ML20094C789

NMSS Licensee Newsletter.Number 95-3

ML20094C789
Person / Time
Issue date:	10/31/1995
From:	NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS)
To:
References
NUREG-BR-0117, NUREG-BR-0117-N95-3, NUREG-BR-117, NUREG-BR-117-N95-3, NUDOCS 9511020357
Download: ML20094C789 (12)

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s U.S. Nuclear Office of Nuclear NUREGlBR-0117 0,f Regulatory Material Safety No.95-3

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i Commission and Safeguards Sept '95/Oct '95

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.7' NRC CHANGES ITS ENFORCEMENT Among other significant changes, the revised POLICY enforcement policy-l The U.S. Nuclear Regulatory Commission has e Provides that licensees who lose radioactive made significant changes to its enforcement sources and do not identify rnd report the j

policy. The revised policy was published in the loss to NRC normally will be subject to a civil i

Federal Register on June 30,1995 (60 FR 34380). It penalty at least on the order of the cost for an has also been published as NUREG-1600, which authorized disposal or transfer to an was mailed to all NRC licensees during the month authorized recipient of such a source; of July.

Provides that minor violations, formerly e

Licensees should become familiar with the new referred to as Seventy Level V violations, will l

Enforcement Policy. There are now increased n t be cited; and incentives for licensees to identify and correct violations. Because of the changes to the Continues a trial program of conducting Enforcement Policy, a non-willful Severity Level

' III violation or problem normally will not be approximately 25 percent of predecisional l

assessed a civil penalty provided: (1) the licensee enforcement conferences open for public j

has had no previous escalated enforcement observation.

actions during the past 2 years or two inspections, whichever is longer; and (2) the licensee takes (Contact: Joseph DelMedico, OE,301-415-2739) prompt and comprehensive corrective action to 3

ensure that similar violations do not occur in the SIGNIFICANT ENFORCEMENT ACTIONS future. However, the policy does recognize some exceptions, such as the loss of radioactive sources discussed below.

More detailed information concerning these enforcement actions will be published in Even where prompt and comprehensive corrective NUREG-0940, " Enforcement Actions: Signifi-action is taken, other Severity Level III violations cant Actions Resolved," Volurne 14, No. 2, and Ievel I and II violations may be subject to Part III.

civil penalty if NRC identifies the violation, or if the licensee does not identify the violation before Medical an event such as an exposure occurs. The pohey also provides that the NRC staff may use discre-tion to propose a civil penalty or to increase or

1. Elias Charles Dow, M.D., Boston decrease a civil penalty where the normal outcome Massachusetts, EA 95-038 of the civil penalty decision procesc does not provide the appropriate regulatory message.

A $750 civil penalty was assessed for failure to maintain security of licensed material. 'Ihe NRC is continuing the policy that non-recurring licensee was dispensing I-131 capsules to level IV violations normally will not be cited if patients to be self-administered at a later identified and corrected by a licensee.

date.

9511020357 951031 PDR NUREG BR-0117 R PDR x--

NMSS LICENSEE NEWSLETTER-

10. Fedeml Register Notices (May 1,1995-SEPTEMBER-OCTOBER 1995 August 1,1995)(General

Contact:

l Kevin Ramsey, NMSS, 301-415-7887)..... 8 1

1%e

11. Generic Communications Issued (May 1, 1995-August 1,1995) (General

Contact:

1. NRC Changes Its Enforcement Policy Keym Ramsey, NMSS, 301-415-7887)..... 9 (Contact: Joseph DelMedico, OE, 301-415-2739)........................... I

12. Summary of Event-Related Reporting Requirements, Intended to Help

2. Sigmficant Enforcement Actions Material Licensees Be More Aware of (Contact: Joseph DelMedico, OE, Them (Contact: Kevin Ramsey, NMSS, 301-415-2739).......................... 1 301-415-7887)......................... 10

3. NRC Policy on Open Staff Meetings

13. A Sampling of Significant Events Reported (Contact: Jona Souder, ADM, to NRC by NRC Material Licensees 301-415-7170).......................... 4 (Contact Walter Lescheck, AEOD,

""""'~'

4. NRC and EPA Publish Joint Guidance on the Storage of Mixed Waste, for Comment (Contacts: Nick Orlando, NRC, 301-415-6749; Newman Smith, EPA, 703-308-8757)..........................

4

2. Robert E Hall, M.D., IA 95-018 A Notice of Violation was issued to this

5. Timeliness Rule Requires Decom.

missioning Action at Some Sites by physician who, as Chairman of the Radio-August 15,1995 (Contact: David Fauver, isotope Committee, deliberately allowed NMSS, 301-415-6625)................... 5 physicians who were not named on the U.S.

