ML20091S417

NMSS Licensee Newsletter.Number 91-4

ML20091S417
Person / Time
Issue date:	12/31/1991
From:	NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS)
To:
References
NUREG-BR-0117, NUREG-BR-0117-N91-4, NUREG-BR-117, NUREG-BR-117-N91-4, NUDOCS 9202060410
Download: ML20091S417 (14)

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Regulatory Material Safety No.91-4 s

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Commission and Safeguards December 1991 w

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<n-DELIBERATE ht!SCONDUCT HY UNLICENSED The rule covers licensee employees; consultants: contrac-PERSONS: NRC EX' HINDS ENFORCEhfENT tors, subcontractors, and their employees; and others SANCTIONS TO EMPLOYEES AND OTilER who knowingly provide goods or senices for activities INDIVIDUALS regulated by NRC. Specific knowledge of the NRC li.

cense or the NRC requirement that would be violated is not necessary; it is erough for the indisidual to know the o A radiographer knows that he is required to conduct a activity is regulated by NRC and that the act would be a survey each time the source is retracted, but deliber.

violation of company procedures or policy.The rule does ately fails to do so, to save time.

not apply to violations caused by simple error, misj adg-ment, miscalculation, ignortmce, or confusion, on the c A nuclear medicine technologist, although b(he) per*

part of an individust.

I forms the daily constancy check of the dose calibrator on weekdays, deliberately does not luther to do the Depending on the circumstances, the action that NRC check when the dose calibrator is used for patient tues against the person might be an Order that prohibits doses on weekends, the person from further involvement in NRC-licensed i

activities for a specified period of time.The person also o A well logger knowm, gly provides inaccurate infor-could be required to inform any ;nospedive emph>ye (or mation during a Nuclear Regulatory Commission customer) engaged in NRC licensed activities that the (NRC) investigation.

person has been subject to an NRC Order. Monetaty P#""

• "* ** " 8 #

"' *"Y o An employee at an irradiator facility deliberately de-pem aus to comph @ We Oh feats a radiation alarm.

Orders associated with enforcement actions are pub-o A manager directs an employee to omit sigm.ficant in' I shed in the FederalRegister and in an NRC pubUc docu-formation duting an NRC inspection.

ment known as NUREG-0940. Orders are normally the o A consultant knowingly includes inaccurate informa, subject of a press release. In addition, NRC has estab-tion in a request for a license amendment that the li-lished a system of records that willinclude a list of all per.

censee submits to NRC.

sons currently subject to an Order that affects their par.

ticipation in licensed activities. This compilation will be made available to materialslicensees and members of the What do these examples have in common? They demou-public, on request.

strate deliberate wrongdoing on the part of empkiyces and consultants who do not hold NRC licenses, but who NRC has a long-standing practice of holding employers are now subject to NRC enforcement action under a rule accountable for the acts of their employees, contractors, change published in the Federal Regirrer on August 15, anc. agents. Thus, in cases where enforcement action is 1991 (56 FR 40654). 'lhis change became effective on taken agains an individual emphiyee at a licensed facility, September 16,1991.

NRC normally will also take related enforcement action directly against the holder of the NRC license, as appro-Under the new rule, unlicensed persons are subject to priate.

NRC enforcement action for deliberate mis ondud ; 't:

(1) causes an NRC licensee to be in violation of any.'.C This rule change affects portions of the NRC regulations requirement. or (2) would have caused the licensee to be in 10 CFR Parts 2,30,40,50,60,61,70,72,110, and 150, in violation, if the misconduct had not been detected in as well as the NRC Enforcement Policy published in time. Enforcement actier may also be to ken against an in-Part 2, Appendix C. For complete details, readers should dividual who deliberately provides incomplete or inaccu-reier to the Federal Register notice cited above. Copics of rate information to NRC, a licenset., or licensce contrac-the Federal Register notice were sent to all NRC licensees.

tor, provided that the infortnation is relevant to NRC regulatory activities.

9202060410 911231 PDP NUREG BR-0117 R PDR

DECEMllER 1991 NMSS LICENSEE

13. Ilulletia Published (Contact: George Ilidinger, NEWSIMI'UR CONTENTS 301 504 2683)..................,.......

I1 page

14. Radioactive Fence Products imported frorn India (Contacts: Cathy llaney, 1.

Deliberate Misconduct by Unlicensed 301-504-2628 or Scott Moore, Persons: NRC Extends Enforcement 301-504-2514)......................... 11 Sanctions to Employees and Other Individuals (Contact: Joe DelMedico,

15. Significant Enforcement Actions 301-504-2739)........................

I against Material licensees (Contact:

Joe De1 Medico. 301-504-2739)...........

12 2.

Investigation and Analysis of Medical

16. New Nuclear Regulatory Commission

'Iherapy Misadmmistnition Events (NRC) Phone Numbers (Contact:

Occurring in 1992 (Contact: Dr. Patricia Paul Goldberg. 301-504-2631)..........

14 Rathbun, 301-504-1407).....,.........

2 INVESTIGAllON AND ANALYSIS OF MEDICAL 3.

New incident. Reporting Requirements

'lllERAPY MISADMINIFIRATION EVENTS (Contact: Kevin Ranucy,301-504-2534)...

3 OCCURRING IN 1992 4.

Guides issued August 8,1991

'the Division of Industrial and Medical Nuclear Safety November 4,1991 (Contact: Paul (IMNS), Office of Nuclear Material Safety and Safe-Goldberg, 301-504-2631)....,..........

3 guards (NMSS), has tasked the Idaho National Engineer.

ing i ahoratory (INEL) to investigate and analyze m: dical 5.

Rulemakings Pubhshed August 8, therapy misadministration events that occur within the 1091-October 29,1991 (Contact: Paul Nuclear Regulatory Commission's (NRC's) jurisdiction Goldberg,301-504-2631) 3 during calendar year 1992.

6.

Revised 10 Cim Part 20: Questions These investigations are designed to provide insights into the root causea of medical misadministrations and to as.

and Answen;(Contact: Cynthia Jones'......

sess the risk significance of the events. In addition, licen.

301-504-2629)..........,....

4 see corrective actions taken in response to the events will 7.

Clarification of Answers in Previous be i+:ntified and compared to existing regulations in Article," Revised 10 CFR Part 20:

10 CFR Part 35 and requirements in the Quality Man, b

Questions and Answers"(September agement (QM) Rule, effective Janttary 27,1992. Data will be collected f rom a combina tion of intaniews with in.

1991 NMSS Licensee Newsletter) volved licensee personnel and review of information con.

(Contact: Cynthia Jones, 301-504-2629)....

4 tained in relevant records.

8.

Mixed Waste Regulatory Update To accomplish these investigations, a team of medicnl er.

(Contacts: Mike Weber,301-504-1465 perts, including physicians, medical physicists, radiation or Nick Orlando, 301-501-2566)........

5 therapy dosimetrists, and technologists with expertise in teletherapy, brachytherapy, or radiopharmaceutical t her.

9.

NRC, EPA, and States 5:g' Memoran, apy will be dispatched to the site of the misa<hninistra.

dum of Understanciing on Rn don tion.The 1NEL team will work in parallel with the NRC Releases from Umnium Mill railings regional inspection team, thus ensuring access to avaib (Contact: Meg liarvey,301-$M-2522).....

