ML20094H226

Office for Analysis and Evaluation of Operational DATA.1993 Annual Report - Nuclear Materials

ML20094H226
Person / Time
Issue date:	05/31/1995
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-1272, NUREG-1272-V08-N02, NUREG-1272-V8-N2, NUDOCS 9511140066
Download: ML20094H226 (122)

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.m AVAILABILITY NOTICE Availability of Reference Materials Cited in NRC Publications Most documents cited in NRC publications will be available from one of the following sources

• 1.

The NRC Public Document Room 2120 L Street, NW., Lower Level, Washington, DC 20555-0001 2. The Superintendent of Documents, U.S. Government Pnnting Office, P. O. Box 37082 Washington, DC 2C402-9328 3. The National Technical information Service, Springfield, VA 22161-0002 Although the listing that follows represents the majority of documents cited in NRC publica-tions, it is not intended to be exhaustive. t Referenced documents available for inspection and copying for a fee from the NRC Public Document Room include NRC correspondence and internal NRC memoranda; NRC bulletins, circulars, information notices, inspection and investigation notices; licensee event reports; vendor reports and correspondence: Commission papers; and applicant and licensee docu-ments and correspondence. The following documents in the NUREG series are available for purchase from the Government ] Printing Office: formal NRC staff and contractor reports, NRC-sponsored conference pro-i ceedings, international sgreement reports, grantee reports, and NRC booklets and bro-Chures. Also available are regulatory guides, NRC regulations in the Code of Federal Regula-tions, and Nuclear Regulatory Commission Issuances. Documents available from the National Technical information Service include NUREG-series reports and technical reports prepared by other Federal agencies and reports prepared by the Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission. Documents available from public and special technical libraries include all opea literature items, such as books, jou nal articles, and transactions. Federal Register notices, Federal and State leg: station, and congressional reports can usually be obtained from these libraries. Documents such as theses, dissertations, foreign reports and translations, and non-NRC con-forence proceedings are available for purchase from the organization sponsoring the publica-tion cited. 1 l Single copies of NRC draft reports are available free, to the extent of supply, upon written request to the Office of Administration, Distribution and Mail Services Section, U.S. Nuclear Regulatory Commission, Washington DC 20555-0001. Copies of industry codes and standards used in a substantive manner in the NRC regulatory process are maintained at the NRC Library, Two White Flint North.11545 Rockville Pike, Rock-ville, MD 20852-2738, for use ay the public. Codes and standards are usually copyrighted and may be purchased from the originating organization or, if they ars American National Standards, from the American National Standards institute,1430 Broadway, New York, NY 10018-3308. i l

OFFICE FOR ytyi <.;.>l-; ANALYSIS and EVALUATION of l OPERATIONAL DATA l l i 1993 ANNUAL REPORT TU / } l x j e e N/ t l $llN I_ p:. u 8 y- ^ \\ S G y +++++++++++ / I!I / U.S. NUCLEAR REGULATORY i M AY 1995 E B B B B B B BB B B B B B E

Previous Reports in Series The following semiannual or annual reports have been prepared by the Office for Analysis and Evaluation of Operational Data (AEOD). Semiannual Report, January - June 1984, AEOD S/405, September 1984 o o Semiannual Report, July - December 1984, AEOD/S502, April 1985 o Annual Report 1985, AEOD/S601, April 1986 o Report to the U.S. Nuclear Regidatory Commission ofAnalysis and Evaluation of Operational Data 1986, NUREG-1272, AEOD/S701, May 1987 o Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational Data 1987, Power Reactors, NUREG-1272, AEOD/S804, Vol. 2, No.1. October 1988 o Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational Data 1987 Nonreactors, NUREG-1272, AEOD/S804, Vol. 2, No. 2, October 1988 o Officefor Analysis and Evaluation of Operational Data 1988 Annual Report, Power Reactors, NUREG-1272, Vol. 3. No.1, June 1989 Officefor Analysis and Evaluation of Operational Data 1988 Annual Report, Nonreactors, e NUREG-1272 Vol. 3, No. 2. June 1989 Officefor Analysis and Evaluation of Operational Data 1989 Annual Report, NUREG-1272, Vol. 4, No. o 1, July 1990 i o Officefor Analysis and Evaluation of Operational Data 1989 Annual Report, NUREG-1272, Vol 4, No. 2. July 1990 Office for Analysis and Evaluation of Operational Data 1990 Annual Report, NUREG-1272, Vol. 5, No. o 1, July 1991 Office for Analysis and Evaluation of Operational Data 1990 Annual Report, NUREG-1272, Vol. 5, No. I o 2, July 1991 Officefor Analysis and Evaluation of Operational Data 1991 Annual Report, NUREG-1272, Vol. 6, No. o 1 1, July 1992 Officefor Analysis and Evaluation of Operational Data 1991 Annual Report, NUREG-1272, Vol. 6, No. o 2, August 1992 i Officefor Analysis and Evaluation of Operational Data 1992 Annual Report, NUREG-1272, Vol. 7, No. o 1, July 1993 Officefor Analysis and Evaluation of Operational Data 1992 Annual Report, NUREG-1272, Vol. 7, No. o I 2, October 1993 Officefor Analysis and Evaluation of Operational Data 1993 Annual Report, NUREG-1272, Vol. 8, No. o 1 November 1994

Abstract This annual report of the U.S. Nuclear Regulatory NRC's Operations Center. NUREG-1272, Vol. 8, Commission's Office for Analysis and Evaluation No. 2, covers nuclear materials and presents a of Operational Data (AEOD) describes activities review of the events and concerns during 1993 conducted during 1993. The report is published in associated with the use of licensed material in two parts. NUREG-1272, Vol. 8 No.1, covers nonreactor applications, such as personnel power reactors and presents an overview of the overexposures and medical misadministrations. operating experience of the nuclear power Note that the subtitle of No. 2 has been changed industry from the NRC perspective, including from "Nonreactors" to " Nuclear Materials." Both comments about the trends of some key reports also contain a discussion of the Incident performance measures. The report also includes Investigation Team program and summarize both the principal findings and issues identified in the incident Investigation Team and Augmented AEOD studies over the past year and summarizes Inspection Team reports. Each volume contains a information from such sources as licensee event list of the AEOD reports issued from 1980 reports, diagnostic evaluations, and reports to the through 1993. i iii NUREG-1272

1 Contents Page Ab st ract........................ i'ii Abbreviations..................................... Vii Execu t ive S u m m a ry.................................................................... ix 1 1 Introduction 2 Nuclear Materials Operating Experience Feedback..................................... 3 2.1 Nuclear Materials Events Data Base......................................... 3 2.2 Medical Misadministrations..... 4 2.3 Rad ia tion Overexpos u res.................................................... 7 2.4 Loss of Control of Licensed M aterial......................................... 8 8 2.5 Leaking Sources.......... 2.6 Release of Material.................... 9 9 2.7 Transportation Events 9 2.8 Equipment Problems....... 10 2.9 Fuel Cycle Facility Events 2.10 Test, Research, and Training Reactors 11 2.11 Annual Radiation Exposure Data. 11 15 3 Abnormal Occurrences.......... 3.1 NRC Licensees................... 15 3.1.1 Medical Institutions 15 3.1.2 Ind ustrial Radiographers................................................ 15 3.1.3 Rese arc h React o rs.................................................... 15 15 3? Agree men t S t at es............................................................ 15 3.2.1 Medical Institutions 16 ) 3.2.2 Industrial Radiographers............ 3.2.3 O ther I n d ustrial Users................................................ 16 ) 17 l 4 AEOD Initiatives 17 4.1 Improved Nuclear Materials Events Data Base.................................. 17 4.1.1 B a c kg r o u n d......................................................... 17 4.1.2 Data Base Developme nt............................................... 4.1.3 Status of the Nuclear Materials Events Data Base.......................... 17 4.1.4 Planned Improvements in the Collection of Operational Experience.......... 18 18 4.2 Systematic Review of Nuclear Materials Experience............................... 18 4.3 Feedback of Nuclear Materials Experience....................................... 18 4.4 Abnormal Occu rrences....................................................... 19 4.4.1 Abnormal Occurrence Reporting......................................... 4.4.2 Abnormal Occurrence Criteria-Revision of the AO Policy Statement........ 19 19 4.5 N on.powe r Rea ct o rs......................................................... NUREG-1272 v

=. Contents (continued) 1 Page 5 Incident Investigation Program....................................................... 21 5.1 Incident Investigation Teams.................................................. 21 5.2 Augmented Inspection Teams. 21 6 Data From the NRC Operations Center............................................. 23 Appendices A Nuclear Materials Data by Event Type B Summary of 1993 Abnormal Occurrences (Nonreactors) C Reports and Videotapes Issued From 1981 Through 1993 D Status of.AEOD Recommendations E Status of NRC Staff Actions for Events Investigated by Incident Investigations Teams (Nonreactors) Thbles

2. r., Nuclear Materials Licensees for 1993...........................................

Number of Reportable Events by Event Type for NRC and Agreement State 4 2.2 Medical Misadministrations Reported by NRC and Agreement State Licensees for 1993.... 6 2.3 Number of Overexposure Events Reported by NRC and Agreement State Nuclear M aterials Licensees for 1993..................................................... 8 2.4 Fuel Cycle Events Reported for 1993............................. 11 2.5 Annual Exposure Data for NRC Industrial Radiography Ucensees, 1988-1993............ 12 2.6 Annual Exposure Data for NRC Manufacturing and Distribution Licensees, 1988-1993.... 12 2.7 Annual Exposure Data for NRC Low-Level Waste Disposal Licensees, 1988-1993......... 13 2.8 Annual Exposure Data for NRC Independent Spent Fuel Storage Licensees. 1988-1993.... 13 2.9 Annual Exposure Data for NRC Fuel Fabrication and Processing Licensees, 1988-1993.... 13 6.1 Nuclear Materials Events Reported to the NRC Operations Center in 1993............ 23 6.2 Alert Events Reported at NRC-Licensed Nuclear Materials Facilities in 1993............. 23 NUREG-1272 vi

Abbreviations ACMUI Advisory Committee on Medical Uses mci millicuries ofIsotopes Nal sodium iodide j AEOD Analysis and Evaluation of Operational l Data (NRC Office for) NMED Nuclear Materials Events Data Base AO abnormal occurrence NMSS Nuclear Material Safety and Safeguards ARM area radiation monitor

1. E" ASLB Atomic Safety and Licensing Board NRR Nuclear Reactor Regulation Bq becquerel (NRC Office of)
2. Y
   1. " 8'"Y OSC Oncology Services Corporation OSP Office of State Programs (NRC)

) Co cobalt-60 RCEP Radiological Contingency and DOE U.S. Department of Energy Emergency Plan DOT U.S. Department of Transportation REIRS Radiation Exposure Information ] Reporting System EDO Executive Director for Operations (NRC) RES Nuclear Regulatory Research (NRC Office of) FDA U.S. Food and Drug Administration R1 Region I FY fiscal year Rll Region 11 I iodine SNM special nuclear material IIP Incident Investigation Program SRP Standard Review Plan IIT Incident Investigation Team ISA integrated safety analysis TRTR Test, Research, and Training Reactors MBq megabecquerel TS Technical Specifications vii NUREG-1272

l Executive Summary One of the activities of the Office for Analysis and 298 by Agreement States. Forty-seven of them and Evaluation of Operational Data (AEOD)is were medical misadministrations,13 of which the review and evaluation of operating experience were also reported to Congress as abnormal of programs involving the use of nuclear materials occurrences. The primary factors contributing to licensed by the United States (U.S.) Nuclear these misadministrations included patient Regulatory Commission (NRC), such as intervention resulting in dislodgement of sources; reactor-produced isotopes, natural and enriched errors in computer treatment planning; equipment uranium, and other special nuclear material malfunctions; errors in calculating the prescribed (SNM). The AEOD review and evaluation dose; and failures to verify the type of identifies safety-significant events and concerns administered radiopharmaceutical or the and their causes. When a safety concern is administered dosage, to calibrate the prescribed identified, the AEOD staff recommends NRC dosage, to verify patient identification, or to actions to resolve the problems underlying the lollow physician's orders. safety concern, and tracks the recommendations until they are resolved. NRC licensees reported 11 events in 1993 that resulted in overexposures to 15 people, and Twenty-nine States have entered into agreements Agreement State licensees reported 22 events that with the NRC to assume regulatory authority for resulted in overexposures to 24 people. Two of byproduct materials, source materials, and small these events were reported to Congress as amounts of enriched uranium or other SNM. abnormal occurrences. Eighty-two percent (18) of These States, known as Agreement States, the overexposures involved whole body exposures, regulate the programs of their licensees. The NRC and 13 percent involved extremity exposures. The directly regulates licensees in the remaining 21 overexposure events reported by NRC licensees States, the District of Columbia and all the U.S. were about evenly distributed among territories. medical / academic, research/ commercial, and industrial radiography licensees. On the other Approximately 7000 licensees are regulated by the hand, over 86 percent of the overexposures NRC and are authorized to possess and use reported by Agreement States involved industrial nuclear materials outside of reactors. About 5000 radiography. of these licensees are authorized to use byproduct materials for such applications as radiography, The primary causes of the medical / academic and gauges, and well-logging. Approximately 2000 research/ commercial overexposures were failure to licensees are authorized to administer byproduct adequately monitor quarterly exposures and materials or radiation from byproduct materials failure to wear adequate protective clothing. In to individuals for medical diagnosis and therapy. most of the events involving industrial Approximately 15,000 users are licensed by the 29 radiography for which a cause was provided, the Agreement States. Of these, about 10,000 are overexposure was attributed to either a personnel authorized to use byproduct materials for error or an equipment problem. radiography, and other industrial and commercial Other nuclear materials events included loss of uses. The remaining 5000 Agreement State licensees are authorized to use radioactive control of licensed material, leaking sources, materials for medical diagnosis or therapy. In release of material, transportation events, response to a 1991 NRC request for annual equipment problems, fuel facility events, and test, submittal of information, all 29 Agreement States research and training reactor events. For 1993 submitted summary reports on nuclear materials there were a total of 377 such events reported by events that occurred in 1993. NRC licensees and 257 reported by Agreement States. While there were no reported in 1993 714 events involving materials licensees overexposures or significant contaminations as a were reported to the NRC-416 by NRC licensees result of these reported events, several of them ix NUREG-1272

had the potential to affect the public health and In 1993 AEOD developed a new data base called safety and two of them met the criteria for the Nuclear Material Events Data Base (NMED). abnormal occurrence reporting to Congress. The NMED contains about 11,000 detailed As part of operational experience feedback, the rec rds of reported events, including voluntary AEOD staff prepared a videotape entitled " Good reports. These records melude material events for Practices in Cobalt-60 Teletherapy," which was all categories of material licensees, including distributed in April 1993. The video shows non-power reactors. Radiation overexposures for simulated administrations of external cobalt-60 commercial power reactors are also maintained in radiation therapy and demonstrates good the NMED. The NMED is expected to be fully practices when using teletherapy equipment. operational by the end of 1995. i P k NUREG-1272 x

1 Introduction The U.S. Nuclear Regulatory Commission (NRC) headquarters offices. (Incidents oflesser licenses the use of reactor-produced isotopes, the significance are investigated by augmented milling of uranium, and the subsequent processing inspection teams directed by one of the NRC of both natural and enriched uranium, as well as regional offices.) AEOD tracks the other special nuclear material (SNM). The NRC recommendations and staff actions contained in directly regulates licensees in 21 States, the its own studies and in IIT reports until they are District of Columbia, and the U.S. territories. resolved. The appropriate NRC program office or The remaining 29 states, known as Agreement regional office acts on each recommendation or States, have entered into agreements with the action and is responsible for resolving it. NRC under Section 274 of the Atomic Energy Act, as amended, to regulate the use of byproduct AEOD also coordinates the overall NRC materials, source materials, and other SNM. operational data program and serves as the central point for interaction with domestic and The NRC's Office for Analysis and Evaluation of foreign organizations performing similar work. Operational Data (AEOD) was created in 1979 to provide, as one of its primary roles, a strong, The 1993 AEOD Annual Report, NUREG-1272, independent capability to analyze operational Vol. 8, is published in two parts, entitled data. This role was strengthened and expanded in " Reactors" and " Nuclear Materials." This report 1987, in accordance with the Commission's on Nuclear Materials presents an overview of emphasis on operational safety. AEOD events reported by materials licensees during implements this role for nuclear materials 1993. The report includes the following applications through the analysis and evaluation appendices: of operating experience data associated with the Appendix A summarizes the 1993 nuclear use of radiological materials in nonreactor applications. AEOD publishes studies of specific materials events by event type. operational events. As appropriate, AEOD Appendix B summarizes the 1993 nuclear recommends actions to reduce the probability that these events will recur with the same materials abnormal occurrences. frequency or will lead to more serious events. Appendix C lists nuclear materials reports AEOD keeps informed of studies undertaken by other organizations within the NRC, and normally and videotapes issued by AEOD from 1981 does not duplicate a study unless a particular through 1993. need or special circumstance exists. Appendix D presents the Status of In May 1987 AEOD also became responsible for Recommendations included in AEOD the NRC's incident response, diagnostic nuclear materials studies. evaluation, technical training, and incident Appendix E presents the status of staff investigation programs. Incidents of potentially major safety significance are investigated by actions resulting from the findings of NRC incident investigation teams (llTs) directed by IITs for nuclear materials events. 1 NUREG-1272, Section 1

2 Nuclear Materials Operating Experience Feedback The primary concern with the use of radioactive employees and uncontrolled exposures to the materials is the potential for overexposure which general public are also a concern in the medical can cause cancer or, in severe cases, death. The use of radioactive materials. However, such potential for radiation-induced genetic mutations incidents are relatively rare considering that is also an important consideration. Extremity or hundreds of thousands of procedures are k)calized skin exposures from radioactively hot performed each year. particles are a lesser health concern but are still important to the NRC in assessing the 2.1 Nuclear Materials Events Data effectiveness of byproduct materials control. Base One measure of licensecs' control of regulated AEOD collects, reviews, and codes nuclear materials is the ability to limit the dose received materials event information reported by NRC by monitored employees. Materials licensees are licensees and Agreement States. Approximately required to monitor all employees who work with, 7(XX) NRC licensees and 15,(XX) Agreement State or may be present in the vicinity of, nuclear licenses submit reports of events, as required by materials and who have the potential for radiation Title 10 of the Code of Federal Regulations (10 exposure. Licensees are also required to monitor CFR), comparable Agreement State regulations, and control activities that can lead to exposing or license conditions. (Licensees also voluntarily their employees or the general public to radiation. submit reports of events that are not required to be reported. Voluntary reports are not considered Lost or stolen radioactive materials sometimes when evaluating operating experience and are lead to unintended personnel exposures. therefore not meluded in this annual report.) Information on leaking sources can provide NRC licensees submit reports directly to the NRC insights on design deficiencies or problems with regional or headquarters offices. Agreement State handling specific sources, both of which can lead licensees submit reports to the States, which m to personnel exposures. Events that involve the tum voluntarily transmit summary ieports to the release of radioactive materials or result in the NRC under an mformal information 3 haring introduction of radioactive material into greement. In addition, the NRC obtains reports consumer products can also result in unplanned of events from other sources, such as NRC radiation exposure. In accordance with the inspection reports, and occasionally from applicable regulations, the NRC requires licensees i' n licensees includmg members of the pubh,c. to submit reports on events which meet Reortable nuclear materials operating events established criteria. In addition, licensees are ine'lude (1) med; cal misadministrations of subject to citation for violation of applicable radiation or radiopharmaceuticals to patients, regulations or failure to meet their license (2) personnel radiation overexposures (3) loss of conditions. control of licensed material. (4) problems with equipment that uses licensed material or is The major problem with the use of radioactive otherwise associated with the use of licensed materials in medical applications arises from material, (5) releases of material or contamina-either the licensee's failure to effectively control a tion, (6) leaking radioactive sources, (7) problems licensed material or from other human errors, during the transportation of licensed material, such as dispensing a radiopharmaceutical that (8) problems in fuel cycle facilities, and (9) does not comply with a physician's prescription. problems in non-power reactors. This can result in a patient receiving an unintended or excessive dose or a dose to the From 1981 through 1992, nuclear materials event wrong treatment site. Occasionally, a data were coded and maintained in two data radiopharmaceutical is administered to the wrong bases, one containing records of medical patient. Excessive exposures to monitored misadministration events and the other containing 3 NUREG-1272. Section 2

AEOD Annual' Re' port,1993 ~ ^ ^ ~ ~~ ~ records of other reported nuclear materials Table 2.1 Number of Reportable Events by events. In 1993 AEOD developed a new data base Event Type for NRC and Agreement State called the Nuclear Materials Events Data base Nuclear Materials Licensees for 1993 (NMED), designed to allow multiple effects of a single event to be appropriately recorded. For Agreement example, an event may involve a medical Type of Event NRC States Total misadministration as well as a radiation Misadministration 28 19 47 overexposure and/or a loss of control of licensed material. In such a case, the event would be Overexposure 11 22 33 included in each applicable category, in 1993 less Loss of Control 116 128 244 than 20 percent of the events produced multiple of Material effects. In developing the data base structure, AEOD solicited and received substantial input Leaking Sources 25 19 44 from the NRC lleadquarters Offices of Nuclear Release of 34 10 44 Materials Safety and Safeguards (NMSS) and Material Nuclear Regulatory Research (RES), the regional offices, and the Agreement States. Transportation 55 33 88 Equipment 93 67 160 The NMED contains about 11,000 detailed Problems records of reported events, including voluntary reports, as well as reference information for Fuel Cycle 46 46 identifying associated reports, such as inspection Operations reports. (Agreement State data are available only Research and 8 8 from 1991 on.) The NMED contains records of Training Reactors materials events for all categories of materials lbtal 416 298 714 licensees, including non-power reactors. Radiation overexposures for commercial power reactors are also maintained in the NMED. The NMED is November 10,1980, required NRC rnedical expected to be fully operational by the end of 1995. licensees to report medical misadmmistrations to the NRC. This rule was revised in 1987 to require medical licensees in the Agreement States to In 1993 714 events involving nuclear materials report misadministrations to the appropriate licensees and nonpower reactors were reported to regulatory agency in their state. Agreement State the NRC-416 by NRC heensees and 298 by agencies had 3 years to promulgate State rules Agreement States. Table 2.1 shows the number of compatible with those of the NRC. Therefore, reportable events by type for both NRC and Agreement State licensees were required to report Agreement State licensees. Because licensees medical misadministrations by 1991. The submit revisions, late reports, or retractions, Agreement States have agreed to voluntarily minor changes may occur in the data published submit misadministration reports to the NRC. from year to year. The Quality Management Program and 2.2 Medical M.isadm.. trations mis Misadministrations Rule, which became effective in 1992, requires a quality management program The NRC and the Agreement States regulate and contains revised definitions of, and reporting certain aspects of reactor-produced radioisotopes requirements for, medical misadministrations, used in nuclear medicine and therapeutic The Agreement States have until January 27,1995, radiology pursuant to Part 35 of Title 10 of the to adopt these requirements. As part of this rule, Code of Federal Regulations (10 CFR Part 35), the definition of a misadministration was changed " Medical Use of Byproduct Material." The to include the following six types of j misadministration rule, which became effective on misadministrations. NUREG-1272, Section 2 4 l

Nuclear Materials-Nuclear Materials Operating Experience Feedback Type of Procedure Misadministrations 1. All Diagnostic Radiopharmaceuticals Wrong patient, radiopharmaceutical e (including < 30 Ci sodium iodide route, or dosage, and 1-125 or I-131) Dose > 5 rem Effective Dose Equivale.it or e 50 rem to an organ 2. Sodium Iodide Radiopharmaceuticals Wrong patient e (> 30 gCi sodium iodide 1-125 or I-131) Wrong radiopharmaceutical e Administered dosage differs from prescribed e dosage by > 20 percent and > 30 Ci 3. Therapeutic Radiopharmaceuticals (other Wrong patient e than sodium iodide, I-125 and 1-131) Wrong radiopharmaceutical e Wrong route of administration e Administered dosage differs by > 20 percent e from prescribed dosage 4. Teletherapy Wrong patient e Wrong mode of treatment e Wrong treatment site e Calculated weekly dose > weekly prescribed e dose by 30 percent Calculated total dose differs by > 20 percent e from prescribed dose e if < 3 fractions, calculated total dose differs by > 10 percent from total prescribed dose Wrong patient 5. Brachytherapy e Wrong radioisotope e Wrong treatment site (excluding migration of permanent implants) Leaking sources e Failure to remove sources for a temporary e implant Calculated administered dose differs by e > 20 percent from prescribed dose Wrong patient 6. Gamma Stereotactic Radiosurgery e Wrong treatment site e Calculated total administered dose differs by e > 10 percent from total prescribed dose As a result of the 1992 revision of 10 CFR Part 35, as diagnostic misadministrations, and (2) those a new classification of misadministration was performed for therapeutic purposes that were defined to include two types of sodium iodide previously defined as therapeutic radiopharma-(Nal) misadministrations: (1) those performed for ceutical misadministrations. These procedures diagnostic purposes that were previously defined involve either iodine-125 (1-125) or iodine-131 5 NUREG-1272, Section 2

~ AEO15 Annual R'ep' 'rt,1993 '^~ ~ ~ ~ ^ ~ ~ ~ ~ ~ ~ ~ ~~ ~ o (I-131) as Nal in amounts exceeding 1.11 radioisotopes because they are not regulated by megabecquerel(MBq)(30 microcuries [ Ci]). the NRC. Misadministrations that demonstrate a major The term " diagnostic misadministration," as used failure of the radiation safety program or result in in NRC regulations, refers to the adverse health effects to a patient are reported to misadministration of radioisotopes in such Congress as abnormal occurrences (AOs). Such nuclear medicine studies as renal, bone, and liver administrations that occurred in 1993 are scans. " Therapeutic misadministration" refers to discussed in detail in NUREG-0090, Vol.16, No. the misadministration of radiation in the 1 through 4, and are listed in Appendix B to this treatment of patients using cobalt-60 (Co-60)(the report. Follow-up of these events may be found in external use of radiation from a single Co-60 subsequent AO quarterly reports to Congress. source for therapeutic treatment), gamma stereotactic radiosurgery (the external use of The NRC regulates approximately 2000 licensees radiation from about 200 small Co-60 sources for in 21 States, the District of Columbia, and the therapeutic treatment), brachytherapy (the U.S. territories, that use radioisotopes in radiation insertion or implantation of sealed sources therapy and nuclear medicine applications. These containing radioactive material for therapeutic facilities submitted reports of 28 misadministra-treatment), or radiopharmaceutical therapy (the tions that occurred in 1993. The 29 Agreement ingestion or injection of radioactive materials for States regulate about 5000 medical institutions, patient therapeutic treatment). which include hospitals, clinics, and physicians in private practice. Agreement States submitted The potential or actual effect of a therapeutic reports of 19 misadministrations that occurred in misadministration generally differs from that of a 1993 (see Table 2.2). These events are listed m, diagnostic misadministration. Therapeutic Tables A-1.1 and A-2.1 respectively, of Appendix misadministrations are associated with A to this report. Thirteen of these events were procedures in which large doses of radiation are reported to Congress as abnormal occurrences. administered to patients to achieve a therapeuti Table 2.2 Medical Misadministrations Reported effect, while diagnostic misadmm, istrations are by NRC and Agreement State Licensees for 1993 associated with chmcal or investigative procedures requiring comparatively small doses of radiation. Agreement However, some misadministrations involving the Misadministrations NRC States 1btal use of Nal-125 or Nal-131 for diagnostic purposes may deliver unintended doses in the Radiopharmaceutical 1 0 1 therapeutic range to the patient's thyroid. Not all Sodium Iodide 7 6 13 therapeutic overdoses result in significant Brachytherapy 17 9 26 radiation-induced clinical effects to patients. Teletherapy 3 4 7 Some misadministrations occur because patients Total 28 19 47 are administered a dose of radiation that is less than that prescribed. In these cases, if the error is found in time, the total prescribed dose can still The primary factors contributing to therapeutic be achieved. misadmmistrations (brachytherapy, teletherapy, and radiopharmaceutical)in 1993 included patient intervention resulting in dislodgement of sources, AEOD routinely reviews reports of therapeutic errors in computer treatment planning, equipment and Nal misadministrations because of the malfunctions, and errors in calculating the potential for radiation-induced health effects. prescribed dose. Therapeutic and Nal misadministrations, individually and collectively, are more significant Sodium iodide misadministrations in 1993 mon than diagnostic misadministrations. AEOD does often resulted in overdoses rather than not review therapeutic misadministrations that underdoses.The primary causes of the Nal involve the use of accelerator produced misadministrations were failure to (1) verify the NUREG-1272, Section 2 6 l