Nuclear Regulatory Commission license to

6. Clarification of NRC's Training and perform teletherapy treatments.

Experience Criteria (Contact: Janet Schlueter, NMSS, 301-415-7894)......... 6

3. Charles K. Loh, M.D., IA 95-017 A Notice of Violation was issued to this

7. Department of Energy Operating P ysician who, as Radiation Safety Officer, h

Experience (Contact: Carrie Brown, NMSS, 301-415-8092)................... 7 deliberately allowed physicians who were not named on the NRC license to perform

8. Formation of Spent Fuel Project Office teletherapy treatments.

(Contact: Earl Easton, 301-415-8520)...

.7 Radiography

9. Failure to Review Label Causes Misadministration (Contact: Susanne

1. J nes Inspection Services, Alderson, Oklahoma, EA 94-241 Woods, NMSS, 301-415-7267)............ 7 An Order was issued suspending authority to conduct radiography in areas under NRC jurisdiction because the proprietor failed to comply with the reciprocity requirements in 10 CFR 150.20.

Comments, and suggestions you may have for information that is not currently being

2. Mattingly Testing Services, Inc., Great Falls, meluded, that might be helpful to h,censees, Montana, EAs95-035 and 95-063 should be sent to:

E. Kraus A civil penalty of $15,500 and an Order NMSS Licensee Newsletter Editor Modifymg License was issued for deliberate Office of Nuclear Material Safety violations involving failure to ensure that an and Safeguards assistant radiographer was trained and 7Wo White Flint North, Mail Stop 8-A-23 supervised and other violations indicative of a U.S. Nuclear Regulatory Commission breakdown in control of licensed activities.

Washington, D.C. 20555-0001 The Order requires that the licensee obtain the services of an independent auditor.

2 n

3. Daron R. Hanson, IA 95-014 material, which resulted in the loss of a A Notice of Violation was issued to this radiographer for deliberate violations of

4. Joseph Paolino and Sons, Inc., Mt. Laurel, 10 CFR Part 34 requirements.

New Jersey, EAs94-248 and 95-090 4.

Bart A. Kutt, IA 95-013 A Confirmatory Order was issued to prohibit the entity or its successor from applym, g for A Notice of Violation was issued to the Vice an NRC license or engaging in NRC licensed President and Assistant Radiation Safety activities for a penod of 5 years. The NRC Officer of a radiography firm for deliberate license had been revoked for nonpayment of violations of 10 CFR Part 34 requirements.

fees and the bcensee had been ordered to transfer its moisture dcastty gauge to an

5. Mark M. Mattingly, IA 95-012 authorized recipient; however, the entity contmued to possess the gauge without a A Notice of Violation was issued to the license.

President and Radiation Safety Officer of a radiography firm for deliberate violations

5. Braun Intertec Corporation, Minneapolis, Minnesota, EA 95-104 involving storage and use at a location not authorized on the license and failure to audit A Notice of Violation was issued for failure to radiographers at 3-month intervals.

maintain a moisture density gauge under constant surveillance, which resulted in the

6. Frank Papalia IA 95-020 gauge being damaged by a bulldozer.

A Notice of Violation was issued to this radi-

6. Geotest, Ltd., Saginaw, Michigan, EA 95-112 ographer for deliberately providing inaccurate information, regarding radiography activities, A Notice of Violation was issued for failure to to an NRC inspector.

maintain security of a moisture density gauge, which was stolen from the open bed of a Measuring Gauges pick-up truck. The gauge was not secured to the bed of the truck.

1.

Highway Engineering & Survey Co., Bonners Ferry, Idaho, EA 95-042 7.

Soil and Materials Engineers, Inc., Plymouth, Michigan, EA 95-055 An Order to Cease and Desist Use and Possession of Regulated Byproduct Material A Notice of Violation was issued for failure to was issued based on possession and use of a mamtam secunty of a moisture density gauge, moisture density gauge without a U.S. Nuclear which was found m, an incoming shipment by Regulatory Commission license. The license a scrap metal dealer.

had expired.

8. IHS Geotech & CMT, Inc., San Antonio,

2. Wi!1iam and Joan Kimbly,IAs95-015 and Texas, EA 95-007 95-016 A $500 civil penalty was assessed for failure to rm NRC 241,(reciprocity) for work in e

A confirmatory Order was issued to the President and to the General Manager and areas under exclusive Federal jurisdiction.

Treasurer to prohibit them from applying for Other Materials Licensees an NRC license or engaging in NRC-licensed activities for a period of 5 years. The Order

1. Honeywell Incorporated, Minneapolis, was based on deliberate violations of NRC Minnesota, EA 92-112 license requirements for the use of moisture density gauges.

A civil penalty of $20,000 was assessed based on a willful violation involving transfer of

3. McCormick, Taylor and Associates, Inc.,

NRC licenses and licensed material to another Philadelphia, Pennsylvania, EA 94-253 entity without first receiving NRC authorization.