5 able dra, minimizing duplication of effort, and climinat.

ing any unnecessary burden on the licensee. The region

10. NRC Requests Comments on Record, investigating the misadministration will oversee the keeping Rule (Contact: Dr. Carl INEL team's ectivities.

Feldman, 301-492-3 883)................

6 Comments, and suggestions you may have br infor-

11. Selected Significant Events Reported mation that is not currently being included, that to the U.S. Nuclear Regulatory might be he:pful to licensees, should be sent to:

Commission (NRC)(Contact; Kathleet. Black. 301-492-0631)..........

6 E. Kraus NMSS Licensee Newsletter Editor

12. Information Notices Published August 16 Office of Nuclear Material Safety and Safeguards 1991-November 12,1991 (Contact: Paul One White Flint. North Mail Stop 6-E-6 Goldberg. 301-504-2631)......,........

11 U.S. Nuclear Regulatory Commission Washington, D.C. 20555 2

l l

P 8s anticipated that opproximately sit to eight such inves-discussion that was published with the final rule on ligations will be carried out in 1992. The t<:am wih pro-August 16,1991 (56 FR 40757).

duce a repot1 documenting the findings of each investiga.

tion. The NRC contact for this project is Dr. Patricis GUIDES ISSUED AUGUST 8,1991-NOVEMBER 4, Rathbun (301-504-1407).

1991 DR AIT GUIDES NEW INCIDliNT-REPORTINC REQUIREMENTS

" Air Sampling in the Workplace," Task DG-8001:

On October 15,1991, the final rule on notification ofinci-R.G. 8.25 (Rev.1) dents (56 FR 40757) went into effect. The final rule has deleted paragraphs (aX3), (aX4), (bX3), and (bX4) in 10 L 1ssued 9/91 CFR 20.403, requiring reports of loss of operations and 2.

Contact:

Dr. Stephen McGuire,301-492-375?

cost of damage.These requirements have been replaced by new reporting requirements in 10 CFR 30.50,10 CFR

" Assessing External Radiation Doses from Airterne o

40.60, and 10 CFR 70.50. Licenstes are now required to Radioactive Materials," Tak DG-8005 report:

1.

issued 11/91 As soon as possible, but not later than 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> after dis-coming an event that prevents immediate protective ac.

2.

Contact:

Alan Roccklein,301-492-3710 tions recessary to avoid exposures or releases exceedmg regulatory limits.Only the prevention of actions that per-RULiiht AY.INGS PUBLISI(ED AUGUSI' 8,1991-sonnel woull normally be able to take is reportable.

OGOBER 29,1991 Within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of discosering an unplanned contamina*

FIN AL RULES tion event that (1) requires access to the contarainated area to be restricted for rnore than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, and (2)in-e " Notifications of inc,Jents" solves a quantity of material greater than 5.;mes the low.

est annuallimit on intake specified in Appendix B of the 1.

Published 8/16/91 new Part 20 (56 FR 23360), and (3) requires access to be restricted tot a reason other than to allow isotopes with a 2.

Contact:

Joseph Mate,301-492-3795 half.ltic less than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> to decay.

• " Revisions to Procedures to issue Orders: Deliberate Within 2d hours of discovering a safety equipment failure Misconduct by Unlicensed Persons" that (1) involves e,quipment required by regulation or li-1.

Published 8/15/91 cense condition to prevent releases and'or overexpo-seres, or to mitigate the consequences of an accident, and 2.

Contact:

James Lieberman,301-504-2741 (2) mvolves equipment that was required to be avadable L Wagner,301-504-1683 and operable when it failed, and (3) occurs when no re-dandant equipment is available and operable to perform

• " Revision of Fee Schedules,100% Fee Recovery" the required safety function. Manual equipmer.t is rmt considered redundant if automatic equipment is re.

L Published 8/9/91 (Correction) quired.

R. 3 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of discovering an event that requires un-

" Change in Commercial Telephor,e Number for planned medical treatment,in a medical facility, of an in-dividual with spreadable contamination in the individuars Region V" clothing er body.

L Published 8/21/91 Withm 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> cf disc (rvering an unpLnned te or ex.

plosion that (1) damages licensed material s r devices, 2.

Contact:

David L Meyer,301-492-7056 containers, or equipment containing licensed matenal, PROPOSED RULES and (2) involves a quantity of matenal greater than 5 times the lowest annual limit on intake specified in Ap-

"Dec mmissioning Regulations: Recordkeeping and a

pendix B of the new Part 20: and (3) affects the integrity of Termination for Decommissioning Documentation the licensed materhl or its ctmtainer.

Addinons' laitial icports must be made by telephone to the NRC 1.

Published 10/7/91 Operations Center, at 301-951-4)550. Written follow-up reports must be submitted within 30 days of the initial re-2.

Contact:

Carl Feldman, ? J1-492-3883 port. Examples of reportable events are provided in the 3

o " Uranium Enrichment Regulations" patient received less than 30 mci,md the dose rate at L Published 9/16/91 No, the hospital room is not requir.d to be posted 2.

Contact:

Charles Nilsen,301-492-3834 provided that th(re are personnel in attendance who will take the necessary precautions to prevent the ex-REVISED 10 CFR PART 20: QUESI1ONS AND posure of individuals to rudiation or radioactive ma-ANSWERS terialin cass of the limits established in the revised Part 20 and to operate within the ALAR A provisions

'Ihis article is the fourth in a series that will discuss the of the licenser's radiation protection program. Note important changes, in radiation protection standards, that only one of the three conditions in 10 CFR made by the sweeping revisions to the new 10 CFR 20.1903(b)(1) needs to be met, and that one has been Part 20.'Itc revised Part 20 was published in the federal met by the patient receiv ng less than 30 millicuries.

Register on May 21,1991.

5.

The defmition of a very high radiation area (10 CFR As a method of helping to learn and understand the new 20.1003) and the requirement for control of access to changes in revised Part 20, the following questions and very high radiation areas spectfy an absorbed dose of answers are provided.

500 rads in an hour. Is this a deep dose, a shallow dose, or an eye dowe?

1.

Part 20 requires that " labeled packages" be moni-tored. Is it correct to assume that only packages with The 500-rad dose is intended to be a deep dose, White L Yellow II, or YelLw III labels must be moni.

evaluated at a tissue depth of I cm (1000 mg/cm ),

e tored, and that marked packages (Iow specifir activity 6.

Must bioassay be performed for a worker who, with-(13A)or radioactive markings)are not required to be monitored?

out respiratory protection, is likely to receive an in-take in excess of the applicable annuallimit on intake Based on the revised Part 20 Statement of Considera.

( ALI), but who is not likely to receive such an intake tions (56 FR 23380), it is correct to assume that only with respiratory protection?

packagt s with Department of Transportation (DOT)

White I, Yellcw II, or Yellow III labels need to be Yes, as indicated in a note m. the revised 10 CFR monitored.

Part 20 " Statement of Considerations" (56 FR 23377), the concentrations to be used (prospectively) 2.

10 CFR 20.1:01 established new requirements for 11 for evaluating monitoring thresholds are those of the censecs' radiation protection programs, including ambient atmosphere before credit is taken for respi-requirements to implement a program, review it, and ratory protection factors. Routine periodic bioassays use as low as is reasonably achievable (ALAR A) pro.

for respirator users are required to demonstrate the ctdures. What would a typical radiography licensee effectiveness of the licensee's respiratory protectica have to do under 10 CFR 20.1101 beyond what that program licensee is doing now?

'Ite radiography li;ensee must ensure that the radia.