Nuclear Materials-Nuclear Materials Operating Experience Feedback ? type of administered radiopharmaceutical (2) categorized as overexposures. Only doses to verify the administered dosage,(3) calibrate the patients not intended to be treated are included in prescribed dosage, (4) verify patient identification, this section. and (5) follow physician's orders. NRC licensees reported 11 events for 1993 that 1b prevent recurrence, NRC and Agreement State resulted in overexposures to 15 people, and licensees took similar corrective actions, including Agreement States reported 22 events for 1993 that implementation of procedures established by the resulted in overexposures to 24 people (see Table licensee's Quality Management Program, to 2.3). These events are listed in Tables A-1.2 and ensure the following: A-2.2, respectively, of Appendix A to this report. o patient identification Eighty-two percent (32/39) of the overexposures involved whole body exposures, and 18 percent o verificat. ion of the dose calculation (7/39) involved extremity exposures. The whole e verification of the treatment planning body overexposures ranged from 1.25 rems to 27.66 rems with a median value of 2.95 rems. program (Four whole body overexposure reports did not o review of the patient's chart provide the dose and were not included in the o staff training verification of the prescribed calculation of the median.)The extremity dose and procedure overexposures ranged from 21.69 rems to 1925 rems with a median value of 146 rems. Two o staff communication overexposure events were reported to Congress as o verification of prescribed treatment site abnormal occurrences. The overexposure events reported by NRC The NRC staff has taken steps to enhance licensees were about evenly distributed among licensec awareness of the potential for medical / academic, research/ commercial, and misadministrations by (1) conducting workshops mdustrial radiography licensees. On the other and meetmgs with professional societics as part of hand, over 86 percent of the overexposures the Quality Management rulemaking,(2)issumg reported by Agreement States involved industrial NMSS Newsletters and NRC Information Notices r diography. and Bulletins,(3) describing NRC requirements in professional society publications, and (4) issuing The primary causes of the medical / academic and inspection reports and enforcement actions. research/ commercial overexposures were failure to adequately monitor quarterly exposures and 2.3 Radiation Overexposures failure to wear adequate protective clothing. The criteria for radiation exposure limits for In most of the events involving industrial radiation workers are defined in 10 CFR 20.101, radiography for which a cause was provided, the 1 " Radiation dose standards for individuals in overexposure was attributed to either a personnel restricted areas"(10 CFR 20.1201, " Occupational error or an equipment problem. The types of dose limits for adults"), and 10 CFR 20.103, personnel errors involved were failures to " Exposure of individuals to concentrations of (1) make adequate radiation surveys,(2) fully radioactive material in air in restricted areas" retract and/or secure the source (3) connect the (20.1201,20.1204, 20.1701,20.1702, and 20.1703). In source, and (4) follow emergency procedures. The addition,10 CFR 20.105 " Permissible levels of types of equipment problems were (1) lock-box radiation in unrestricted areas"(20.1301 and malfunctions, (2) source disconnects, and 20.1302) addresses overexposures to non-radiation (3) sources stuck in the guide-tube. In essentially workers (members of the public). all cases involving equipment failures, the overexposures could have been prevented had the Medical misadministrations resulting in doses to radiographer or the assistant performed an patients in excess of planned treatments are not adequate radiation survey. 'A revised 10 CFR Part 20 became effective January 1,1994. The equivalent section(s) of the new 10 CFR Part 20 is shown in parentheses. 7 NUREG-1272, Section 2

MB01Q Annualn1%eport, %%S 1 Table 2.3 Number of Overexposure Events Reported by NRC and Agreement State Nuclear Materials Licensees for 1993 No. of Reports No. ofIndividuals Agreement Agreement Type of Licensee NRC States Total NRC States Total Medical / Academic 4 3 7 4 3 7 Research/ Commercial 3 0 3 7 0 7 Industrial Radiography 4 19 23 4 21 25 Total 11 22 33 15 24 39 2.4 Loss of Control of Licensed The causes associated with the reported events Material generally involved inadequate accounting procedures for licensed material or madequate security procedures, such as leaving material Events included in this category are reportable un tiended. A review of the event reports shows under 10 CFR 20.402, " Reports of theft or loss of that radiation momtors mstalled at commercial licensed material"(10 CFR 20.2201), except for abandoned well logging sources, which are I ndfills and scrap metal yards can reduce the mount of heensed material entering such reported in accordance with 10 CFR Part 39. The primary safety concerns stem from the loss of f cilities. For NRC and Agreement State licensees control of licensed material whether or not the gombm, ed, about 22 percent of the event reports material is recovered later. my lved radioactive material bemg detected at a landfill or scrap yard by a radiation monitor. Well logging sources may be abandoned (left in While there were no reported overexposures or place) m accordance with the requirements of 10 significant contaminations as a result of the CFR 39.77 and gmdelines approved by the NRC reported events, several of the events had the and Agreement States.They are tracked in the potential to affect the public health and safety NMED as lost sources so that the associated risk and one event met the criteria for abnormal can be more easily quantified. occurrence reporting to Congress. NRC licensees reported 116 events for 1993 that AEOD is sponsoring a study of the loss of control involved actual loss or loss of control of licensed of licensed material. The study will focus on how material, while Agreement States reported 128 material is lost, the !ikely uhimate disposition of such events. These events are listed in Tables the material, and the pteatial risk to the public. A-1.3 and A-2.3, respectively, of Appendix A. The study is scheduled to be completed by the end of FY 1995. Reported events can be grouped into five general areas: (1) licensed material (mostly medical waste) 2.5 Leaking Sources inadvertently sent to commercial land. fills; (2) licensed material (usually contaminated metal Sealed sources containing licensed material or industrial measuring gauges) inadvertently generally are required to be tested for leakage on shipped to metal scrap yards:(3) licensed material a periodic basis. The frequency usually ranges (most often in portable moisture density gauges) from quarterly to annually, depending on the that was stolen;(4) licensed material (usually source construction and the device in which the cesium-137 and americium-241) in well logging source is stored. Leak test results that show 18.5 sources that are abandoned downhole; and becquerels (Bq)(.0005 Ci) or greater of (5) miscellaneous losses from inventory of removable beta or gamma emitters, or 185 Bq calibration sources and medical marker sources. (.005 Ci) of removable alpha emitters, are l Groups 1 through 4 account for almost two thirds required to be reported. Detecting leaking sources of the reports. carly is essential to preventing significant facility NUREG-1272, Section 2 8

Nuclear Materials-Ndelear MateriaMs Operatliighperience Fehads contamination, personnel contamination, and neighborhoods. The remaining events involved personnel exposures. releases or administrative deficiencies, such as the loss of confinement of a sealed source and a failure to perform radiation surveys. For 1993 the NRC licensees reported 25 leaking sources for 1993 and Agreement States reported 19. These yeported release of material events did not result events are listed in Table A-1.4 and Table A-2.4, in any adverse health effects. respectively, of Appendix A to this report. About 2.7 'IYansportation Events 40 percent of the leaking source reports involved nickel-63 foils in gas chromatographs. These sources are covered with a thin film and are prone NRC licensees reported 55 transportation events to show minor leakage with normal use. Another for 1993 and Agreement States reported 33. These 10 percent of the reports involved leaking iron-55 events are listed in Table A-1.6 and Table 2.6, sources used in portable gas analyses. The respectively, of Appendix A to this report. About remainder of the leaking source reports involved 57 percent of the transportation events involved industrial gauges, medical and industrial administrative deficiencies (e.g., failure to keep calibration sources, tritium light sources, well records or improperly completed shipping papers) logging sources, and sources used for therapy and and other shipping deficiencies (e.g., failure to diagnosis (strontium-90 eye applicators and bone survey or failure to brace and block the package densitometers). There were no reported facility during shipping). Approximately 25 percent were contaminations or radiation overexposures accidents involving vehicles transporting resulting from leaking sources. radioactive material that did not result in the loss of shielding or the release of material. Less than 20 percent of the events (16 events) involved 2.6 Release of Material contamination, release of matenal, or radiation levels in excess of regulatory limits. No Release of material events include spills and transportation events reported to the NRC for gaseous or effluent releases where licensed 1993 had any adverse effects on public health and material was released to the environment (air or safety. water) or resulted in personnel and/or facility contamination in excess of regulatory limits. 2.8 Equipment Problems Typically, these events are reported under 10 CFR 20.2202 and 20.2203. Reportmg requirements related to equipment problems for material licensees are not contained For 1993 NRC licensees reported 34 release of in a common regulatory requirement, other than material events and Agreement States reported the requirement of 10 CFR Part 21, " Reporting of

10. These events are listed in Table A-1.5 and Defects and Noncompliance," to report defects Table A-2.5, respectively, of Appendix A to this and failures which create a substantial safety report. Approximately 65 percent of the reported hazard. Rather, reporting requirements are release of material events involved minor specific to the type of licensed program and may contamination of facilities licensed to possess be contained in a license condition or clarified in nuclear materials, although one event did result in a bulletin.

extensive low level contamination beyond the facility boundaries. One additional event, In addition to the reporting requirements of 10 involving the meltmg of a multi-cune source at a CFR Part 21, equipment problem reporting steel mill, resulted m site contammat,on that requirements are contained in the following i required the facility to shut down to regulations: decontaminate the plant's filtration rystem. Ten of e 10 CFR 30.50 for notification of events the remaining release of material events involved releases to the general environment, which related to the use of byproduct material when included four events involving minor equipment is disabled or fails to function as contamination found in residential designed 9 NUREG-1272, Section 2

AEOD Annual Report,1993 10 CFR 31.5(c)(5) for failures of or damage to Tc/ctherapy, Bmchytherup-Timer failures and the shielding or on-off mechanisms of sources failing to retract are the primary failure measuring or gauging devices modes of therapy equipment. There was one report of a beam interkick failure that could allow 10 CFR 34.30 for radiography equipment the teletherapy beam to strike the wall or ceiling, problems Equipment problems reported for high dose 10 CFR 40.26(c)(2) for notification of failures brachytherapy rate devices included failure of the or unusual conditions in tailings or waste source to move to the next position, source retention systems blockage, and electromes failures. A problem reported for low dose rate brachytherapy 10 CFR 50.36 (non-power reactors) for equipment was the ejection of a source without notification of exceeding safety limits the device being programmed and without the 10 CFR 70.50 for notification of events applicator attached to the corresponding related to the use of special nuclear material umbilical cord. This was caused by excessive when equipment is disabled or fails t moisture in the compressor that caused water to function as designed leak into the treatment tube, impeding the pneumatic control of the source. 10 CFR 71.95 for problems with shipping packages Irradiators-Irradiator equipment problems reported included interlock problems, irradiator Reports of problems with equipment that use or is p 1 excessive conductivity, and sticking of the source rack, integral to the use of licensed material can be helpfulin preventing personnel radiation overexposures, personnel and facihty IndustrialMeasuring Dcrices-Essentially all contamination, releases of material, and nuclear problems reported for portable gauges involved criticalities. Reported equipment problems m damage by construction equipment. Problems which there are no direct health and safety with fixed gauges generally involved damage from consequences can provide early warning of more molten steel and malfunctioning shutter m~ chanisms' serious events that could have health and safety effects. 2.9 Fuel Cycle Facility Events NRC licensees reported 93 events for 1993 The NRC regulates all fuel cycle facilities. NRC involving equipment prob' ems and Agreement licensees submitted 46 reports of fuel cycle events States reported 67 such events. These events are for 1993 (see Table 2.4). These events are listed in listed in Table A-1.7 and Table A-2.7, Table A-1.8 of Appendix A to this report. Fuel respectively, of Appendix A to this report. cycle events can be grouped into the following Personnel exposure or personnel or facility four categories: (1) potential criticalities, contamination were reported to have occurred in (2) equipment problems, (3) contamination, and less than one percent of the events. The reports (4) miscellaneous. The majority of the potential were about evenly distributed among radiography criticality events were caused by a lack of, equipment, medical therapy devices, irradiators, management control or equipment failures. industrial measuring devices and fuel facility Examples of management deficiencies include equipment. Each of these areas is discussed (1) handling of nuclear material without all below, except for fuel facility problems, which is physical restraints in place, (2) missing criticality discussd in Section 2.9. evaluations, and (3) excessive residual nuclear material build-up in undesignated areas. Radiography equipment-Source disconnects, k>ck Equipment failures include (1) loss of the box malfunctions and sources stuck in guide tubes uninterruptable power supply,(2) failure of a account for most of the problems associated with cooling water jacket. (3) a tear in a rubber boot, radiography equipment. Past reviews of events of (4) a failed gasket, and (5) failed radiation this type have shown the same problems. monitors. Other events reported by fuel cycle NUREG-1272, Section 2 10

l facilities include one contamination event facility pool. Although the release did not exceed the 10 fires, and a variety of other administrative CFR Part 20 effluent release limits,it did exceed deficiencies. Events reported by fuel cycle the license condition reporting limit for leakage, facilities for 1993 did not have any adverse effects The second release involved a discharge of 7600 on public heahh and safety. gallons from a collection sump to the reactor facility foundation drain sump as a result of a Table 2.4 Fuel Cycle Events Reported for 1993 system misabgnment. This discharge exceeded the 10 CFR Part 20 efDuent release limit. The TRTR Type of Event Number events reported to the NRC did not adversely Potential Criticalities 33 affect the public health and safety, although one Equipment Problems 17 cvent was reported to Congress as an abnormal Contamination 1 occurrence. Miscellaneous 8 Total 59 2.11 Annual Radiation Exposure Data i Peop'e are exposed to naturally occurring Note that this table shows the total number of r diatmn and to radiatmn from man-made each type of event that occurred at fuel cycle applications of radmactive materials, meludm, g facilities. These numbers differ from the total medical diagnosis Imd thert.py, mdustrial and number of reported events because one event may commerci 1 etivities, production of electricity, involve more than one event type. and consumer products. According to the National Council on Radiation Protection and l 2.10 Test, Research, and 'IYaining Measurements, the total average effective Reutors dose. equivalent to a person in the U.S. from all sources is approximately 3.6 mSv (360 mrem) per The NBC regulates all reactor facilities, including year. Naturally occurring radon is the largest l power reactors and all test, research, and training source of human exposure, about 2.0 mSv (200 l reactors (TRTR). NUREG-1272. Vol 8, No.1, mrem) per year. About 1.0 mSv (100 mrem) per l covers power reactors and presents an overview of year comes from natural background radiation the operating experience of the nuclear power other than radon. The average person in the U.S. industry from the NRC perspective. The operating receives an effective dose-equivalent of about 0.5 l experience of TRTRs is discussed below. mSv (50 mrem) per year from medical l applications. The entire fuel cycle, including Here are 58 TRTR facilities currently licensed by reactor operation, contributes less than 0.01 mSv l the NRC,46 with operating licenses,7 with (1 mrem) per year. All other man-made sources of possession-only licenses, and 5 with dismantling radiation add up to approximately 0.06 mSv (6 orders. Of the 46 facilities with operating licenses, mrem) per year effective dose-equivalent. l 37 are owned and operated by universities,4 by l the federal government, and 5 by commercial The NRC is responsible for regulating both companies. reactor and nonreactor applications of nuclear i materials. All nuclear materials licensees are Eight TRTR events were reported for 1993. These required to provide radiation monitoring events are listed in Table A-1.9 of Appendix A to equipment to each individual who has the this report. Five TRTR events were reported for potential for receiving a dose in any calendar 1993 that involved equipment failures resulting in quarter in excess of 25 percent of the allowable the loss of one or more safety systems required by limits specified in Part 20 of Title 10 of the Code the licensee's technical specifications (TS). In of Federal Regulations (10 CFR Part 20), addition, one licensee reported operating at 115 " Standards for Protection Against Radiation." percent of full power for 11 minutes, resulting in a The performance of power reactors is discussed in TS violation. The two remaining events involved NUREG-1272 Vol. 8, No.1. That report also releases of radioactive materials. One was caused compares the performance of power reactors with by a 100 gallon per minute leak from the reactor the performance of materials licensees. 11 NUREG-1272, Section 2

JMoD A\\nnuafl#eport, le ^ ~ ~ ~ ~~ ~~ '~ Personnel exposure data from 1988 through 1993 required to supply this information to the NRC. are given in Tables 2.5 through 2.9 for the Because licensees submit revisions, late reports, following five categories of material licenses:(1) or retractions, data are updated as appropriate. industrial radiography, (2) manufacturing and This may cause minor changes in the data distribution, (3) low-level waste disposal, (4) published from year to year. The data are taken independent spent fuel storage, and (5) fuel from the Radiation Exposure Information fabrication and processing. Exposure data for Reporting System (REIRS) funded by NRC's Agreement State licensees are not included in Office of Nuclear Regulatory Research. these tables because the Agreement States are not Table 2.5 Annual Exposure Data for NRC Industrial Radiography Licensees, 1988-1993 No. of Average Workers Average hieasurable No. of with Collective Dose Individual Dose per No. of Monitored Measurable person-cSv Dose-cSv Worker-Year Licensees Individuals doses (rem) (rem) cSv (rem) 1988 286 6878 4223 1981 0.29 0.47 1989 276 6745 4352 2067 0.31 0.47 1990 258 6523 4458 2120 0.33 0.48 1991 248 6S20 4649 2MO 0.31 0.46 1992 156 4582 3005 1540 0.34 0.46 1993 176 4720 3006 1627 0.34 0.54 Table 2.6 Annual Exposure Data for NRC Manufacturing and Distribution Licensees, 1988-1993 No. of Average Workers Average Measurable No. of with Collective Dose Individual Dose per No. of Monitored Measurable person-cSv Dose-cSv Worker-Year Licensees Individuals doses (rem) (rem) cSv (rem) 1987 24 3589 2317 716 0.20 0.31 19S8 16 2177 868 343 0.16 0.40 1989 48 4554 2345 770 0.17 0.33 1990 55 4195 2272 693 0.17 0.31 1991 58 4930 1956 721 0.15 0.37 1992 55 3779 1363 461 0.12 0.34 1993 58 4913 2254 680 0.14 0.30 NUREG-1272, Section 2 12

. _ _ _. ~ WiicfarWaFrFaWCRFuducan&Fa7M)peraWg1 Experience treeTsWcY ' a i l 4 4 t ' 7 Annual Exposure Data for NRC Low Level Waste Disposal Licensees,1988-1993 No. of Average Workers Average Measurable No. of. with Collective Dose Individual Dose per No. of Monitored Measurable person-cSv Dose-cSv Worker-Year Licensees Individuals doses (rem) (rem) cSv (rem) i i 1987 2 778 173 24 0.03 0.14 l 1988 2 864 171 27 0.03 0.16 j 1989 2 925 119 35 0.04 0.29 i i 1990 2 784 115 26 0.03 0.23 t i-1991 2 905 147 39 0.04 0.27 i 1992 2 467 82 27 0.06 033 i 1993 2 432 76 21 0.05 0.28 f e i I Table 2.8 Annual Exposure Data for NRC Independent Spent Fuel Storage Licensecs, 1988-1993 1 l No. of Average 1 Workers Average Measurable No. of with Collective Dose Individual Dose per i No. of Monitored Measurable person-cSv Dose-cSv Worker-j Year Licensees Individuals doses (rem) (rem) cSv (rem) l 1987 2 129 64 41 032 0.64 1988 2 217 57 25 0.12 0.44 1989 2 190 102 33 0.17 033 i 1990 2 56 22 6 0.11 0.27 1991 2 41 24 4 0.10 0.17 1992 2 279 84 11 0.04 0.13 j 1993 2 135 52 14 0.10 0.27 i i i Table 2.9 Annual Exposure Data for NRC Fuel Fabrication and Processing Licensees,1988-1993 No. of Average 4 Workers Average Measurable 1 No. of with Collective Dose Individual Dose per i No. of Monitored Measurable person-cSv Dose-cSv Worker-i Year Licensees Individuals doses (rem) (rem) cSv (rem) 1987 10 10,370 3,994 514 0.05 0.13 1988 10 11,994 3,869 455 0.04 0.12 1989 8 11,583 2.992 243 0.02 0.08 j 1990 11 14,505 3,871 422 0.03 0.10 j 1991 11 11,702 3,929 378 0.03 0.11 1992 7 3,772 1,654 237 0.06 0.14 { 1993 8 9,649 2,611 339 0.04 0.13 i 13 NUREG-1272, Section 2

AEOD Annual Report, IT@3 ~~ ~~ ^ ^ ^ ~ ~ ~ ^ ~ ~ ~ ~ "~ 4 As can be seen from these tables, in 1993 NRC measurnble dose among all categories of licensees i radiography licen. ees had the highest collective except independent fuel storage licensees and s dose and average measurable dose per worker, manufacturers and distributors. Over this same followed by manufacturers and distributors. period the average measurable dose per worker Low-level waste disposal licensees and has been relatively constant for all categories of independent spent fuel storage licensees had licensees except low-level waste disposal licensees, relatively low collective doses. where it has doubled, and independent spent fuel storage licensees, where it has dropped by 58 From 1987 to 1993 inclusive, there has been a percent. For each category of licensee, the average decreasing trend in the number of individuals measurable dose per worker is far below the monitored and the individuals that receive a allowable limits of 10 CFR Part 20. i l l l t NUREG-1272, Section 2 14

l I i 3 Abnormal Occurrences AEOD prepares the quarterly " Report to 3.1 NRC Licensees Congress on Abnormal Occurrences," NUREO-0090.This effont requires coordinating 3.1.1 Medical Institutions staff activities, reviewing and submitting the report to the Commission for approval, and Nine brachytherapy misadministrations publishm, g the report and associated Federal involving a therapeutic dose to a part of Register notices. The quarterly report may includ the body not scheduled to receive radiation recurring events, generic concerns, or other - incidents that the Commission determines to be

• Two rodium iodide misadministrations significant to public health and safety.

involving a diagnostic dose of a radiopharmaceutical that was five times the prescribed dose In general, the NRC determines whether an event One moderate exposure of a 9-month-old is an abnormal occurrence (AO) by using the nursing infant to iodine-131 that the criteria promulgated in an NRC policy statement nursing mother received for a diagnostic published in the Federal Register on February 24, scan 1977 (92 FR 10950). That policy statement contained no examples of medical

• One therapeutic radiopharmaceutical misadministrations. ne NRC published misadministration where the misadministration reporting requirements in 1980 administered dose was half of the (10 CFR Part 35). In 1981 the Commission prescribed dose developed AO guidelines for medical misadministrations that were in effect for about 3.1.2 Industrial Radiographers two years. On the basis of the experience with the
• One fatal radiation exposure of a guidelines, the Commission decided to revise the radiographer (This 1981 event was guidelines again. On July 18,1989, the staff previously reported as an Appendix C amended NRC Management Directive 8.1, item. However, in 1993, this event was

" Abnormal Occurrence Reporting Procedure," to upgraded to an AO after the NRC incorporate the revised guidance. The current became aware of new information.) guidelines apply different criteria for occupational doses, doses received by a member of the general 3.1.3 Research Reactors public, and doses received by a medical patient. One event involving research reactor (AEOD recently imtiated efforts to revise the AO scram functions that were made critena. See Section 4.4.2 for further discussion.) inoperable because of a major deficiency in operating, management, or procedural The four AO reports published in calendar year 1993 contained 15 events reported by NRC 3.2 Agreement States licensees and 16 events reported by Agreement States. The events reported by NRC licensees 3.2.1 Medical Institutions included 13 that occurred at medical institutions, 1 at an mdustrial radiographer, and 1 at a Three brachytherapy misadministration research reactor. The events reported by the reports involving 10 patients receiving Agreement States meluded 10 that occurred at therapeutic doses to a part of the body not scheduled to receive radiation medical institutions,2 at industrial radiographers, and 4 at other industrial users. There were no e One brachytherapy misadministration AOs at fuel cycle facilities. Appendix B of this involving a therapeutic dose gicater than report includes summaries of the AOs. 1.5 times the prescribed dose 15 NUREG-1272, Section 3

AEOD AnnuE[Meport, E93 ]

• Two sodium iodide misadministrations 3.2.2 Industrial Radiographers involving a diagnostic dose of a Two radiation overexposure events radiopharmaceutical that was five times involving radiographers the prescribed dose 3.2.3 Other Industrial Users Three teletherapy misadministrations, one
• One event involving contaminat. ion of a of which was fatal and involved a dose that was twice the prescribed dose, while pool irradiator facility the other two involved a therapeutic dose One event involving theft of radioactive to a part of the body not scheduled to material during transport and improper receive radiation (The fatal disposal misadministration occurred in 1987, and
• One event involving a lost source that was was investigated by the State of California in 1993. The NRC reevalunted the event found at a scrap metal facility and determined that it was an AO.)

One event involving a source lost or stolen from an instrument user One therapeutic radi.) pharmaceutical misadministration involving an The AOs reported in 1993 at nuclear power plants administered dose that was 50 percent and research reactors are summarized in greater than the prescribed dose Appendix B to NUREG-1272, Vol. 8, No.1. l NUREG-1272, Section 3 16

4 AEOD Initiatives AEOD provides a strong, independent capability nuclear materials experience, which would include to analyze the operational experience of programs a broad range of operating event data, using nuclear materials licensed by the NRC. Additionally, it would be directly accessible by the This role was expanded in 1987. It was further NRC staff and Agreement States. enhanced in 1993 as a consequence of the increased attention directed toward nuclear 4.1.2 Data Base Development materials events by Congress, the NRC's In the fall of 1993, the NRC contractor, Idaho Inspector General, the media and the pubh.c. The AEOD nuclear materials staff was Engineering National Laboratony, began reviewing augmented and programs were redesigned t and coding materials events into the NMED. strengthen and expand AEOD s role in ensuring AEOD organized two 1-day workshops in operational safety. AEOD began the following November 1993, with various NRC headquarters eU rts m M and regional staff and Agreement State representatives participating. These workshops (1) developing an improved nuclear materials provided the forum for all potential users to events data base (NMED) that would provide discuss their individual needs and to come to the NRC and Agreement States with consensus on suitable fields to satisfy those needs. consistent coding of material events to Based on the input received during the identify safety concerns, trends, and workshops, the INEL staff restructured the data performance problems, and would also base and continued coding materials events from provide users with information about 1993 and earlier years (event reports from significant occurrences at other facilities that Agreement States are available only from 1991 on would help them prevent similar incidents at and are complete only for 1992 and 1993). their own facilities 4.1.3 Status of the Nuclear Materials Events (2) performing more in-depth analyses of Data Base operational experience to identify trends, performance problems, and good practices Once validated for quality and completeness, the NMED be a valuable tool to provide a common (3) establishing a more consistent and effective information base on nuclear material events for feedback mechanism the NRC and the Agreement States. Most importantly, this data base will provide a system 4.1 Improved Nuclear Materials for maintaining a traceable and reproducible Events Data Base inventory of consistently coded material events, and will also facilitate systematic and 4.1.1 Background comprehensive assessment of materials experience. For example, this data base will Since 1987 AEOD has published annual furnish the information base for case studies on compilations of U.S. non-power reactor single or aggregated events, trends and pattern operational experience (NUREG-1272 series, analyses, and AEOD's Annual Report, it will also Part 2). However, to support a comprehensive support rulemaking and provide the basis for analysis of nuclear material experience, a materials performance indicators. nationwide data base of consistently reviewed and coded events was needed. The interim data base program, along with the available NRC and Agreement State data for 1991 In the summer of 1993, NRC headquarters offices through 1994, will be distributed to all potential and the Regions agreed that AEOD would users in the summer of 1994. This program will develop and maintain a centralized NMED to also have a data entry module to assist the serve the needs of the entire agency. This Agreement States in preparing event data reports. information source would be used for analysis of The use of a standard program will crisure 17 NUREG-1272, Section 4

motonennuanif;F6MiDFS consistent event collection. The test phase for the staff use a formal screening process to revnw final data base system will begin in September event reports to identify AOs for reporting to 1994 (the test group will include selected NRC Congress and other significant events, specific headquarters and regional offices and Agreement safety issues and concerns, program deficiencies, States). The system is scheduled to be operational and performance problems. The results of the in the first quarter of CY 1995, it will be staff's event reviews are coded in the tracking accessible NRC-wide through AUTOS and by system. A two-tier review process provides Agreement States through remote a complete and consistent review.13ased on this communication link. review, the staff also identified future study topics, some of which are discussed in Section 4.3. 4.1.4 Planned Improvements in the Collection of Operational Experience In 1993 AEOD staff participated, along with the Regional Agreement States Officers,in the Consistent, complete, and timely event reporting Annua! Program Review of the States of from Agreement States is crucial to the successful Tennessee and Texas. AEOD's participation implementation of the NMED. Timely reporting focused on the States' event collection and review of events by Agreement States in a format that is process. AEOD staff gained a better compatible with the data base is essential to understanding of the States' efforts and the States ensuring a complete and viable materials event came to appreciate the NRC's need for complete information base. There was improved and timely collection of event reports, and the cooperation between the NRC and Agreement NRC process for identifying potential AOs and States in 1993, which is expected to continue. The other significant events. NRC will also consider establishing standards for event reporting by the use of a standard report 4.3 Feedback of Nuclear Materials form, where applicable, and will examine licensee Experience reporting requirements to determine if regulatory guidance for reporting is needed. On their part, Between 1981 and 1993 AEOD issued 8 Case Agreement States should ensure prompt reporting Studies,50 Engineering Evaluations,4 special of events. There ts a need for all events to be studies, and 2 videotapes (see Appendix C). reported soon after they occur, and also a need Videotapes have proven to be a particularly for event information to be consistent with the effective method for feedback of lessons learned information attributes of the NMED. States may from operating experience A videotape entitled also consider the use of standard computer " Good Practices in Co-60 Teletherapy" was programs for collecting event data. In the past, released in 1993. The video shows simulated workshops and meetings between the NRC and administrations of external cobalt-60 radiation the Agreement States have proven to be very therapy and demonstrates good practices when beneficial. They offer a forum to address using teletherapv equipment. Also in 1993, as a concerns and,ssues of mutualinterest. Both the i part of its renewed commitment to the systematic NRC and the Agreement States are committed to and comprehensive assessment of nuclear enhanced cooperatmn to achieve common goals. materials experience, AEOD contracted with national laboratories to initiate a review of the 4.2 Systematic Review of Nuclear past 5 years of materials experience for case Materials Experience studies on radiography overexposure events, and the loss of licensed material in scrap metal yards. In 1993 AEOD implemented a formal process to review nuclear materials operating experience in a l timely manner. A computerized Event Tracking 4.4 Abnormal Occurrences System was implemented to log incoming licensee event reports (prompt notifications via telephone AEOD continued to fulfill the NRC's statutory as well as written reports), preliminary obligation to report AOs to Congress by l notifications, and inspection reports. The AEOD preparing and publishing the quarterly Report to i NUREG-1272, Section 4 18