)

A $2000 civil penalty was assessed for failure to maintain proper security of licensed (Contact: Joseph DelMedico, OE,301-415-2739) 3

_ _ _ _ _ _ _ ____. _ __ _ ~ _

NRC POLICY ON OPEN STAFF MEETINGS NRC staff's execution of its safety and regulatory responsibilities, such as when ne U.S. Nuclear Regulatory Commission has the meeting is an integral part of the adopted a new policy aimed at increasing public execution of the NRC inspection program.

access to meetings with the NRC staff. The final policy statement (59 FR 48340) was published on Whether a meeting should be open to the public September 20,1994, and became effective depends primarily on the subject matter to be November 1,1994. In general, meetings conducted discussed, not on who is participating (i.e., staff and sponsored by NRC staff are to be open to level versus senior management). The telephone public attendance and observation when the recording and computer bulletin board will in-purpose is to discuss substantive issues bearing clude information on the date, time, and location on NRC's regulatory and safety responsibilities. A of the meeting, its purpose, the NRC offices and toll-free telephone recording and a computer outside organizations m attendance, and the name bulletin board service have been established to and telephone number of the NRC contact for the inform interested parties of upcoming public meeting. Information about canceled or re-meetings.

scheduled meetings will be updated as necessary.

The new policy allows greater public scrutiny of he recording and bulletin board will cover public NRC's regulatory activities, and replaces an meetings scheduled during the next 60 calendar earlier policy statement on open meetings days and new meetings will be added daily. In published in 1978. Meetings between the NRC addition, a weekly listing will be posted in the staff and outside parties will generally be NRC Public Document Room at 2120 L Street classified as public meetings unless the subject (Iower Level) NW., Washington, DC, and in all matter to be discussed:

Local Public Document Rooms. He Office of Public Affairs will continue to issue public a.

is specifically authorized by an Executive announcements on the more significant meetings.

i Order to be kept secret in the interests of The toll-free number for the telephone recording 1

national defense or foreign policy (classi-is 1-800-952-%74. The telephone number for the fled information), or is specifically computer bulletin board is 1-800-303- % 72 exempted from public disclosure by (access through Gateway).

statute; (Contact: Jona Souder, ADM,301-415-7170)

b. contains trade secrets and commercial or financial information (proprietary NRC AND EPA PUBLISH JOINT GUIDANCE information);

ON THE STORAGE OF MIXED WASTE, FOR COMMENT

c. contains safeguards information; Draft guidance on the storage of mixed waste was

d. is of a personal nature where pub!!c published in the Federal Register on August 7, disclosure would constitute a clearly 1995 (60 FR 40204). He U.S. Nuclear Regulatory unwarranted invasion of personal privacy; Commission and the U.S. Environmental Protec-tion Agency (EPA) will accept public comments e.

is related to a planned, ongoing, or on the draft guidance until November 6,1995.

completed investigation and/or contains Mixed waste is defm' ed as waste that contains information compiled for law enforcement both hazardous waste and source, special nuclear, purposes; or byproduct material subject to the Atomic Energy Act of 1954. Persons who generate, treat, f.

could result in the inappropriate dis-store, or dispose of mixed wastes are subject to closure and dissemination of preliminary, the requirements of the Atomic Energy Act, as unverified information; amended, and the Solid Waste Disposal Act, as amended by the Resource Conservation and l

g. is a general information exchange having Recovery Act (RCRA), and the Hazardous and I

no direct, substantive connection to a Solid Waste Amendments. The Federal agencies i

specific NRC regulatory decision or responsible for ensuring compliance with the action; implementing regulations of these statutes are NRC and EPA.

h. indicates that the administrative burden associated with public attendance at the Despite concerted State efforts for more than 15 meeting could result in interfering with the years, no new disposal facility for commercial 4

low level radioactive waste, or mixed waste, has detecting leaks, locating the source, and respond-begun operation, with the exception of Envirocare ing within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of detection to mitigate any of Utah, which accepts some low-activity wastes significant release.

and certain mixed wastes for disposal. Develop-Issue 4: Confusion exists over ways to comply with ment of new treatment facilities for mixed waste has been limited also. Mixed-waste generators b th NRC and EPA waste management require-have raised concerns that NRC's storage require-ments, especially those for incompatible wastes.

ments for radioactive waste run counter to the Resolution: Incompatible wastes or other aims of RCRA. As part of a larger cooperative materials must be separated or protected by effort, NRC and EPA have developed draft means of a dike, berm, wall, or other device to guidance for public comment that, when finalized, prevent ignition or reaction. However, this can can be used by commercial mixed waste occur in the same storage facility and does not generators currently storing their waste.

necessitate the construction of an entirely separate storage unit. In situations where high-The four issues identified to the agern:ies by the activity mixed wastes are monitored by remote regulated community, and the proposed resolu-means and/or stored using dense packing, tions, are as follows:

facilities must demonstrate to the EPA Regional Administrator the need to control the radiation Issue 1: Generators may not use decay-m.-storage hazard. The determination to waive or alter the to reduce the hazard of mixed waste as it would aisle space requirement will be made on a case-violate the RCRA prohibition on the storage of by-case basis and be incorporated into the hazardous waste.

facility's RCRA permit.