CLARIFICATION OF ANSWERS IN ARTICLE, tion protection program is documented and review

• REVISEL) 10 CFR PART 20: QUESrlONS AND the program's content and implementation perindi.

ANSWERS"(SEPFFMllER 1991 NMSS LICENSEE cally (at least annually). lf the licensee does not have NEWSIETTER) a radiation protection program, then such a program must be developed. Regulatory Guide 8.10 provides

'The September 1991 NMSS Licensee Newsletter in-some guidance for implementation of an ALARA cluded an article on

• Revised 10 CFR Part 20: Questions program.

and Answers." Two of the answers could have been con-fusmg to some licensees. To clarify those issues, we are 3.

Should the radiation protection progmm referer.ced providing the following.

in 10 CFR 20.1101 be a stand-alone document or can it be the sum of many accuments or manuals?

2.

What are the requirements for including dose from non-licensed sources (x rays, accelemtors, naturally 10 CFR 20.1101 requires a documented radiation occur-ing radioactive material) as part of occupa.

protection program. 'Ihis dmm:ntation does not tional dose?

have to be a stand alone document, but it must be re-(

viewed annually.

ANSWER 4.

Do posting requirements apply to the hospital room The combined total of doses from heensed and unh.

of a hospitalized nuclear medicine patient, if the censed sources (other than background and medical 4

treatment) must be below the Part 20 cccupational dose scymnsible operation in determining the civil enforce-limits. The requirement for inclusion of all doses from ment priority of storage violations at particular mixed non licensed sources is intended to acmunt for all occu.

waste generator facilities. 'the Filicy also details those pational doses received while working in activities involv-wastes and generators to which this pohey will apply and ing radiation, or with radioactive materials. *lhus, licen-the duration of the policy.

sees must sum the doses from non licensed wurces to the doses from licensed sources, to obtain the total dose, for Afhed Wasrc Er@rement Action at NFS Erwin comparison to the occupational hmits of 100 mrem per On August 8,1991. EPA issued a Complaint and Compli.

year.

ance Order to Nuclear Fuel Services, Inc. (NFS) of 6.

A licensec nonitors a worker for both external and Erwm, Tennessee.The Order stated that NFS was oper-internal exnosure, but the internal exposure for the ating a hazardous waste generation and treatment facility year is lers than 10 percent of the annual limit on in-witho :t an RCR A permit, or interim status, and was dis-take, Doce the licensee add it to the external expo-posing of the waste in a facility that was not authorized to receive haurdous waste.The alleged violations involve a sure?

bottle-washing operation that produces a freon waste It depends uprm whether the reason for monitoring containing enriched uranium. Although ti.e State of Ten-the individual was because s(he) was likely to exceed nessee was granted mixed waste authorization from EPA the 0.5-rem monitoring threshold. If tnth internal in 1987. EPA initiated the enforcement action based on and external doses were required to be monitored, its identification of th potential violationt EPA has pro-then they must be summed. If either the internal or posed a penalty of $993,461 in the Complaint.'the licen-external dose wouldn't have required monitoring, ace has requested a hearing and intends to contest the or-then it wouldn't have to be summed.

der.

Myou have any questions, please contact NRC staff mem-MIXED WASTE REGULATORY UPDATli bers Mike Weber at 301-504-1298, or Nick Orlando at 301~504*2566-NRCIEPA Joint Guidance Documents The Nuclear Regulatory Commission (NRC) and the NRC. EPA. AND STATES SIGN MEMORANDUM Unvironmental Protection Agency (EPA) are currently OF UNDERSTANDING ON RADON RELEASES developing two joint guidance documents, for use by Fed.

FROM URANIUM MlliTAll.lNGS eral and State agencies and the regulated community, on the requirements for mixed waste testing and storage.

On October 24,1991, the Nuclear Regulatory Commis.

These twa guidance documents will outline procedures sion (NRC), the En ironmental Protection Agency that will allow mixed wasu generators and operators of (EPA), and the States of Colorado, Texas, and Washing-treatment, storage, and disposal facilities to test and store ton (Affccted Agreement States) signed a Memorandum their waste in a manner that complies with EPA require-of Understanding (MOU) setting out a series of actions ments under the Resource Conservation and Recovery that, when completed, will minimize regulatog duplica-Act (RCRA) and NRC requirements under the Mmic tion and conserve resources in the control of radon emis.

Energy Act (AEA), while maintaining worker expuares sions from NRC. and Agreement State-licensed uranium as low as is reasonably achievable (AIAR A). Ilefore for-mill tailings sites.

mal publication, NRC and EPA will solicit comments on the guidance from inter ested individuals and selected us-On December 15, 1989, pursuant to Clean Air Act ers. The agencies have targeted December 1991 for issu-(CAA) authority, EPA promulgated a radon flux stand-ing the testing guidance for public comment. A date for ard and timely closure provision (40 CI'R Part 61, Sub-requesting comments on the storage guidance has not yet parts T and W) to control ndon releases from uranium been determined. Interested individuals should monitor mill tailings dispmal and opera tion. Under authonty of the Federal Register for Natices cf AvailabCity and Re-the Uranium Mill Tailings Radiation Control Act quests for Comment.

(UMTRCA) of 1978 NRC and the Agreement States also regulate radon releases from these sites. EPA and ETA's Policy Statemun cn Afhed Wasrc Storage NRC programs overlap each other, in recent months, there has been heightened concern over this regulatory Oa August 29,1991, EPA announced,in the FederalReg-duplication, because certain facilities must be in compli-ister (56 FR 42730), an enforcement policy for the storage ance with Subpart T by December 15, 1991, and many prohibition, at Section 3004(j) of RCR A, for facilities that sites face the prospect of being unable to comply with the generate mixed waste. Under the policy, EPA will ascribe standard. Because of this fast approaching d:adline, low enforcement priority to violations involving the stor-NRC and the affected Agreement States began,in July age of mixed wastes subject to the I;md Disposal Restric-1991, a series of discussions with EPA about a wide range tions, under certain conditions. The policy outlines wbat of options for reconsidering Subparts T and W, including EPA considers to be indicators of environmentally rescinding the standards, based ou a finding that NRC

and Agreement State regulatory Storrams protect the and many individual buildings identified only as an ad-public bealth and safety with an vmple margin of safety dress on the license. In addition, over the course of many (i.e., a determination under S.:ction ll2(d)(9) of the years, corporate memory about rooms, buildings, areas, CAA).

or onsite burial grounds that were used for licensed op-erations may be lost.

NRC and the Affected Agreement States are continuing to fulfill their hiOU commitments, including timely re-nese new regulations would require licensees to main-view and approval of mill tailings disposal site closure tain a listing, contained in a single document, of all areas plans and solicitation of firm closure schedules from each that have been contaminated. This listing would include:

licensee, for incorporation as an enforceable license con-

dition, 1.

All areas designated and formerly designated as re-stricted areas, defined under 10 CFR 20.3(14) or 10 For funhet information contact:

CFR 20.1003:

Meg Harvey, Decommissioning and Regulatory lasues 2.

All areas, other than restricted areas, where radioac-Branch, Office of Nuclear hiaterial Safety and Safe-tive materials are, or have been, used, possessed, or guards, ILS. Nuclear Regulatory Commission, at 301-stored, in quantities greater than those listed in 504-2522, 10 CFR Part 20, Appendix C to 10 CFR 20.M01-20.2401, NRC REQUESTS COhih1ENTS ON 3.