Nuclear hiaterials-AEOD Initiatives Congress on Abnormal Occurrences, publication of the final policy statement is NURtiG-0090. expected in the spring of 1995. After publishing the final policy statement, the AEOD staff will 4.4.1 Abnormal Occurrence Reporting reevaluate the earlier nuclear materials events to determine if any of the previous eunts qualify as In 1993 the NRC reexamined earlier nuclear AOs or as Appendix C items. materials experience. Three events previously reviewed were reclassified as AOs:(1) the 1987 AEOD is also streamlining the AO process to radiation overexposure of a radiographer in assure an efficient internal system and an effective Oklahoma which resulted in his death, (2) interface with Agreement States. The revised multiple medical misadministrations in 1988 at process is aimed at timely identification of the Sacred Heart Hospital in Cumberland, potential AOs, transmittal of complete write-ups hiagland, and (3) a medical misadministration at expeditiously from the appropriate source (NRC Alta Bates hiedical Center in Berkeley, California, Offices / Regions or Agreement States), and which resulted in the death of a juvenile patient. prompt preparation and timely publication of the The first event was reported as an Appendix C, AO report. "Other Events of Interest," item in NUREG-0090, Vol. 4, No.1. The second event is still an open 4.5 Non-power Reactors AO while the NRC continues to work with the State of hiaryland to get more information. The The NRC had not in the past considered research third event was reinvestigated by the State of reactors to pose a serious risk because of the low California (assisted by the NRC) and was frequency of occurrence and the relatively minor determined to be a misadministration although it consequences of accidents at these facilities, as did not qualify as a misadministration according well as the initiatives within the academic to the regulations existing at the time of the event. community to self-regulate. The NRC relied upon the Test, Research and Training Reactor (TRTR) Committee to investigate and report on significant in 1993 there was improved cooperation between events. Ilowever, several events at university the NRC and Agreement States in identifying and reactors in 1992 raised questions about their reporting AOs at Agreement State-licensed overall management and safety. Therefore,in facilities. The States either identified potential 1993 AEOD began a survey of the past five years AOs during their routine reviews and submitted of TRTR operating experience including operating write-ups to the NRC, or provided the events, inspection findings, feedback to the TRTR information on potential AOs in response to NRC community, NRC feedback of lessons learned, and requests. NRC enforcement actions. The purpose of this survey is to provide an independent assessment of 4.4.2 Abnormal Occurrence Criteria-the safety performarce of TRTRs, to assess the Revision of the AO Policy Statement adequacy of the feedback of operating experience within the TRTR community, to provide insights AEOD initiated efforts to develop a policy into safety practices at TRTRs and to identify statement for AO reporting to use objective recommendations for improvement if needed. criteria to identify events as AOs and Appendix C items, so that only events significant to public The staff is currently reviewing operational data health and safety are reported. An interoffice pertaining to TRTRs, augmented by site visits to working group was established for this purpose. assess the safety performance of the non-power The final draft policy statement is due to the reactor facilities. This study is expected to be Commission in September 1994, and the completed in 1995. 19 NUREG-1272, Section 4

5 Incident Investigation Program The Incident Investigation Program (IIP) ensures event involving a loss of an iridium-192 source, a that NRC investigations of significant events are therapy misadministration, and a patient fatality timely, thorough, well coordinated, and formally which occurred at the Indiana Regional Cancer administered. The scope of the IIP includes Center in Indiana, Pennsylvania, on November 16, investigations of significant operational events 1992. The finalinvestigation report was issued in involving reactor and nonreactor activities February 1993. The results of this IIT licensed by the NRC. Incident Investigations investigation were documented in the 1992 AEOD Teams (IITs) are assigned to determine the Annual Report. Appendix E documents the status circumstances and causes of the event and to of staff actions that the EDO assigned to various assess the safety significance so that appropriate NRC offices associated with IIT report findings. followup actions can be taken. 5.2 Augmented Inspection Teams 5.1 Incident Investigation Teams During 1993, one augmented inspection team Of the approximately 300 nuclear materials events conducted an inspection at the Siemens Power reported during 1993, none was judged to have a Corporation involving a uranium powder oxide level of safety significance sufficiently high to spill on February 7,1993. This event had no warrant an IIT investigation. However, one IIT applicability to other facilities and no generic investigation was still ongoing during 1993 for an communication was issued. 21 NUREG-1272, Section 5

6 Data From the NRC Operations Center The NRC Operations Center serves as the focal nuclear materials events. Table 6.1 shows the point for communicating with NRC licensees, as distribution of these events. well as State and Federal agencies, about operating events in the commercial nuclear sector. Four of these notifications, all at fuel facilities. The Operations Center is staffed 24 hours a day were for events classified as emergencies. Three by an NRC Headquarters Operations Officer, of them were "Notificiations of Unusual Event." who is trained to receive, evaluate, and respond to The only " Alert",was for a fire at the Nuclear Fuel events reported to the Operations Center. Services facility m Envin, Tennessee (see Table 6.2). No " Site Area Emergencies, occurred. Actions taken by the NRC operations officer in response to these notifications ranged from In 1993 the NRC Operations Center received 216 making a log entry and the appropriate notifications of events related to nuclear notifications, to establishing emergency materials. These included 44 fuel facility,3 conference calls with the NRC Incident Response nonpower reactor,44 hospital,18 transportation, staff, the licensee, and senior NRC regional and 39 radioactive material, and 68 miscellaneous headquarters staff members. Table 6.1 Nuclear Materials Events Reported to the NRC Operations Center in 1993 Event Power Fuel Nonpower Type Reactor Facility Reactor Hospital Transport Materials Miscellaneous Total Non-emergency 1413 40 3 44 18 39 68 1625 Notification of 100 3 0 0 0 0 0 103 Unusual Event Alert 7 1 0 0 0 0 0 8 Site Area 1 0 0 0 0 0 0 1 Emergency General 0 0 0 0 0 0 0 0 Emergency Total 1521 44 3 44 18 39 68 1737 Table 6.2 Alert Events Reported at NRC. Licensed Nuclear Materials Facilities in 1993 Facility Event Date Description Duration *

Response

Nuclear Fuel Services 26215 10/13/93 Roof fire on " Wet 9 minutes N/A Envin, TN Cell" building

• Time from commencement to termination of emergency 23 NUREG-1272, Section 6 l

Appendix A a . Nuclear Materials Data by Event Type A-1 NRC Licensee Events A-2 Agreement State Licensee Events 1 4 a 1 a J a

Appendix A-1 NRC Licensee Events i I l l

i Table A-1.1 Medical Misadministrations Reported by NRC Licensees,1993 ITEM LICENSEE EVENT TYPE OF NO. . LICENSEE NO. CITY STATE DATE MISADMINISTRATION 940134 AIR FORCE, 42-23539-01AF llROOKS AFB TX 06/10/93 BRACilYTilERAPY DEPARTMEET OF THE 940604 CHARLESTON AREA 47-15473-02MD CilARLESTON WV 12/0&93 URACilYTllERAPY MEDICAL CENTER 940876 DEACONESS MEDICAL 25-01051-01 BIlllNGS MT 09/24/93 IIRACliYTIIERAPY CENTER 941281 DEACONESS MEDICAL 25-01051-01 IllLLINGS MT 11/30/93 IIRACllYTIIERAPY CENTER 940032 GENESYS REGIONAL 21-01103-04 FLINT MI 04/20/93 BRACIlYTilERAPY MEDICAL CENTER 940072 GOOD SAMARITAN 34-16725-02 ZANESVILlE Oli 11/10/93 BRACllYTilERAPY llOSPITAL 940155 HOSPITAL 52-16033-01 SANJUAN PR 12/11/93 IIRACHYTIIERAPY METROPOLITANO 940036 MARQUETTE GENERAL 21-05432-04 MARQUETTE MI 11/19/93 IIRACIIYTHERAPY HOSPITAL 940098 MERCY HOSPITAL 37-01374-03 SCRANTON PA 04/23/93 IIRACilYTHERAPY 940034 MERCY MEMORIAL 21-04177-01 SAINT JOSEPil MI 02/16/93 BRACHYTHERAPY MEDICAL CENTER,INC. 941659 MIAMI VALLEY HOSPITAL 34-00341-06 DAYTON 0 11 01/29/93 11RACllYTHERAPY l 940043 MINNESOTA. 22-00187-46 MINNEAPollS MN 0&08/93 BRACHYTilERAPY UNIVERSITY OF 940616 MOUNTAINSIDE 29-03297-02 MONTCIAIR NJ 07/01/93 BRACilYTilERAPY HOSPITAL 940085 SAINT LOUIS UNIVERSITY 24-00196-07 SAINT IDUlS MO 11/12/93 IlRACllYrilERAPY 940655 VA., DEPARTMENT OF 42-00084-06 IlOUSTON TX 09/25/93 BRACHYTHERAPY 940958 WASilINGTON UNIV. 24-00167-11 SAINT LOUIS MO 01/07/93 BRACHYTHERAPY MEDICAL SCIIOOL 940003 YALE-NEW HAVEN 06-00819-03 NEW IlAVEN CT 01/21/93 BRAC11YTHERAPY llOSPITAL 941012 TRlANGLE RADIATION 37-20758-01 IIEAVER PA 12/17/93 TEIETHERAPY ONCOIDGY ASSOCIATES 940001 VA., DEPARTMENT OF 04-00181-12 IDS ANGELES CA 05/13/93 TELElllERAPY 940040 X-RAY TREATMENT 21-19572-01 EASTPOINTE M1 07/13/93 TEIETHERAPY CENTER, PC. 941542 CENTER FOR 29-28554-01 NEWARK NJ 03/11/93 RADIOPHARMA-MOLECUIAR MEDICINE CEU11 CAL AND 1MMUNOIDGY 1 NUREG-1272, Appendix A-1

a9mmnarnrIntrporcwis Table A-1.1 Medical Misadministrations Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT TYPE OF NO. LICENSEE NO. CITY STATE DATE MISADMINISTRATION 940106 BRYN MAWR llOSPITAL 37-07722-04 BRYN MAWR PA 10/07/93 SODIUM IODIDE 940108 CIIESTNUT IIILL 37-13919-01 PilILADELPIIIA PA 03/11/93 SODIUM IODIDE IIOSPITAL 941296 COMMUNITY MEMORIAL 25-19824-01 SIDNEY MT 02/02/93 SODIUM IODIDE liOSPITAL 941298 COMMUNITY MEMORIAL 25-19824-01 SIDNEY MT 01/25/93 SODIUM IODIDE IIOSPITAL 940090 OSTEOPAT111C 1IOSPITAL 35-05860-01 TULSA OK 07/27/93 SODIUM IODIDE FOUNDERS ASSOCIATION 940005 PAPASTAVROS' 07-16529-01 WILMINGTON DE 01/14/93 SGDIUM IODIDE ASSOCIATES MEDICAL IMAGING 940739 PUERTO RICO, 52-01946-07 SAN JUAN PR 09/13/93 SODIUM IODIDE UNIVERSITY OF NUREG-1272, Appendix A-1 2 o

3 Table A-1.2 Overexposures reported by NRC Licensees,1993 4 ITEM LICENSEE EVENT TYPE OF NO. DOSE NO. LICENSEE NO. CITY STATE DATE EXPOSURE EXPOSED (REMS) q 940062 COOPER llOSPITAll 29-08285-01 CAMDEN NJ 04/05/93 EXT I 21.69 UNIVERSITY MEDICAL CENTER 940974 WASli1NGTON HOSPITAL 08-03604-03 WASil1NGTON DC 10/31/93 WB 1 8.09 9f.0039 IIEART INSTITUTE 21-18912-01 KALAMAZOO MI 03/05/93 WB 1 1.46 OF MIC111GAN 941166 ISOTOPE PRODUCIS 04-16778-01E BURBANK CA 02/18/93 WB 1 NR LABORATORIES 940030 MICllIGAN, 21-00215-04 ANN ARBOR MI 05/12/93 EXT I 22.87 UNIVERSITY OF l 941599 MILWAUKEE COUNTY 48-04193 4 1 MILWAUKEE WI 02/01/93 WB 1 1.33 MEDICAL COMPLEX 940074 ADVANCED MEDICAL 34-19089-01 GENEVA Oli 11/11/93 WII 5 1.53-3.075 SYSTEMS, INC. 940119 SCIENTIFIC INSPECrlON 41-25027-01 IIIXSON TN 04/16/93 EXT 1 1107 TECHNOLOGIES,INC 941029 TECIINICAL WELDING 42-25214-01 PASADENA TX 06/19/93 WB 1 4.22 IABORATORY INC. 4 941627 TECllNICAL WELDING 42-25214-01 PASADENA TX 12/31/93 WB 1 6.48 LABORATORY, INC. 941567 WESTERN IND. X-RAY 49-27356-01 EVANSTON WY 07/31/93 WB 1 6 INSPECTION CO. WB indicates W11011 BODY NR indicates NCIT REPORTED EXT indicates EX'IREMITY f i 3 NUREG-1272, Appendix A-1

55dD dnnual Report, i95 ~ ~ ~ ^~ t' Table A-1.3 Loss of Control of Material Events Reported by NRC Licensees,1993 ITEM LICENSEE EVENT RADIO-NO. l.ICENSEE NO. CIFY STATE DATE NUCLIDE 940947 A&K FINISlilNG, INC. GENERAL LIC KENTWOOD MI 12/16/93 PO-210 941109 AGRICULTURE, DEPARTMENT OF 19-00915-03 IlYATTSVILLE MD 10/26/93 NI-63 942061 AGRICULTURE, DEPARTMENT OF 19-00915-06 GREENBEIT MD 05/01/93 NI-63, NI-63 940138 AlR FORCE. DEPARTMENT OF TIIE 42-23539-01AF BROOKS AFil TX 04/27/93 SR-90 940266 AIR FORCE, DEPARTMENT OF TIIE 42-23539-01AF BROOKS AFIl TX 09/22/93 SR-90, SR-90, SR-90, SR-90 941294 AIR FORCE, DEPARTMENT OF Tile 42-23539-01AF BROOKS AFil TX 09/22/93 11-3 940157 Alf0 CORE 52-24843-01 CANOVANAS PR 12/07/93 CS-137, AM-IIE 940082 ALPilA-OMEGA GEOTECil, INC. 15-23181-01 KANSAS CITY KS 10/05/93 CS-137, AM-BE 940015 ALT & WITZIG ENGINEERING, 13-18685-01 INDIANAPOLIS IN 09/22/93 CS-137, INC. AM-BE 941007 ALUMINUM CO. 0F AMERICA 37-07653-02 ALCOA CENTER PA 12/28/93 U-NAT 940667 AMERSIIAM CORE 20-12836-01 BURLINGTON MA 08/18/93 YB-169 941361 ANNISTON ARMY DEPOT NR NR AL 08/1W93 11-3 940006 ARMY, DEPARTMENT OF Tile 12-00722-06 ROCK ISI AND IL 10/12/93 II-3 940008 ARMY, DEPARTMENT OF Tile 12-00722-06 ROCK ISIAND 1L 11/17/93 Il-3 940009 ARMY, DEPARTMENT OF TiiE 12-00722-06 . ROCK ISIAND IL 08/15/93 11-3,Il-3 940010 ARMY,, DEPARTMENT OF Tile 12-00722-06 ROCK ISIAND 1L 08/19/93 11-3 9405 % ARMY, DEPARTMENT OF Tile 42-01368-01 FORT TX 09/29/93 NI-63 SAM llOUSTON 941241 ARROW TERMINAL INDUSTRIES NON LICENSEE INDUSTRY PA 05/31/93 CO-60 i 940019 BAKER HUGilES OILFIELD 17-27437-01 IIROUSSARD IA 06/11/93 AM-BE j OPERATIONS, INC. 940664 DEST FOOD TECIINICAL CENTER 29-07524-04 SOMERSET NJ 05/13/93 NI-63 940068 BETIIESDA IlOSPITAL 34-10921-03 CINCINNKII Oli 12/08/93 CS-137 940990 BLANCIIARD VALLEY !!OSPITAL 34-06295-02 FINDIAY Oil (M/02/93 ND 940083 BOSTON UNIVERSITY MEDICAL 20-02215-01 IlOSTON MA 10/01/93 P-32 CENTER 940989 BURGESS & NIPLE, LTD. 34-20259-01 COL,UMBUS 01I 07/23/93 CS-137, AM-IIE 940608 CASE WESTERN RESERVE 34-00738-04 CLEVEIAND 01I 01/22/93 II-3, C-14, UNIVERSITY P-32 940025 CIIARM SCIENCES INC. 20-18145-01E MALDEN MA 12/29/93 11-3, C-14 940187 ClllLDRESS SERVILE CORP. GENERAL LIC IIEAVER WV 07/22/93 CS-137 NUREG-1272, Appendix A-1 4 i

NIrsWFlaBMitWE ;WJ1CnOMRM#1S%W i i l Table A-1.3 Loss of Control of Malerial Events Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT RADIO-NO. LICENSEE NO, CITY STATE DATE NUCLIDE 940088 CINCINNATI, UNIVERSITY OF 34-06903-05 CINCINNATI Oli 10/05/93 SR-90 940079 COMMUNITY NUCLEAR RADIOLOGY 34-25962-01 MAYFIEll) Oli 04/23/93 CS-137 FACIUTY llEIG11TS 940933 CTS GENERAL LIC STOLT13VillE OH 02/10/93 NR l 940724 DANA-FARBER CANCER INSTITUTE 20-19761-01 BOSTON MA 11/05/93 S-35 940727 DE1 AWARE STATE COLLEGE 07-11871-05 DOVER DE 08/19/93 II-3 941402 EDWARDS PIPELINE TESTING,INC. 35-23193-01 TUISA OK 01/(M/93 IR-192 940186 EVART PRODUCIS CO. GENERAL LIC EVART MI 01/12/93 PO-210 941447 FIBER-LITE CORP. GENERAL LIC 11EBRON 0 11 08/20/93 KR-85, KR-85 941953 FOX CllASE CANCER CENTER 37-02766-01 Pill 1ADELPIIIA PA 09/07/93 P-32 940969 GARDEN CITY OSTEOPATHIC 21-04072-01 GARDEN CITY. M1 04/14/93 TC-99M i HOSPITAL 940160 GENERAL ATOMICS SNM-696 SAN DIEGO CA 05/21/93 U-ilE 940972 GENERAL DYNAMICS 21-21068-01 STERLING MI 11/22/93 11-3 HEIGHTS 940065 GOODYEAR TIRE & RUBBER CO. 34-00508-16 AKRON 0 11 09/10/93 PO-210 940131 HALLIBURTON CO. 42-01068-07 HOUSTON TX 02/26/93 CS-137, AM-BE 940726 HARTFORD IIOSPITAL 06-("253-04 !!ARTFORD CT 09/12/93 TC-99M 940016 INDIANA DEPARTMENT OF 13-26344-01 CRAWFORDVIILE IN 01/18/93 CS-137, TRANSPORTATION AM-BE 940685 INLAND STEEL CO. 8-213 13-03086-03 EAST CHICAGO IN 04/02/93 PM-147 940725 KCE STRUcrURAL ENGINEERS. PC 08-30006-01 WASIIINGTON DC 11/25/93 CS-137, AM-BE 940999 KUAKINI MEDICAL CENTER 53-17797-01 HONOLULU 111 11/04/93 1-125, 1-131 940162 LOUISIANA STATE UNIVERSITY SNM-1966 BATON ROUGE 1A 10/21/93 PU-BE 940956 LUKENS STEEL CO. NON-LICENSEE COATESVILLE PA 12/12/93 U-238 940051 MALilNCKRODT MEDICA 1 INC. 24-04206-13MD SAINT LOUIS MO 07/09/93 M O-99 940096 MCKEESPORT HOSPITAL 37-00896-03 MCKEESPORT PA 09/27/93 1-125 940145 MEDICAL COLLEGE OF HAMPTON 45-15877-01 NORFOLK VA 01/26/93 P-32 ROADS 940905 MELICK-TUl1Y & ASSOCIATES,INC. 29-20773-01 SOUTH BOUND NJ 08/07/93 CS-137, BROOK AM-BE 941033 MICIIIGAN HEALTli CENTER 21-03835-01 DETROIT M1 01/05/93 ND 940695 MOBILE CARDIOVASCUIAR 48-24566-01 MILWAUKEE W1 05/26/93 TC-99M TES11NG 5 NUREG-1272, Appendix A-1

/AE01DTNiiii'OhYlEQ16ffCNdS Table A-1.3 Loss of Control of Material Events Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT RADIO-NO. LICENSEE NO. CITY STATE DATE NUCLIDE 940994 MOUNT SINAI MEDICAL CENTER 34-00746-02 CLEVEIAND 0 11 04/20/93 1-125 941028 NAVY, DEPARTMENT OF THE 45-23645-01NA WASHINGTON DC 04/19/93 AM-241, AM-241 941045 NEN RESEARCH PRODUCTS NON-UCENSEE BOSTON MA 07/30/93 NR 940962 NEWARK BETH ISRAEL MEDICAL 29-00102-07 NEWARK NJ 11/08/93 I-131 CENTER 941023 NEWARK BETH ISRAEL MEDICAL SNM-1370 NEWARK NJ 03/03/93 PU-238 CENTER 940184 O'SULUVAN CORE GENERAL UC WINCHESTER VA 01/28/93 PO-210 941887 OGDEN-MARTIN SYSTEMS NON-UCENSEE BOSTON MA 12/20/93 NR 940027 OITICAL CORP. OF AMERICA 20-23742-01 MARLBORO MA 11/29/93 II-3 941645 PANTEX PLANT DOE AMARILLO TX 12/01/93 PU-OTH 940064 PAULUS, SOKOLOWSKI & SARTOR 29-19269-01 WARREN NJ 07/15/93 CS-137, AM-BE 940671 PENNSYLVANIA, COMMONWEALTli 37-06677-01 HARRISBURG PA 12/18/93 CS-137 OF AM-BE 940189 PORT WASillNGTON PLANT OF GENERAL UC MILWAUKEE WI 08/31/93 H-3 WISCONSIN 940612 PRINCETON COMMUNITY HOSPITAL 47-16307-01 PRINCETON WV 09/13/93 NR 941249 PROFESSIONAL SERVICES 12-16941-01 LOMBARD IL 05/25/93 CS-137, INDUSTRIES, INC. AM-BE 941600 PUERTO RICO, UNIVERSITY OF 52-01946-07 SANJUAN PR 09/10/93 P-32,S-35, CR-51, 1-131 941991 PUERTO RICO, UNIVERSITY OF 52-01946-07 SANJUAN PR 02/02/93 1-131 940057 R.W. JOlINSON PHARMACEUTICAL 29-02608-03 RARITAN NJ 01/22/93 FE-59 RESEARCH INSTITUTE 940681 ROCKY MOUNTAIN PilOENIX GENERAL BRIGHTON CO 11/14/93 CS-137 SURVEYS INC. 940968 RUTGERS STATE UNIVERSITY 29-05218-28 PISCATAWAY NJ 04/27/93 NI-63 941032 SAINT ANNE'S HOSPITAL CORE 20-05696-02 FALL RIVER MA 10/03/93 1-131 940103 SAINT ELIZABETH HOSPITAL 13-08615-04 LAFAYETTE IN 11/10/93 AU-198 MEDICAL CENTER 940114 ST. ELIZABETH MEDICAL CENTER 34-02176-01 DAYTON Oli 12/03/93 I-125 940966 SAINT JOSEPli RADIOIDGY 24-05592-01 SAINT JOSEPH MO 04/26/93 CO-60, ASSOCIATES, INC. U-DEP 940048 SAINT JOSEPil'S HOSPITAL 22-01448-01 SAINT PAUL MN 01/18/93 NR 940954 SAM KATZ CO. NON-UCENSEE CLEVELAND Oli 06/02/93 TA-182 940121 SCHLUMBERGER TECHNOLOGY 42-00090-03 HOUSTON TX 07/18/93 AM-LIE NUREG-1272, Appendix A-1 6 i

1EdEifWateFiaYs'-~MCODeensee lEvents Table A-1.3 Loss of Control of Material Events Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT RADIO-NO. LICENSEE NO. CITY STATE DATE NUCLIDE 93122 SCHLUMBERGER TECHNOIDGY 42-000 % 03 IlOUSTON TX 08/18/93 AM-BE, CORR AM-IlE 940123 SCHLUMBERGER TECHNOLOGY 42-000 4 03 HOUSTON TX 05/19/93 CS-137, CORE AM-IlE i 940125 SCHLUMBERGER TECHNOLOGY 42-00090-03 HOUSTON TX 03/20/93 AM-IIE CORE 940126 SCHLUMBERGER TECHNOLOGY 42-00090-03 HOUSTON TX 01/29/93 AM-IIE CORE 940127 SCHLUMBERGER TECHNOLOGY 42-000 % 03 IlOUSTON TX 11/01/93 AM-BE, CORR AM-IlE l 940128 SCHLUMBERGER TECHNOLOGY 42-00090-03 HOUSTON TX 01/31/93 AM-11E CORE 940129 SCHLUMBERGER TECHNOLOGY 42-000 % 03 HOUSTON TX 12/02/93 CS-137, CORE AM-IlE. 1 AM-BE 940130 SCHLUMBERGER TECHNOLOGY 42-000 % 03 HOUSTON TX 11/15/93 AM-IIE, CORE AM-BE 940588 SCHLUMBERGER TECHNOLOGY 42-00090-03 HOUSTON TX 07/29/93 CS-137, CORE AM-BE 940714 SCHLUMBERGER TECHNOLOGY 42-00090-03 HOUSTON TX 02/03/93 CS-137, CORE AM-BE i l 940789 SCHLUMBERGER TECHNO1DGY 42-000 5 03 HOUSTON TX 12/29/93 AM-241 CORN 940861 SCHLUMBERGER TECHNOLOGY 42-000 % 03 IIOUSTON TX 0 & 29/93 AM-IlE, CORE 940995 SCHLUMBERGER TECHNOLOGY 42-000 h 03 IIOUSTON TX 08/06/93 CS-137, l CORE AM-BE 940022 SCHNABEL ENGINEERING 45-19703-01 RICIIMOND VA 04/16/93 NR ASSOCIATES, INC. l 940165 SEQUOYAH FUELS CORE SUB-1010 GORE OK 02/08/93 UF4 940837 SEQUOYAH FUELS CORE SUB-1010 GORE OK 12/12/93 NR 940142 SPERRY-SUN DRILLING 42-26844-01 HOUSTON H 06/18/93 CS-137, SERVICES,INC. AM-IlE 940143 SPERRY-SUN DRILLING 42-26844-01 HOUSTON TX 08/11/93 CS-137, SERVICES,INC .AM-II, 940144 SPERRY-SUN DRILLING 42-26844-01 HOUSTON TX 11/07/93 CS-137, SERVICES, INC. AM-IlE 940894 SPERRY-SUN DRILLING 42-26844-01 HOUSTON TX 01/24/93 CS-137, SERVICES, INC. AM-BE i 940101 SYNCOR INTERNATIONAL CORE 06-19661-01MD GLASTONBURY CT 07/26/93 1-131 7 NUREG-1272. Appendix A-1 l

i AEOD Annual Report,1993 Table A-1.3 less of Control of Material Events Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT RADIO-NO. LICENSEE NO. CITY STATE DATE NUCLil)E 940919 SYNCOR INTERNATIONAL CORP. 21-17189-DIMD SOUTilFIELD MI 03/24/93 ND 940906 TELEDYNE ISOTOPES, INC. 29-00055-14 WESTWOOD NJ 07/08/93 CO-60, 11-3 940991 TOIEDO IlOSPITAL 34-01710--05 TOIEDO Oli 01/06/93 ND 940992 TOLEDO IIOSPITAL 34-01710-05 TOLEDO OH 06/30/93 IR-192 940091 TUISA GAMMA RAY,INC. 35-17178-01 TUISA OK 04/07/93 IR-192 940023 UNIFORMED SERVICES UNIV. OF 19-23344-01 BETilESDA MD 03/26/93 G D-153, llEALTil SCIENCES IN-114M, SN-113, SR-85. NB-95, SC-46 940137 AIR FORCE, DEPARTMENT OF TlIE GENERAL LIC SAN ANTONIO TX 09/22/93 11-3 940029 UPJOllN CO. 21-00182-03 KAIAMAZOO MI 04/29/93 P-32 941333 V.A. IlOSPITAL 36-01395-01 PORTIAND OR 06/11/93 NR 940060 V.A. MEDICAL CENTER 29-04481-01 EAST ORANGE NJ 05/24/93 P-32,S-35 940613 V.A. MEDICAL CENTER 09-12467-02 GAINESVILLE FL 04/30/93 113, S-35, C-14 940944 VISIIAY NON-1ICENSEE MALVERN PA 05/18/93 PM-147 940967 WASlilNGTON UNIVERSITY 24-00063-04 SAINT LOUIS MO 09/13/93 MG-TII MEDICAL CENTER 1 940038 WAYNE COUNTY OFFICE OF 21-13687-01 DETROIT MI 07/07/93 CS-137, PUBLIC SERVICE AM-BE 941030 WESTERN ATIASINTERNATIONAl. 42-02964-01 1IOUSTON TX 12/05/93 CS-137, INC. CS-137, AM-BE NR indicates NUT REPORTED ND indicates NOT DETERMINED NUREG-1272, Appendix A-1 8

Table A-1.4 Leaking Sources Reported by NRC Licensees,1993 ITEM LICENSEE EVENT RADIO-l N O. LICENSEE NO. CITY STATE DATE NUCLIDE 1 942002 ABIl PROCESS AUTOMATION,INC. 34-00255-03 COI UMilUS 01I 06/30/93 PM-147 940021 AGRICULTURE, DEPARTMENT OF 19-00915-06 GREENilELT MD 04/28/93 NI-63 940742 AGRICULTURE, DEPARTMENT OF 19-00915-06 GREENBELT MD 09/09/93 NI-63 940007 ARMY, DEPARTMENT OF TIIE 12-00722-06 ROCK ISLAND 1L 09/29/93 11-3 940708 ARMY, DEPARTMENT OF TiiE 29-00047-02 PICATINNY ARSEN NJ 06/14/93 CS-137 940031 DOW ClIEMICAL CO. 21-00265-06 MIDIAND M1 04/20/93 NI-63 940081 ENVIRONMENTAL PROTECTION 05-14892-01 DENVER CO 11/10/93 NI-63 AGENCY 940615 GERMANIUM POWER DEVICES GENERAL LIC ANDOVER MA 08/18/93 CD-109 940089 IIALLIBURTON CO. 35-00502-03 DUNCAN OK 11/16/93 CS-137 940092 IIAYES EVALUATION LOGGING 35-19614-01 ARDMORE OK 05/27/93 CS-137 & PERFORATING,INC. 940153 IIES 48-26453-01 MADISON WI 11/07/93 NI-63 941026

1. GONZALEZ MARTINEZ 52-13471-01 IIATO REY PR 07/06/93 CS-137, ONCOLOGIC HOSPITAL CS-137 941011 KEMRON ENVIRONMENTAL 34-26054-01 MARIETTA 0 11 02/12/93 NI-63 SERVICES, INC.