Resolution: Limited periods of decay-in-storage of Interested individuals should send written com-mixed waste do not violate the RCRA storage ments on the published guidance to: David L.

prohibitions because decay-in-storage is a nec-Meyer, Chief, Regulatory Publications Branch, essary and useful part of the best demonstrated Division of Freedom of Information and Publica-available technology (BDAT) treatment process.

tion Service, Office of Administration, U.S.

Herefore, the Land Disposal Restrictions storage Nuclear Regulatory Commission, Washington, DC prohibition does not apply to mixed waste held 20555, or hand-deliver comments to the pursuant to an NRC approved decay-in storage Commission's offices at 11545 Rockville Pike program during the period of decay.

(Room T6-D59), Rockville, MD 20555.

Issue 2: Daily or weekly " walk-through" inspec-For further information, contact Dominick A.

tions of high-activity mixed waste may result in Orlando, Division of Waste Management, Office increased exposures to workers at their facilities of Nuclear Material Safety and Safeguards, U.S.

and thus violate the requirement to maintain Nuclear Regulatory Commission, Washington, radiation exposures as low as is reasonably DC, 20555, telephone (301) 415-6749, or Newman achievable.

Smith, Permits and State Programs Division, Office of Solid Waste, U.S. Environmental Resolution: RCRA regulations and permit Protection Agency, Washington DC,20460, guidance do not require that inspections of mixed telephone (703) 308-8757.

waste in storage be " walk-through" inspections.

Alternative methods for mspection could include (Contacts: Nick Orlando, NRC,301-415-6749'-

Newman Smith, EPA,703-308-8757) the use of remote monitoring devices to determine if a waste container is leaking, or television moni-TIMELINESS RULE REQUIRES DECOM-tors, or other means that are capable of detecting MISSIONING PLANS FOR SOME SITES BY leakage or deterioration. These measures should AUGUST 15,1995 be coupled with a means to promptly locate and segregate or remediate leaking containers.

The September October 1994 NMSS Licensee Newsletter (NUREG/BR-0117, No. 94-3)

Issue 3 RCRA inspection requirements restrict announced the issuance of the " Final Rule on the use of containers with low radiation levels to Decommissioning Timeliness" which added shield containers with higher radiation levels, and schedule requirements. The timeliness rule was such a restriction could cause an increase in effective August 15,1994. He article provided an worker exposures.

explanation of the rule and also stated that significant failure to conform to the new Resolution: Containers may be used for radiation requirements has been classified as a Severity shielding, so long as a licensee is capable of Level III violation.

5

De " timeliness" rule requires licensees to notify CLARIFICATION OF NRC'S TRAINING AND 4

NRC within 60 days if: 1) the license has expired, EXPERIENCE CRITERIA or has been revoked 2) the licensee has decided to cease principal activities at the entire site or in ne U.S. Nuclear Regulatory Commision staff and any separate building or outdoor area; or 3) no management routinely receive inquiries from phy-pnncipal activities, under license, have been sician applicants, members of the medical com-conducted at the site, or in any separate building munity, and Agreement States on 10 CFR Part 35, or outdoor area, for 24 months. He timeliness Subpart J requirements, particularly, whether cer-rule should be carefully reviewed for applicability tain required training elements may be obtained to your site.

concurrently. In some cases, the 500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> of practical experience requirements [10 CFR ne Implementation Section of the Supplementary 35.920(b)(2)] and the 500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> of clinical experi-Information on the rule (59 FR 36026) states that ence requirements [10 CFR 35.920(b)(3)] associ-licensees with unused facilities as of July 15,1994, ated witb the use of byproduct material have been would be allowed 2 years from the effective date perceived as being able to be completed concur-of the rule, August 15,1994, to submit the re-tently for a total of 500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> of experience.

quired notification, even though the total period Additionally, NRC regional license reviewers re-ofinactivity may actually end up being greater ceive medical use applications or amendments for than 2 years. This provides licensees 2 years in authorization of physicians who do not appear to which to determine whether the unused facility meet 10 CFR Part 35, Subpart J training and would be put into use again or to submit notifica-experience criteria. Specifically, the applicant doc-tion as required under the rule. However, this uments less than the required number of accept-statement only applies to licensees that have not able hours of training and experience, as de-previously notified NRC that principal operations scribed in the applicable section of Subpart J have ceased.

(e.g.,60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br /> for 10 CFR 35.100 materials,1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br /> for 10 CFR 35.200 materials,80 hours9.259259e-4 days <br />0.0222 hours <br />1.322751e-4 weeks <br />3.044e-5 months <br /> for For those sites that are required to submit a 10 CFR 35.300 materials, etc.). The NRC staffis decommissioning plan, the timeliness rule developing guidance on this, and other issues requires that the plan be submitted within 12 regarding the review of training and experience months of making the above notification to NRC.

documentation, for use by the regional staff.

