,1986, the Bos-to 1892.7 liters per minute (300 to 500 gallons per ton Edison Company (BECo) notified NPC that a signifi-minute);

cant design deficiency in the residual heat removal system (RHR) minimum flow protection logic at the Pilgrim Nu-(4) Changing the operating procedures to reflect the c! car Power Station had been discovered. Pilgrim is a above changes; and General Electric (GE) designed boiling water reactor (BWR) located in Plymouth County, Massachusetts. Lat-er, it was found that some other GE-designed BWRs also (5) Completing operator training.

contained the same design deficiency.

He AO report is updated as follows:

tions that were taken and closed the item in Inspection Report No. 50-293/88-25 (Ref.1).

BECo submitted a written notification of noncompliance on May 23,1986, regarding a RHR systra minimum flow This event is closed for the purpose of this report.

13 NUREG-0090, Vol.17, No. 3

I Abnormal Occurrences,3rd Qtr CY94 Other NRC Licensees 92-18 Loss of Iridium-192 Source Washington University Medical and Medical Therapy School in St. Louis, Missouri Misadministration at Oncology nis abnormal occurrence was originally reported in Services Corporation in NUREG-0090, Vol.16, No. 4, " Report to Congress on Indiana, Pennsylvania

^bnormal Occurrence," October-December 1993.

ne AO critcrion used was Eventlype 3 in Thble A A His abnormal occurrence (AO) was originally reported in therapeutic dose that results in any part of the body re.

NUREG-0090, Vol.15, No. 4, " Report to Congress on Abnormal Occurrences," October-December 1992, un-ceivmg unscheduled radiation.

der the title " Loss of Iridium-192 Source and Medical At that time, it was reported that in f wo separate incidents Therapy Misadmmistration at Indiana Regional Cancer in January and February 1993, a Nucletron Micro-Selec-Center m Indiana, Pennsylvanm,.,

tron low-dose-rate remote afterloader ejected a radiation The AO criteria used were,-

soum whout Wg programmeq to & so anMom a guide tube and applicator. In each mstance, the source lay close to the patients' skin and resulted in a portion of the (1) EventType 5,in'lhble A Atherapeuticdose that patient's body receiving an unscheduled radiation dose.

is greater than 1.5 times the prescribed dose; and (2) For All Licensees, No. 2-An exposure to an individ-ual in an unrestricted area such that the whole body On June 10,1994, NRC Region 111 issued a Notice of Vio-dose received exceeds 0.5 rem in one calendar year, lation (N OV) (Ref. 2) to the licensee, citing it for failing to provide written notifications to the patients of the misad.

At that time, it was reported on November 16,1992, On-ministration within 15 days, as required.nc licensee had cology Services Corporation had lost a 159,000 gigabec-notified the referring physicians, but the written patient querel (4.3 curie) scaled iridium-192 source from a high notifications were not made until May 1994. Here was no dose rate (HDR) remote afterloader brachytherapy unit civil penalty associated with the NOV.

j at its Indiana Regional Cancer Center in Indiana, Penn-l sylvania.The source had:(1) broken off of the HDR unit This event is closed for the purpose of this report.

while in service; (2) subsequently killed a patient with a 1,600,000 centigray (1,600,000 rad) absorbed dose, after remaining on the patient's body for almost 4 days; and (3) 93-16 Med.ical Brachytherapy caused 94 other people to receive radiation ranging from Misadministration at l

400 microsievert to 220 millisievert (40 millirem to 22 Mar 4uette General Hosp tal in i

rem). He source was eventually mixed by accident with medical biohazard waste and was subsequently found and Marquette, Michigan recovered at the site of a company that had been con-tracted to dispose of biological waste material.

This abnormal occurrence was originally reported in NUREG-0090, Vol.16, No. 4, " Report to Congress on The AO report is updated as follows:

Abnormal Occurrence," October-December 1993.