940961 MERCK & CO.,INC. 29-00117-06 RAHWAY NJ 06/29/93 NI-63 940035 MICIIIGAN, STATE OF 21-05199-03 LANSING Mi 09/10/93 NI-63 940042 MINNESOTA MINING & 22-00057-03 SAINT PAUL MN 11/3G/93 AM-241 MANUFACTURING CO. 940112 OliMART CORP. 34-00639-01 CINCINNATI Oli 09/10/93 CS-137, CS-137 940052 RALSTON PURINA CO. 24-08334-02 SAINT LOUIS MO 02.0 1/93 NI-63 940070 SAINT-GOBAIN/NORTON 34-13845-01 NEWBURY Oli 04/22/93 CS-137 940213 V.A., DEPARTMENT OF 04-00181-04 LOS ANGELES CA 09/27/93 NI-63 940609 VARIAN CIIROMATOGRAPil NR WALNUT CREEK CA 12/10/93 NI-63 SYSTEMS 940788 VIRGINIA, UNIVERSITY OF 45-00034-26 CliARLOTTESVIILEVA 06/16/93 CF-252 940154 WISCONSIN ELECTRIC POWER CO. 48-16729-01 MILWAUKEE WI 01/30/93 NI-63 940152 WISCONSIN, UNIVERSITY OF, 48-09843-18 MADISON WI 02/09/93 NI-63 AT MADISON 941302 ZENECA PIIARMACEUTICAIJS GROUP 07-03990-01 WILMINGTON DE 12/21/93 NI-63 WR indicates NOT REPOKITID 9 NUREG-1272, Appendix A-1

AEOD AnnudReport,1993 ~ ~~ ~' "" ~ ~ ~ ~ '~ f Table A-1.5 Release of Material Events Reported by NRC Licensees,1993 ITEM LICENSEE EVENT TYPE OF RADIO-NO. LICENSEE NO. CI1Y STATE DATE RELEASE NUCLIDE 940135 AIR FORCE, DEPARTMENT OF THE 42-23539-01AF BROOKS AFB TX 09/15/93 SURFACE l-131 1940605 AIR FORCE, DEPARTMENT OF THE 42-23539-01AF BROOKS AFB TX 02/05/93 SURFACE CS-137 941985 AIR FORCE DEPARTMENT OFTHE 42-23539-01AF BROOKS AFB TX 05/18/93 SURFACE NR 942011 ARMY, DEPARTMENT OF THE 12-00722-06 ROCK ISLAND 1L 01/22/93 SURFACE 11-3 940873 BABCOCK & Wilf0X FUEL CO. SNM-1168 LYNCHBURG VA 11/23/93 SURFACE II-3 940985 BAKER llUGHES OILFIELD 17-27437-01 BROUSSARD IA 09/28/93 SURFACE CS-137 OPERATIONS, INC. 940026 BIOGEN, INC. 20-19808-01 CAMBRIDGE MA 04/16/93 SURFACE P-32 941683 CHEMETRON CORE SUB-1357 PROVIDENCE RI 09/17/93 SURFACE U-DEP 941684 CHEMETRON CORP. SUB-1357 PROVIDENCE RI 06/23/93 SURFACE U-DEP 940852 COMBUSTION ENGINEERING,INC. SNM-33 HEMATITE MO 07/02/93 AIR UO2 940853 COMBUSTION ENGINEERING,INC. SNM-33 HEMATITE MO 08/25/93 AlR UF6 941571 CURATORS OF THE UNIVERSITY 24-00513-32 COLUMBIA MO 12/18/93 SURFACE P-32 OF MISSOURI 941004 DOE-PINELLAS PLANT DOE LARGO FL 04/20/93 AIR KR-85 940099 GEISINGER MEDICAL CENTER 37-01421-01 DANVILLE PA 01/28/93 SURFACE TC-99M 940024 HARVARD UNIVERSITY 20-00297-53 CAMBRIDGE MA 01/13/93 SURFACE P-32 941989 HENRY FORD HOSPITAL 21-04109-16 DETROIT MI 02/01/93 SURFACE TC-99M 940602 JOSLYN ELECTRONIC SYSTEMS 04-13468-01E GOLETA CA 06/06/93 AIR 11-3 CORE 940044 MAYO FOUNDATION 22-00519-03 ROCllESTER MN 03/21/93 SURFACE P-32 940086 MIAMI VALLEY HOSPITAL 34-00341-06 DAYTON OH 09/10/93 SURFACE SH-89 940028 MICHIGAN STATE UNIVERSITY 21-00021-29 EASTIANSING MI 03/09/93 SURFACE C-14 940748 MICHIGAN, UNIVERSITY OF R-28 ANN ARBOR MI 07/30/93 SURFACE H-3 940215 MORTON INTERNATIONAL NO LICENSE OGDEN UT 10/19/93 SURFACE Til-NAT 941027 NAVY, DEPARTMENT OF THE 45-23645-01NA WASHINGTON DC 10/07/93 SURFACE P-32 l 940059 NEW JERSEY UNIVERSITY OF 29-02957-13 NEWARK NJ 12/24/93 SURFACE P-32 MEDICINE & DENTISTRY 940678 NORTH CAROLINA STATE R-120 RALEIGH NC 11/23/93 SURFACE NR UNIVERSITY 941837 NUCLEAR PHARMACY OF IDAHO, 11-27398-01MD BOISE ID 12/31/93 AIR I-131 INC. 940689 PENNSYLVANIA, UNIVERSITY OF 37-00118-07 PHI 1ADELPHIA PA 07/14/93 WATER TC-99M NUREG-1272, Appendix A-1 10

Table A-1.5 Release of Material Events Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT TYPE OF RADIO. NO. LICENSEE NO. CrlY STATE DATE RELEASE NUCLIDE 940164 SEQUOYAll FUEIS CORE SUB-1010 GORE OK 05/18/93 SURFACE U-DEP 940849 SEQUOYAll FUEIS CORE SUB-1010 GORE OK 03/17/93 AIR UF4 941716 SEQUOYAll FUELS CORE SUll-1010 GORE OK 10/01/93 SURFACE ND 941010 TRINITECli INTERNATIONAL. INC. 34-264 % 01 TWINSBURG Oli 08/05/93 SURFACE 11-3 940691 V.A., DEPARTMENT OF 42-00084-06 HOUSTON TX 09/17/93 AIR XE-133 940874 WESTINGHOUSE ELECTRIC CORE SNM-1107 PflTSBURGli PA 11/1003 SURFACE II-3 940740 XAVIER UNIVERSITY 34-08941-01 CINCINNATI Oli 12/29/93 SURFACE CS-137 NR indicates NUr REPOKITE ND indicates NOT DETERMINED 11 NUREG-1272, Appendix A-1

~ ^ AEOD Annual Report,1993 Table A-1.6 Transportation Events Reported by NRC Licensees,1993 'IYPE OF ITEM LICENSEE EVENT TRANSPORTATION f NO. LICENSEE NO. CITY STATE DATE EVENT 940139 AIR FORCE. DEPARTMENT 42-23539-01AF BROOKS AFB TX 02/08/93 EXCESS RADIATION LEVELS OF TI1E 940710 AIARON CORP. 37-20826-02 WAMPUM PA 07/20/93 EXCESS RADIATION EVEIS 941260 ARKANSAS NUCLEAR ONE NR RUSSELLVILLE AR 02/18/93 VElllCLE ACCIDENT 940656 ARMY, DEPARTMENT 42-05255-07 EL PASO TX 01/29/93 IMPROPER SIIIPPING PAPERS OF TIIE 941445 BABCOCK & WIlfOX CO. SNM-42 LYNCHBURG VA 06/04/93 IMPROPER SHIPPING PAPERS 942008 CllMP, INC. 21-18701-01 GRAND BLANC MI 07/01/93 IMPROPER SHIPPING PAPERS 942017 CONSULTING ENGINEERS 45-25053-01 VIENNA VA 09/02/93 IMPROPER SillPPING PAPERS CORP. 942005 CTI, INC. 50-19202-01 ANC110 RAGE AK 07/14/931MPROPER SHIPPING PAPERS 940698 DRAPER ADEN 45-25246-01 GLEN ALLEN VA 08/18/93 IMPROPER SIIIPPING PAPERS ASSOCIATES 940981 DU PONT MERCK 20-00320-16MD NORTH MA 02/21/93 VElilCLE ACCIDENT PIIARMACEUTICAL CO. BILLERICA 942018 FAIRFAX, CITY OF 45-10273-02 FAllIFAX VA 08/30/93 IMPROPER SillPPING PAPERS 942025 FLUOR DANIEL, INC.. 39-01261-04 GREENVILLE SC 05/03/93 IMPROPER SIIIPPING PAPERS i 942003 FORT WAYNE, CITY OF 13-16526-02 FORT WAYNE IN 04/21/93 IMPROPER SIIIPPING PAPERS 940866 GENERAL ELECTRIC CO. SNM-1097 WILMINGTON NC 12/01/93 VElilCLE ACCIDENT 941922 GEORGIA INSTITUTE OF R-97 ATIANTA GA 08/02/93 IMPROPER SillPPING PAPERS TECHNOLOGY 940706 GREAT falls, CITY OF 25-15247-01 GREAT FALIS MT 08/09/93 IMPROPER SHIPPING PAPERS 942006 HEALTH & HUMAN 50-23219-01 ANCHORAGE AK 07/19/93 FAILURE TO MAINTAIN SERVICES, DEPARTMENT RECORDS OF 942007 HERRON TESTING 34-00681-03 CLEVELAND OH 01/01/93 IMPROPER SHIPPING IABORATORIES,INC. CONTAINER, IMPROPER i SHIPPING PAPERS, FAILURE l [ TO BRACE AND BLOCK PACKAGE 942022 liORNOR BROTHERS 47-24 % 2-01 ClARKSBURG WV 05/26/93 IMPROPER SHIPPING PAPERS ENGINEERS 941606 INDEPENDENT TESTING GEN. LICENSE HOUSTON TX 12/14/93 IMPROPER SillPPING PAPERS IABORATORIES 941987 INDIANA, DEPARTMENT 13-26343-01 VINCENNES IN 09/21/93 IMPROPER SHIPPING PAPERS l OF TRANSPORTATION 6 942021 INDUSTRIAL NDT CO., INC. 39-24888-01 NORTH SC 06/16/93 FAILURE TO BRACE AND CHARLESTON BIDCK PACKAGE NUREG-1272, Appendix A-1 12

Table A-L6 Transportation Events Reported by NRC Licensees,1993 (continued) TYPE OF ITEM LICENSEE EVENT TRANSPORTATION NO. LICENSEE NO. CITY STATE DATE EVENT 942000 IlVINGSTON COUNTY 21-20064-01 HOWELL MI 06/29/93 FAILURE TO BRACE AND ROAD COMMISSION BLOCK PACKAGE 940610 MAlllNCKRODT 24-04206-13MD SAINT LOUIS MO 05/07/93 CONTAMINATED PACKAGE MEDICAL. INC. 940611 MALLINCKRODT 24-04206-13MD SAINT LOUIS MO 05/11/93 EXCESS RADIATION LEVEIS MEDICA 1, INC. 940097 MALilNCKRODT, INC. 37-23326-01MD FOlrROFT PA 05/07/93 CONPAMINATED PACKAGE 942001 MAIJJNCKRODT, INC. 24-04206-01 MARYLAND MO 02/19/93 FAILURE TO ClIECK FOR llEIGilTS SURFACE CONTAMINATION 941998 MAYO FOUNDATION 22-00519-03 ROCHESTER MN 01/07/93 FAILURE TO MAINTAIN RECORDS 940665 MEDI+ PHYSICS, INC. 29-28341-02MD LIVINGSTON NJ 09/03/93 EXCESS RADIATION LEVE13 940907 MICHIGAN STATE 21-00021-29 EAST LANSING MI 02/28/93 IMPROPER SHIPPING PAPERS UNIVERSrTY FAILURE TO BRACE AND BLOCK PACKAGE 941997 MINNESOTA MINING & 22-00057-07 SAINT PAUL MN 01/27/93 IMPROPER SHIPPING MANUFACTURING CO. CONTAINER 940824 MISSOURI, UNIVERSITY R-103 COLUMBIA MO 01/01/93 IMPROPER SillPPING PAPERS AT COLUMBIA 940677 NAVY, DEPARTMENT OF 45-23645-01NA WASIIINGTON DC 08/03/93 IMPROPER SHIPPING PAPERS 940690 NORTil AMERICAN 37-23370-01 WillTEHALL PA 09/01/93 IMPROPER SHIPPING PAPERS INSPECTION, INC. 941999 NORTil COUNTRY 22-24742-01 BEMIDJI MN 08/19/93 FAILURE TO CliECK FOR HOSPTPAL SURFACE CONTAMINATION 942033 OFTICAL CORP. OF 20-23742-01 MARLBORO MA 11/19/93 IMPROPER SillPPING PAPERS AMERICA 940715 PUBLIC SERVICE CO. OF NR PlATTEVILLE CO 03/04/93 VEHICLE ACCIDENT COLORADO 942010 QUAllTY INSPECTION & 50-29038-01 FAIRBANKS AK 08/04/93 IMPROPER SHIPPING TESTING CONTAINER 941835 RADIATION 37-13129-01 PHIIADELPHIA PA 03/31/93 IMPROPER SHIPPING PAPERS MANAGEMENT CONSULTANTS 940683 RADIOPHARMACY,1NC. 13-26246-01MD EVANSVILLE IN 02/24/931MPROPER SHIPPINO PAPERS 941608 SAINT LUKE'S MEDICAL 34-00398-08 CLEVELAND OH 04/07/93 IMPROPER SHIPPING CENTER CONTAINER, IMPROPER SHIPPING PAPERS 941005 SAINT MARGARET 37-14014-01 PITTSBURGli PA 05/03/93 CONTAMINATED PACKAGE MEMORIAL HOSPITAL 13 NUREG-1272, Appendix A-1

~ AEUU Annual Repor1,1713 ^- ~ ~~ Table A-1.6 Transportation Events Reported by NRC Licensees,1993 (continued) TYPE OF ITEM LICENSEE EVENT TRANSPORTATION NO. LICENSEE NO. CITY STATE DATE EVENT 940676 SCHNABEL ENGINEERING 45-19703-01 RICllMOND VA 08/25/93 IMPROPER SI11PPING PAPERS ASSOCIATES,INC 940879 SIEMENS NUCLEAR SNM-1227 RICHLAND WA 01/20/93 VElllCII ACCIDENT POWER CORP. 940660 SOIL ENGINEERS & 21-26066-01 TRENTON MI 08/18/93 IMPROPER SillPPING PAPERS SCIENTISTS,INC 940699 SUPERIOR PAVING CORE 45-24949-01 CENTREVILLE VA 07/21/93 IMPROPER SillPPING PAPERS 941460 TROJAN NUCLEAR PLANT NR PRESCOTT OR 12/23/93 EXCESS RADIATION LEVELS 940659 UNITED STATES TESTING 41-25235-01 MEMPHIS TN 09/09/93 IMPROPER SillPPING PAPERS CO., INC 940497 V.A., DEPARTMENT OF 04-00181-04 LOS ANGELES CA 12/20/93 IMPROPER SIIIPPING PAPERS 940704 V.A., DEPARTMENT OF 30-01747-02 ALBUQUEROUE NM 02/02/93 IMPROPER TRANSPORTArlON 940132 WESTERN ATLAS 42-02964-01 HOUSTON TX 06/02/93 EXCESS RADINflON LEVELS INTERNATIONAI. INC 941992 WILLIAM BEAUMONT 21-01333-01 ROYAL OAK MI 05/21/93 IMPROPER SHIPPING HOSPITAL CONTAINER 940694 WILSON ENGINEERING 50-23263-01 JUNEAU AK 09/09/93 IMPROPER SillPPING PAPERS 942020 WILSON ENGINEERING $0-2.$263-01 JUNEAU AK 08/12/93 IMPROPER SHIPPING PAPERS 942009 WOLVERINE ENGINEERS 21-25970-01 MASON MI 01/19/93 IMPROPER SHIPPING AND SURVEYORS,INC PAPERS, FAILURE TO BRACE AND BLOCK PACKAGE NR indicates NOT REPORTED NUREG-1272, Appendix A-1 14

Riidear1&5IeFiFs ARPLC'lCicenseelEvents Table A-1.7 Equipment Problems Reported by NRC Licensees,1993 ITEM LICENSEE EVENT NO. LICENSEE NO. CITY STATE DATE EQUIPMENT 940591 ABBOTT HEALTil PRODUCTS, 52-249945-01 VEGA ALTA PR 10/19/93 1RRADIATOR INC. 940963 ABBOTF-NORTIIWESTERN 22-04588-01 MINNEAPOLIS MN 01/06/93 BRACllYTilERAPY HOSPITAL NON-MAN AFT-IIDR 940020 AGRICULTURE, DEPARTMENT 19-00915-03 IlYAT13V111E MD 07/14/93 GAUGE, MOISTURE OF DENSrFY 940595 AIR FORCE, DEPARTMENT OF 42-23539-01AF BROOKS AFB TX 09/03/93 MODERNTOR CO11JMETER Si11 ELD 940713 AIR FORCE, DEPARTMENT OF 42-23539-01AF BROOKS AFB TX 10/19/93 IRRADIATOR INTERLOCK 940218 AMERSHAM CORE NO UCENSE BURLINGTON MA 11/22/93 55 GALLON DRUM 940668 AMERSHAM CORR 20-12836-01 BURUNGTON MA 07/29/93 COBALT SOURCE ASSEM13LY 940669 AMERSHAM CORP. 20-12836-01 BURIJNGTON MA 07/16/93 SOURCE ASSEMllLY 940982 ARMY, DEPARTMENT OF THE 19-17250-05 ADELPI11 MD 10/26/93 IRRADIATOR POOL 940146 ATEC ASSOCIATES OF VIRGINIA, 45-16546-04 ALEXANDRIA VA 04/09/93 GAUGE, MOISTURE INC. DENStrY 940794 ATEC ASSOCIATES, INC. 34-18893-01 CINCINNATI OH 07/29/93 GAUGE, MOlSTURE DENSTTY 940827 BABCOCK & WILCOX CO. SNM-42 LYNCHBURG VA 07/02/93 EVACUATION AIARM l 940845 BABCOCK & Wilf0X CO. SNM-42 LYNCHBURG VA 10/21/93 EVACUATION AIARM 940094 BARNETT INDUSTRIAL X-RAY 35-26953-01 STILLWATER OK 06/10/93 RADIOGRAPilY CAMERA 940095 BARNETF INDUSTRIAL X-RAY 35-26953-01 STILLWATER OK 08/18/93 RADIOGRAPHY CAMERA 1 940156 DETTEROADS ASPHALTCORE 52-19845-01 RIO PIEDRAS PR 02/04/93 GAUGE MOISTURE DENSITY 940973 BRIDGEPORT BRASE CORE 13-26078-01 INDIANAPOLIS IN 06/15/93 GAUGE 940014 CALUMET TESTING SERVICES, 13-16347-01 HIGHLAND IN 06/14/93 RADIOGRAPIlY INC. CAMERA 940217 COBIN, RHODA 11., M.D. 29-18376-01 MIDIAND NJ 03/05/93 DOSE CALillRATOR PARK 940069 COLUMBUS, CITY OF 34-13103-02 COLUMBUS OH 04/06/93 GAUGE, MOISTURE DENS 11Y 940869 COM13USTION ENGINEERING, SNM-1067 WINDSOR CF 08/04/93 CRITICALrrY AIARM INC. 1 940150 CONSOLIDATED PAPERS. INC. 48-01117-01 WISCONSIN WI 01/06/93 GAUGE RAPIDS 940151 CONSOLIDATED PAPERS,INC. 48-01117-01 WISCONSIN WI 09/17/93 GAUGE RAPIDS 15 NUREG-1272, Appendix A-1

AEOD Annual Report,1993 Table A-1.7 Equipment Problems Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT NO. LICENSEE NO. CITY STATE DATE EQUIPMENT 940116 CONSTRUCrlON ENGINEERING 37-18456-02 PIT 13BURGli PA 06/15/93 GAUGE, MOISTURE CONSULTANTS, INC. DENSITY 940666 CFL ENGINEERING, INC. 34-18533-01 COLUMBUS 0 11 07/22/93 GAUGE, MOISTURE DENSrfY 941281 DEACONESS MEDICAL CENTER 25-01051-01 BILLINGS MT 11/30/93 TiiERAPIAN-L COMPUTER 940228 DEFENSE NUCLEAR AGENCY 19-08330-03 UETilESDA MD 06/22/93 IRRADIATOR 940229 DEFENSE NUCLEAR AGENCY 19-08330-03 IIETilESDA MD 06/16/93 IRRADIATOR 940686 DEFENSE NUCLEAR AGENCY 19 4 8330-03 IIETilESDA MD 10/19/93 IRRADIATOR INTERLOCK 940147 ENGINEERING CONSULTING 45-24974-01 CIIANTILLY VA 04/28/93 GAUGE, MOISTURE SERVICES, LTD. DENStrY 940705 EVERGREEN RADIOLOGY 29-02023-06 WAYNE NJ 05/14/93 11RAC11YTIIERAPY ASSOCIATES NON-MAN AFT-IIDR 940622 FARWELL & llENDRICKS,INC. NO LICENSE CINCINNATI Oli 11/29/93 OVERLOAD RELAYS 941449 FOX CIIASE CANCER CENTER 37-02766-01 PillIADELPlilA PA 08/18/93 11DR PLANNING SYSTEM 940183 GEISINGER MEDICAL CENTER 37-01421-04 DANVILLE PA 03/31/93 TElEriiERAPY UNIT 940868 GENERAL ELECTRIC CO. SNM-1097 WILMINGTON NC 05/13/93 RECEIVING PAIL SENSOR 940111 GLENN O. IIAWBAKER, INC. 37-19636-01 STATE PA 08/16/93 GAUGE, MOISTURE COLIIGE DENSITY 940071 GLITSCII FIELD SERVICES /NDE, 34-14071-01 NORT11 Oli 04/08/93 RADIOGRAPIIY INC. CANTON CAMERA 941424 II&G INSPEC110N CO., INC. 42-26838-01 IIOUSTON TX 02/09/93 RADIOGRAPliY GUIDE TUBE l 940625 liEALT11 & liUMAN SERVICES, 19-00296-12 BET 11ESDA MD 10/07/93 IRRADIATOR DEPARTMENT OF 940687 IIEALTil & 11UMAN SERVICES, 19-00296-12 BETilESDA MD 09/24/93 IRRADINFOR DEPARTMENT OF 940743 IIEALTil & 11UMAN SERVICES, 19-00296-17 BETiiESDA MD 12/03/93 IRRADIATOR DEPARTMENT OF 940819 IIEALTli & IIUMAN SERVICES, 19-00296-17 BETIIESDA MD 12/15/93 IRRADINFOR DEPARTMENT OF 940680 IIENRICO DOCTORS IIOSPITAL 45-16231-02 RIC11MOND VA 04/30/ IRRADIATOR INTERIDCK 940984 IIEAL'ITI & 11UMAN SERVICES, 19-00296-10 BETilESDA MD 08/04/93 SEIICTRON DEPARTMENT OF REMOTE i l AFTERIDAD-LDR NUREG-1272, Appendix A-1 16

WORear AarefiM^;WL4C'1CicenseeIEvenSs l Table A-1.7 Equipment Problems Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT NO. LICENSEE N O. CI1Y STATE DATE EQUIPMENT l 940589 IIONOLULU RESOURCE 53-23291-01 EWA BEACll 111 12/27/93 ASil TOWER SURGE RECOVERY VENTURE 111NS 940692 IIULL& ASSOCIATES,INC 34-24957-01 TOLEDO Oli 06/17/93 GAUGE, MOISTURE L)ENSITY 940623 INTERIOR, DEPARTMENT OF 02-21080-01 TUllA CITY AZ 09/28/93 GAUGE, MOISTURE DENSITY 940158 IAS PIEDRAS CONSTRUCrlON $2-25!25-01 LAS PIEDRAS PR 07/13/93 GAUGE, MOISTURE CORE DENSITY f 940077 MARIETTA COAL CO. 34-23333-01 SAINT 0 11 02/25/93 SObtLE IIOLDER i CLAIRSVILI.E l 940124 MOUNT SINAL MEDICAL CENTER 34-00746-02 CLEVE1AND 01I 03/01/93 SOURCE SAFE 941852 NORTil AMERICAN INSPECTION, 37-23370-01 WIIITEHALL PA 05/06/93 PROJECTOR INC. f 941854 NORTIl AMERICAN INSPECrlON. 37-23370-01 WillTEllALL PA 11/03/93 RADIOGRAPilY INC CAMERA 941972 NORTH AMERICAN INSPECTION, 37-23370-01 WillTEllALL PA 07/29/93 RADIOGRAPIIY INC CAMERA 940075 NORTH STAR STEEL 01110 34-20328-01 YOUNGSTOWN OH 05/28/93 GAUGE, FIXED l f 940971 NTil CONSULTANTS, LTD. 21-14894-01 FARMINGTON Mi 09/24/93 GAUGE, MOISTURE IllLIS DENSITY 940914 NUCL. EAR FUEL SERVICES, SNM-124 ERWIN TN 11/16/93 SUETlG. TYPE B [ INC. PROTOVERPACKS 940182 NUCLETRON CORE 19-28772-01 COLUMillA MD 03/02/93 BRACHYTilERAPY NON-MAN AFr HDR 940803 NUCLETRON CORE 19-28772-01 COLUMBIA MD 04/01/93 BRACilYTiiERAPY NON-MAN AIT-HDR i 94W88 NUMERICAL APPLICATIONS,INC. NR RICIIIAND WA 11/06/93 COMPUTER PROGRAM i l 903087 OHIO DEPARTMENT OF 34-05239-01 COLUMBUS 0 11 08/03/93 GAUGE, MOISTURE i TRANSPORTATION DENSITY 940494 OHIO STATE UNIVERSITY R-75 COLUMBUS OH 03/05/93 REACTOR 941054 OMNITRON INTERNATIONA1. NO1JCENSE IlOUSTON TX 03/09/93 BRACIIYTHERAPY INC NON-MAN AFT-IIDR 940709 OMNITRON INTERNATIONAI, NO1JCENSE IIOUSTON TX 03/03/93 BRACHYTHERAPY INC NON-MAN AFr-HDR 940603 PARKVIEW HOSPITAL 37-12141-01 PlillADELPHIA PA 01/20/93 NR 940711 PERMAGRAIN PRODUCTS,INC. 37-17860-02 MEDIA PA 06/01/93 IRRADINFOR POOL 17 NUREG-1272, Appendix A-1 _~