However, if a licensee were to make the above notification, pursuant to the rule on " Expiration While developing the guidance discussed above, and Termination of Licenses," before August 15, NRC staff recently determined that, in cases 1994 and such notification were documented by where an applicant does not appear to meet the letter, license amendment, m, spection report, or applicable required number of training and exper-other means, a decommissionmg plan would not ience hours, an exemption to the regulations is be required until August 15,1995, since the needed to approve the authorized user. It should 12-month period is not applied retroactively to the be noted that Section 35.19 indicates that NRC date of the notification. Likewise,if the will seek assistance from the Advisory Committee notification were made before August 15,1994, on the Medical Uses of Isotopes (ACMUI) when and a decommissioning plan were not required, reviewing requests for exemptions from the Sub-decommissioning would have to be completed by part J criteria. 'Ib streamline the exemption review August 15,1996. However, the rule does provide process, and provide guidance to the regions, the the opportunity for heensees to propose alternate staff proposed a minimum number of acceptable schedules.

2 training and experience hours for discussion with the ACMUI at its semi-annual meeting (May 11-There has been some confusion as to the applica-12,1995). The consensus of the ACMUI was that bility of the 24-month " grace" period for unused the committee would not identify a minimum facilities, buildings, or outdoor areas, to licensees number of acceptable training and experience that provided notification before August 15,1994.

hours, for any category of medical use, at this ne grace period does not apply to such licensees.

time. Rather, the ACMUI recommended that If you have not properly understood the applica-rulemaking was necessary, and that the staff bility of the schedule requirements of the time-should continue to bring requests, for exemptions imess rule, and are now late, please call your to Subpart J criteria, to the attention of the project manager or license reviewer to explore ACMUI for its review. As a result, the staff is avenues of relief.

developing a procedure to document and stream-line the ACMUI review of such exemption (Contact: David N. Fauver, NMSS,301-415-6625) requests, so that the process will not be overly 6

burdensome for either the applicant, NRC staff, URL: (3) click on the " paste" button; and (4) click or the ACMUI.

on the "OK" button. He URL is either of th following.

(Contact: Janet R. Schlueter, NMSS, gopher://146.138.63.106:70/11%5cdir%5cnfs%5 301-415-7894) coeweekly DEPARTMENT OF ENERGY (DOE) 80P er// apollo.eh. doe. gov:70/11%5cdir%5cnis h

OPERATING EXPERIENCE

%5coeweekly The DOE Office of Nuclear and Facility Safe,ty publishes a weekly publication titled "Operatmg

{her://146.138.63.106:70/11%2Fdir%2Fnfs%

e Experience Weekly Summary." The purpose of gY this summary is to enhance safety throughout the Users can then save the URL as a Bookmark. 'Ib DOE complex.oy promoting feedback of operatmg expenences, and encouragmg the access other documents published by DOE, users exchange of mformation among DOE nuclear can type in the URL for the TIS home gopher facilities. Many of the lessons learned in this server. De URL is gopher://dewey. tis. incl. gov.

periodical are from experiences of DOE manufacturing and processmg operations, which (Contact: Carrie Brown, NMSS,301-415-8092) may be similar to processing operations at.

FORMATION OF THE SPENT FUEL NRC-heensed fuel conversion and fabn, cation PROJECT OFFICE facilities. His summary is available for your information by contacting Mr. Richard L.

The Spent Fuel Project Office (SFPO) has been

'Ilrevilhan, EH,33 Room E-460 GTN, U.S.

created, within the Office of Nuclear Material Department of Energy, Washington, DC,20585, Safety and Safeguards (NMSS) to provide a dedi-telephone number (301) 903-3074.

cated organization and to focus management attention on the time-sensitive matters and The summary is also available on the Internet high-visibility tasks associated with licensing the through the World Wide Web (WWW). 'Ib access Department of Energy's proposed Multi-Purpose the WWW server, users must have web browser Canister (MPC) system, and the possible licensing software such as NCSA Mosaic or Netscape and of a monitored retrievable storage (MRS) facility, means to access the Internet, such as direct-or a private independent spent fuel storage connect modems. Network access through a installation (ISFSI). He SFPO is also responsible network modem or network computer termmal for ongoing reviews of radioactive waste transpor-may also be used.

tation and spent fuel storage systems. ne Director of the SFPO is William D. ' Ravers and The Uniform Resource Locator (URL) for the the Deputy Director is Charles J. Haughney.

home page for the WWW server is http://.www Mr. Tiravers can be reached at (301) 415-8500, and

.ch. doe. gov / frequent.htm. De operating experi-Mr. Haughney can be reached at (301) 415-8560.

ence weekly summary portion of the home page The SFPO reports to the Director of NMSS.

provides the user with two choices: a link to the current Weekly Summary and a link to past (Contact: Earl Easton, NMSS,301-415-8520)