He licensee responded to the NRC's Notice of Violation The AO criterion used was Event Type 3 in Thble A-1-A

(

and Proposed imposition of Civil Penalties in a letter therapeutic dose that results m any part of the body re-l dated August 31,1994, contesting a number of the viola-ceivmg unscheduled radiation.

tions and the amount of the civil penalty. NRC is evaluat-I mg the licensee s response.

At the time, it was reported that a patient underwent a brachytherapy procedute using cesium-137 sealed sources in a catheter inserted into the uterus from November 17 This event will be updated when additional information to 19,1993. When the catheter was removed on Novem-i l

becomes available.

ber 19, it was determined that it had not been fully in-serted into the uterus and that the patient's vagina re-ceived an unintended radiation dose, 93-11 Medical Brachytherapy i

Misadministration at ne abnormal occurrence is updated as follows:

NUREG-0090, Vol.17, No. 3 14

Abnonnal Occurrences,3rd Qtr CY94 On May 16,1994, NRC Region Ill issued a Notice of Vio-The AO criterion used was Eventlype 5 in 'Ihble A A lation (Ref. 3) to the hospital, citing it for failing to provide therapeutic dose that is greater than 1.5 times the pre-written notification to the patient of the misadministra-scribed dose.

tion within 15 days, as required.The patient was informed orally of the misadministration at the time it was discov.

At the time, it was reported that on June 21,1994, a pa-ered, but was not provided with written notification until tient was implanted with 112 iodine-125 (I-125) seeds hav-April 27,1994. No fine was assessed.

ing an activity of 166 megabecquerel (MBq) (4.49 millicu-rie [ mci]) each, rather than the prescribed 112 I-125 This event is closed for the purpose of this report.

seeds having an activity of between 15.9 and 17.0 MBq (0.43 and 0.46 mci) each.

94-12 Medical Sodium Iodide ne AO rep rt is updated as follows:

Misadministration at Stamford ne license submitted its 15-day report on the misadmi-Hospital in Stamford, nistration by letter dated July 6,1994 (Ref. 4). The report stated that m addition to the prostatectomy performed l

Connecticut during the initial surgery on June 21,1994, the patient's I

bowel was diverted via a colostomy. The initial dose was This abnormal occurrence (AO) was originally reported in intended to deliver a peripheral target dose of 16,000 cen-NUREG-0090, Vol.17, No. 2, " Report to Congress on tigray (cGy)(16,000 rad). A conservative estimate of the Abnormal Occurrences," April-June 1994.

final dose is 55,137 cGy (55,137 rad) based on the remain-ing residual seeds. The NRC medical consultant's final The AO criterion used was Event Type 1 in ihble A report was in agreement with the licensee's report. De Administering a radiopharmaceutical other than the one consultant indicated that the misadministration, and sub-intended which results in any part of the body receiving sequent multiple surgical procedures to remove the iso-unscheduled diagnostic radiation, and the actual dose to tope, predisposes the patient to a variety of future medical the wrong body part is five times the upper limit of the Problems. The licensee agreed to provide monthly up-normal range of exposures prescribed for diagnostic pro-dates on the patient's condition to NRC for at least one cedures involving that body part.

year.

At the time,it was reported that on May 17,1994. s patient At the Enforcement Conference held on August 24,1994, the b,censee presented corrective actions that meluded:

was administered 37 megabecquerel (MBq) (1 millicurie

[ mci]) of sodium iodide iodine-131 (I-131) for a whole (1) requtnng nuclear medicme technologists to verify all body scan when no such study was prescribed.

inf rmation contamed in the packing slip, certificate of activity, vial label, and written directive at the time the package is received, as well as requiring the Radiation The AO report is updated as follows:

Safety Officer to be notified if any discrepancy is identi-fied; (2) confirming all orders in writing with the supplier The licensee responded to the NRC's Notice of Violation prior to implantation; (3) providing training to the nuclear and Proposed Imposition of Civil Penalties in a letter medicine staff; (4) revising procedures to require verifica-dated August 10,1994, contesting a number of the viola-tion in accordance with the written directive prior to ad-tions and the civil penalty. NRC is evaluating the licens-ministration of doses; (5) revising the Quality Manage-ce's response.

ment program; and (6) creating the staff position of Brachytherapy Safety Nurse Coordinator to provide in-His event will be updated when additional information creased control over these activities.

becomes available.