All areas, other than restricted areas, where spdts or RECORDKFEPING RULE other unusual occurrences involving the spread of contamination in and areund the facility, equipment, On October 7,1991, the Nuclear Regulatory Commission or site have occurred that required reporting pursu-announced, in the federal Rg;hrer (56 FR 50524), that it ant to 10 CFR 30.50(b)(1)or (4),10 CFR 40.60(b)(1) proposed to amend its regulations at 10 CFR Parts 30,40, or (4), and 10 CFR 70.5(b) (1) or (4), including areas 70, and 72, to require licensees to maintain information, where subsequer.t cleanup has removed the contami-in a singk document, identifying areas where licensed nation; and materials were used or stored. ne amended regulations would apply to Ucenses issued for tht possession of He kcation of all known current and previousonsite 4.

byproduct msterial, source material, special nuclear ma-burial areas and radioactive contents.

terial, and the mdependent storage of spent nuclear fuel and high level waste. Licensees would be required to llef re license termination, a list of locations and de-maintain documentation listing the areas where these acriptions of equipment myolved in the hcensed op-materials were used or stored for restricted and unre-er tion that is to remain onsite would be required.

stricted areas, areas where spills have occurred, and loca-tions and contents of current and previous burial areas He Commission has proposed to except certain types of enthin the site. The location and a description of equip' I cem,ces from the rulemaking and is soliciting comments ment involved in the licensed activity that will remam on-on these exceptions.Rese exceptions would include ac-site at the time of heense termination would also be re-tivities involving radioactive materials with half lives of quired to be listed. He Federal Register announcement 10 days or less for Part 30 Itensees, sealed sources used requested all interested parties to submit comments on at " temporary" job sites out:,ide of the licensee's perma-thes roposed new requirements no later than Decem-nent facihty, and areas containing depleted uranium used only for shielding or as penetrators in unused munitions.

The Federal Register Notice should be consulted for a de.

These new regulations are in response to concerns ex-t iled diset:s', ion of these exceptions, prer. sed by the General Accounting Office and the Envi~

ronment, Energy, and Natural Resources Subcommittee For further information contact:

of the House Committee on Government Operations' Before termmating a license, the Lommission must de-Dr. Carl Feldman, Office of Nuclear Regulatory Re-termine that all areas invo1ved m, licensed operations search. U.S. Nuclear Regulatory Commission, Washinp ton, DC 20555, at 301-492-3883, have been decontaminated m, accordance with Commis-sion regulations llowever, the Commission could inad-venently release contaminated facilities and sites for un-SELECTED SIGNIFICANT EVENTS REPORTED restricted use because of poor or insufficient knowledge TO Tile U.S. NUCLE AR REGULATORY as to the h> cation within a licensce's site where licensed CON 1hilSSION (NRC) activities were condacted. licensees are authorized to possess and use licensed materials only in areas described IAent 1: Potential Criticality Accident at the General in their license application or license conditions. Ilow-Electric Nuclear Fuel and Component ever, a licensee's facib'y could include large areas of land hianufacturing Facihty in Wilmington, NC 6

Dcte Reported: May 29,1991

'the 11 t' identified numerous problems at the plant (in.

adequa e managernent oversight, design deficiencies, lacenue: General Electric Company procedural noncompliance, inadequate incident investi-Wilmington, NC gation, and a general deterioration of criticality controls) and concluded that three interrelated root causes con.

tributed to the incident:

On May 29,1991, the licensee notified NRC Region 11 that it had identified a potential criticality safety problem.

3,

,there was a pervasive licensee attitude that a nuclear During the morning of May 29, the licensee found higher criticality was not a credible accident scenario. Al-than expected amounts of uranium in a favorable geome-th( ugh the licensee understood and recognized that try vessel in its solve nt-extraction systerns, because of car-a nuclear criticality with low enriched uranium was tier problems with controls and equipment in that system.

technically possibic, and that there were regulatory

'Ihc licensee shut down the solvent-extraction process requirements to establish rocasures to guard against and subsequently discovered higher than expected such an accident, the licensce's perception was that amounts of uranium had also been imprtnerly trans.

the risk was no low that a critiamty accident inher-ferred into an unfavorable geor'ictry waste tank. licen.

endy wouW not happen.

see management was notified and a tecanical evaluat;on team was co,vened, in addition, sparging (i.e, mixing) 2.

Licensee management did not provide effective guid-was inittated in this tank, to mimen,ze the criticality poten-ance and oversight of licensed activities, to ensure t

tial. During the afternoon of May 29, the licensee notified that operations were conducted in a safe manner.

NRC Region 11 of the modent. later, the licensee also began uranium recovery civ~ rations from thts tank via a

3. Dere was a deep-scated, production-minded orien.

centrifuge linked to the tank.

tation within the licensee's organization that was not sufficichtly tempered by a" safety first' attitude, par-Also on May 29, NRC dispatched a Region 11 site team, ticularly regarding nuclear criticality safety.

which arrived early during the morning of May 30. At 6:38 a.m., EDT, on May 30, after discussions with the NRC re-la eddition,th Ifl' identified various weaknesses in NRC sponse centers, the licensee declared an alert, in accor-regulatory guidance, licensing, and ir.spection programs dance with its Radiologi;al Contingensy and Err.t rgency that had the effect of contributing to the incident.

Plan.

Corrective actions included the following: system walk-On May 31, NRC issued a letter confirming the licensce's downs and verifying that documentation matched curr ent agreement to refram from transferring material in certain plant configuration; revising procedures; retraining of portions of the waste streams, refram from using the operatort,; revamping sampling to ensure adequacy for solvent-extraction itstem, and cooperate with the ineasurement of uranium; sensitivity training of all plant inc dent Investigation 'lcam (IIT). The licensee corain.

personnel to follow procedures and repon problems:

ued to remove uranium by centrifuge from the tank' documenting a scheme for reporting events; instituting through June 1. On June 1, the licensee had transferred additional management oversight of of erators; establish-afficient amounts of solution containing uranium from ing an audit s/ stem; and establishing a,ong term plan to a tank via the centrifuge process and to other nearby improve performance in staffiri emergency response, nks to reduce the uranium in the tank to an amount less equipment reliability, and engineered systems to replace it an the enticality safety Lmit. ~lhe licensee then termi-administrative criticality controls. The licensee reports nated the alert status' the status of short-and long term correuive actions to NRC Region 11 on a biweekly basis The licensee will pre-An IIT, arriving onsite June 2, was directed to determme sent to NRC its corrective actions for restart of the the circumstances associated with the event, identify the solvent extraction system. The licensee presented an probable causes of the event, and make appropriate find-outime of these corrective actions to NRC in an August 9, ings and conclusions that would form the basis for any 1991, lett er.

necessary follow-on actions. It len the site June 13. A Re-gion 11 inspection team continued to monitor the licen' De special N RC Region 11 inspection team inspected all see's followup actions at the site from May 30 through corrective actions taken by the licensee in response to the July 18.

event.

On June 25, the licensee met with NRC to discuss the The NRC IIT formal report was published in August status of the sptems shut down as a result of the event, 1991 as NUREG-1450.

the correctim actions needed before restart and the longer-term corrective actions needed at the facility.The Event 2: Multiple Medical Teletherapy licensee certified that the corrective actions for restart of M sadministrations the waste systems, including a procedure for reporting all types of events to NRC, were complete in lettets dated 1.icensee: St. John's Regional NDdical Centei July 4 and July 7,1991. NRC authorized the hcensee to Joplin, MO restart certzia waste-stream systems on July 7.