Weekly Summaries. The DOE Technical Infor-mation Services (TIS) also provides a home page FAILURE TO REVIEW LABEL CAUSES (DOE Lessons Learned Information) to the MISADMINISTRATION sop er server that stores the Weekly Summaries.

h The URL is http:// venus.hyperk.com/trl/ll/ll.html A recent misadministration resulted when labels (1 is lower-case letter "L"). The Office of Nuclear for two separate I-131 doses were placed on the and Facility Safety (DOE) encourages WWW lids of the corresponding vial shields, and the lids users to save this home page as a "HotList Item" were inadvertently switched. The labeling on the (in Mosaic) or as a " Bookmark" (in Netscape) to individual dose vial was not reviewed before shorten the time for finding Weekly summaries.

administering the dose to one of the patients.

Consequently,1110 MBq (29.9 mci) of I-131 were Gopher users can access the weekly summaries by delivered to a patient for whom the intended dose typing in the URL on a command line provided in was 300 MBq (8 mci). He patient scheduled to h

most go? er software programs. In the program, receive the larger dose cancelled his appointment; WSGop ier, the user must: (1) select "New hence, a second misadministration did not occur.

Gopher Item"in the File menu;(2) type in the The misadministration was discovered the l

7

following day; then the remaining dose was

Contact:

measured for further use and the activity was Jona L. Soudct, ADM,301-415-7170 found to be much lower than expected.

FINAL RULES (All Parts are from 10 CFR.)

Nuclear Material Safety and Safeguards medical licensees are encouraged to review their vial label.

Parts 2,19, 20, 30, 32, 40, 50, 51, 60, 61, 70, 71, ing processes and consider actions to avoid simi.

72,73,74,76, and 150, " Changes to NRC lar problems. Label placement and label review Addresses and Telephone Numbers," 60 FR processes may vary in effectiveness from one facil.

24549, May 9,1995.

ity to another. In the described case, the method

Contact:

of labeling the vial shield and the failure to com.

Michael T.12sar, ADM,301-415-7163 pare the shield label with the dose vial label couM have resulted in multiple misadministrations.

Part 20, " Low-Level Waste Shipment Manifest Review of the labeling processes implemented at a Information and Reporting; Correction," 60 facility and periodic retraining on the importance FR 25983, May 16,1995.

of dose verification may prevent such occurrences.

Contact:

Mark Haisfield, RES,301-415-61%

(Contact: Susanne Woods, NMSS,301-415-7267)

Parts 11 and 25, "NRC Licensee Renewal /

FEDERAL REGISTER NOTICEa Reinvestigation Program"(access authori-(May 1,1995-August 1,1995) zations),60 FR 26355, May 17,1995.

Contact:

GENERAL NOTICES James J. Dunleavy, ADM,301-415-7404 Part 34, " Performance Requirements for

" Governor's Designees Receiving Advance Notification of Transportation of Nuclear Radiography Equipment,, 60 FR 28323, Waste"(annual update of list),60 FR 34306, May 31,1995.

C#"'"####

June 30,1995*

'Ihomas Rich, NMSS,301-415-7893; J. Bruce Carrico, NMSS,301-415-7826 POLICY STATEMENTS Parts 170 and 171, " Revision of Fee Schedules;

. Revision of the NRC Enforcement Policy,,,

100% Fee Recovery, FY 1995," 60 FR 32218, 60 FR 34381, June 30,1995.

June 20,1995.

Contact:

C" James Lieberman, OE,301-415-2741 Ja es bolloway, OC,301-415-6213 PETITIONS FOR RULEMAKING (All Parts are Part 72, " Emergency Planning Licensing from 10 CFR.).

Requirements for Independent Spent Fuel Storage Installations (ISFSIs) and Monitored Part 72, " Maryland Safe Energy Coalition; Retrievable Storage (MRS) Facilities," 60 FR Denial of Petition," 60 FR 38286, July 26, 32430, June 22,1995.

1995

Contact:

Contact:

Michael T Jamgochian, RES,301-415-6534 Gordon E. Gundersen, RES,301-415-6195 Part 2, " Policy and Procedure for Enforcement DRAFT REGULATORY GUIDES (NOTICE Actions: Removal," 60 FR 34380, June 30, OF AVAILABILITY) 1995.

Contact:

DG-0008, " Applications for the Use of Sealed James Lieberman, OE,301-415-2741 Sources in Portable Gauging Devices," 60 FR 29719, June 5,1995.

Parts 19 and 20, " Radiation Protection Requirements: Amended Definitions and PROPOSED RULES (All Parts are from 10 Criteria," 60 FR 36038, July 13,1995.

CFR.)

Contact:

Alan Roecklein, RES,301-415-6223 Part 9, " Revision of Specific Exemptions under the Privacy Act," 60 FR 38282, July 26, Part 110," Import and Export of Radioactive 1995.

Waste," 60 FR 37556, July 21,1995.