NRC is evaluating the licensee's corrective actions, and is reviewing its enforcement options as a result of the En-94-14 Medical Brachytherapy f reement C nferen e held on August 24,1994.

Misadministration at The NRC performed an inspection on September 19, 1994, William W. Backus Hospital in and bserved that all of the corrective actions had not yet been fully implemented. The licensee agreed to notify Norwich, Connecticut NRC Region I in writing when implementation of the cor-rective actions was completed.

This abnormal occurrence (AO) was originally reported in NUREG-0090, Vol.17, No. 2, " Report to Congress on his event will be updated when additional information Abnormal Occurrences," April-June 1994.

becomes available.

15 NUREG-0090, Vol.17, No. 3

Abnormal Occurrsnces,3rd Qtr CY94 Agreement State Licensees AS 88-5 Medical Dietherapy AS 94-3 Radiation Burn of an Misadministration at Sacred Industrial Radiographer at Heart Hospital in Blazer Inspection in Texas e

Cumberland, Maryland City, %xas This abnormal occurrence (AO) was originally reported in This abnormal occurrence (AO) was originally reported in NUREG-0090, Vol.11, No. 4, " Report to Congress on NUREG-0090, Vol.17, No 2," Report to Congress or Ab-Abnormal Occurrences," October-December 1988.

normal Occurrences," April-June 1994.

l He AO criterion used was a moderate or more severe im-He AO criterion used was For All Licensees No.11-A l

pact on public health or safety, as stated in the second senous deficiency in management or procedural controls.

paragraph of the General Criteria.

At that time it was reported that the incident occurred

"#"E"* *

"*'I At the time it was reported that on September 2,1988' an radiographer accidently dropped a source into a muddy l

81-year-old patient received a therapeutic dose of I400 I

centigra7 (1400 rad) to a Part of the body not scheduled to ditch and then attempted to retrieve it with a pair of phe,rs.

As the source was slipping loose from the pliers, the radio-l receive radiation. The event was reported as an AO be-grapher instinctively caught it with the forefinger and cause it myolved a moderate or more severe impact on thumb of his left hand for a brief instant and received an Public health or safety.

overexposure. Consequently, blisters appeared on his fin.

He AO report is updated as follows:

As reported by the State of %xas, one of the causes of the NRC is continuing to work with the State of Maryland to event was the mistaken delivery of a wrong radioactive-obtain more information regarding this occurrence.

source pigtail by the manufacturer, and the radiography company's attempt to use the wrong pigtailin a radiogra-phy camera for which it would not fit properly. (The man-AS 88-6 Medical Dietherapy ufacturer and supplier was Industrial Nuclear Company, Misadministration at Sacred Inc., which is licensed by the State of California, and the radiography company was Blazer Inspection, which is h,.

Heart Hospital in censed by the State of Exas.)

Cumberland, Maryland Before closing out the AO report, NRC asked the State of his abnormal occurrence (AO) was originally reported in California to provide the following additional information NUREG-0090, Vol.11, No. 4, " Report to Congress on concerning its investigation: (1) the cause for the suppli-Abnormal Occurrences," October-December 1988.

er,s mistake; (2) wh eth er oth er mstances of mistaken ship-ments were found; (3) what violations were found; and The AO criterion used was a moderate or more severe im-(4)whether the supplier's procedures are adequate to pact on public health or safety, as stated in the second Prevent a recurrence or, if not, what changes were made.

paragraph of the General Criteria.