Table A-1.7 Equipment Problems Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT NO. LICENSEE NO. CITY STATE DATE EQUIPMENT 940109 PRECISION COMPONENTS CORR 37-16280-01 YORK PA 09/07/93 RADIOGRAPHY CAMERA i 940063 PROCESS TECllNOLOGY OF 29-13613-02 ROCKAWAY NJ 03/08/93 CIRCUIATION PUMP NORTII JERSEY 940702 PROCFER & GAMBLE CO. 34-01572-13 CINCINNATI OH 04/02/93 GAUGE, FIXED 940100 ROBERT PACKER llOSPITAL 37-01893-01 SAYRE PA 04/22/93 BRACHYTIIERAPY NON-MAN AFT-HDR 940594 ROCKINGIIAM MEMORIAL 45-05594-02 IIARRISBURG VA 12/13/93 TELETilERAPY UNIT IlOSPITAL i 940860 RTS TECHNOLOGY, INC. 20-2796 H 1 NORTH MA 05/11/93 SOURCE ASSEMBLY ANDOVER 940697 RUSSELL COUNTY MEDICAL 45-19940-01 LEBANON VA 04/15/93 DOSE CALIBRATOR CENTER INC. 940102 SAINT FRANCIS liOSPITAL 13-02128-02 BEEClf GROVE IN 07/02/93 TELETHERAPY UNIT 940210 SAINT LOUIS COUNTY 24-26279-01 CLAYTON MO 06/14/93 GAUGE, MOISTURE DENSITY 940033 SAINT MARY'S MEDICAL 21-03646-04 SAGINAW MI 05/19/93 TELETHERAPY UNIT CENTER 940675 SCHNABEL ENGINEERING 45-19703-01 RICHMOND VA 07/11/93 GAUGE, MOISTURE i ASSOCIATES. INC. DENSITY 940847 SEOUOYAll FUEIS CORR SUB-1010 GORE OK 02/25/93 OFF SITE SIRENS 940848 SEQUOYAH FUELS CORE SUB-1010 GORE OK 04/03/93 OFF SITE SIRENS i 940888 SHADYSIDE HOSPITAL SNM-1531 PITTSBURGH PA 08/30/93 NUCLEAR PACEMAKER 940212 SHANNON & WIISON,INC. 24-18839-01 SAINT LOUIS MO 09/12/93 GAUGE, MOISTURE DENSITY 940662 SOIL ENGINEERS & SCIENTISTS, 21-26066-01 TRENTON MI 07/16/93 GAUGE, MOISTURE INC. DENSITY 940115 SUMMIT TESTING & INSPECTION 34-2341 M 1 AKRON OH 07/08/93 GAUGE, MOISTURE CO. DENSITY 940118 TEI ANALYTICALSERVICES,INC. 37-28004-01 WASHINGTON PA 01/26/93 RADIOGRAPIlY CAMERA 940045 TWIN CITY TESTING CORR 22-01376 4 2 SAINT PAUL MN 02/02/93 RADIOGRAPHY CAMERA 940046 TWIN CITY TESTING CORR 22-01376 4 2 SAINT PAUL MN 06/04/93 RADIOGRAPilY CAMERA 940875 TWIN CITY TESTING CORR 22-01376-02 SAINT PAUL MN 06/29/93 RADIOGRAPilY CAMERA 940078 VALLEY ASPHALT CORR 34-24771-01 CINCINNATI OH 03/17/93 GAUGE, MOISTURE DENSITY NUREG-1272, Appendix A-1 18

Table A-1.7 Equipament Problems Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT NO. LICENSEE NO. CITY STATE DATE EQUIPMENT 940161 WASHINGTON HOSPITAL SNM-1446 WASIIINGTON DC 04/19/93 NUCLEAR CENTER PACEMAKER 040049 WASHINGTON UNIVER$1TY 24-00167-11 SAINT LOUIS MO 05/05/93 SEALED SOURCE MEDICAL SCllOOL 940958 WASHINGTON UNIVERSITY 24-00167-11 SAINT LOUIS MO 02/26/93 IIRACllYTIIERAPY MEDICAL SCHOOL REMOTE AFT-LDR 940037 WAYNE COUNTY OFFICE OF 21-13687-01 ROMULUS MI 08/16/93 GAUGE, MOISTURE . PUBLIC SERVICE DENSITY 940056 WiiEATON GLASS CO. 29-00968-02 MILLVillE NJ 08/23/93 GAUGE, FIXED 941036 WISCONSIN ELECTRIC POWER GENERALLIC MILWAUKEE WI 08/31/93 EXIT SIGN CO. NR indicates NOT REPORED 19 NUREG-1272, Appendix A-1

AEOD Ariniial Report,1993 ~ ~ ^ ~ ^ ^~~ ~ ~ ~~' ~~ ^ Table A-1.8 Fuel Cycle Events Reported by NRC Licensees,1993 ITEM LICENSEE EVENT TYPE OF FUEL NO. LICENSEE NO. CITY STATE DATE CYCLEINENT 940631 IIABCOCK & Wilf0X CO. SNM-42 IXNCIIBURG VA 04/19/93 POTENTIAL CRmCAUTY 940828 BABCOCK & WIlf0X CO. SNM-42 IXNCIIBURG VA 06/02/93 POTENTIAL CRmCAUTY 940829 BABCOCK & WILCOX CO. SNM-42 IXNCHBURG VA 04/20/93 POTENTIALCRmCAUTY 940830 BABCOCK & WILCOX CO. SNM-42 LYNCHBURG VA 04/16/93 POTENTIAL CRmCAUTY 940831 BABCOCK & WilCOX CO. SNM-42 IXNCliBURG VA 02/2fv93 POTENTIAL CRITICAUTY 940846 BABCOCK & WIlf0X CO. SNM-42 IXNCilBURG VA 09/16/93 POTENTIAL CRmCAUTY 940893 BABCOCK & WILCOX CO. SNM-42 LYNCliBURG VA 03/11/93 POTENTIAL CRmCAUTY 941601 BABCOCK & WilfOX CO. SNM-42 LYNCIIBURG VA 11/11/93 POTENTIAL CRITICAUTY 941602 BABCOCK & WIILOX CO. SNM-42 INNCIIBURG VA N/09/93 POTENTIAL CRITICAUTY 941677 BABCOCK & WIlfOX CO. SNM-42 IXNC11 BURG VA 02/16/93 POTENTIAL CRITICAUTY 9416S0 BABCOCK & Wilf0X CO. SNM-42 IXNCIIBURG VA 02/19/93 POTENTIALCRmCAUTY 941686 BABCOCK & WIlfoX CO. SNM-42 LYNCilBURG VA 07/17/93 POTENTIAL CRmCAUTY 940864 GENERAL ELECTRIC CO. SNM-1097 WILMINGTON NC 12/21/93 POTENTIAL CRmCAUTY 940843 NUCLEAR FUEL SERVICES SNM-124 ERWIN TN 04/07/93 POTENTIAL CRITICAUTY 940841 NUCLEAR FUEL SERVICES SNM-124 ERWIN TN 05/20/93 POTENBAL CRITICAUTY 940842 NUCLEAR FUEL SERVICES SNM-124 ERWIN TN 05/10/93 POTENTIAL CRmCAUTY 940880 SIEMENS NUCLEAR SNM-1227 RICIIIAND WA 01/27/93 POTENTIALCRmCAUTY POWER CO.RE 941570 SIEMENS NUCLEAR SNM-1227 RICIIIAND WA 02/08/93 POTENTIAL CRITICAUTY POWER CORE 940882 SIEMENS NUCLEAR SNM-1227 RICIIIAND WA 04/27/93 POTENTIALCRmCAUTY POWER CORE 940883 SIEMENS NUCLEAR SNM-1227 RIClllAND WA 06/09/93 POTENTIAL CRmCAUTY POWER CORE 940884 SIEMENS NUCLEAR SNM-1227 RICIIIAND WA 12/28/93 POTENTIAL CRITICAUTY POWER CORE 941020 WESTINGIIOUSE SNM-1107 PITFSBURGli PA N/08/93 POTENTIAL CRITICAUTY ELECTRIC CORE 940850 BAllCOCK & WIlfOX CO. SNM-42 LYNCIIBURG VA 07/17/93 POTENTIAL CRITICAUTY, EQUIPMENT PROBLEM 940835 COMBUSTION SNM-33 IIEMATITE MO 03/31/93 POTENTIAL CRITICAUTY, ENGINEERING, INC. EQUIPMENT PROBLEM 940871 GENERAL ATOMICS SNM-696 SAN DIEGO CA 01/11/93 POTENTIAL CRmCAUTY, EQUIPMENT PROBLEM 940865 GENERAL ELECTRIC CO. SNM-1097 WILMINGTON NC 12/09/93 POTENTIAL CRITICAUTY, EQUIPMENT PROBLEM NUREG-1272, Appendix A-1 20 l - ' ^

Table A-1.8 Fuel Cycle Events Reported by NRC Licensees,1993 (continued) ITEM LICENSEE EVENT 'IYPE OF FUEL NO. IJCENSEE NO. CITY STATE DATE CYCLE EVENT 940895 NUCLEAR FUEL SERVICES SNM-124 ERWIN TN OU28/93 POTENTIAL CRITICALITY, EQUIPMENT PROBLEM 940881 SIEMENS NUCLEAR SNM-1227 RICI!!AND WA 02/07/93 POTENTIAL CRITICALITY, POWER CORE EQUIPMENT PROBLEM 940887 SIEMENS NUCLIAR SNM-1227 RICHLAND WA 06/16/93 POTENTIAL CRITICAIJTY, POWER CORE EQUIPMENT PROBLEM 940862 WESTINGHOUSE SNM-1107 PFITSBURGli PA 05/2U93 POTENTIAL CRITICAIITY, ELECTRIC CORE EQUIPMENT PROBLEM 940896 WESTINGHOUSE SNM-1107 PITTSBURGli PA 08/13/93 POTENTIAL CRITICALITY, ELECTRIC CORE EQUIPMENT PROBLEM 940897 WESTINGHOUSE SNM-1107 PITISBURGli PA 07/20/93 POTENTIAL CRITICAllTY, ELECTRIC CORE EQUIPMENT PROBIEM 941703 WESTINGHOUSE SNM-1107 PITrSBURGl1 PA 02/16/93 POTENTIAL CRrrlCAIJTY, ELECTRIC CORE EQUIPMENT PROBIEM 940851 BABCOCK & WILCOX CO. SNM-42 1.YNCllBURG VA 07/04/93 EQUIPMENT PROBLEM 941701 BABCOCK & WILCOX CO. SNM-42 LYNCllBURG VA 06/04/93 EQUIPMElff PROBLEM 940844 NUCLEAR FUEL SERVICES SNM-124 ERWIN TN 02/(M/93 EQUIPMENT PROBLEM 941679 SEQUOYAH FUEIS CORR SUB-1010 GORE OK 02/25/93 EQUIPMENT PROBLEM 940886 SIEMENS NUCLEAR SNM-1227 RICllLAND WA 10/13/93 EQUIPMENT PROBLEM, POWER CORR CONTAMINATION 940870 COMBUSTION SNM-1067 WINDSOR CF OUO6/93 EQUIPMENT PROBLEM, ENGINEERING, INC. OTHER 940839 NUCLEAR FUEL SERVICES SNM-124 ERWIN TN 10/13/93 OTilER 940840 NUCLEAR FUEL SERVICES SNM-124 ERWIN TN 09/02/93 OTHER 940892 BABCOCK & WIlfOX CO. SNM-42 1YNCHBURG VA OU21/93 OTilER 940832 BABCOCK & WIlfOX CO. SNM-42 LYNCHBURG VA OU27/93 OTHER 940939 CHEMETRON CORE SUB-1357 PROVIDENCE RI 12/08/93 OTHER 941688 GENERAL ATOMICS SNM-696 SAN DIEGO CA 08/16/93 OTHER 940863 WESTINGHOUSE SNM-1107 PITISBURGil PA 01/13/93 OTHER EIECTRIC CORR 21 NUREG-1272, Appendix A-1

AEOD Annual Report,1993 ~" l Table A-1.9 Research and Training Reactor Events Reported by NRC Licensees,1993 ITEM LICENSEE EVENT TYPE OF NO. LICENSEE NO. CIIY STATE DATE REACI'OR EVENT 940825 ARMED FORCES R-84 BETHESDA MD 11/05/93 EQUIPMENT PROBLEM RADIOBIOLOGY RESEARCH q INSTITUTE 940770 MASSACIIUSETTS INSTITUTE R-37 CAMBRIDOE MA 12/07/93 EQUIPMENT PROBLEM OF TECIINOLOGY 940820 MICHIGAN, UNIVERSITY OF R-28 ANN ARBOR MI 03/24/93 LICENSE CONDITION VIOLATION 940748 MICHIGAN, UNIVERSITY OF R-28 ANN ARBOR MI 07/30/93 AQUEOUS RELEASE OF RADIOACTIVE MATERIAL 940826 MISSOURI, UNIVERSITY OF, R-79 ROLLA MO 10/26/93 EQUIPMENT PROBLEM AT ROLLA 940494 OHIO STATE UNIVERSITY R-75 COLUMBUS OH 03/05/93 EQUIPMENT PROBLEM 940771 VIRGINIA, UNIVERSITY OF R-66 CHARLOTTESVILLE VA 04/28/93 EQUIPMENT PROBLEM 940747 VIRGINIA, UNIVERSITY OF R-66 CHARLOTTESVILLE VA 11/05/93 WATER IDSS FROM REACFOR POOI, I l l NUREG-1272, Appendix A-1 22

Appendix A-2 Agreement State Licensee Events i f e

Table A-2.1 Medical Misadministrations Reported by Agreement States,1993 ITEM LICENSEE EVENT TYPE OF NO. IJCENSIo NO. CITY STATE DATE MISADMINISTRATION J70 BAlrriST MEMORIAL R-79032-F97 MEMPHIS TN 11/26/93 IIRACIIY111ERAPY llOSPITAL 941126 CAIJFORNIA, UNIVERSITY 1334-57 DAVIS CA 12/14/93 BRACliYTIIERAPY OF, AT DAVIS 940734 CIEAR 1AKE REGIONAL NR WEBSTER TX 07/06/93 BRACHYTIIERAPY MEDICAL CENTER 940207 JOHNSON CITY MEDICAL R-90005-K97 JOHNSON CITY TN 04/21/93 BRACIIYTHERAPY CENTER 941975 IDNG llOSPITA1. 1725-90 SAN FRANCISCO CA 12/07/93 BRACilYTIIERAPY UNIVERSITY OF CALIFORNIA 940738 MEMORIAL MEDICAL NR LUFKIN TX 10/05/93 IIRACHYT!iERAPY CENTER 940457 MICilAEL REESE 86-411097-01 CHICAGO IL 10/10/93 BRACHYTHERAPY HOSPITAL & MEDICAL CENTER 941001 MOUNT SINAL MEDICAL FL-64-12 MIAMI FL 11/24/93 BRACHYTHERAPY CENTER 940295 REGIONAL MEDICAL R-79160-L97 MEMPHIS TN 06/16/93 BRACHYTilERAPY CENTER OF MEMPHIS 940524 AS TELETHERAPY NR ALBANY NY 05/10/93 TELETHERAPY llCENSEE 940477 PRESBYTERIAN HOSPITAL 60-019-A CHARIDTTE NC 10/01/93 TElITHERAPY 941245 SAINT FRANCIS MEDICAL IA-0193-IEl MONROE lA 01/19/93 TELETHERAPY CENTER 940802 ROCKY MOUNTAIN NR DENVER CO 07/08/93 TELETilERAPY-GAMMA GAMMA KNIFE CENTER KNIFE 1 941127 CALIFORNIA, UNIV. 1725-90 SAN FRANCISCO CA 07/19/93 SODIUM IODIDE OF, AT SAN FRANCISCO 941125 CENTINElA IIOSPITAL 0940-70 NR CA 05/18/93 SODIUM IODIDE 940205 lilGHSMITH RAINEY 26-129-2 FAYETTEVf!AE NC 05/27/93 SODIUM IODIDE IlOSPITAL 940284 KAISER-FRANKLIN NR DENVER CO 08/17/93 SODIUM IODIDE MEDICAL CENTER 940473 NORTH CAROLINA 34-158-1 WINSTON-SAlIM NC 06/17/93 SODIUM IODIDE BAPTIST HOSPITAL 941128 SIERRA VISTA HOSPITAL 3872-70 NR CA 06/29/93 SODIUM IODIDE NR indicates NOT REPORTED 25 NUREG-1272, Appendix A-2

^EOD ^nnual Report, NW ~ Table A-2.2 Overexposures Repor1ed by Agreement States,1993 ITEM LICENSEE EVENT TYPE OF NO. DOSE NO. LICENSEE NO. CITY STATE DATE EXPOSURE EXPOSED (REM) 940380 MOUNT SINAI MEDICAL 0064-1 MIAMI FL 09/14/93 WB 1 56 CENTER BEACH 940539 WESTCHESTER COUNTY 586-2 VALHALIA NY 07/31/93 WB 1 2.79 MEDICAL CENTER 940682 X-CEL GROUP, INC NR CORPUS 'DC 05/22/93 EXT 1 1925 CHRISTI 940200 MOS INSPECTION,INC 86-01136-01 ELK GROVE IL 07/15/93 EXT 1 146 940629 TECHNICAL WELDING NR PASADENA TX 04/12/93 EXT 1 65 LABORATORY,INC 940813 UNIVERSAL TESTING, UT-06003-23 CLEARFIELD UT 07/28/93 EXT 1 306.4 INC 940790 ANAID, INC. NR DICKINSON TX 09/01/93 WB 1 3.71 940804 APPLIED STANDARDS NR BEAUMONT TX 11/05/93 WB 1 6.159 INSPECTION, INC. 940805 APPLIED STANDARDS NR BEAUMONT TX 11/05/93 Wil 1 3.371 INSPECTION, INC. 940584 B.ESHAW 074 lAURENS SC 02/02/93 WB 1 1.6 941422 BASIN INDUSTRIAL NR CORPUS TX 01/25/93 WB 1 4.7 X-RAY CHRISTI 941611 BERRY FABRICATORS NR CORPUS TX 02/01/93 WB 1 1.44 CHRISTI 941612 BERRY FABRICATORS NR CORPUS TX 05/01/93 WB 1 1.68 CHRISTI l l 940766 D-ARROW INSPECTION, NR HOUSTON TX 09/01/93 WB 1 3.1 INC 941902 EL PASO INSPECTION NR EL PASO TX 08/01/93 WB 1 1.9 940626 GUARDIAN NDT NR CORPUS TX 03/15/93 WB 2 1.25, 1.25 SERVICES CHRISTI 940735 GUARDIAN NDT NR CORPUS TX 06/01/93 WB 1 4.223 SERVICES CHRISTI 940383 GULF COAST OUALITY 1495-1 JAY FL 09/21/93 WB 2 1.32, 2.81 ASSOCIATES,INC 940204 INSPECTION 1A-4266-Ih1 MERAUX 1A 05/07/93 WB 1 27.66 SPECIAllSTS,INC 941620 PHOENIX NR CHANNELVIEW TX 10/31/93 WB 1 3.265 NON-DESTRUCTIVE TESTING CO.,INC 940581 PROFESSIONAL NR LONGVIEW TX 05/10/93 WB 1 1.66 SERVICES INDUSTRIES 941621 RADIOGRAPHIC NR HOUSTON TX 10/01/93 WB 1 4.495 SPECIALISTS,INC WB indicates WilOW DODY NR indicates NOT REPORTED EXT indicates EXTREMITY NUREG-1272, Appendix A-2 26

7bdearWaleTiE!ii-A\\greemennThaYelOcensee LEvents Table A-2.3 Loss of Control of Material Events Reported by Agreement States,1993 ITEM LICENSEE EVENT RADIO-NO. LICENSEE NO. CITY STATE DATE NUCLIDE 940312 ACRE IRON AND METAL NON-UCENSEE PINELLAS PARK FL 03/12/93 U-DEP 940777 ALUMAX MILL PRODUCTS NR TEXARKANA TX 09/14/93 FE-55 941400 AMERICAN EAGLE WELL NR WITCHITA FAILS TX 01/07/93 CS-137 LOGGING, INC. 940453 AMERSIIAM CORP. 12-12836-01 NR IL 08/27/93 P-32 940800 APPLIED STANDARDS NR BEAUMONT TX 09/29/93 IR-192 INSPECTION, INC. 940178 AS SCRAP METAL DEALER NON-UCENSEE MAGNOLIA AR 03/24/93 CS-137 940648 AT LABORATORIES, INC. NR ARUNGTON TX 06/01/93 CS-137, AM-BE 940381 ATLANTIC COAST ELECTRONICS 023-GL POMPANO BEACII FL 09/14/93 SR-90 941609 BAYLOR COILEGE OF MEDICINE NR HOUSTON TX 10/12/93 CS-137 941209 BFI NR NR CA 06/12/93 NR 940226 BFI IANDFILL NON-UCENSEE BIIDXI MS 08/14/93 NR 940566 BFI WASTE SYSTEMS NR GALVESTON TX 04/01/93 CS-137 940586 BOGGS/VAUGIIN 090-0892-1 MONROE NC 09/10/93 CS-137, AM-BE 941313 BRADFORD SQUARE NURSING NON-UCENSEE FRANKFORT KY 11/26/93 I-131 IlOME 940812 BRIGilAM YOUNG UNIVERSITY UT-25000-81 PROVO UT 01/04/93 NI-63 941141 BROTMAN MEDICAL DTR NR NR CA 01/22/93 PU-238 941201 CAUFORNIA TRANSPORTATION NR NR CA 05/24/93 CS-137 DISTRICT 15 AM-DE 941208 CAUFORNIA, UNIVERSITY OF, NR DAVIS CA 06/11/93 C-14 AT DAVIS 940401 CENTRAL FLORIDA TESTING 1062-1 1ARGO FL 12/09/93 CS-137, IABORATORIES, INC. AM-BE 940674 CHAPARRAL STEEL NR MIDIDTHIAN TX 05/11/93 CS-137 940755 CHAPARRAL STEEL NR MIDIDTIIIAN TX 09/18/93 CS-137 940201 CHICAGO, UNIVERSITY OF 12-00509-03 CHICAGO IL 05/04/93 CS-137 940562 CIARKSTOWN RECYCUNG,INC. NON-UCENSEE WEST NYACK NY 0(49/93 I-131 941563 CONVERSE CONSULTANTS 00-11-0094 4 1 LAS VEGAS NV 04/26/93 CS-137, SOUTHWEST AM-BE 941913 CORSICANA WASTE WATER NR CORSICANA TX 12/27/93 CS-137 TREATMENT DEFT., CITY OF 940632 CUMMINGS WIREUNE SERVICES, NR SOMERSET TX 03/20/93 AM-BE INC. 27 NUREG-1272, Appendix A-2

[ AEOD Annual Report 1993 Table A-2.3 Loss of Control of Material Events Reported by Agreement States,1993 (continued) ITEM UCENSEE EVENT RADIO-NO. UCENSEE NO. CI1Y STATE DATE NUCLIDE 940620 DAVID JOSEPli SCRAP CO. NON-UCENSEE TAMPA FL 03/12/93 NR 941248 DAVID JOSEPH SCRAP CO. NR NEWPORT KY 05/19/93 ND 941251 DAVID JOSEPli SCRAP CO. NR NEWPORT KY 03/24/93 NR 941273 DAVID JOSEPH SCRAP CO. NON-UCENSEE NEWPORT KY 07/14/93 NR 941261 ELK CORE GEN. UCENSEE AR 03/24/93 CS-137 940952 ELK ROOFING COMPANY NR STEVENS AR 03/24/93 CS-137 940461 ENGINEERS INTERNATIONAI,INC. 86-01385-01 ClllCAGO IL 11/05/93 CS-137, AM-BE 940406 ENVIRONMENTALSCIENCE AND 2119-1 GAINESVi1LE FL 11/17/93 Til-229, ENGINEERING, INC. TH-230, PU-239, AM-241, CM-244 940196 FLO-LOG, INC. 4204-70 SOUTII GATE CA 02/17/93 CS-137 940352 FLORIDA ATIANTIC UNIVERSITY 734-1(3143)) BOCA RATON FL 04/29/93 S-35 940346 FLORIDA KIDNEY CENTER 1976-1(5D) TAMRAC FL 04/22/93 1-125 940407 FLORIDA. UNIVERStrY OF 0356-1 GAINESVILLE FL 11/10/93 AM-BE 941423 FUGRO-MCCELIAND, INC. NR AUSTIN TX 02/17/93 CS-137, AM-BE 940235 GAllEr ASSOCIATE Alc991 GAINESVILLE GA 11/22/93 CS-137, AM-BE 941914 GEORGIA-PACIFIC CORPORATION ND PAlATKA FL 03/19/93 CS-137 941120 GLYNN IRON AND STEEL CO. NR BRUNSWICK GA 04/19/93 RA-226 941119 GOLDBERG BROTHERS,INC. NR AUGUSTA GA 01/11/93 KR-85 940322 GOOD SAMARITAN HOSPITAL 493-1(5B) WEST PALM FL 02/18/93 NA BEACH 941264 GREATIAKES CHEMICAL CORE ARK-515 NR AR 10/14/93 CS-137 940192 GROUND ENGINEERING & NR NR AL 08/24/93 CS-137 TESTING SERVICE,INC. AM-241 941243 HALUBURTON CO. IA-2353-IA1 VENICE 1A 03/24/93 CO-60, CO-60, CO-60, CO-60 941197 IIALUBURTON ENERGY SERVICES WIA86 HOUSTON TX 10/03/93 CS-137 941198 HALLIBURTON ENERGY SERVICES WIA86 HOUSTON TX 09/20/93 CS-137 941505 HENDRICK MEDICAL CENTER 1A2433 ABILENE TX 01/15/93 1-131 NUREG-1272, Appendix A-2 28