7

D:te Reported: April 12,1991 On Apnl 18,1994, NRC Region !!! conducted a specist NRC Region III was notified by the licensee that a num*

safety insputkm at the Median) Center, in response to ber of cobalt-40 telethenipy misadministmtions had oc.

the mbalt40 misadministrations. On May 10,1991. Re-gion til issued a Severity level IV Qust above least se.

curred tlctween September 1984 and Alarch 1991. the vere) violation, citing the licensee for failing to notify misadmmistrations (defined as therapeutic doses varyms more than 10 perrent irom presenbed doses) were disco *

• NRC within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of discxwcry of the initial misadmin-i hiratbn.

cred during a i tview of pau ticatment data in March r.nd April 1901. C n Anni 25, the lice *.see fonnatly reported that 12 misattninistratior.s had occurted.

On April 15,1991, Regin ill approved Amendment 18 of the Medical Center's teletherapy license, which re.

Of the 12 'W patients rece,ved doses 10 to 18 percent quises the licensee to perfonn dual calculations for all higher than the prescribed dases, and nine patients re*

cobalt 40 therapies before initiation of treatment. De licensee also must malatain records I the dual verifica-ce'ved doses from 10 to 27 percent below the prercribed

ginn, doses. /11 misadministrations iesulted from erroneout in-formation in the treatment planning computer program.

All treatments, with one exception (an are treatmtnt)in.

volved the use of wedges.

M d

dh Public from a lest Radioactne Source ne treatment dacrepancies were l'rst discovered in Date Notified: September 5,1991 March 1991, when a therapy technologist, preparing for an upcoming board certification test, pulled the files of

!)censee: Western Atlas international previously treated patients to practice hand-aticulated Yukon,OK dosimetry.ne technologist later infonned licensee man.

agement that her results did not match the wedge-related On Seg' ember 5,1991, Western Atlas International noti.

treatment dosca indicated in the patient files. On ficd the State of Texas that a 2 curie cesium-137 scaled March 22 the Radiaticn Safety Officer (RSO) was asked well logging source had been lost that morning from the to investigate the apparently conflicting raults. ne RSO licensee's vehicle enroute from the licensee's Yukon, developed a list of patients who ter:ived wedge-related Oklahoma, facility to its llouston, Texas, facility.

treatments since the inception of that type of treatment in August 1989. On March 25, the RSO presented the list to ne licensee initiated a search. Meanshile, at approxi.

the Radiation Oncology staff, who began hand calcula.

mately 5:30 p.m. that day, a citizen spotted the shipping tions of all patient treatments. Reruns of the original container lying on a gravel shoulder near the Interstate computer calculations also were initiated, 45 Exit 118 roaJ, and notified the fluntsville Police De-partment.

Ily Mt th 29, the reworks supported the technologist's origira finding that actual administered doses had devi.

A police officer was dispatched to the scene, found the ated significantly from prescribed doses. All of the pa.

radioactive source 3 to 4 feet from its shipping container, tients' referring physicians were subsequently notified of picked it up, and is believed to have held it for about 5 the dose dtfferentials, except for one physicim who had seconds before dropping it near the container. %e area left Ihe area (the patient was notified dircetly, here), ne was closed to the public until a member ofIhe city's emer.

licensee stated that no adverse effects have been ob.

gency management services retrieved the source, using 2 served, to date.

Lnives as handimg tools; at approximaiety 6:15 p.m., the source was placed back into the shipping container, which in 11 of the 12 mir. administrations, the licensee failed to was missing its shield plug. Ikensee personnel placed the calculate a computer program's " wedge normalization source in a complete shipping container at approximately factor," in making initial dose calculatians. He wedge M0 p.m.

normalliation factor is describco in the manufacturer's knputer program instruction manual. Instead of using De large pin attached to the bar securing the shipping this factor, the lit.nsee used different.neasured wedge container shield plug was missing. His allowed the safety factors that were not compatible with the computer pro-tw to slide out of position, and the plug and source to 4

gram. nc other misadministration resulted from the 11 oc.me out of the shipping container.

censee's failure tv correct the computer program,~as di.

rected by the manufacturer's r@se notes, in addition..he truck bed from which the source was lost was flat, with only a canvas cover held in place with four On April 12,1991,thelicensww.stedanamendment clastic straps. During transponation, several shipping to its NRC license, requiring inovpendent venfication of containcts fastened on the truck bed by locks attached to cobalt 40 teletherapy treatment plans, to prevent further the mntainers and to the links of a slack steel chain misadministrations. In addition, the licensee has imple.

(which was attached to truck structures) moved some.

mented an interna' procedure that also requhes inde.

what, on the truck bed. nc shipping containers acceler.

pendent verification of treatment plans before treatment, ated their movement when the vehicle turned corners, 8

~..

br ecking a lock and allowing the shipping container to fall l noted that the volume of the technetium-99m h1DP was off the back of the tra greater than expected, reched ed th r dose tick et, and dis-covered the error.

The police officer whc. held 11.4 source received an esti.

mated exposure of approximately 5 rem to his fmgers.

Ilecause the error would not negate the results of the di-i

'Ihc ndividual uho retrieved the source received an esti-agnostic study, the txmc scan was completed Although mated exposure of approsimately 360 millitern to his fin.

the amount of radiation the child acceived was greater gets.

than intended, the licent.ee determined the increased risk of biologic effects was not signincant.1he calculated ra-

'Ihe event was attributed to human error. Western Atlas diation dose for the study was about 4.4 rads to the banc International perrionnel did not follow the licensee's pro-and 1.3 rads to the total !=dy, This compares to about cedures or management instructions in correcting ship-0.38 rads to the bone and 0.11 rads to the w hole taly, had pmg mntainer sleficiervies and in properly securing the the correct dosage been administered.

shipping ecntainers to the transporting vehicle.

The cause is attributed to human error on the pari of the 1

Ga Septemist 6,1941, the day after the incident West-radiopharmacist and the nuclear inedicine technician.

ern Atlas international issued a memorandum to all its

'the hospital has counseled the Iwo emphiyces involved North American facilities, on corrective measures, effec-in the error,llospital management met with the nuclear tive immediately. Shortly thereafter, the licensee re-medicine department staff on September 17,1991, to re.

moved the personnel involved in the incident from li.

view the impact of the errors in this inciderit, to stiess the censed activitics.

importance of checking one's own work as well as the work of others, and to point out the need to follow de.

i F. vent 4: hiedical Diagnostic Misadministration partment policies.

Date Reported: Septernber 9,1991 1: vent 5: Overexposure of a Non.Hadiation Worker IJcensee: St. John's hiercy hiedical Center Date Reported: May 1991 St. leuis, hlO I (censce: ll&G Inspection Co., Inc., llouston, TX A bone scan diagnostic study was scheduled for Septem.

(Agreement State IJcensee) ber 9,1991, for a l$ month-old male child with possible osteomyelitis (bone inflammation) of the ankle, llecause During radiography operations by 11& O Inspection Com-of an error in the hospital's radiopharmacy, the child was pany, incorporated,llouston, Texas, on a barge near Port given an adult dose of technetium-99m htDP, the radio.