The requested information from the State of Caliform,a s mvestigation is as follows:

At the time it was reported that over a 13-month period 33 (1) The cause of the supplier's mistake was einployee er-patients undergom, gbrain cancer treatments had received tor; the employee fabricated the wrong source for therapeutic radiation exposures from a cobalt-60 telether-the licensee. However, it is noted that Blazer Inspec-

's apy machine that exceeded the prescribed dose by at least tion, Inc., is an authorized user for the sources and 10 percent in each case.The event was reported as an AO customarily ordered both model 22 and model 32 because it involved a moderate or more severe impact on sources. It would appear that failure to properly use public health or safety.

the model 32 source would be Blazer's error. Please note that the two sources are easily identified; the The AO report is updated as follows:

model 22 uses a flexible aircraft cable pigtail and the R

model 32 uses a stiff Teleflex ggh]g, [please note NRC is continuing to work with the State of Maryland to that based on incorrect preliminary information, AS obtain more information regarding these occurrences.

94-3 in NUREG-0090, Vol.17, No 2, erroneously NUREG-0090, Vol.17, No. 3 16

Abnormal Occurrences,3rd Qtr CY94 reported a model 23 source instead of the correct sent to authorized recipients. He State is following model 32.)

up with a letter to the licensee.

(2) Dere were no other mistaken shipments.

NRC also asked the State of'Ibxas to provide an estimate of the eFtremity dose received by the radiographer. He (3) No violations were identified based on the State's in-State of'Ihxas reported that the estimated dose received spection.

to the radiographer's left hand, as determined by the ex-tent of the injury, was between 1200 and 1700 centigray (4) The State of California indicated in its inspection (1200 and 1700 rad).

that Industrial Nuclear Company, Inc., should im-prove its methods to assure that proper sources are This event is closed for the purpose of this report.

p l

l l

17 NUREG-0090, Vol.17, No. 3 i.

-.-=...- - -.

Abnormat Occurrences,3rd Otr CY94 APPENDIX C OTHER EVENTS OF INTEREST ne following items are described because they may possi-occurrences.

bly be perceived by the public to be of health or safety sig-nificance. The items did not involve a major reduction in the level of protection provided for public health or safe-During the period July through September 1994, two ty; therefore they are not reportable as abnormal "Other Events of Interest" were reported.

Nuclear Power Plants 1.

Fracture of a Frozen Pipe at Dresden tential for freeze-damage failure of the portion of the fuel Unit I with a Consequent Release of transfer system inside contair. ment. nis could result in Water Partial draining of shielding water from the SFP, with con-l sequent exposure of workers in and near the SFP building 8n antT8 m e 8PeM fuel. hWent Dresden Unit 1 (Dresden 1)is a permanently shut down

'*"' ' W**

General Electric designed boiling water reactor. It is li-been damaged.ne hcensee took actions to guard against -

censed by Commonwealth Edison Company and located uture freezing and formed an mvestigative team to re-14.5 kilometers (9 miles) east of Morris, Illinois.

view the event.

Dresden I was permanently shut down on October 31, ne licensee's investigative team concluded that an un-1978, and all of its spent fuel was transferred to its spent fuel pool (SFP). It will remain in an NRC-approved safe derlying cause of the event was that many of the staff at Dresden beheved that the shut down and defueled Dres.

storage status until Dresden Units 2 and 3 are permanent-den 1 could not cause a serious safety problem; therefore, ly shut down. At that time, the licensee plans to dismantle all three units.The spent fuel from Dresden 1 will remain the L :ility received little attention.

on site until the Department of Energy accepts it at either a high level waste disposal facility or a monitored retriev-NRC formed a Special Inspection Tbam (Str) to review able storage facility.

and evaluate the circumstances and significance of the i

event. The inspectors learned that following the perma-On January 24,1994, while investigating the reason for a nent shut down of Dresden 1 in 1978, there was a progres-higher than expected water level in a drain tank, the li.

sively worsening pattern of management neglect. Little l

censee discovered a leak in a service water line located in attention w3s given to the facility by senior management l

tlie Dresden 1 off-gas filter building. The leak was from since it was saut down, which resulted in significant dete-service water piping in the unheated building which had 1rioration. Ft.rthermore, information for the facility's De-fractured because of freeze damage. Tb isolate and repair commissioning Plan which was submitted by the licensee the leak, the licensee shut down the entire Dresden 1 ser.

to NRC did not agree with the actual conditions because vice water system.

of management's carelessness and the lack of a dedicated and knowledgeable staff.