8

Contact:

This letter provides the policy statement on Ronald Hauber, OIP,301-415-2344.

open communications between licensecs and NRC staff, and states that inappropriate Parts 30, 40, 70, and 72, " Clarification of actions by NRC staff against licensees who Decommissioning Funding Requirements,"

communicate concerns to the Agency will not 60 FR 38235, July 26,1995.

be tolerated.

Contact:

Contact:

Mary L Thomas, RES,301-415-6230 Kevin M. Ramsey, NMSS,301-415-7887 (General Contac t: Kevin Ramsey, NMSS, Information Notices (ins) 301-415-7887)

IN 95-25, " Valve Failure during Treatment GENERIC COMMUNICATIONS ISSUED with Gamma Stereotactic Radiosurgery Unit,"

"I (May 1,1995-August 1,1995)

This notice alerts addressees to an incident in I

Note that these are only summaries of U.S.

which the atient couch of a Leksell Gamma Nuclear Regulatory Commission generic System M el 23016 (" gamma knife") unit commumcations. If one of these documents failed to retract from the treatment position appears relevant to your needs and you have not because of a valve failure on the hydraulic received it, please call one of the techmcal system of the unit.

contacts listed below.

Contact:

Patricia K. Holahan, NMSS,301-415-7847

)

Administrative letters (ALs)

IN 95-28, " Emplacement of Support Pads for AL (unnumbered), " Final Revisions to 10 CFR Parts l'M and 171 on License, Inspec-Spent Fuel Dry Storage Installations at Reactor Sites," June 5,1995.

l tion, and Annual Fees for FY 1995," June 19, i

1995'

{*

His notice reminds addressees cf the Dis letter explains the changes contained in importance of complying with all co.'ditions the final fee rule for fiscal year 1995 and and requirements specified in 10 CFR includes a copy of the rule. The fees for most 72.212(b) and other regulations before using NMSS licensees have been reduced.

certified casks under the provisions of the j

Contact:

general license in Part 72.

Contacts:

C. James Holloway, OC,301-415-4213 E Sturz, NMSS,301-415-7278 AL 94-13, Revision 1, " Access to Nuclear M. Gamberoni, NRR, 301-415-3024 Regulatory Bulletin Board Systems," June 29, 1995.

IN 95-29," Oversight of Design and Fabrication Activities for Metal Components This letter updates information provided in Used in Spent Fuel Dry Storage Systems,"

the original letter concerning the availability June 7,1995.

of NRC computer bulletin board systems.

Contacts:

This notice alerts addressees to shortcomings Andrew J. Kugler, NRR,301-415-2828 found in the oversight of design and Kevin Ramsey, NMSS,301--415-7887 fabrication activities for metal components used in spent fuel dry storage systems.

AL (unnumbered), "NRC Policy on Communi-Contacts:

cations between the NRC and Licensees,"

Stephen C. O'Connor, NMSS,301-415-7878 j

July 12,1995.

Stephen S. Koenick, NRR,301-415-2841 9

i

SUMMARY

OF EVENT-REIATED REPORTING REQUIREMENTSo INTENDED TO HELP MATERIAL LICENSEES [2E MORE AWARE OF THEM (St units used only when cited regulations contain them.)

l l

10CFR REPORTABLE EVENT TO WHOM?

WHEN?

l 20.1906(dX1)

Removable contamination on package > limits in 10 CFR 7L87.

Final delivery carrier &

(1) Immediately l

(dX2)

. Radiation levels on package > limits in 10 CFR 71.47.

Regional Administrator (2) Immediately 20.2201(aXIXi) Lost / stolen / missing material 11000 X App. C value.

NRC Operations Center (i) Immediately (aXIXii)

Iest/ stolen /missin8 material 110 X App. C value.

(Both events)

(ii)30 days 20.2202(aX1)

Exposure (real or threatened) A TEDE of 25 rem (0.25 Sv), or LDE NRC Operations Center &

(aX1)Immediately of 75 rem (0.75 Sv), or SDE (WB or ME) of 250 rads (2.5 Gy).*

Regional Administrator (bX1) 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> (bX1)

Exposure (real or threatened)1 TEDE of 5 rem (0.05 Sv), or LDE (Both events) of 15 rem (0.15 Sv), or SDE (WB or ME) of 50 rads (0.5 Gy).*

20.2202(aX2)

Release where individual could have intake > 5 X ALI over 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.* NRC Operations Center &

(aX2)Immediately (bX2)

Release where individual could have intake > 1 X ALI over 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.* Regional Administrator (bX2) 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> (Both events) 21.21(aX2)

Interim evaluation report-basic component may be defective or (aX2) Document Control Desk (aX2) 60 days 5

may not comply with procurement document.

and Regional Administrator j

(c)

Receipt of information reasonably indicting that a basic component (c) NRC Operations Center (c) 2 days is defective or fails to comply with its procurement document.

l 30.9(b)

Receipt of any information having significant implication for public Regional Administrator 2 days I

health and safety i

30.34(h)

The filing of any petition for bankruptcy by or against the licensee, Regional Administrator Immediately its parent, or an affiliate.