Arthur, Texas, an unmonitored, non radiation worker active pharmaceutical used for a txmc scan.1he normal emphiyed by the P.xxon Corporation receiveo a whole.

dose for a child of his weight would be 1.91 millieuries, lxdy cyposure, estimated to be between 1.8 and 3.9 rem.

lhe standard adult dosage used for the diagnostic study from a radioactive riource that was not properly shielded.

ns about 21.96 millicuries, more than 10 times the in.

This exceeds the abnormal occurrence reporting thresh-tended dosage to the child, old of 0.5 rem in one calendar year for a member of the general public. In addition a radiographer received a lhe licensee uses a computer system to determine the ap.

whole-txdy exposure of about 7.7 rem. [1his exceeds the l

propriate amounts of the radiopharmaceutical to use in license limit for whole txdy exposure to a radiation the bone scan. For adult patients, there are standardized worker in one calendar quarter; however, it is below the dosages; for patients under 18 years old, the dosages are abnonnal occurrence reporting threshold of 25 rem calculaed v, the basis of body weight.The pediatric po whole body.) There were three root causes for the event.

thats are identified on the licensee's treatment.:st with 1he first cause was a camera kvkinc, with the source in an asterisk, accompanied by a handwritten notation of the the unshielded position.1he second cause was the failu N patient's body weight.

of the radiographer to perform an adequate survey Iqde.

termine whether the source was in the shielded lwillon, lhe radiopharmacist who prepared the technet.'um-99m lhe third cause was inadequete procedures regarding MDP for the bone scan failed to note the asterisk and unmer.Nad personnel entering a restricted area.

handwritten lxVy weight on the computer printout of scheduled diagnostic studies. As a result, he prepared the The radiopphers and the F.non ernph>yee were rsotified standard adult dosage.

of theirexposure. All!icensee emph>yces were notifiedof the incident by memo.1he incident was discussed durms The nuclear medicine technician failed to detect the error the next safety meeting. New procedures were developed before administering the radiopharmaecutical to the pa-pertaining to unmonitored personnel entering restricted tient.1he technician checked the patient's name on the reas. !he tcquirements for performing a proper survey dose ticket accompanying the syringe, but did not venfy were reemphasired to ensure that a source has been the radiopharmaceutical and dosage, as reaulted by hos-properly retracted into its shielded position, When the pital policy. After the administration, the technician camera is moved to a different job site, the guide tube will l

9

be diwonnected end the salcry plug inserted. Anyone not Theworker'scapi n:tionof thiseventisen errorinrc:d.

following the new proceduto will Se fined $100, ing the 1LD or an imperfection in the 'lLD rr'terial it-self,'the wor ker stated that he knew of no enerr.tes at the

• Ihe licensee was cited by the Texas agen y for allowing an plant who would sabotage his dosimetry, lie also stated unmonitored indhidual to receive an caposure g/ cater that access to his dosimetry u hile not being worn is rather than 2 millitem in an hour,irr the c.spsutes of the two restricted.

radiographers, and for the failure 19 perform adequate surveys to de termine wl ether the radiation source was se.

The State Agtncy inspectors witnessed a rernactment of cured.

the source extraction procedure, using a blank stainless steel source holder, and it is unlikely that the worker re*

ceived an caposure of 714 tem, llowever, the Agency Event 6: Extremity Overexposure of a Radiation mncluded that an extretnity oscruposure did oxur, esti-Worker mated to be approximately 200 to M0 rem.

Date Reported: July 10,1990 The following recommendations were offered during the inte M m Ucensee: Rosemont, Inc., Mt. Prospect, IL (Agreement State IJcensec) 3,.lhe licensee should contact the procepor an j have it While extracting a 10 curie cesium-137 source from its check the 'ILD chip and readmg system for proper

E"""' I4"" Y """""CO housing, an employee (radiction worker) received an overexposure to his lef t hand.'lhe actual exposure is not 7,.lk licensee should seriously consider engineering preciscly known, but was likely between 200 and 714 rem, changes or changes in procedure that would increase Hecause the higher value, which was indicated by the the distance between the source and the source worker's dodmetry, could not be disproved,714 rem to remover's hand in the absence of this change, the li-the left hand was entered into the worker's radiation rec.

ccnsee should consider discontinuing the practice of ords.1hc event was investigsted by the !!!!nols Depart-reusing high acthity sources, because of the poten.

ment of Nuclear Safety (referred to as the State Agency),

tial for a radiation overexposure of this kind.

On July 10,1990, the worker was removing the source

'Ihe causes are attributed to inadequate procedures and from a Model 70MP source housing. Operating on this supervision during operations involving a high acthity particular sourte holder was a special case requiring dl*

source, Greater use of remote handling equipment could rect obr.ervation and timing of operations by the worker's considerably reduce the potential for overexposure, supemsor.

Extractiori of the source from the sourca holder began.

After about 25 percent of the crimp was peeled back, the

1. Effective immediately, no source capsule larger than cylinder in which the source was contained separated 2 curies will be uncrimped from its holder, from the base of the source holder, After uncrimping the broken soun;c holder, the worker tried to extract the

2. Effective lmmediately, no saurce capsule larger than source, and was successful on his second attempt. 'the 0.5 curie will be uncrimped from its holder without source was then placed 8n a lead pig. The total time re-direct supervision of the operation.

por;ed by the worker's supersisor for the entire proce.

dure was 4 minutes and 45 seconds.

3. 11cginning September 17, 1990, as a precaution against tampering hil source ksaders'dostmeters will Decause the source manipulation was unusual, the super.

be kept under kick and key, when not in use.

visor suggested that the worker's ring thennoluminescent dosimeter (1LD) be procened. On July 12,1990, the re-On July 31,1990, the State Agency issued a notice of vio-sults irdicated an exposure of 714 rem (instead of the lation for the overexposure.'the license was amended to usual 3 to 4 rem) to the left hand, include tne licensee's proposed corrective actions, and the letter transmitting the amendment included a strong

'Ite worker was examined by a pt ysician on the evening of suggestion that remote-handling equipment be consid.

July 12 and found normal.The worker showed no visible ered more often in the interest of keeping exposures as signs of acute radiation overexposure to his left hand, lie low as reasonably attainable, stated that there was no discomfort, reddening, swelling or other ill effects. On July 20, an Wologistmematolo.

Event 7: Overexposure of a Radiographer gist informed the worker that.rl tests were normal and Date Reported: November 1990 that he could find no sign of damage. Ilased on these find.

ings, the doctor believed that the worker had not been ex-IJeensee: llig State X Ray, Eastland, TX posed to the high level of radiation reported.

(Agreement State IJecnsee) 10

~

i a

l During radiography operations at Pnde Refinety in (1) Table 2.8 of the guide referred toin(l)above contains Abilene. Texas, a radiographer received an estimated ci-crrors in the calculated suberitical limits for mixtures of t

posure of 35 rem to his nght thigh, from a radioacdve U(93.5) metal, water, and graphite.*lhe values in the ta-sourte not kicked in its $hicided p>sition, ble were intended to indicate limits corresponding to a

)

rnultiplimtion factor of 0.95, llowever, after the discov.

The primary cause of this incident was a failure of the ra-cry of errors by two lndependent groups, calculations per-diographer to properly kick a source in a camera and re-formed at Oak Ridge National laturatory (ORNL) sug-move a key before moving a carnera. 'the radiographer gested that limits presented in the table correspmd to also faued to determine a hether hh survey meter was op-multiplication factors as high as 1.09. ORNI, has gener.

erating correctly after it became wel in the rain.

ated a correction table that users may obtain. (2) ORNL was informed of a discrepancy between CAShlO-3 and 1he licesce was cited by ihe State Agenn for the overen NITAWIdliNO-V.a. calculations invohing fuel stor.

posure and failure to properly lock and remove a key from aEe at elevated tempenitures. larger water gaps en.

a radiography camera before rehicating it.

hanced the temperature effects.