Riidear WaceriET;MgmaiammeMEEcelaRe Table A-2.3 Loss of Control of Material Events Reported by Agreement States,1993 (continued) ITEM LICENSEE EVENT RADIO-NO. LICENSEE NO. CITY STATE DATE NUCLIDE 940349 HENDRY COUNTY GENERAL NR CLEWISTON FL 05/02/93 PD-103 HOSPITAL 940324 111AIIAllllOSPITAL 340-3(5B) tilALEAll FL 01/20/93 1-131 941623 HOECilST CELANESE CORP. 1A0409 CORPUS CIIRISTI TX 12/23/93 NI-63 ) 940555 llUDSON METAL NON-UCENSEE AU1ANY NY 06/11/93 AM-241 940447 ILUNOIS, UNIVERSITY OF, AT 12-4)0088-06 CIllCAGO IL 08/23/93 S-35 CIllCAGO 940199 JACKSONVILLE, CITY OF, WASTE 1031-1 JACKSONVILLE FL 10/22/93 CS-137, WATER DIVISION CS-137, CS-137 941270 JEWISil llOSPITAL 202-15 IDUlSVILLE KY 08/22/93 1-131 941016 JOHNS IlOPKINS MEDICAL NR UALTIMORE MD 01/21/93 1-125 INSTITUTIONS 941385 KASEIAAN AND D'ANGE1D NR NEW YORK NY 12/22/93 NR ASSOCIATES 941373 KCITECHNOLOGY MD-05-037-01 EllJCOlT CITY MD 02/08/93 CS-137, AM-BE 941268 KENTUCKY, UNIVERSITY OF NR lEXINGTON KY 05/25/93 CS-137 941142 LAYTON AND ASSOCIATES NR NR CA 01/27/93 NR 941357 LEVIN'S SCRAP NR NR NY 01/28/93 CO-60 940437 MEDI + PHYSICS, INC. 86-01109-01 NR IL 06/11/93 1-125 941389 MEDI-RAY, INC. NR TUCKAllOE NY 06/21/93 GE-68 941397 MEDI-RAY, INC. NR TUCKAHOE NY 04/01/93 NR 941288 MEDICAL NR NR OR 12/17/93 PU-238 941610 MEDICAL PHYSICS CONSUL,TANTS NR DALIAS TX 10/04/93 CO-57, BA-133, CS-137 940456 MEMORIAL MEDICAL CENTER 86-01343-01 NR IL 10/01/93 1-131 941246 METAL CENTER NON-UCENSEE LOUISVILLE KY 06/29/93 U-DEP 940645 METilODIST llOSPITAL NR LUD13OCK TX 06/24/93 1-131 940757 MUSEUM OF NATURAL HISTORY NR NR NY 03/02/93 NR 940107 NEWPORT STEEL 20-1450-56 WILDER KY 08/03/93 NR 941269 NON-UCENSEE NON-13CENSEE JEFFERSONVillI KY 08/26/93 XE-133 941344 NON-UCENSEE NR NR OR 03/03/93 NR 941326 NUCLEAR MEDICINE NR NR OR 10/06/93 PU-238 29 NUREG-1272, Appendix A-2

y -- Table A-2.3 Loss of Control of Material Events Reported by Agreement States,1993 (continued) ITEM UCENSEE EVENT RADIO-NO. LICENSEE NO. CITY STATE DATE NUCLIDE 940325 NITITING ENGINEERS 934-1(314 1)) BOYNTON BEACH FL 01/17/93 CS-137, AM-BE 941207 ORANGE COAST ANALYTICAL 1 ABS NR NR CA 06/10/93 NR 940368 PARKWAY HOSPITAL ND NR FL 08/16/93 1-131 940269 PRIVATE INDIVIDUAL NON-LICENSEE KINGSPORT TN 12/09/93 CS-137 941002 PRIVATE INDIVIDUAL NON-LICENSEE 1ARGO FL 09/14/93 CO-60 941236 PRIVATE INDIVIDUAL NON-LICENSEE TUCSON AZ 11/12/93 CO-60 941338 PRIVATE INDIVIDUAL NR NR OR 04/24/93 U-235 941564 PRIVATE INDIVIDUAL NON-LICENSEE MOUNDHOUSE NV 05/31/93 CS-137 940759 PROCTOR AND GAMBLE NR NR NY 02/22/93 THORIUM 940409 PROFESSIONAL SERVICES 0022-8 LOMBARD IL 11/03/93 CS-137. INDUSTRIES, INC. AM-BE 940779 QRS SYSTEMS INC. NR SAN ANTONIO TX 09/29/93 AM-BE 940510 RADIAN CORP. NR AUSTIN TX 03/17/93 PO-210 940558 RECSO NON-LICENSEE PEEKSKILL NY 06/21/93 G E-68, GA-68 940783 ROCKWELLINTERNATIONAL NR RICHARDSON TX 10/05/93 H-3 941212 ROGER PRATER ASSOCIATES NR NR CA 06/25/93 NR 940438 RUSH-PRESBYTERIAN-12-00929-13 CHICAGO IL 06/17/93 N1-63 SAINT LUKES 941228 SACRED HEART MEDICAL CENTER WN-M031-1 SPOKANE WA 03/29/93 M O-99, TC-99M 940424 SAINT JOSEPH HOSPITAL 86-01268-01 ELEIN IL 03/11/93 1-125 940241 SAINT THOMAS HOSPITAL R-19001-B98 NASHVILLE TN 03/08/93 1-125 941386 SCHNEIDER FREIGHT USA,INC. NR JAMAICA NY 11/23/93 CS-137, CS-137 941327 SCRAP METAL YARD NR NR OR 09/20/93 NR 940649 SETON NORTHWEST NON-IJCENSEE AUSTIN TX 07/22/93 1-13 1 941317 SHEEIABRATOR CONDORD CO. NON-lJCENSEE PENACOOK NH 04/09/93 1-131 941218 SIEMENS WN-1030-1 REDMOND WA 08/30/93 CO-57 CO-57, AM-241 940193 SOllS LABORATORY 7-386 MESA AZ 05/26/93 RA-226 940756 SONIC SURVEYS, INC. NR MONT BELVIEU TX 08/31/93 CO-60 NUREG-1272, Appendix A-2 30

Table A-2.3 Loss of Control of Material Events Reported by Agreement States,1993 (continued) ITEM LICENSEE EVENT RADIO-NO. LICENSEE NO. CITY STATE DATE NUCLIDE 941244 SOUTHERN SCRAP METAL NON-LICENSEE BATON ROUGE LA 05/21/93 CO-60 940955 SOUTHERN ZINC CO. NON-LICENSEE EAST POINT GA 04/22/93 U-DEP 941121 SOUTHERN ZINC CO. NR EAST POINT GA 04/21/93 RA-226, U-DEP 941366 SOUTilERN ZINC CO. NR EAST POINT GA 04/21/93 U-DEP 941204 SRI INTERNATIONAL NR CA 05/26/93 SR-90 ) 940197 STONE AND WEBSTER F1-1693-1 PLANTATION FL 12/15/93 CS-137, ENGINEERING CORE CS-137, AM-BE, AM-BE 940285 STONE CONTAINER NON-UCENSEE LOUISVILLE KY 06/25/93 KR-85 941407 STRULTURAL METALS, INC. NR SEQUIN TX 01/15/93 CS-137 940624 SUN STATE RECYCUNG NON-UCENSEE GAINESVILLE FL 06/25/93 CS-137 942114 SYNCOR INTERNATIONAL CORE MS-493-01 JACKSON MS 12/13/93 TC-99M 941622 TEXAS HEALTH CENTER, NR TYLER TX 12/22/93 I-125 UNIVERSITY OF 940653 TEXAS, UNIVERSITY OF, AT NR DALIAS TX 07/15/93 NI-53 DALLAS 940763 TEXAS, UNIVERSITY OF, NR HOUSTON TX 08/18/93 H-3, C-14, M.D. ANDERSON CANCER CTR P-32,S-35, I-125 940750 TEXAS, UNIVERSITY OF, MEDICAL NR GALVESTON TX 09/15/93 P-3LI-125 BRANCH 940838 TMG ENTERPRISES METALCENTER NON-UCENSEE LOUISVILLE KY 06/29/93 U-DEP 940202 TMG ENTERPRISES METALCENTER NON-LICENSEE 1.OUISVillE KY 06/29/93 U-DEP 941303 TRACERCO NR LOUSTON TX 03/14/93 CO-60 940810 TRINITY ENGINEERING & TESTING NR ABILENE TX 11/11/93 CS-137 AM-BE 940365 TROXLER ELELTRONICS NR RESEARCH TRI. NC 08/05/93 AM-BE LABORATORIES, INC. PARK 940723 UNAFORM, INC. IA-5652-1D1 SHREVEPORT 1A 07/12/93 AM-241 940177 UNITED METAL RECYCLERS NON-UCENSEE KERNERVILLE NC 03/15/93 ND 940585 W.R. GRACE AND CO. 232 SIMPSONVILLE SC 08/13/93 AM-241 940347 WALT DISNEY WORLD CO. 12731-1(3141)) 1AKE BUENA FL 04/23/93 11-3, H-3 VISTA 940397 WEST PALM BEACH SOUD NON-UCENSEE WEST PALM FL 12/14/93 1-131 WASTE AUTHORITY BEACH 940399 WEST PALM BEACH SOLID NON-LICENSEE WEST PALM FL 12/10/93 1-131 WASTE ALTTHORTTY BEACH 940538 WESTCHESTER COUNTY MEDICAL 586-2 VAIJIALIA NY 10/29/93 1-125 CENTER NR indicates NM REPOKIED ND indicates NM DL7 ERMINED 31 NUREG-1272, Appendix A-2

l4E01DT74nnuaDI$po00, lh'45) Table A-2.4 Leaking Sources Reported by Agreement States,1993 ITEM LICENSEE EVENT RADIO-NO. LICENSEE NO. CI1Y STATE DATE NUCIIDE 940194 ALZA CORR 1994-43 Pali) ALTO CA 02/06/93 NI-63 940417 AMERSHAM CORR 12-12836-01 ARIJNGTON ll 01/21/93 AM-241 IIEIGill3 940418 AMERSHAM CORR 12-12836-01 ARIJNGTON IL 01/28/93 1-125 HEIGH 13 940480 ASOMA INSTRUMENTS,INC. NR AUSTIN TX 12/19/93 FE-55 940481 ASOMA INSTRUMENTS. INC. NR AUSTIN n 01/07/93 FE-55 940482 ASOMA INSTRUMENTS, INC. NR AUSTIN TX 01/29/93 FE-55 941165 BECKMAN NR NR CA 02/18/93 CS-137 941203 CALIFORNIA, UNIVERSITY OF, NR SANTA IIARBARA CA 05/25/93 NR AT SANTA BARBARA 94N58 CHICAGO, UNIVERSITY OF 99-90974-11 ClllCAGO IL 10/27/93 CS-137 940745 IEE NR NR NY 02/19/93 CS-137 941167 NORTIIROP NR NR CA 02/19/93 PM-147 941101 REGIONAL WEST MEDICAL CENTER 21-01-02 SCOTI3 BLUFF NE 04/15/93 SR-90 940529 ROCHESTER, UNIVERSITY OF 436 ROCHESTER NY 06/08/93 NI-63 940485 SOUTHWEST RESEARCH INSTITUTE NR SAN ANTONIO TX 03/10/93 NI-63 940574 TEXAS NUCLEAR TECHNOLOGIES, NR ROUND ROCK TX 04/08/93 FE-55 INC. 940774 TN TECHNOLOGIES, INC. NR ROUND ROCK TX 09/14/93 FE-55 940769 TUBOSCOPE VETCO NR llOUSTON U 05/19/93 CS-137 941427 TUBOSCOPE VETO INTERNATIONAL NR HOUSTON TX 01/25/93 CS-137, CS-137 940814 UTAH STATE UNIVERSITY UT-03001-59 LOGAN UT 10/22/93 NI-63 NR indicates NOT REPORTED i NUREG-1272, Appendix A-2 32

R1idear WiEeff!Es-MgreemennWN10m!6EG1sufE Table A-2.5 Release of Material Events Reported by Agreement States,1993 ITEM LICENSEE EVENT 'ITPE OF RADIO-NO. LICENSEE NO. CITY STATE DATE REl, EASE NUCLIDE 941262 ARKANSAS, UNIVERSITY OF, ARK-001 IJTILE AR 03/29/93 SURFACE I-131 MEDICAL SERVICES ROCK 940206 AUllURN STEEL NR SYRACUSE NY 05/17/93 SURFACE 11-3 940801 AUSTIN DIAGNOSTIC CilNIC NR AUSTIN TX 10/15/93 SURFACE 11-3 940646 AUS11N llEART ASSOCIATES NR AUSTIN TX 0 & l4/93 SURFACE TC-99M 941421 DIAGNOSTIC SYSTEMS NR WEUSTER TX 02/17/93 SURFACE ND LABORATORIES, INC. 940262 FEDERAL EXPRESS NON-LICENSEE MEMPillS 1N 08/31/93 SURFACE SR-89 940423 MED!+ PIIYSICS,1NC. 86-01109-01 NR ll 03/08/93 AIRBORNE l-125 941625 SAINT PAUL MEL)lCAL CENTER NR DALLAS TX 12/01/93 SURFACE TC-99M 941330 SMOKE DETECTOR NR NR OR 08/06/93 SURFACE ND MANUFACTURER 941123 TilERAGENICS CORP. 881-3MD UUFORD GA 07/01/93 SURFACE ZN-65, Ril-102M. PD-103 NR indicates NOT REPOKrED ND indicates NUT DirrERMINED 33 NUREG-1272. Appendix A-2

Table A-2.6 Transportation Events Reported by Agreensent States,1993 l TYPE 01-ITEM LICENSEE EVENT TRANSPORTATION i NO. LICENSEE NO. CITY STATE DATE EVENT 941015' AMERSHAM CORP NR ARUNGTON IL 01/30W3 CONTAMINATED llEIGIIIS PACKAGE l 941102 AS NON-UCENSEE NR OMAHA NE 11/19/93 RE! EASE DURING TRANSIT 941113 AS NON-LICENSEE NR ORlANDO FL 05A19/93 CONTAMINATED PACKAGE 941331 AS NUCLEAR MEDICINE NR NR OR 08/03/93 FAILURE TO BRACE i UCENSE ANDDIDCKPACKAGE 940393 BIACK SilEEP EXPRESS NON-UCENSEE GROVE CITY FL 12/27/93 DAMAGED SHIPPING l CONTAINER i 941381 CONSTRUCrlON .NR SCOTIO NY 10/20/93 IMPROPER TECliNOLOGY PIACARDING l 941163 COUNTY IIAZARDOUS NR NR CA 02/11/93 VEHICLE ACCIDENT MATERlAIS { 940315 FLORIDA DEPARTMENT 109-1(6) NR FL 03/08/93 VEHICLE ACCIDENT OF TRANSPORTATION 940356 FIDRIDA DEPARTMENT 109-1(3L-1) BARTOW FL OW10/93 VEHICLE ACCIDENT OF TRANSPORTATION l 940387 FLORIDA DEPARTMENT 0109-1 GAINESVILLE FL 10/04/93 VEHICLE ACCIDENT OF TRANSPORTATION, SMO i 940391 FLORIDA DEPARTMENT 0109-1 GAINESVillE FL 10/28/93 VEHICLE ACCIDENT OF TRANSPORTATION, SMO 940395 FLORIDA DEPARTMENT 0109-1 GAINESVillE FL 12/21/93 VEHICLE ACCIDENT OF TRANSPORTATION, SMO f 940396 FLORIDA DEPARTMENT 0109-1 GAINESVILLE FL 12/20/93 VEHICLE ACCIDENT OF TRANSPORTATION, SMO 940403 FLORIDA DEPARTMENT 0109-1 GAINESVillE FL 11/22/93 VEHICLE ACCIDENT OF TRANSPORTATION, SMO I 940436 KAY RAY /SENSAll lic01010-03 MT. PROSPECT IL 06/08/93 CONTAMINATED PACKAGE 940305 MEDI + PHYSICS, INC. 2133-2(3B) MELBOURNE FL 03/2&93 DAMAGED SHIPPING l CONTAINER I 940441 MEDI+ PIlYSICS, INC. 86-01052-01 CHICAGO IL 07/10/93 VEHICLE ACCIDENT I 941158 MEDICAL MESSENGERS INC NR NR CA 02/01/93 VEHICIE ACCIDENT 941199 NEW MEXICO STATE W1150 SANTA FE NM 09/01/93 VEHICLE ACCIDENT COMMISSION 940440 NORDION INTERNATIONAL NON-UCENSEE CHICAGO IL 07/01/93 FAILURE TO BRACE INC. AND BLOCK PACKAGE 941258 NUCIIAR P1IARMACY,INC. Alr927 MOBILE AL 10/01/93 VEHICLE ACCIDENT 941383 NUCLETRON NR NR NY 05/14/93 FAILURE TO BRACE j AND BIDCK PACKAGE r NUREG-1272, Appendix A-2 34

~ INuclear Matenals-Agreernant Stets 12csusca laents i l l Table A-2.6 Transportation Events Reported by Agreement States,1993 (continued) 1 TYPE OF ITEM LICENSEE EVENT TRANSPORTATION N O. LICENSEE NO. CITY STATE DATE EVENT 940355 PROFESSIONAL SERVICES 22-4(31(1)) LOMBARD IL 06/09/93 FAILURE TO BRACE INDUSTRIES, INC. AND BLOCK PACKAGE 940513 OUALITY INSPECTION NR BATAVIA NY 04/12/93 VElllCLE ACCIDENT SERVICES CO. 940459 SAINT JOSEPH HOSPITAL 86-01475-01 CHICAGO IL 10/28/93 EXCESS RADIATION LEVEL 940274 SCIENTIFIC ECOLOGY R-37008-E94 OAK RIDGE TN 09/07/93 CONTAMINATED GROUP VElIICIE 941305 SPECTRATEK PROTECHNICS TA172 ALBUQUERQUE NM 02/04/93 VElllCLE ACCIDENT INTER., INC. 940222 SYNCOR INTERNATIONAL MS-493-01 JACKSON MS 01/29/93 VElllCIE ACCIDENT CORE i l 940460 SYNCOR INTERNATIONAL 86-01721-01 CHICAGO IL 11/02/93 VElllCII ACCIDENT CORE i l l 941017 SYNCOR INTERNATIONAL NR AUGUSTA GA 09/03/93 VEHICII ACCIDENT CORE 940793 TECHNICAL WELDING NR PASADENA TX 09/21/93 VElllCII ACCIDENT I ABORATORY, INC. 940791 TEXAS FOUNDRIES NR LUFKIN TX 08/30/93 CONTAMINATED PACKAGE 940321 WEST PARK COMMUNITY NR HAMMOND LA 02/25/93 IMPROPER HOSPITAL PIACARDING NR indicates NOT REPORTED 35 NUREG-1272, Appendix A-2

AEO3HsnuaMeport,EIN Table A-2.7 Equipment Problems Reported by Agreement States,1993 ITEM LICENSEE EVENT NO. LICENSEE NO. CITY STATE DATE EQUIPMENT 940795 APPLIED STANDARDS NR BEAUMONT TX 09/20/93 RADIOGRAPilY INSPECTION, INC. CAMERA 941336 AS IRRADIATOR IJCENSE NR NR OR 05/05/93 IRRADIATOR 941267 ATEC ASSOCIATES 20-1221-52 LOUISVILII KY 10/22/93 GAUGE, MOISTURE DENSITY 940234 ATIANTIC STEEL GA-461-1 CARTERSVILIE GA 09/03/93 GAUGE,IIVEL 941232 BASS AND MAVES TESTING 10277-1 EVERETT WA 06/16/93 GAUGE, MOISTURE DENSITY 940579 BAXTER IIEAl;111 CARE CORP. NR EL PASO TX 04/29/93 SOURCE RACK 940578 BIX TESTING 1ABORATORIES NR BAYTOWN TX 03/13/93 RADIOGRAPilY CAMERA 940637 BlX TESTING 1ABORATORIES NR BAYTOWN TX NR RADIOGRAP11Y DRIVE CABLE 940900 BOEING COMPUTER SERVICES NO LICENSE NR WA 03/03/93 STRUCTURAL ANALYSIS PROGRAM 940652 BROWNWOOD, CITY OF NR BROWNWOOD TX 07/29/93 GAUGE, MOISTURE DENSITY 940448 ClllCAGO, UNIVERSrFY OF 12-00509-03 ClilCAGO IL 08/25/93 BRACilYTilERAPY NON-MAN AFT-11DR 940450 ClllCAGO, UNIVERSITY OF 12-00509-03 ClllCAGO IL 08/27/93 1RRADIATOR 941559 CONVERSE CONSULTANE 00-11-0094-01 IAS VEGAS NV 07/14/93 GAUGE, MOISTURE SOUTliWEST DENSITY 940806 COONEY X RAY NR ODESSA TX 10/20/93 RADIOGRAPilY CAMERA 941825 COOPER INDUSTRIES 7095-1111 VillE PIA 1TE 1A 12/10/93 RADIOGRAPriY CAMERA 940785 EAGIE X-RAY NR MONT BELVIEU TX 10/04/93 RADIOGRAPIIY CAMERA 941239 EXXON REFINERY NR NR IA 08/02/93 GAUGE, MOISTURE DENSITY 941263 FIDRENCE ANDllUTCIIISON 20-1129-52 PADUCAli KY 08/23/93 GAUGE, MOISTURE DENSITY 940291 G.A. TECTINICAL SERVICES R-19168 NASilVIllE TN 04/22/93 GAUGE, MOISTURE DENSITY 941363 GAUGE IJCENSE NR NR AL 06/12/93 GAUGE, LEVEL 941364 GAUGE IJCENSE NR NR AL 06/02/93 GAUGE, MOISTURE DENSITY 941098 GEOTECIINICAL SERVICES, 01-38-01 OMAllA NE 05/05/93 GAUGE, MOISTURE INC. DENSITY NUREG-1272, Appendix A-2 36

= _ - Nuclear Materials-Agreement State Licensee Evcnts Table A-2.7 Equipment Problems Reported by Agreement States,1993 (continued) ITEM LICENSEE EVENT NO. LICENSEE NO. C11Y STATE DATE EQUIPMENT 940753 GOOISBY TESTING NR llUMBLE TX 06/09/93 RADIOGRAPilY IABORATORIES CAMERA 940390 IIARRIS SEMICONDUCTOR 0662-3 MElllOURNE FL 09/23/93 IIAK DETEC110N CORE EQUIPMENT 940640 llOECliST CEIANESE NR lllSilOP TX 06/16/93 GAUGE, LEVEL 940792 IlOECilST CEIANESE NR IllSilOP TX 09/17/93 GAUGE,IIVEL 940244 INDUSTRIAL 1ABORATORIES, R-33017 CllATTANOOGA TN 03/09/93 RADIOGRAPilY INC. CAMERA 941238 INDUSTRIAL RADIOGRAPHY 1A-4342-ID1 AMELIA LA 02/05/93 RADIOGRAPilY MAINTENANCE AND SUPPLY CAMERA 940682 ITT llARTON NR CITY OF CA 03/29/93 PIAS'11C IINS INDUSTRY 941311 JOIIN D.JAQUESS AND DM112 ROSWELL NM 06/09/93 GAUGE, MOISTURE ASSOCIATES DENSITY 940506 1AW ENGINEERING NR llOUSTON TX 02/19/93 GAUGE, MOISTURE DENSITY 940815 MET-CllEM TESTING UT-18001-46 SALT IAKE UT 06/26/93 RADIOGRAPilY LABORATORIES OF UTAll,INC. CITY CAMERA 940752 MIDIAND INSPECrlON & NR MIDIAND TX 08/04/93 RADIOGRAPilY CAMERA ENGINEERING 940679 MMP OUALITY INSPECTIONS, 4832-70 NR CA 06/04/93 RADIOGRAPIIY CAMERA INC. l 940809 NAN YA PIASTICS CORE, USA NR WilARTON TX 10/26/93 GAUGE, MOISTURE DENSITY l l 941558 NEVADA DEPARTMENT OF 00-14-0012-01 CARSON CITY NV 07/01/93 GAUGE, MOISTURE DENSITY TRANSPORTATION 940787 NEW YORK CITY SANITATION NR NEW YORK CITY NY 03/29/93 GAUGE DEPARTMENT 940449 NICIIOIS ALUMINUM 86-01801-01 IlNCOLNSlilRE IL 08/25/93 GAUGE 940816 NUCOR STEEL CORE UT-02001-03 PLYMOUTil UT 05/14/93 GAUGE, FlXED 940817 NUCOR STEELCORE UT-02001-03 PLYMOUTil UT 04/12/93 GAUGE, FIXED 940516 OUR 1ADY OFIDURDES 25 BINGIIAMTON NY 04/06/93 11RACilYTilERAPY REMOTE AIT-IIDR HOSPITAL 941378 E FlANIGAN & SONS,INC. MD-07-136-01 UALTIMORE MD 07/29/93 GAUGE, MOISTURE DENSITY 940630 PERRY EQUIPMENT CORE NR MINERAL TX 04/21/93 RADIOGRAPilY WEllJS CAMERA 940505 PETROLEUM INDUSTRY NR llOUSTON TX 03/09/93 RADIOGRAPIfY SOURCE TUDE INSPECTORS 37 NUREG-1272. Appendix A-2

/a60bTAnnuantepos, m's Table A-2,7 Equipment Problems Reported by Agreement States,1993 (continued) ITEM LICENSEE EVENT NO. LICENSEE NO. CITY STATE DATE EQUIPMENT 940634 PETROLEUM INDUSTRY NR HOUSTON TX 05/10/93 RADIOGRAPilY INSPECTORS CAMERA 940773 PROFESSIONAL SERVICES NR HOUSTON TX 09/08/93 GAUGE, MOISTURE INDUSTRIES, INC. DENSITY 941380 RADAMERICA MD-05-051-01 BALTIMORE MD 12/20/93 TELETHERAPY UNIT 941135 RADCLIFFE, PHILIP NR NR CA 01/13/93 RADIOGRAPlIY CAMERA 941377 RATRIE, ROBBINS & SCliWEIZER MD-05-ll6-01 WALDORF MD 07/06/93 GAUGE 941384 RTS TEC1INOLOGY, INC. NR NORTH NY 05/20/93 RADIOGRAPilY ANDOVER CAMERA 940290 SCIENTIFIC INSPECTION R-33092-B% HIXSON TN 04/16/93 RADIOGRAPHY TECHNOLOGIES, INC. CAMERA 941426 SCIENTIFIC TUBUIAR NR CORPUS TX 01/01/93 GAUGE, PIPE INSPECTIONS CHRISTI INSPECTION UNIT 941130 SOUTHERIAND GEOTECHNICAL NR NR CA 01/05/93 GAUGE 940567 SOUTIIERN TECHNICAL NR 1AKE JACKSON TX 04/13/93 RADIOGRAPHY SERVICES CAMERA 940575 SOUTilWESTERN NR llOUSTON TX 03/01/93 RADIOGRAPHY IADORATORIES INC. DRIV 3: CABLE l 941374 STATE HIGIIWAY MD-05-049-01 BALTIMORE MD 03/03/93 GAUGE, MOISTURE ADMINISTRATION DENSITY 940416 STERIGENICS 86-01220-01 SCHAUMBURG IL 01/08/93 IRRADIATOR 940776 TECHNICAL WELDING NR PASADENA TX 12/13/93 RADIOGRAPIIY LABORATORY, INC. SOURCE ASSEMBLY 941217 TERRA ASSOCIATES INC. WN-0246-1 SEATTLE WA 10/19/93 GAUGE, MOISTURE DENSITY 940462 TESTING SERVICE CORE 86-01178-01 CAROL STREAM IL 1UO8/93 GAUGE, MOISTURE DENSITY 940796 TEXAS A&M UNIVERSITY NR COLLEGE TX 09/11/93 TE!ErilERAPY UNIT STATION 941256 WEAVEXX MS-745-01 STARKSVILLE MS 01/08/93 GAUGE 940533 WESTCHESTER COUNTY 586-2 VALHALIA NY 12/07/93 TELETHERAPY UNIT MEDICAL CENTER TIMER 940542 WESTCIIESTER HOSPITAL, 585 MOUNT KISCO NY 11/02/93 TELETHERAPY UNIT NORTHERN 940195 WESTEX COMPANY 5324-56 OXNARD CA 12/19/93 RADIOGRAPHY CAMERA 941259 WILilAMS, WILLIAMS, AND MS-633-01 YAZOO CITY MS 09/23/93 GAUGE, MOISTURE CIARK DENSITY 940628 X-CEL GROUP, INC. NR CORPUS TX 05/22/93 RADIOGRAPHY CHRISTI DRIVE CABLE CONNECTOR NR indicates NOT REPORTED NUREG-1272, Appendix A-2 38

1 4 ( l 4 Appendix B f e J-i j Summary of 1993 Abnormal Occurrences (Nonreactors) I i l ) 3 1 I l 5 J 1 1 1 6 4 9 J 4 4 v

~- ~_ I i Summary of 1993 Abnormal Occurrences (Nonreactors) I 93-2 Medical Sodium Iodide 93-4 Medical Therapy Misadministration Misadministration at Ingham Medical at Papastavros' Associates Medical Center in Lansing, Michigan Imaging in Wilmington, Delaware j 1 On May 11,1992, a patient was administered a On January 14,1993, a patient was administered a j diagnostic dose of a radiopharmaceutical that was therapeutic dose that was 0.5 times the prescribed j greater than five times the prescribed dose. This dose. A patient was presenbed 1.11 gigabec-patient received 366.3 megabecquerel (MBq)(9.9 querel (GBq) (30 milheurie [ mci]) of iodme-131 millicurie [ mci]) of iodine-131 in preparation for f r hyperthyroidism and only received one capsule a whole body scan instead of the intended f a two capsules dosage,0.56 GBq (15 mci) of technetium-99m thyroid scan. This misadminis- ".) dine 131. The technolog,ists failed to read the tration was caused by a miscommunication of the vialI bel and was unaware that two capsules were verbal request between the referring physician's Provided to meet the prescribed dose. office and the licensee; no written directive was The patient and the patient's physician were i Provided. 4 notified of the error and the patient was scheduled for follow-up therapy. No adverse The referring physician and the patient have been effects are expected as a result of the ? notified. An NRC medical consultant determined misadmimstration. the most probable effect to the patient would be permanent hypothyroidism, and noted that this 93-5 Medical Brachytherapy condition appears to have already occurred. De Misadministration at Parkview 2 licensee has also observed indications of Memorial IIospital in Fort Wayne, i decreased thyroid function. Indiana i On December 9,1992, a patient was administered 93-3 Medical Brachytherapy a therapeutic dose to a part of the body not Misadministration at Yale New Haven scheduled to receive exposure. The patient was i IIospital in New Itaven, Connecticut scheduled to receive a 500 centigray (cGy)(500 rad) radiation dose for vaginal cancer using a i On January 21,1993, a patient was administered a high-dose-rate brachytherapy treatment device. l therapeutic dose to a part of the body not The dosimetrist and the medical physicist worked scheduled to receive exposure. A patient was together durmg dose calculation and both used prescribed three treatments of 700 centigray (cGy) the same source start position which was (700 rad) to the vagina. During the first incorrect. The wrong start position resulted in the l treatment, the physician mistakenly inserted the intended 500 cGy (500 rad) radiation dose being brachytherapy applicator into the patient's rectum dehvered to an area 5.25 centimeters (2.07 inches) and incorrectly administered the 700 cGy (700 away from the intended treatment site. No second rad) directly to the rectum instead. ndependent check of the calculations were l performed. t The licensee discovered the error after the The referring physician and the patient were treatment was completed and immediately informed of the error. The licensee reported that ~ notified the patient. The requesting physician, the no physical effect was observed as a result of the attending physician, and an NRC medical misadministration. An NRC medical consultant consultant are presently evaluating the probable concluded that no noticeable biological effect was consequences of this misadministration. expected as a result of this misadministration. 1 NUREG-1272, Appendix B