On January 25,1994, during a routine quarterly radiation survey, the licensee discovered approximately 208,200 li.

On June 13,1994, following the SIT inspection, NRC im-ters (55,000 gallons) of water in the basement of the un-Posed a civil pena % of $200,000 on the licensee for its fail-heated Drcsden 1 containment.This water came from a ure to maintair d lay up certain systems and to staff break in the service water system piping inside contain.

Dresden 1 in accordance with the Decommissioning Plan.

ment, which was also caused by freeze damage. lf the ser-On July 13,1994, the licensee concurred with the conclu-vice water system in containment had not been isolated in sions of the SIT and listed the corrective actions that it response to the service water rupture in the off-gas filter would take to resolve the identified deficiencies.

building on January 24, the volume of water inside con-1 tainment would have been much greater and the structur.

On August 8 through August 11,1994, NRC conducted a alintegrity of the containment may have been challenged.

follow-up inspection to determine the status of corrective l

actions by the licensee. The inspectors found that the li-Following the identification of the ruptured piping inside censee had made significant progress in improving condi-containment, the licensee concluded that there was a po-tions at Dresden 1 by:

19 NUREG-0090, Vol.17, No. 3 i

Abnormal Occurrences,3rd Qtr CY94 (1) selecting a project manager for Dresden 1 and pro-The laborer had performed work on the Quad Cities Unit viding him with a well qualified support staff; I turbine building main floor within the RCA. Prior to en-tering the work area, the laborer removed her outer cloth-(2) p'anning to provide heat to selected areas inside con.

ing and donned work coveralls in a change area on the tainment so that the spent fuel pool would be pro-ground floor of the Unit 1 turbine building. This unat-tected from potential freezing accidents that might tended open change area, adjacent to the walkway for result in a loss of shielding water from the pool; general access to the turbine buildings of Units 1 and 2, was shared by both male and female workers and accessi-(3) isolating and draining other fluio systems that en.

ble to anyone in the turbine building. Upon completion of tered containment; and her work, she returned to the change area and changed out of the coveralls into personal clothing. When she at-(4) improving the quality of the water in the spent fuel tempted to leave the work area, she set off the alarm of a pool by installing a temporary filtration and demin-whole body radiation momtor. Although the m,tial radt-i eralization system, and expediting the final design ation survey of the worker failed to locate the source, a and installation of the permanent system.

subsequent survey revealed the source in the pants pock-et.

As a result of the event at Dresden 1, NRC issued Bulletin The Sr-90 source had apparently been removed from its 94-01 on April 14,1994, to all nuclear power reactor li-holder that was bolted to a metal cabinet on the Unit 1 tur-censees and to all fuel cycle and material licensees autho-bine building main floor.The cabinet was in the vicinity of rized to possess spent fuel. The bulletin described the the job site for the laborer and the other members of iner Dresden 1 event, and requested licensees of all perma-work crew.

nently shut down reactors having spent fuelin their SFPs to: (1) verify the adequacy of SFP structures and systems Immediately after the incident, the licensee's health phys-l for containment, cleaning, water level monitoring and ics staff began reviewing the worker's activities after she makeup; (2) ensure adequate area heating and ventilation changed into her personal clothing in order to determine l

to preclude potential freezing failures that may cause the the radiation dose received. NRC was notified of the inci-l loss of pool water; (3) ensure that potential siphon paths dent. Investigators from the licensee's corporate staff for loss of pool water are climinated; and (4) ensure that were dispatched to the Quad Cities site to investigate the operating procedures address SFP maintenance, calibra-circumstances surrounding the incident, including the re-tion, surveillance and leak detection. NRC is verifying the moval of the source from its holder and the apparent de-adequacy of bulletin responses at these facilities with in-liberate placement of it in the worker's pocket. The inci-spections that are scheduled for completion before the dent was also reported to the Federal Bureau of winter of 1994.