Criticality safety evaluations based on the incorrect data INFORhlN110N NOl1CES Pull!JSilED in the Nuclear Safety Guide, 'I1D-7016, or on calcula.

AUGUSI'16,1991-NOVEhllti!R 12,1991 tions with inappropriate hydrogen scattering matrices, A. Emergency Access to low level Radioacthe may 6%nhandy nonconsmah Wer Mew of Waste Disp > sal Facilities-IN No. 91-65, ose eva uadons for condnWng opuadons would ensure dated October 16,1991 that adequate safety margins are retam, ed.

Technical

Contact:

Richard ll.Turtil,301-504-3447

'this notice informs licensees w ho generate or may gener.

IIUll#IIN PUIILISIIIIU d

ate low level waste (I.LW)of the strict requirements gov.

crning implementation of the emergeng access provision Reporting loss of Criticality Safety Controls-NRC 11ulletin 91411, dated October 18,1991 of the I ow Ixvel Radioactive Waste Policy Amendments Technical Contacts:

Act of 1985 (l.IJtWPAA). Congressional concern that a George II. llidinger,301-504-2683 seriou6 and immediate threat to the public health and Robert E. Wilsea,301-504-2126 safety could result from denial of access to a 11W dis-A.1homas Clark,301-504-3424 posal faellityled to inclusion of the emergency access pro-vision, which permits a generator of 11W or any Gover-

'Ihis bulletin requests that all fuel cycle and uranium fuel not to request that NRC grant access to a disposal facility.

research and development licensees inform the Commis-NRC's emergency access iule (10 CFR Part 62)and Com-sion of

• heir criteria and procedures that ensure the mission policy follow Congressional intent in discourag-prompt evaluation and reporting, to licensee manage.

ing use of emergency access as a means for dispisal for rnent, of the degradation vf any controlled pararneters any circumstance other than an urgent situation that re-used mrevent nuclear criticality and that ensure the im-quires disposal to protect public health and safety. Appli-me'

.cporting, to the Commission, of any significant cations must provide information on the need for dis-degr,.. tion of such controls, as required by 10 CFR posal; the material to be disposed of; the health and safety 20.403(a). IJcensees must respond in writing.

ccmsequences of not granting emergency access; and al-temath es to emergency access, including onsite storage, As the result of oautrences involving Ica 9f criticality voluntary agreement for access to a disposal facility, pur-controls at licensed activities, one of whici. 4 described, chasing disposal capacity, and ceasing generation of the Commission is concerned that licensees rnay pay in.

11W. NRC can grant access only if all alternatives prove sufficient attention to the need for internal reporting and unreasonable, prompt evaluation of faUures of controlled parameters related to enticality safety, and that licensees may not II. (1) Erroneous Data in "Nuc! car Safety Guide, have adequate procedures for rep)rting these matters to TID-7016, Revision 2"

(NURiiO/CR4)095.

the Commission.

ORNI/NUREO/CSD-6 (1978)) and (2) "Ihermal Scattering Data IJmitation in the Cross Section Sets Provided with the KliNO and SCAL.E Codes"-

RADIOACTIVE FENCE PRODUCTS IMPORTED IN No. 91-66, dated October 18,1991 FROh! INDI A Technical

Contact:

Charles 11. Robinson,301-504-2576 On August 9,1991, the State of Washington notified the U.S. Nuclear Regulatory Commission (NRC) that radio-This notice alerts licensees to errors in a common tefer.

active material had been detected during a routine survey ence for nuclear criticality calculations and to potential of a truck leaving the Department of Energy's (DOE's) problems resulting from limitations in a cornmon cross-Ilanford Reservation facility.1hc DOE staff found two section library used in support of criticality safety.

chain. link. fence tension bars contaminated with 11

-~

cobalt 40. Radiation control progroms in the States of enforcement cctions include civil penalties, orders of War.hington and Oregon traced thc material to a whole-various types, and notices of violations.

sale fence distributor in Portland, Oregon, where addi-tional mntaminated fence products were found, A. Cwil penalties and Orders Within several days, NRC, with several States' help, as-1.

American Fibrit, Inc., llat le Creek, h{ichigan sened the extent of the ctmtammation throughout the Supplement VI, !!A 91490 United States. 'IVo U.S. importers had brought in the 1

contaminated fence products from India.'they had pur-A gotice ci Violation and Proposed imposition of chased material from two separate Indian steel facilitics, Civil Penalty was issued August 2,1991, to empha.

Kata Steel Rolling Works, in Calcutta, India, and hiangal site the importance of effcetively rnanaging the li-Steel Enterprites. Ltd., in llowrah, India, censee's radiation safety program, to ensure the health and safety of the workers and the public.'the

!!ased on the initial sutvey and laboratory analysis of con-action was based on violations involving the failure to taminated fence products, NRC concluded that no action have an individual serve as radiation protection offi.

was nectuary for bars already installed in fences or in the cer (RPO), improper use of licensed material, failure possession of retail companics, due to the estimated low to test sealed sources, and failure to maintain records risk and wide distribution of the fence products. In addi-of the physicalinventory oflicensed scaled sources, tion, it was mncluded that any mntaminated bars in the The base civil penalty was escalated 200 percent be-possenion of wholesale distributors should be returned cause NRC identified the violations, prior notice that to India or transferred to a low level waste site, for dis.

identified the lack of a qualified R PO, and the lenEth of time the licensee was without a qualified RPO.

pos33, 2.

Cleveland Clinic Foundation, Cleveland, Ohio Analysis of data from the importers, distributors, and the Supplernents IV and VI, EA 91484 States indicates that contaminated fence products were identified at 64 of the initial 145 sites that were identified A Notice of Violation and Proposed imposition of as receiving material from the two importers. Additional Chil Penalty was issued July 29,1991, to emphasite evaluation of these survey results indicated that less than the need for effective leadership, management, and 5 percent of the products at these hications were contami' oversight of licensed activities. ~lhe action was based nated, and that radiation levels for the majority of con-on 14 violations in the licensce's radiation safety pro-taminated fence products ranged from 30 to 200 gram.The base civil peaalty was esclated 20 percent 4

microroentgens/ hour, at contact.

because NRC identified all but one of the violations, the licensee did not correct all the immediate viola-NRC informed the Government of India of the contami-tions, and the licensee was provided prior notice of a nation. India has initiated its own investigation into the similar event in a previous enforcement action, cause of the incident. NRC is contin uing to communicatc with the Indian Goveniment and has receivea two pre.

3 Cotton llouston Ser3 ices, Inc., iluffman, Texas liminary reparts of its investigation.

Supplement VI, EA 91487 He Office of Nuclear Material Safety and Safeguards A Notice of Violation and Proposed imposition of mntinues to analyre the survey informatbn on existing Civi! Penalty was issued July 31,1991, to emphasize inventories and incoming shipments. To prevent further the imporsmcc of ensunng that radiographers are import of contaminated products, NRC has requested equipped with all devices designed.o ensure their safe,ty, and the importance of taking prompt action to that both the imponers and suppliers involved ensure avoid noncompliance, when given notice of the po.

that all incoming shipments are surveyed before export tendal for such noncomphance.The hetion was Dased from India. In addition, transportation of the contami-on the failure to provide alarm rate dosimeters.

nated fence products within the U.S. is being coordinated with the U.S. Department of Transportation. NRC re-4.