AEOD AnnuaD12eport,lWS i 93-6 Inoperable Research Reactor Scrams of the radiation exposure from the dislodged at University of Virginia in source. Charlottesville, Virginia 93-8 Medical Brachytherapy On April 28,1993, the University of Virginia Misadministration at Keesler Medical reported an incident involving a major deficiency Center, Keester Air Force Base in in operating, management, or procedural controls Biloxi, Mississippi of its research reactor that impacted reactor On June 10,1993, a patient was admimstered a safety. The reactor had been experiencing repeated, unannounced scrams for approximately therapeutic dose to a part of the body not 6 months. In an attempt to trouble-shoot one of scheduled to receive exposure. The United States t these scrams, a senior reactor operator began Air Force Radioisotope Committee Secretanat interchanging some of the electronic equipment in reported an incident of a patient receivmg an i the reactor control console. After approximately unintended dose of approximately 2.09 cGy (2.09 30 minutes, no further scrams were received rad) to the facial area. An iridium-192 because the operator had unknowingly defeated high-dose-rate remote afterloader source was five scram functions. These actions were mispositioned during the second of two performed without procedure or post-treatments. Due to an erroneous keystroke, a maintenance testing to ensure safety systems default catheter length of 100 cm (39.4 in.) was operations. entered into the treatment plan instead of the intended 150 centimeters (cm)(59.1 inches [in.]). The incorrect catheter length resulted in the The reactor was subsequently restarted and source being positioned.about 10 cm (3.9 in.) in operated at full power for 5.5 hours with the front of the patient's face for approximately 46 defeated scram functions. Dunng normal plant seconds. shutdown at the end of the day, an electronic period scram was introduced to complete the The patient was notified of the misadministration. shutdown but failed. The reactor had to be No adverse effects are expected from the manually scrammed to complete the shutdown. misadministration. 1 93-9 Medical Sodium lodide 93-7 Medical Brachytherapy Misadministration at Mercy Memorial Misadmimstration at Osteopath,ic Medical Center in St. Joseph, 11 spital Founders Association DBA Michigan (doing business as) Tulsa Regional Medical Center in 'Ibisa, Oklahoma On February 16 and 17,1993, a patient was On July 27,1993, a patient was administered a administered a therapeutic dose to a part of the diagnostic dose of a radiopharmaceutical that was body not scheduled to receive exposure. During a greater than five times the prescribed dose. A brachytherapy implant, one 862.1 megabecquerel technologist mistakenly administered 0.21 (MBq)(23.3 millicuries [ mci]) cesium-137 seed gigabecquerel (GBq) (5.7 millicuries [ mci]) of fell out of the insert onto the patient's bed. iodine-131 (I-131) to a patient that was I About 15 hours later, a nurse found the source prescribed technetium-99m (Tc-99m). The beneath the patient and removed it. The licensee technologist, who was preparing to administer calculated that the dislodged source resulted in an doses to two patients, called the patient whom she exposure of about 45.8 centigray (cGy)(45.8 rad) believed was to receive the 1-131, and verified his to the perineum, an area different from the identity by reviewing a second form of intended treatment site. identification. However, the patient name on the written directive was not checked, resulting in the The referring physician and patient were notified wrong patient receiving the I-131 dose. The error of the misadministration. The licensee stated that was quickly discovered and the second patient there was no observable clinical effect as a result was not administered the remaining Tc-99m dose. NUREG-1272 Appendix B 2

WuNarWatents-MLEnormano;ccurrences I i i l The patient was notified of the misadministration. 93-11 Medical Brachytherapy An NRC medical consultant estimated the dose to Misadministration at Washington the patient's thyroid to be in the range of 400-700 University Medical School in St. cGy (400-700 rad) and believes the medical Louis, Missouri consequences of this misadministration will be j negligible. On January 7,1993, and again on February 26, 1993, a patient was administered a therapeutic l dose to a part of the body not scheduled to receive exposure. A malfunction in a Nucletron 93-10 1981 Fatal Radiation Exposure of a Micro-Selectron low-dose-rate remote afterloader Radiographer in Northeast Oklahoma unit resulted in an unprogrammed ejection of a radioactive source without a guide tube and In January 1981 an individual received a fatal applicator attached to the channel. The first j dose of radiation. This event was previously ejected unguided source resulted m an estimated reported to Congress in NUREG-0090, Vol. 4, 0.1 centigray (cGy)(0.1 rad) of additional dose to No.1, as an "Other Event of Interest." It was the patient's skm surface. The second ejected not previously reported as an abnormal source resulted m an estimated 3.5 cGy (3.5 rad) f addit,onal dose to the patient's skm surface. In i occurrence because the NRC was unable to conclusively determine that the exposure in both cases, the patient treatment was completed question resulted from material subject to NRC n another umt. The failure was eventually determmed to be a faulty operational amplifier. regulation. The referring physician and the patient were notified. No adverse health effects are expected On January 5,1981, an NRC-licensee in from either misadministration, i Henryetta, Oklahoma, reported that a i radiographic exposure device containing a 1221 93-12 Medical Brachytherapy gigabecquerel (33 cune) iridium-192 source was M. i isadm.. trat. ion at Mercy Hosp.tal inis i 1 stolen from a locked camper on or about December 30,1980. The licensee subsequently in Scranton, Pennsylvania renorted that the source was anonymously On April 23,1993, a patient was administered a returned intact to a licensee representative's therapeutic dose to a part of the body not l residence. On January 22,1981, the State of scheduled to receive exposure. The patient was Oklahoma notified the NRC that an unemployed scheduled to receive brachytherapy treatment to radiographer had been hospitalized with serious the apex of her vagina in three fractions of 500 radiation injuries to his chest and left forearm. centigray (cGy)(500 rad) each. After the first treatment, the physician revised the written directive. While entering the changes, the The NRC performed an in-depth investigation therapist erroneously entered the wrong catheter which included interviewing the exposed length into the treatment computer which resulted individual. He stated that he could not recall how in 500 cGy (500 rad) being delivered to the wrong or when he received the exposure but stated that treatment site and a 20 percent underdose to the he had last worked with a radioactive source in intended treatment site. October 1980. Medical authorities estimated his l exposure occurred between December 15,1980, The referring physician and the patient have been and January 5,1981. Cytogenetic studies of the notified. The attending physician stated that no l patient's blood indicated that he received an adverse clinical effects are expected as a result of l equivalent whole body dose of 365 centigray (cGy) the underdose to the target site. The oncologist l (365 rad) from iridium-192 or 405 cGy (405 rad) stated that the patient is not expected to i from cobalt-60. On July 27,1981, the NRC was experience any adverse effects from the 500 cGy notified that the individual had died of his (500 rad) overexposure to the wrong treatment injuries. site. The NRC medical consultant also stated that l 3 NUREG-1272, Appendix B

mcnRra'nispwn,qua it is unlikely the patient would suffer any adverse 93-15 Medical Brachytherapy effects from this misadministration. Misadministration at Good Samaritan Medical Center in Zanesville, Ohio 93-13 Medical Brachytherapy On November 10,1993, a patient was Misadministration at Mountainside administered a therapeutic dose to a part of the Hospital in Montclair, New Jersey body not scheduled to receive exposure. A lung cancer patient was prescribed a 6000 cGy (6000 On July 1,1993, a patient was administered a r d) dose to be delivered by an iridium-192 therapeutic dose to a part of the body not therapeutic implant. A catheter was surgically !mP anted and a ribbon of iridium-192 seeds was l scheduled to receive exposure. The patient was prescribed three brachytherapy treatments of 700 inserted into the catheter. A radiograph was centigray (cGy) (700 rad) to the right mainstem completed but was not reviewed for two hours. When the seeds could not be seen in the bronchus using a Nucletron Micro-Selectron high-dose-rate remote afterloader. During the last radiograph, additional radiographs were taken treatment, a shorter than required catheter was which showed the seeds to be in the patient,s used, preventing the source from reaching the throat. The ribbon was moved to the proper location about 1 hour later. The target site. A negligible dose was delivered to the misadmimstration resulted in a dose of i tumor site. The misadministration also resulted in a surface dose to the lens of 1.97 cGy (1.97 approximately 282 centigray (282 rad) to the rad), a dose to the chin of 4.56 cGy (4.56 rad), and I 'Y"** a dose to the thyroid of 3.07 cGy (3.07 rad). The patient was notified of the misadministration. An NRC medical consultant concluded that the The referring physician and patient were notified. dose to the larynx and surrounding area was not An NRC medical consultant concluded that the clinically significant. patient would not suffer any adverse effects from this misadministration. 93-16 Medical Brachytherapy Misadministration at Marquette 93-14 Exposure to a Nursing Infant at General Hospital in Marquette, Queen's Hospital in Honolulu, Hawaii Michigan From November 17 to 19,1993, a patient was On December 2,1991, a moderate exposure to, or release of, radioactive material licensed by the administered a therapeutic dose to a part of the NRC resulted in an exposure of a 9-month old body not scheduled to receive exposure. A mfant. A nursing mother was admmistered 0.56 patient undergoing cesium-137 brachytherapy treatment to the uterus was administered 2700 megabecquerel (15 microcurie) of iodm, e-131 for a diagnostic scan. Although the patient noted on a centigray (2700 rad) to the vaginal area because a hospital form that she was breastfeeding, the shorter than required catheter was used. The technologist failed to notice this notation until the intended treatment area received only 50 percent of the intended dose. patient returned the following day for a scan. The patient was informed of the treatment error. The patient was informed of the oversight and An NRC medical consultant concluded that the was instructed to stop breastfeeding. An NRC radiation dose to the vagina would not be medical consultant estimated the dose to the expected to cause any acute or long-term effects infant's thyroid to be between 160 to 650 mSv (16 because vaginal tissue is extraordinarily tolerant to 65 rem) and concluded that the infant was not of radiation. Subsequently the patient received an likely to experience any adverse effects as a result additional dose to the uterus to complete the of this misadministration. prescribed treatment. NUREG-1272, Appendix B 4 ?

-. _ - - - - - -Nuclear Materials-Abnormal Occurrences Agreement State Licensees AS 93-1 Contamination of Pool Irradiator administered a 218.3 MBq (5.9 millicuries [ mci]) i Facility Owned by Radiation I-131 dose intended for another patient. The Sterilizers, Inc., in Decatur, technologist immediately discovered the error. Georgia Vomiting was induced within 5 minutes of administration and then the patient was given a In June 1988 an event involving the loss of thyroid blocking agent. A thyroid uptake and i licensed material in such quantities, and under scan were performed 24 hours after the incident such circumstances that substantial hazard may and showed the thyroid uptake to be about 0.3 result to persons in unrestricted areas, was percent of the dose administered. reported to the State of Georgia. An event review was preformed by a joint Georgia and NRC The referring physician and patient were notified of the misadministration. No adverse effects were incident evaluation task force and documented in i NUREG-1392," Leakage of an Irradiator Source expected as a result of this misadministration. - the June 1988 Georgia RSI incident." At the AS 93-3 Medical Brachytherapy time, this event was not identified as an abnormal Misadministration at Maine occurrence (AO). In 1993 this event was reevaluated against current reporting criteria and Medical Center in Portland, classified as an AO. Maine On June 6,1988, the Radiation Sterilizers, Inc. On yovember 11,1992, a patient was admimstered a therapeutic dose to a part of the (RSI) facility in Decatur, Georgia, ceased body not scheduled to receive radiation. The operations because radiation levels on the surface Patient was prescribed a brachytherapy treatment of the pool were 600 microsievert (Sv) (60 usmg 13 seeds of iridium-192 m a nylon ribbon. millirem) per hour. Analysis of the pool water A kink m the catheter stopped the ribbon 26 indicated that one or more of the 252 cesium-137 centimeters (cm) (10.24 inches) from the source capsules (444,000 terabecquerel [12 prescribed treatment area. This resulted m, a megacuries]) used in the irradiator were leaking. dose to the patient s hypopharynx area of 3500 The U.S. Department of Energy (DOE) was asked centigray (cGy)(3500 rad), which was the to manage the safe removal of the leaking capsule Prescribed dose to the lung. The intended and oversee the cleanup and recovery activities at treatment area of the lung was estimated to have RSI. Five capsules were suspected of leaking but received less than 10 cGy (10 rad). The licensee only one capsule was confirmed to be leaking. stated that no long-term effects are expected. The The cause of the capsule leaking was not Patient was notified of the misadmimstration. determined. On September 11,1992, the DOE contractor completed decontamination of the AS 93-4 Industrial Radiographer facility. DOE estimated the cost of the cleanup Overexposure Event at Murphy to be $45 million. Oil Refinery in Meraux, Louisiana AS 93-2 Medical Sodium Iodide On May 7,1993, a moderate exposure to, or Misadministration at Grenada release of, radioactive material licensed by the Lake Medical Center in Grenada, NRC resulted in a 21-year old industrial Mississippi radiographer receiving a 27.66 centisievert (27.66 rem) whole body exposure as indicated by a On April 1,1992, a patient was administered a thermoluminescent dosimeter badge. The diagnostic dose of a radiopharmaceutical that was radiographer failed to lock the exposure device, so greater than five times the prescribed dose. The that when the radiographer's assistant moved patient was scheduled to receive 3.7 megabec-toward the device with the control handle, the querel(MBq)(100 microcurie [ Ci]) of iodine-131 source moved out of the shielded position. A (1-131) for a thyroid uptake study but was preliminary physical examination of the 5 NUREG-1272, Appendix B

AEOD Annual Report,1993 radiographer's blood showed no indication of any AS 93-7 Medical Radiopharmaceutical adverse effects from the overexposure. Misadministration by " Unspecified Licensee"in Albany, New York AS 93-5 Medical Teletherapy On October 5,1992, a patient was administered a Misadministration at Alta Bates therapeutic dose that was greater than 1.5 times Medical Center in Berkeley, the prescribed dose. The patient was California, inadvertently administered 303.4 megabecquerel (MBq)(8.2 millicurie [ mci]) of phosphorus-32 In response to an mquiry m April 1992, the State (P-32),instead of the prescribed 185 MBq (5 mci) of P-32' of California investigated a fatal radiation exposure that occurred in 1987. At the request of the State, the NRC assisted in the mvestigation. The attending physician and patient were notified Tlus event was not required to be reported under of the misadministration. No long-term adverse the State law m, affect at that time, effects are expected as a result of this misadministration. AS 93-8 Medical Sodium Iodide A 9-year old autistic boy, diagnosed to have cancer of the nasopharynx, was prescribed Misadministration at Inland radiation therapy using a cobalt-60 source of Imag.mg in Spokane, Wash.mgton. 186,850 gigabecquerel (5050 Curie). An error in On December 14,1992. a patient was the treatment plan resulted in the patient administered a diagnostic dose that was greater receivmg double the total presen, bed dose dun.ng the imtial treatment phase, than 5 times the prescribed dose. A patient that was prescribed a diagnostic thyroid procedure using 0.26 to 0.37 megabecquerel (MBq) (0.007 to The patient's physicians and mother were 0.010 millicurie [mCij) of iodine-131 (I-131) promptly notified. The patient died on August 21, erroneously received 196.1 MBq (5.3 mci) of 1988, of complications resulting from this I-131. The licensee estimated that the patient's misadmm, istration. thyroid received a dose of approximately 7950 centigray (7950 rad) and did not show any signs of adverse side effects 3 days after the misadministration. The referring physician and AS 93-6 Overexposure of a Radiographer patient were notified. at X-Cel Group in Corpus Christi, Texas AS 93-9 Medical Teletherapy Misadministration by " Unspecified Licensce"in New On May 22,1993, a radiographer received an York, New York exposure of the right hand of more than 375 rem. A camera locking mechanism came apart from On July 11,1992, a patient was administered a the camera allowing the source assembly (pigtail) therapeutic dose to a part of the body not and the 3626 gigabecquerel(98 curie) iridium 192 scheduled to receive radiation. The patient was source to be pulled from the camera. Thinking prescribed multiple cobalt-60 teletherapy that the source had disconnected, the treatments of 200 centigray (200 rad) to the right radiographer picked up the source with the thumb axilla. However, the first five treatments were and index finger of his right hand, resulting in an given to the left axilla in error, estimated overexposure of 19.25 sievert (1925 rem). No symptoms of radiation injury were The NRC has not yet been informed that the noted on the radiographer's hand. referring physician and patient have been notified. NUREG-1272, Appendix B 6

Wuclear Gaterials-A%normaRGecurrences ~ ~ The potential adverse effects as a result of this AS 93-12 MedicalTeletherapy misadministration have not yet been determined. Misadministration at Rocky Mountain Gamma Knife Center in AS 93-10 Theft of Radioactive Material Denver, Colorado During Transport and Improper Disposal On July 8,1993, a patient was administered a therapeutic dose to a part of the body not In February 1993, the NRC was notified of a scheduled to receive radiation. A patient was substantiated case of actual theft or diversion of admitted for treatment of a longstanding licensed material that had been going on for arteriovenous malformation (AVM)in the left several years. This event involved the diversion of posterior dura of the brain. During treatment of spent nuclear medicine generators from the this malformation, the patient's brainstem transportation stream by an employee of a courier received a dose of no more than 2.5 gray (Gy)(250 service. They were stolen in order to reclaim the rad) due to an error in the gamma plan program lead shielding as scrap metal. The generator input. The program error was caused by the internals were burned in an open barrelin a posterior / anterior angiogram being reversed residential area and the ashes were often during setup. The tolerance dose for the discarded in rural wooded areas. Several brainstem was stated to be 10 Gy (1000 rad). attempts to interview the individual suspected, and later confirmed, of diverting the licensed material were unsuccessful and on February 22. The patient was notified of the misadministration. State officials were informed that the individual It was the opinion of the neurosurgeon that the dose delivered was well below the dose-volume had died the day before from natural causes. threshold for inducing any neurological damage. Although the risk to the general public from this prolonged diversion of licensed material was not significant, the radiation exposure to the deceased AS 93-13 Lost or Stolen Radiation Source at individual could have been significant due to his BPB Instruments, Inc., in repeated direct contact with the generators. Midland, Texas However, no estimate of his exposure could be made without more information. On September 2,1993, a licensee reported a lost source of licensed material in such quantities and AS 93-11 Found Source at Scrap Metal under such circumstances that a substantial Facilityin Magnolia, Arkansas hazard may exist to persons in unrestricted areas. The licensee notified the State of Texas that On March 24,1993, a licensee reported a source during a physical inventory a 555 gigabecquerel of licensed material found in such quantities and (15 curie) americium / beryllium source made by under such circumstances that a substantial Amersham (Serial Number 7004NE) was not hazard may have resulted to persons in located and may have been lost or stolen. The unrestricted areas. TN Technologies notified the licensee believes that a disgruntled employee may State that a Texas Nuclear Model 5176 source have taken the source to cause problems for the holder, containing a 148 gigabecquerel (4 curies) company. Surveys were performed in areas cesium-137 source, had been located at Tillman around Midland. BPB placed an ad in the Scrap Yard in Magnolia, Arkansas. The holder Midland newspaper offering a $10,000 reward for shutter was found to be padlocked in the open information leading to the recovery of the source. position. The padkick was cut away and the The State agency issued a press release describing i shutter was secured in the closed position. The the source, warning that it should not be handled, source was removed from the affected area. A and requesting that the licensee or the State contamination survey of the entire work area was agency be contacted if the source is found. All carried out. No contamination was found. The attempts to locate the source have been area was released for unrestricted use. unsuccessful. 7 NUREG-1272, Appendix B

AEOD Annual Report,1993~ ~ ~ ~ ~ ~~ ~" ~~~ ~ ~ ~ ' ' ~ ~ ^ ~ ' ~ ^^ AS 93-14 Medical Brachytherapy transfer tube / applicator combination length Misadministration at Michael instead of a 1.0 meter (3.3 foot) length as Reese Medical Center in Chicago, intended. Seven of the eight patients received an Illinois average dose per treatment of 3.6 centigray (cGy) (3.6 rad) at approximately 51 centimeters (cm) (20 On October 6 through 10,1993, a patient was inches) from the intended site and outside of the administered a therapeutic dose greater than 1.5 Patients' bodies, with the source approximately 30 times the prescribed dose. The patient was to 34 cm (12 to 13 inches) from the patients' prescribed a total dose of 6000 centigray (cGy) knees. Two of these patients sustained (6000 rad) by a combination of 4000 cGy (4000 third-degree skin injury and five had no physical rad) from an external beam (linear accelerator) effects. One patient received an estimated dose and 2000 cGy (2000 rad) from vaginal implant of 4000 to 6000 cGy (4000 to 6000 rad) and therapy. The external beam therapy was developed skin erythema in the area of the knee. completed as prescribed. The required time of the implant therapy was then incorrectly AS 93-16 Medical Brachytherapy calculated to deliver 6000 cGy (6000 rad)instead Misadministration at Richland of the remaining 2000 cGy (2000 rad). The Memorial Hospital in Columbia, attending physician reviewed the dose calculations South Carolina on the fourth day of the implant and immediately terminated the treatment. The patient received On September 24,1992, a patient was 4000 to 4500 cGy (4000 to 4500 rad) from the administered a therapeutic dose to a part of the brachytherapy treatment. The patient has been body not scheduled to receive radiation. A notified of the misadministration. radiation oncology nurse found a 1.1 gigabecquerel (GBq) (30 millicurie [ mci]) cesium-137 source under a patilnt undergoing AS 93-15 Medical Brachytherapy treatment. The source was misplaced for Misadministration at Mt. Sinai approximately 2 hours and resulted in a dose of Medical Center in Miami Beach, less than 10,000 centigray (10,000 rad). Florida The patient and her family were notified. The From September 28 to November 24,1993, eight unscheduled exposure resulted in an ulceration patients were administered therapeutic doses to a beneath her right thigh which responded part of their body not scheduled to receive favorably to treatment. A second treatment to radiation during 22 gynecological treatments. The makeup for the dose deficiency to the target site cause of the misadministrations was the use of a was not attempted because the patient was unable l 1.5 meter (4.9 foot) obstetrical / gynecological to cooperate. NUREG-1272, Appendix B 8

l Appendix C Reports and Videotapes Issued From 1981 Through 1993 (Nonreactors) I l 1 i

Reports and Videotapes Issued From 1981 Through 1993 (Nonreactors) Nonreactor Reports issued in 1993 Video Tapes Date Title No. Author 04/93 Good Practices in Cobalt-60 Teletherapy H. Karagiannis Nonreactor Reports Issued in 1992 Engineering Evaluations Date Title No. Author 08/92 Report on 1991 Nonreactor Events NUREG-1272 K. Black Vol. 6, No.2, App.A 08/92 Report on 1991 NRC Licensee Misadministrations NUREG-1272 H. Karagiannis Vol. 6, No. 2, App.B 08/92 Report on 1991 Agreement State Licensee NUREG-1272 H. Karagiannis Nonreactor Events and Misadministrations Vol. 6, No. 2, App.C Nonreactor Reports issuedin 1991 Engineering Evaluations Date Title No. Author 01/91 Brachytherapy Incidents Involving a N91-411 H. Karagiannis Handloading, Endobronchial Technique 07/91 Report on 1990 Nonreactor Events NUREG-1272 K. Black Vol.5, No. 2, App.A 07/91 Report on 1990 Misadministrations Reports NUREG-1272 H. Karagiannis Vol. 5, No. 2, App.B Video Tapes Date Title No. Author 02/91 Good Practices in Preparing and Administering H. Karagiannis Radiopharmaceuticals 1 NUREG-1272, Appendix C

AEOD Annual Report,1993 Nonreactor Reports issued in 1990 Engineering Evaluations Date Title No. Author 06/90 Report on 1989 Nonreactor Events NUREG-1272 K. Black Vol. 4, No. 2, App.A 06/90 Medical Misadministration Report - NUREG-1272 11.Karagiannis Vol. 4, No. 2. App.B Nonreactor Reports issued in 1989 Engineering Evaluations Date Title No. Author 06/89 Use of Radioactive lodine for Infrequent Medical N901 H. Karagiannis Studies and Those Performed Under an FDA Investigational Exemption of a New Drug (IND) 06/89 Report on 1988 Nonreactor Events NUREG-1272 K. Black Vol.3, No. 2. App.B 06/89 Medical Misadministration Report - Medical NUREG-1272 H.Karagiannis Misadministrations Reported to NRC From Vol.3, January 1988 Through December 1988 No. 2, App.B 05/89 Review of Therapy Misadministrations That Involved 'F)08 K. Black Multiple Patients and the Use of Computer Programs Nonreactor Reports issuedin 1988 Date Title No. Author 09/88 Review of Events at Large Pool-Type S807 E. Trager Irradiators (NUREG-1345, March 1989) 10/88 Report on 1987 Nonreactor Events N801 K. Black 10/88 Medical Misadministration Report - to NRC for the N802 S. Pettijohn Period January Through 1987 Through December 1987 NUREG-1272, Appendix C 2

i i Nonreactor Reports Issued in 1987 Special Study Report Date Title No. Author 10/87 Radiography Overexposure Events Involving S703 S. Pettijohn Industrial Field Radiography 1 Engineering Evaluations Date Title No. Author 01/87 Diagnostic Misadministrations Involving the N701 S. Pettijohn Administration of Millicurie Amounts of Iodine-131 03/87 Diagnostic Misadministrations Reported to NRC for N702 S. Pettijohn the Period January 1986 Through December 1986 i 03/87 Report on 1986 Nonreactor Events N703 K. Black Technical Review Reports Date Title No. Author 11/87 Review of Data on Teletherapy Misadministrations T711 S. Pettijohn i Reported to the State of New York That Were the Title of PNO-1-87-74A 12/87 Distribution of Information Notices and Other " Mass T714 S. Pettijohn j Mailing" Information to Licensees That Have Users at Locations Remote From the Headquarters Locations 1 1 Nonreactor Reports issued in 1986 Case Study Date Title No. Author l 08/86 Rupture of an Iodine-125 Brachytherapy Source C601 S. Pettijohn at the University of Cincinnati Medical Center s Engineering Evaluations Date Title No. Author 06/86 Report of 1985 Nonreactor Reported and Five-Year N601 K. Black Assessment for 1981 - 1985 Reports 1 06/86 Medical Misadministrations Reported for 1985 and N602 S. Pettijohn ~ Five-Year Assessment of 1981-1985 3 NUREG-1272, Appendix C

Nonreactor Reports issued in 1985 Case Studies Date Title No. Author 12/85 Therapy Misadministrations Reported to NRC C505 S. Pettijohn Pursuant to 10 CFR 35.42 05/85 Summary of the Nonreactor Event Report Data N501 K. Black Base for the Period January Through June 1984 Engineering Evaluations Date Title No. Author 06/85 Summary of the Nonreactor Event Data Base for N502 K. Black the Period July Through December 1984 07/85 Report on Medical Misadministrations for N503 S. Pettijohn January Through December 1984 Nonreactor Reports issued in 1984 l Case Studies Date Title No. Author 09/84 Breaching of the Encapsulation of Sealed C405 S. Pettijohn Well Logging Sources 05/84 Report on Medical Misadministrations for N204D S. Pettijohn January Through June 1983 06/84 Nonreactor Event Report Database for the Period N401 K. Black July Through December 1983 06/84 Events Involving Undetected Unavailability of the N402 E. Trager Thrbine Driven Auxiliary Feedwater 11 rain 07/84 Report on Medical Misadministrations for N403 S. Pettijohn July Through December 1983 NUREG-1272 Appendix C 4

Nuclear Materials-Reports Nonreactor Reports issuedin 1983 Engineering Evaluations and Technical Reviews Date Title No. Author 01/83 Nonreactor Event Report Database for the N209A E. Trager Period January Through June 1982 03/83 I-125/I-131 Effluent Releases by Material Licensees N301 S. Pettijohn 06/83 Mound Laboratory Fabricated PuBe Sources N302 K. Black 06/83 Americium Contamination Resulting From N303 K. Black Rupture of Well-Logging Sources 06/83 Nonreactor Event Report Database From N209B K. Black July Through December 1982 07/83 Americium-241 Sources N304 07/83 Report on Medical Misadministrations for N204C S. Pettijohn January 1981 Through December 1982 12/83 Potentially Leaking Americium-241 Sources N306 S. Pettijohn Manufactured by Amersham Corcuation ]12/83 Nonreactor Event Report Database for the N307 K. Black Period January Through June 1983 03/83 Internal Exposure to Am-241 NT301 K. Black 04/83 Kay-Ray, Inc. Reports of Suspected Leaking NT302 S. Pettijohn Sealed Sources Manufactured by General Radioisotope Products 08/83 Possession of Unauthorized Sealed Sources / Exposure NT303 S. Pettijohn Device Combinations by MidCon Inspection Services, Inc. l 5 NUREG-1272, Appendix C