Investigation which, at the licensee's request, initiated an investigation at the Quad Cities facility.

'I'*"8** ' "*'*I"* "'*I "8 I"'I"d d; II) '** "i"8 "II 2.

Possible Deliberate Exposure of a Con, smular radioactive sources from their holders, and keep-tract Laborer to Radiat. ion at Quad Cl-ing them in locked areas; and (2) impro<ing procedures i

ties Nuclear Power Station and training for technicians who perform hand-held frisk-l er surveys of workers.

Quad Cities Nuclear Power Station (Quad Cities) has tw NRC Region 111 inspection personnel and the resident in-General Electric boiling water reactors. It is licensed by spectors monitored the licensee's investigation, dose de-l Commonwealth Edron Company and is located 32.2 kil -

terminations, and corrective actions. The NRC Office of l

meters (20 miles) noetheast of Moline, Illmois.

Investigations also conducted an inquiry into the incident.

The NRC review found two apparent violations of NRC i

On August 8,1994, as a female contract laborer attempted requirements: (1) inappropriate use of licensed material; to leave the radiological controlled area (RCA)in the tur-and (2) failure to perform surveys to determine the radi-bine building, she set off a radiation monitor. Radiation ation hazard to a radiation worker. On October 18,1994, protection staff found a coin-sized scaled radiation source NRC issued a Severity Level II violation with a $100,000 containing strontium-90 (Sr-90)in her back pants pocket.

fine against the licensee for misuse of radioactive material i

ne Sr-90 source is normally used to check t he opembility which resulted in a substantial potential for an overexpo-of hand-held radiation detection instruments.The licens-sure, because of the apparent deliberate actions on the ec estimates that the worker received a radiation dose of part of worker (s).

221.7 millisievert (mSv)(22.17 rem) to the skin. NRC finds l

this calculation reasonable. NRC's annual limit is 500 mSv

'IWo other incidents of the apparently deliberate place-(50 rem) to the skin.ne worker's total accumulated skin ment of radioactive contamination on personal clothing dose did not exceed the limit.

of two female workers occurred in November 1993 at l

j NUREG-0090, Vol.17, No. 3 20 l

L

Abnormal Occurrences,3rd Qtr CY94 another nucicar power plant licensed by Commonwealth cited for three violations, two of which involved the appar-Edison Ccmpany. In May 1994, NRC issued a $225,000 ent deliberate placement of radioactive contamination on fine against the licensee for violations of NRC radiation the stored personal clothing of two workers while they protection requirements at its LaSalle Nuclear Power were working at the plant.

Station located near Seneca, Illinois. The licensee was i

I 21 NUREG-0090, Vol.17, No. 3

Abnormal Occurrences,3rd Qtr CY94 APPENDIX D AGREEMENT STATE EVENTS BEING CONSIDERED AS ABNORMAL OCCURRENCES During the period July through September 1994, NRC re-at the deadline for publication of this report, none of viewed a number of events reported by the Agreement these events was identified as a potential abnormal occur-States. For several of them, additional information was rence.

provided. Evaluation of thesc events continues: however, I

l l~

23 NUREG-0090, Vol.17, No. 3

1 I

Abnormal Occurrences,3rd Qtr CY94 I

REFERENCES FOR APPENDICES i

1.

Letter from Samuel J. Collins, Deputy Director, Di-3.

Letter from John D. Jones, Acting Chief, Nuclear vision of Reactor Projects, to Ralph G. Bird, Senior Materials Inspection Section 2, NRC Region III, to Vice President-Nuclear, Boston Edison Company, Sharon Shaffer, Assistant Administrator,Marquette b

Pilgrim Nuclear Power Station forwarding Inspec-General Hospital, enclosing Notice of Violation, tion Report No. 50-293/88-25, dated August 17, Docket No. 030-18133, License No. 21-05432-04, 1988.*

dated May 16,1994.*

s 4.