30.50(a)

Event that prevents immediate protective actions necessary to avoid NRC Operations Center Within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> overexposure or releases of discovery l

30.50(bX1)

Unplanned contamination requiring access to be restricted for NRC Operations Center Within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> (for reason other than decay of isotopes with of discovery half-lives < 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />).

j I

30.50(bX2)

Safety equipment, required by license or regulation. is disabled or NRC Operations Center Within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> fails to function when equipment is required to be available and of discovery -

j operable and no redundant equipment is available and operable.

l 30.50(bX3)

Unplanned treatment in medical facility of contaminated individual.

NRC Operations Center Within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of discovery l

?

10CFR REPORTABLE EVENT TO WHOM?

WHEN?

30.50(bX4)

Unplanned fire or explosion damaging licensed material or any NRC Operations Center Within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> device, container, or equipment containing licensed material.

of discovery 30.55(c)

Attempted theft or unlawful diversion of tritium > 10 curies Regional Administrator Imnediately (370 GBq) at one time, or > 100 curies (3700 GBq) in a year.

34.25(d)

Leak test result 10.005 microcuries (185 Bq).*

Director, Office of Nuclear Within 5 days Material Safety and Safeguards, of test

& Regional Administrator 34.30(a)

Source disconnect, inability to retract source, or failure of Medical, Academic, and

. Within 30 days any component critical to safety.

Commercial Use Safety of event Branch, & the Director, Office for Analysis and Evaluation of Operational Data 3533(aX1)

Medical misadministration.

NRC Operations Center Next calendar day after discovery gO 35.59(eX2)

Leak test result 10.005 microcuries (185 Bq).*

Director, Office of Nuclear Within 5 days Ma erial Safety and Safeguards, of test

& Regional Administrator 36.83(a)

Irradiator events listed in 10 CFR 36.83 (aX1)-(aX10), if not NRC Operations Center Within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> reported under other NRC regulations.

of discovery 39.35(dX2) teak test result 2 0.005 microcuries (185 Bq).*

Regional Office Within 5 days of discovery 39.77(a)

Ruptured well-logging source.

Regional Office Immediately i

39.77(c)

Irretrievable well-logging source.

Regional Office When apparent that recovery not possible i

(Contact: Kevin Ramsey, NMSS,301-415-7887)

• Note:

l

• EDE total effective dose equivalent.

LDE cye (or lens) dose equivalent.

SDE shallow dose equivalent.

WB whole body.

=

=

ME manmum extremity.

ALI annuallimit on intake.

Sv sievert.

Bq beaguerci.

9 FBq giga becquerel (10 ).

l

A SAMPLING OF SIGNIFICANT EVENTS Event 2-On another day, the same REPORTED TO NRC BY NRC MATERIAL patient was prescribed a dose of 1500 LICENSEES (SECOND QUARTER CY 1995) cGy (1500 rad) for lung treatment, but received a dose of about 2350 cGy Event 1:

Multiple Medical Brachytherapy (2350 rad) instead.

Misadministration Patient C: ne patient was prescribed a dose o Date Reported: June 2,1995 3000 cGy (3000 rad) for gynecologhal treatment, but received a dose of Licensee: Madigan Army Medical Center about 5142 cGy (5142 rad)instead.

Fort Lewis, Washington Patient D: The patient was prescribed a dose of From February 1994 through May 1995, four 1500 cGy (1500 rad) for a biliary tract patients were prescribed brachytherapy proce-treatment, but received a dose of dures and received doses other than those about 2050 cGy (2050 rad)instead.

prescribed because of the same computer input error. Details of the misadministrations are as The licensee does not expect the patients to follows:

experience any adverse health effects as a result of the misadministrations. Based on NRC's initial Patient A: He patient was prescribed a dose of review, the probable causes of the treatment 2800 centigray (cGy)(2800 rad) for a errors were failures to: (1) independently check gynecological brachytherapy treat-the data input to the computerized treatment ment, but received a dose of about planning system; (2) independently check dose 1680 cGy (1680 rad)instead-rate calculations generated by the planning sys-tem; and (3) adequately train licensee staff. The Patient B: Event 1-He patient was prescribed physics staff at the medical center promptly cor-a dose of 1600 cGy (1600 rad) for lung rected the calculations, and took steps to ensure treatment, but received a dose of that appropriate data will be used for future about 2128 cGy (2128 rad)instead.

treatment plans.

UNITED STATES FIRST CLASS MAIL NUCLEAR REGULATORY COMMISSION POSTAGE AND FEES PAlo WASHINGTON, D.C. 20555-0001 USNRC PERMIT NO. G 67 OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300 4c1CC1CY194 sc531 CC 0[puBLIFAII i

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