Industrial NDT Company, Inc., North Charleston, mains in frequent contact with the importers and distribu.

South Carolina Supplement IV, EA 91461, tors as they arrange proper disposal, probably by return of the contaminated material to ind'a.

A Notice of Violation and Proposed imposition of Civil Penalty was issued June 28,1991, to emphasize the importance of maintaining proper control of 11-SIGNIFICANT ENFORCEMENT ACTIONS censed material and ensuring that only authorized in.

AG AINST MATERIALS L102NSEES dividuals have access to such material. 'Ihe action was based on a violation inmhing the failure to se-One way to avoid segulatory problems is to be aware of cure licensed material frorc cauthorized removal enforcement problems others have faced.Hus, we have and a failure to provide constant turveiltance and included here a aiscussion of some representative control of licensed material. A licensee radiogra.

enforcement actions against materials licensees. These pher, unaware that a radiographic exposure device 12

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

had been placed on the tailgate of the vehicle he was An Order Suspending General ikeni.e (Effective to drive to a jobsite, left the facility with the device Imtnediately)and Termination of NRC 1 icense was sitting on the tailgate.*lhe device fell off about a mile issued September 6,1991.'the action was based on a from the facility and was found by a private citizen.

history of failures to meet numerous regulatory re.

quirements and commitments as to licensing, audits.

5.

Materials Inspection and Testing, Incorporated, and corrective actions; the intentional failure of an Fort Way:te, Indiana assistant radiographer to conduct a survey of an es.

Supplements IV, V nd VI,11A 91478 posure device, which resulted in injury to him; and a radiographer's intentionally allowing the assistant to A Notice of Violation and Proposed Irnposition of perform unsupervised radiography. 't he licenice re-Ch'il Penalty was issued July 19,1991, to emphasite quested termination of its NRC license. NRC sur' i

the importance of complying with license and regula-pended the general license to prohibit conduct of ra-lory requirements and ensuring effective manage-diography in NRC States under reciprocity, ment oversight of Ilcensed programs 'the action was based on numerous violations that represented a sig.

9.

Western Strcs4 Inc., llouston, Texas nificant lack of management control of licensed ac-Supplements IV and VII EA 90-213 tivities. 'Ihe base civil penalty was escalated 250 per.

cent because of NMC identification of the violations; A Notice of Violation and Proposed linposition of the licensee being provided ample prior notice of Civil Penalty was issued May 6,1991, to emphasize i

sirnitar events, during previous inspections and via the importance of strict attention to radiation safety i

NRC information notices; the duration of the viola-requirements in the conduct of industrial radiogra-tions, inc* vling the 5. year duration of the most sig.

phy and the importance of providing accurate infor-nificant viitationi and the lack of radiatan safety mation to NRC personnel. 'Ihe action was based on training Qr Iwo gauge users, an incident where the radiographer intentionally re.

moved his dosimetry to avoid recording a high radia.

6.

St. l : ke's Midland Regional Medical Cen;et, tion dose, and either did not carty or did not use a sur-Aberleen, South Dakota "cy meter, when approaching the f.ource, which had Supp ements IV and VI, EA 91-109 (allen from its mounted position on n tank.

A No.c of Violation and Proposed Imposition of

11. Severity Level til Violation, No Civil Penalty v

C: d Penalty was issued August 28,1991, to empha-site the importance of conducting the licensee's nu-1.

Cintichem. Inc., Tuxedo, New York clear med: cine progmm in accordance with all radia.

Supplement IV EA 91479 tion safety requirements and the importance of developing an effective management system to en.

A Notiec of Violation was issued July 3,1991, based sure that such requirements are met.The action was on violations involving a contamination incident that based on 13 violations of NRC requirements in the occurred duting a radioactive waste-handling opera-licensee's nuclear medicine program. He base civil tion. A civil penalty was not proposed because the li-penalty was increased $0 percent, because NRC dis-censee identified the violations and promptly re-covered the violation.

ported them to NRC, and the licensee's corrective actions, which include measures to prevent recut-7.

Stone Container Corporation, Coshocton, Ohio r ence of all of Ihe violations, were considered prompt Supplements IV and VI, EA 91 112 and extensive.

A Notice of Violation and Praposed Irnposition of 2.

Department of the Navy, Portsmouth Naval llospi.

Civil Penalty was issued September 16,1991, to em-tal, Portsmouth, Virgin la phasize the need to effectively manage the licensee's Supplement VI. EA 91-094 radiation safety program and ensure the health and safety of workers and the public. The action was A Notice of Violation was issued July 26,1991, based based on six violations, including the kiss of a 25 mill-on the unauthorized administration of licensed ra-icurie cesium-37 scaled source encased in a density /

dioactive material to a ruernber of the facility nuclear level gauge, that, in the aggregate, represented a sig-medicine staff. A civil penalty was not proposed be-nificant lack of management control of licensed ac-cause of the licensee's extcasive corrective action, tivities. 'the base civil penalty was escalated 100 per-which included retraining of the nuclear medicine cent because NRC identified the licensee's weak staff, notification of all Department of the Nagy nu-management control of licensed aethities and the 11-c! car medicine activities of the event, revision of pro-censee had received prior notice of similar events.

cedures, and appropriate counseling for those indi-viduals directly involved.

8.

Tumbleweed X-Ray Company, Greenwood, Arkansas 3.

Photon Field Inspection, Inc. Saginau, Michigan EA 91-102 Supplements VI and Vil, EA 89-243 13

1 A Notice of Violatina and Termination of license Material Safety and Safeguards (NhtSS), but not the was issued September 23,1991, based on the licen.

phcne numbers within some of the other NRC offices Sce's failures to: comply with empkiyce protection such as the Office of Nuclear llegulatory itescarch.

regulatioris, provide accurate and complete informa *

'lhere is no change to numbers for the five legional of-tion, and maintain radiographic utilization logs. 'lhe

fices, licensee requested termination of its license.

As part of a switch from the previous systern to the new 4.

University of Cincinnati. Cincilmati, Ohio Washington Interagency Telecommunications System Supplement IV EA 91-097 (Wfl3), hical numbers (in the 301 area code) beginning with 492-0,492-1, and 492-3 will change to 504 prefixes A Notice of Viohtlon was issued August 8, if91, for commercial calls, l'or 492-I and 492-3 numbers, the based on the loss et licensed material. A civil penalty suffix will remain the same as it was for the 492-XXXX was not proposed because of the licenwe's prompi

,,Ik

@n numb dose suffMs Man ntification, reporting, and extenuve corrective ac-i

2  !!

lace the *O." Calls to the old 492-XXXX number will be answered for six months by an intercept recording that will give the caller NEW NUCLEAR REOUIEIORY COMMISSION the nt w $04-XXXX number.

(NRC) PilONE NUMilERS For calls on the Federal Telecornmunications System NRC has changed the phone numbers at its ifcadquar-(Iri$), the new numbers will be %4-XXXX, where the ters, in Rockville, Md., One White 11(nt North. This in+

XXXX suffix is the same as the suffix for the WTIS cludes the phone numbers within the Office of Nuclear

$04-XXXX number.

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