Letter from Brian J. Smithwick, Vice President,The j

William W. Backus Hospital, to Charles W. Hehl, Di-2.

Letter from John A. Grobe Chief, Nuclear Maten.

rector, Division of Radiation Safety and Safeguards, als Inspection Section 2, NRC Region III, to Walter dated July 6,1994.*

W. Davis Jr., Assistant Dean, Washington University Medical School, forwarding Notice of Violation, Li-cense No. 24-00167-11, Docket No. 030-02271,

}^;,Mf,.','f.

NIN! i

• l$'b'.

i$s R

dated June 10,1994.*

Dc.

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NUREG-0090, Vol.17, No. 3 24

4 NRC FORM 336 U.S. NUCLEAR REGULATORY COMMIS8 ION

1. REPORT NUMBEA M 1102, Rev and Num-3aci,3ao2 BIBLIOGRAPHIC DATA SHEET tors, w any.)

(See instructions on the reverse)

NUREG-M i

Vol.17, No. 3

2. Tm.E AND SUSDTLE

3. DriE ReeORT eUuus40 i

Report to Congress on Abnormal Occurrences:

July-September 1994

,oy7g y,

January 1995

4. FIN OR GRANT NUMBER

)

5. AUTHOR (S)

6. TYPE OF REPORT Quarterly i

J

r. PERIOD COVERED (inclusive Dtes)

July-September 1994 i

i

8. PERFORMING ORGANIZATION - NAME AND ADDRESS (tf NRC, provide Divis6on. Offce or Regnon. U.S. Nuclear Regulatory Commission, and a

mailing address; N contractor, provide name and malling address.)

Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission j

Washington, DC 20555-0001 i

I

9. SPONSORING ORGANIZATION - NAME AND ADDRESS (if NRC, type *Same as above"; if contractor, prov6de NRC DMadon. Office or Region.

U.S. Nuclear Regulatory Commission, and mailing address.)

Same as 8., above i

J

10. SUPPLEMENTARY NOTES

11. ABSTRACT (200 words or less)

Section 208 of the Energy Reorganization Act of 1974 identifies an abnormal occurrence (AO) as an unscheduled incident or event that the Nuclear Regulatory Commission determines to be significant from the standpoint of publir, health or safety and requires a quarterly report of such events to be made to Congress. This report provides a description of those events that have been determined to be abnormal occurrences during the period of July 1 through September 30,1994.

This report addresses five abnormal occurrences (AOs) at NRC-licensed facilities. One involved a medical brachytherapy misadministration, two involved medical teletherapy misadministrations, one involved a medical sodium iodide misadmi-nistration, and one involved a medical sodium iodide event. One AO report submitted by an Agreement State is included.

It involved the loss of management and procedural control of a radioactive source. (Due to publication schedule con-straints, NRC was unable to include all of the AO information received from the Agreement States. Any Agreement State information that was not included in this report will be published in the next quarterly report.)

The report also contains updates of six AOs previously reported by NRC licensees and three AOs previously reported by Agreement State licensees. Tho "Other Events of Interest" concerning nuclear power reactors are also reported. One involved the fracture of a frozen pipe at Dresden Unit I with a consequent release of water, and the other involved the possible deliberate exposure of a contract laborer to radiation at Quad Cities Nuclear Power Station.

12. KEY WORDS/DESCRPTORS (List words or phrases that will assist researchers in locating the report.)

13. AVAILABluTY STATEMENT Unlimited Medical; Misadministration Brachytherapy; Tbletherapy; Sodium Iodide; Loss of Man-

14. SECURITY CLASSIFICATION agement and Procedural Control; Radioactive Source.

(This Page)

Unclassified (This Report)

Unclassified j

16. NUMBER OF PAGES

16. PRICE NRC FORM 336 (2-89)

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