Nonreactor Reports issued in 1982 Engineering Evaluations Date Title No. Author 02/82 Report on hiedical hiisadministrations for the Period N201 S. Pettijohn November 10.1980 - September 30,19S1 01/82 Buildup of Uranium-Bearing Sludge in Waste Tanks N202 K. Black 02/82 Lost Plutonium-238 Source N203 K. Black 03/82 Report on hiedical hiisadministrations for CY 1981 N204 S. Pettijohn (M/82 Preliminary AEOD Review of Iodine-125 N205 E. Dager Scaled Source Leakage Incidents 05/82 Eberline Instrument Corporation Part 21 Report N206 K. Black 05/82 AEOD Review of lodine-125 Scaled Source N207 E. Dager Leakage incidents 08/82 Potentially Leaking Plutonium-Beryllium N208 S. Pettijohn Neutron Sources 08/82 A Summary of the Nomenetor Event Report N209 K. Black Data Base for 1981 11/82 Leaking 11oses on Self-Contained Breathing N210 K. Black Apparatus (SCBA) hianufactured by h1SA Nonreactor Reports issued in 1981 l Engineering Evaluations l Date Title No. Author 1 03/81 Interim Report on Brown Boveri Betatron N101 E. Dager Calibration Check Source 03/81 Irradiator Incident at an Agreement State Facility N102 K. Black (Becton-Dickinson. Broken Bow, Nebraska) l 04/81 Interim Report on the October 1980 Fire at the N103 E. Trager l Licensee's Sweetwater Uranium hiill l 04/81 Interim Report on the January 2,1981, Fire at N104 E. Dager the Atlas Uranium hiill 05/81 Interim Report on Tailings Impoundment Liner N105 E. Dager Failure at the Sweetwater Uranium hiill NUREG-1272. Appendix C 6

Nonreactor Reports hsued in 1981 (continued) Engineering Evaluations Date Title No. Author 08/81 Review of Reports of Leaking Radioactive Sources N106 E. Trager 12/81 Engineering Evaluation of Fire Protection at N107 E. Trager Nonreactor Facilities 12/81 Notes on AEOD Review of Emissions From Tritium N108 E. Trager Manufacturing and Distribution Licensees 7 NUREG-1272, Appendix C

Appendix D Status of AEOD Recommendations

Status of AEOD Recommendations The Office for Analysis and Evaluation of issues involving AEOD recommendations are Operational Data (AEOD) tracking system unresolved that warrant the attention of the ensures that all formal AEOD recommendations Executive Director for Operations. are tracked until resolution. At this time, no 1 NUREG-1272, Appendix D

i Appendix E Status of NRC Staff Actions for Events Investigated by Incident Investigation Teams (Nonreactors) i 1 i

Status of NRC Staff Actions for Events Investigated by Incident Investigation Teams (Nuclear Materials) In accordance with NRC Management Directive adequacy of the actions taken by the responsible 8.3, "NRC Incident Investigation Program [ IIP]," office (s), and documenting the resolution of all dated August 12,1992, the Executive Director for staff actions. Operations shall, upon receipt of an Incident Investigation Team (IIT) report, identify and This Appendix provides the written disposition or s a us, along wie appropriate references, for ead assign NRC office responsibility for generic and of the NRC staff action items that the EDO plant-specific actions resulting from the assigned to the various NRC offices associated investigation that are safety significant and with the IIT reports on the 1990 ever.t at warrant additional attention or action. Office Amersham Corporation, the 1991 event at Directors designated by the EDO as having General Electric Nuclear Fuels Component responsibility for the resolution of issues or Manufacturing Facility, and the 1992 event at the concerns are responsible for providing written Indiana Regional Cancer Center. His Appendix status reports on the disposition of assigned also provides the status of the staff actions that actions. AEOD is responsible for' monitoring the were not documented as resolved in the 1992 status of assigned staff actions, evaluating the AEOD Annual Report. Action Source: IIT Report on " Inadvertent Shipment of a Radiographic Source from Korea to Amersham Corporation, Burlington, Massachusetts," NUREG-1405, dated May 1990 (Reference 1). Item 6: Adequacy of Reporting Requirements Action: Evaluate whether NRC and U.S. Department of Transportation (DOT) regulations should be amended to include the requirement to report the receipt of shipments of radioactive materials that were improperly prepared, labeled, identified, or classified, or had improper contents. (Responsible Office: NMSS) Disposition: Ongoing On August 13,1990, the NRC requested that DOT provide comments on the need for a requirement for consignees to report improperly labeled or prepared packages upon receipt. The staff evaluated NRC and DOT reporting requirements (Reference 2) and concluded that requiring licensees to report all mislabeled or misidentified packages would require both licensees and the NRC staff to expend significant resources for problems that are of little or no safety concern. However, the staff also concluded that the NRC should be informed and should respond to any situation similar to the Amersham incident. The NRC staff determined that because the new 10 CFR Part 20 requirements will only apply to labeled or damaged packages, the previous situation in which Amersham received a cropped source in a package thought to be empty may not be covered. The NMSS staff recommended to RES that Section 20.906 of 10 CFR Part 20 be amended to require licensees to notify the NRC if the licensee determines that it has received an unlabeled package containing radioactive materials that should have been labeled in accordance with DOT requirements (Reference 3). 1 NUREG-1272, Appendix E

AEOD Annual Report,19N j i i Item 9: Adequacy of Shipper Instructions i Action: (a) Meet with DOT and determine (1) the purpose and expectations of actions by i forwarding agents at the place of United States entry for shipments of radioactive materials,(2) whether such agents are informed of the pertinent DOT requirements, and (3)whether such requirements are realistic and important to the handling of radioactive material shipments and should be enforced. (Responsible Office: NMSS) Disposition: Resolved (Pending AEOD independent review) On August 13,1990, the NRC requested that DOT provide comments on this issue. DOT completed its initial investigation on July 30,1991. NRC licensees, in NRC Information Notice 90-56 (Reference 4), were informed of the need to comply with DOT import and i export requirements. If appropriate, the NRC will notify licensees of the DOT investigation findings in a supplemental Information Notice. The responsible office considers this item resolved. Action:(b) Pending the results of Action Item 9(a), initiate action to ensure that Amersham has taken appropriate corrective measures to ensure the completeness and accuracy of information provided to forwarding agents. (Responsible Office: RI) Disposition: Resolved (Pending AEOD independent review) DOT issued a proposed Notice of Violation to Amersham on July 31,1991. Amersham [ has since requested a formal hearing before an administrative law judge. However, based on a review of the DOT investigation, NMSS and RI concluded that Amersham has taken the appropriate corrective measures. The responsible office considers this item resolved.

References:

1. NUREG-1405," Inadvertent Shipment of a Radiographic Source from Korea to Amersham Corporation, Burlington, Massachusetts," dated May 1990. 2. Memorandum for J. Glenn to J. Hickey, " Evaluation of NRC and DOT Reporting Requirements: NMSS Followup to Inadvertent Shipment of a Radiographic Source from Korea to Amersham Corporation"(NUREG-1405), dated October 31,1990. 3. Memorandum from R. Bernero to E. Beckjord, " Request for Rulemaking - i Amendment to 10 CFR 20.906, Procedures for Receiving and Opening Packages," dated February 5,1991. 4. NRC Information Notice 90-56, " Inadvertent Shipment of a Radioactive Source in a Container Thought to be Empty," dated September 4,1990. NUREG-1272 Appendix E 2 1

Nuclear Materials-Staff Actions Action Source: IIT Report on General Electric Nuclear Fuels and Component Manufacturing Facility (GE-Wilmington) Potential Criticality Event of May 29,1991 (References 1,2,3). Item 1: Adequacy of Criticality Safety Reviews Action:(a) Evaluate existing regulatory requirements, guidance, and review standards for criticality safety analyses of fuel facility licensees to modify processes, procedures, and facilities and to develop new regulatory guidance, requirements, and review standards (Responsible Office: NMSS/RES) Disposition: Ongoing In February 1992, the NMSS Materials Regulatory Review Task Force issued its report, NUREG-1324," Proposed Method for Regulating Major Materials Licensees," evaluating these and other weaknesses in the fuel facilities regulatory requirements, guidance, and review standards. After collecting and reviewing public comments on NUREG-1324, staff of the NMSS Division of Fuel Cycle Safety and Safeguards developed an action plan (SECY-93-128) that presented an integrated approach to revamping the regulations and guidance for fuel facility licensing, and developed a standard review plan (SRP) for license reviews. As stated in SECY-93-128, NMSS is taking a fresh look at the fuel cycle regulatory, licensing, and inspection programs, emphasizing activities that will offer the greatest and/or near-term safety benefit without placing undue burden on the licensees. Among the principal products of the effort will be a major revision of 10 CFR Part 70 and its supporting regulatory guidance, and issuance of a review standard in the form of an SRP. The review will require performance of an integrated safety analysis (ISA) for the initial application and, as appropriate, reanalysis to support amendment of the application or a 10 CFR 50.59-type process. Criticality safety is one aspect to be analyzed by the ISA. These activities supersede the recommendation to consider separate action on criticality safety provided in the February 1993 task force report. The expected completion date is August 31,1994. Action:(b) Evaluate the use of safety operating specifications for radiation and nuclear safety instruments and controls. (Responsible Office: NMSS) Disposition: Ongoing The staff has evaluated and rejected establishment of criteria for fuel facility structures, systems, and components important to safety. The staff has evaluated a requirement for licensees to include in their applications technical specifications for nuclear safety instrumentation and controls. Instead, the staff intends to address radiation and nuclear safety instruments and controls in the same manner as other safety-related structures, systems, and components. Specifically, the staff is involved in the planned revision to 10 CFR Part 70 and accompanying standard format and content guidance for fuel cycle facility license applications. It is expected that the planned revision to 10 CFR Part 70 will require licensees to perform ISAs. These ISAs will allow determination of defects or failures to comply which could create substantial safety hazards. Once the ISAs are in place, licenses will have NRC-approved analyses to ensure that changes to facility operations do not introduce new risks that have not been evaluated by the NRC staff. 3 NUREG-1272, Appendix E

AEOD Annual Report, &% . He licensing project manager and the inspection staff will ensure that a licensee does not significantly change its ISA process without NRC approval, and that the tool is used on an ongoing basis to evaluate any changes to the operations. The rule nll make clear ' that licensees can make changes to the facility, including plant operations and equipment, without prior Commission approval, only under certain limited conditions that involve no additional risk. This rulemaking and associated guidance will address management control and oversight of safety-related equipment and procedures, including assurance of reliability and availability, human factors aspects, and training regarding safety significance and deviations from the licensee's safety basis standard. This staff action has been included in the action plan in SECY-93-128. The expected completion date is August 31,1994. Action:(c) Evaluate the need to change the licensing practice of incorporating a license condition by reference in fuel facility licenses. Ensure that the resultant licensing practice is mutually understood by all involved in the process. (Responsible Office: NMSS) Disposition: Ongoing The staff has been working with the fuel facility licensees during the amendment and I renewal processes to include greater specificity in the commitments on their applications. The revamping of the regulations and guidance for fuel facility licensing, discussed in-1(a) above, will specifically address the information to be included in Part I of the application. The expected completion date is August 31,1994. Action: (d)- Evaluate the existing NRC programs and develop new guidance for the inspection of changes to criticality safety controls at fuel fabrication facilities. (Responsible Office: i NMSS) Disposition: Ongoing The staff will evaluate the existing NRC programs for the inspection of changes to i criticality safety controls at fuel fabrication facilities. This evaluation will include a i review of Regulatory Guide 3.52, " Standard Format and Content for the Health and l Safety Sections of L.icense Renewal Applications for Uranium Processing and Fuel - Fabrication," and Inspection Manual Chapter 2600, " Fuel Cycle Facility Operational Safety Inspection Program" including Inspection Procedures 88015, " Criticality Safety," and 88025, " Operations Review." These documents will be revised as appropriate after the evaluation is completed. In addition, the evaluations will include the reviews and evaluations associated with NUREG-1324, mentioned in Item 1(a) above. He NRC expects that inspector training will be provided under Action 1(e) below. Expected completion date is September 30,1994. Action:(e) Evaluate the adequacy of NRC training and qualification programs to effectively support j criticality safety inspections at fuel facilities, and develop enhancements to the training l program. (Responsible Office: NMSS/AEOD) i Disposition: Resolved (Pending AEOD independent review) A criticality safety training program for NRC inspectors has been developed under contract and made part of the curriculum of the NRC's Technical Training Center. He program was given for the first time in June 1993. The responsible office considers this j item resolved. j NUREG-1272, Appendix E 4 P -m

~- ~ - _ _ Wudiesi?N Action:(f) Evaluate General Electric's (GE) response to the IIT report with respect to the site-specific corrective actions. Include in this evaluation the adequacy of(1) the current license, (2) the Facility Change Request process and its implementation, and (3) the criticality safety margins. (Responsible Office: NMSS/RII) Disposition: Resolved (Pending AEOD independent review) The staff evaluated GE's response to the IIT report with respect to the site-specific corrective actions. This evaluation included the adequacy of the current license, the facility change request process and its implementation, and criticality safety margins. The NRC conducted inspections to verify that adequate corrective actions have been taken. The responsible office considers this item resolved. Item 2: Adequacy of Facility Operational Safety Action:(a) Upgrade existing inspection guidance related to management controls and oversight, including audits, personnel training, and procedure adequacy and compliance for major materials licensees. (Responsible Office: NMSS/RES) Disposition: Ongoing The staff will evaluate the existing inspection guidance related to management controls and oversight, including audits, personnel training, and procedural adequacy and compliance for major mMerials licensees. This evaluation will include guidance presently found in Inspection Maml Cnapters 2600 and 2800. In addition, the reviews associated with NUREG-1324, mentioned in Item 1(a) above, will be included in this evaluation. If the evaluation determines that new guidance is appropriate, the NRC will issue new guidance. The expected completion date is September 30,1994. Action:(b) Determine the need for regulatory requirements, guidance, and standard review plans regarding management controls and oversight, including audits, personnel training, and procedural adequacy and compliance for major materials licensees. Conduct reviews or inspections at selected licensees to collect additional information on management controls and practices. If necessary, on the basis of these assessments, develop new guidance, requirements, and standards as appropriate. (Responsible Office: NMSS/RES/NRR) Disposition: Ongoing NUREG-1324 placed considerable emphasis on improving licensees' management controls because past accidents can be traced directly to breakdowns in these controls. The staff has allocated FY94 funds for a contract to develop a guidance document, for j licensees and applicants, in the form of a NUREG report on modern organizational control theory and practice, and the role of management control in ensuring the safety of operations. It is intended that the contractor report will present management control systems in detail, because the breakdown of these systems has allowed development of conditions adverse to safety. In addition, the planned revision to 10 CFR Part 70, discussed in 1(a) above, will include requirements for management controls and oversight. These requirements are being addressed in detail in the SRP for review of applications for fuel cycle facility licenses both in general and in chapters on specific topics, such as, nuclear criticality safety. The Standard Format and Content Guidance, derived directly from the SRP, will convey the details to the licenses. An NMSS task l 5 NUREG-1272, Appendix E

AEOD Annual Report,1993 force produced the rough draft of the SRP, which is being further developed in parallel with the revision of 10 CFR Part 70. The expected completion date is August 31,1994. Action:(c) Examine the overall inspection process for monitoring and collecting fuel facility safety performance information. Include in the evaluation the merits of(1) a resident inspector program:(2) more frequent inspections, including use of team inspections; (3) establishment of a systematic performance appraisal and feedback program analogous to the Systematic Assessment of Licensee Performance (SALP) for 10 CFR Part 50 licensees. (Responsible Office: NMSS/NRR) Disposition: Ongoing The staff will examine the overall inspection process for monitoring and collecting fuel facility safety performance information. This examination includes the merits of (1) a resident inspector program:(2) more frequent inspections, including the use of team inspections; and (3) establishment of a systematic performance appraisal and feedback program analogous to the SALP program for 10 CFR Part 50 licensees. In addition, the reviews associated with NUREG-1324, mentioned in Item la above, will be included in this examination. The expected completion date is September 30,1994. Actiom (d) Evaluate the adequacy of the NRC training and qualification programs to effectively support fuel cycle facility inspections and to develop enhancements to the training program. (Responsible Office: NMSS/AEOD) Disposition: Resolved (Pending AEOD independent review) A training course, title " Fuel Cycle Technology (H-107)" was presented in FY 1992. This 5-day course provided an overview of the nuclear fuel cycle. Course topics included uranium mining and milling; uranium conversion, including dry and wet processes; uranium enrichment, including gaseous diffusion, gas centrifuge, and atomic vapor laser isotope separation: and uranium fuel fabrication and scrap recovery. The course was developed by the Technical Training Center through a contract for technical assistance through NMSS. The course has been revised to incorporate feedback from the pilot course. Additionally, a Fuel Cycle and Materials Training Advisory Group has been formed. This advisory group will continue to evaluate the adequacy of NRC training programs to effectively support criticality safety and fuel cycle facility inspections. The responsible office considers this item resolved. Item 3: Adequacy of Emergency Preparedness Action:(b) Reevaluate the adequacy of the GE fuels facility Radiological Contingency and Emergency Plan (RCEP) and implementing procedures for emergency planning and event classification and notifications. Ensure that the RCEP and implementing l procedures are revised as necessary. (Responsible Office: NMSS/Ril) Disposition: Resolved (Pending AEOD independent review) By letter dated January 17,1992, GE submitted an amended application, dated December 28,1991, to update its RCEP. From January to September 1992 GE submitted i several draft applications, and several meetings and telephone conference calls were held NUREG-1272, Appendix E 6

i i between GE, Region II, and the NMSS staff. On October 2,1992, GE resubmitted the amendment application to incorporate all changes agreed to by GE, Region II, and NMSS staff. This amendment application replaced the submittal of January 17,1992, in its entirety. It was later supplemented by a submittal dated October 26,1992. On October 29,1992, the NRC issued License Amendment No. 27 authorizing GE to implement the RCEP changes. A routine inspection in October 1992 included evaluation of the annual emergency response exercise and detailed review of the RCEP implementing procedures. No exercise weaknesses or program deficiencies were identified. The responsible office considers this item resolved. Item 4: Adequacy of Operating Experience Reviews Action:(a) Reevaluate regulatory requirements and guidance for event reporting for fuel facilities as related to potential criticalities and failed contingencies (barriers). Develop additional guidance and requirements as appropriate. (Responsible Office: NMSS/RES/AEOD) Disposition: Resolved (Pending AEOD independent review) The staff is continuing to reevaluate the regulatoy requirements and guidance for event reporting for fuel facilities as related to potential criticalities and failed contingencies (barriers). On October 18,1991, the staff issued NRC Bulletin 91-01, " Reporting Loss of Criticality Safety Controls." The bulletin requested that licensees evaluate their criticality safety criteria and procedures, modify them as appropriate to assure that events involving degradation of controls will promptly be evaluated and reported to licensee management and the NRC as appropriate, and provide a description of their criteria and procedures to the NRC. Supplement 1 to NRC Bulletin 91-01, published on July 27,1993, clarified which events need to be reported within 4 hours, and which could be reported within 24 hours. The responsible office considers this item resolved. Action:(b) Reevaluate NRC operating experience review and feedback program for fuel facilities. Revise the program as appropriate. (Responsible Office: NMSS) Disposition: Ongoing The staff will reevaluate the NRC operating experience review and feedback program for fuel facilities. After completing the evaluation, the staff will revise the program as appropriate. The expected completion date is September 30,1994. Action:(c) Develop NRC inspection guidance for licensee event reporting and reviews for fuel facilities. Issue new guidance as appropriate. (Responsible Office: NMSS/AEOD) Disposition: Ongoing The staff will evaluate the need to develop NRC inspection guidance for licensee event reporting and reviews for fuel facilities and will issue new guidance. This evaluation will primarily include the guidance presently in Inspection Manual Chapter 2600, " Fuel Cycle Facility Operational Safety Inspection Program." The expected completion date is September 30,1994. Action:(d) Extend the independent NRC operating experience program to nuclear fuel fabrication j facilities. Examine the existing operating experience review program for other licensee 7 NUREG-1272, Appendix E

groups not in the scope of AEOD activities. Revise the program as appropriate. (Responsible Office: AEOD) Disposition: Ongoing AEOD currently reviews reports from fuel fabrication facilities as well as inspection reports to obtain information on operating events. The NRC is revising the reporting threshold. New reporting requirements (10 CFR Part 70 revision and the bulletin on criticality reports) will provide additional information to identify precursors. The NRC (contractor) will visit fuel fabrication plants and audit licensee internal event reviews for adequacy. The audit will also include an evaluation of the adequacy of reporting requirements to provide NRC with the information necessary to assess important safety significant events. AEOD reviews event reports and inspection reports for all licensee groups licensed by the NRC. Efforts are currently underway to obtain reports of events from Agreement States on a timely basis so that they can be added to the operating experience base. This program wa:; begun in late 1991. AEOD will review Agreement State data, in conjunction with non-Agreement State data, to determine whether the AEOD review program needs revision to include classes of licensees that exist only in Agreement States. The full implementation of this item requires completion of Action 4a and implementation of reporting ofincidents pursuant to 10 CFR Part 70 and agreements with the Office of State Programs. The expected completion date is September 30,1994.

References:

1. NUREG-1450, " Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991," August 1991. 2. Memorandum from J. Taylor to NRC staff, " Staff Actions Resulting from the Investigation of the Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991 (NUREG-1450)," August 13,1991. 3. Memorandum from E. Jordan to J. 'Iaylor, " Staff Actions in Response to the Investigation of the Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility Findings"(NUREG-1450), September 6,1991. 4. Memorandum from R. Bernero to J. Taylor, " Staff Action Plan Responding to the Investigation of the May 29,1991, Incident at the General Electric (GE) Nuclear Fuel and Component Manufacturing Facility"(NUREG-1450) September 9,1991. l 5. Letter to S.D. Ebneter to W. Ogden, "NRC Incident Investigation Team Report Followup"(NUREG-1450), August 13,1991. 6. NRC Inspection Report No. 70-1113/91-0, August 12,1991. NUREG-1272, Appendix E 8

7. Letter from J. Stohr to W. Ogden, " Management Meeting Summan," October 2, 1991. 8. Letter from B. Wolfe (GE) to J. Taylor (NC), August 26,1991. 9. Letter from W. Ogden to J. Taylor, August 27,1991.

10. NRC Inspection Report No. 70-1113/91-04, December 23,1991.

11. NRC Inspection Report No. 70-1113/91-09, January 15, 1992.

12. NRC Inspection Report No. 70-1113/91-06, Januay 22,1992.

13. Regulatory Guide 3.67, " Standard Format and Content for Emergency Plans for Fuel Cycle and Materials Facilities," January 1992.

14. Letter from G. Bidinger to T.P. Wnslow, Januay 7,1992.

15. NRC Bulletin No. 91-01, " Reporting Loss of Criticality Safety Controls," October 18,1991.

16. NUREG-1324. " Proposed Method for Regulating Major Materials Licensees," dated February 1992.

17. Memorandum from R. Bernero to J. Taylor, " Staff Actions Resulting from the Investigation of the May 29,1991, Incident at General Electric (GE) Wilmington,"

dated September 29,1993.

18. Memorandum from R. Bernero to J. Taylor, " Completion of Item 1.F to General Electric Staff Action Plan, Response to Investigation of the May 29.1991, Incident at the General Electric Nuclear Fuel and Component Manufacturing Facility" (NUREG-1450), dated August 2,1993.

19. Memorandum from E. Jordan to R. Bernero, " Completion of Items 1.E and 2.D to General Electric Staff Action Plan, Response to Investigation of the May 29.1991, Incident at the General Electric Nuclear Fuel and Component Manufacturing Facility," dated September 13,1993.

20. Memorandum from R. Bernero to J. Taylor, " Completion of Item 3.B to General Electric (GE) Staff Action Plan, Response to Investigation of the May 29,1991, Incident at the GE Nuclear Fuel and Component Manufacturing Facility" (NUREG-1450), dated December 2,1992.

9 NUREG-1272, Appendix E

Action Source: IIT Report on " Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16,1992 (NUREG-1480)," dated March 12,1993. (Reference 1) Item 1: Adequacy of Oncology Services Radiation Protection Program Action la: Review by Oncology Services Corporation (OSC) corrective actions in response to the finding ofineffectiveness of the radiation safety program. (Responsible Office: RI) Disposition: Ongoing In a letter dated September 13,1993, OSC requested a relaxation of the NRC order to obtain high dose-rate scaled sources for two facilities. In addition,in a letter dated September 20,1993, OSC requested authorization to perform patient treatments. Finally, in letters dated September 17, and October 4,1993, OSC requested individual licenses for all six facilities. Region I sent a deficiency letter dated November 1,1993, stating that OSC's request would not be considered until the order affecting all six facilities was relaxed. The staff is currently reviewing the licensee's response in a letter dated December 7,1993. A meeting with the Atomic Safety and Licensing Board (ASLB) was held on January 27,1994, to identify the issues for future litigation, and to determine whether to combine the license suspension actions for OSC and Dr. Bauer, the authorized user at Indiana Regional Cancer Center, during the November 1992 misadministration. The ASLB will issue an order establishing a schedule for actions leading to a hearing. The expected completion date was February 11,1994. Action Ib: Evaluate whether NRC regulations and guidance need to be modified to explicitly define the functions and responsibilities of the radiation safety officer and the authorized user. (Responsible Office: NMSS) Disposition: Ongoing A task force of NMSS, regional, and Agreement State representatives for development of a NUREG report for radiation safety officers met during September and December 1993 and is scheduled to again meet from January 31 through February 2,1994. Additionally, the staff will evaluate the need to further define and provide guidance on the responsibilities of the authorized user. This issue will be addressed during a major revision of 10 CFR Part 35, scheduled for completion in December 1997. The project was also discussed with the Advisory Committee on Medical Uses of Isotopes (ACMUI) at the November 1993 meeting. At that time, the ACMUI requested a copy of the draft NUREG report for review and discussion at its May 1994 meeting. In addition, the draft report will undergo a peer review during the March to April 1994 time frame. As a result of the ACMUI request and the staff's decision on peer review, the due date for publication of the NUREG has been extended from June 30,1994, to September 30, 1994. The expected completion date is December 30,1997. Action Ic: Evaluate the performance and design of PrimAlert-10 Area Radiation Monitors (ARMS) and take appropriate followup action. (Responsible Office: NMSS/ Regions) Disposition: Ongoing NUREG-1272, Appendix E 10

The staff wrote to Victorcen, the manufacturer, and requested an evaluation of the potential for non-ionizing radiation fields or electromagnetic fields (associated with linear accelerators) to cause spurious alarms by the PrimAlert-10 ARM, as well as similar models used by medical licenses (such as the PrimAlert-50 ARM). Victorcen responded to the staff's letter in October 1993. The staffintends to forward a second letter to Victorcen by February 15,1994, to seek additional information regarding guidance for licensee event reporting and reviews for fuel facilities, and will issue new guidance as appropriate. The staff's evaluation will primarily include the guidance presently in Inspection Manual Chapter 2600, " Fuel Cycle Facility Operational Safety Inspection Program." In addition, NMSS will develop a Temporary Instruction for the Regions to review the operation and reliability of PrimAlert ARMS as part of the routine inspection program. The staff will evaluate the information compiled by the Regions as well as the manufacturer's response and, if appropriate, will issue an Information Notice to licensees. The expected completion date is September 30,1994. Action:(1) Extend the independent NRC operating experience program to nuclear fuel fabrication facilities. Examine the existing operating experience review program for other licensee groups not in the scope of AEOD activities. Revise the program as appropriate. (Responsible Office: AEOD) Disposition: Ongoing AEOD currently reviews reports from fuel fabrication facilities, as well as inspection reports, to obtain information on operating events. The NRC is revising the reporting threshold. New reporting requirements defined in the forthcoming 10 CFR Part 70 revision and the bulletin on criticality reports will provide additional information to identify precursors. The NRC (contractor) will visit fuel fabrication plants and audit licensee internal event reviews for adequacy. The audit will also include an evaluation the adequacy of instrument response at the high-energy spectrum. In addition, the staff will review the response to the second letter, as well as information developed by the Regions and, if appropriate, issue an Information Notice to licensees. The expected ate is April 29,1994. Item 2: Adequacy of NRC Protocols for Informing the Public and Authorities of Radiation Exposures Resulting from Licensed Activities. Action 2a: Evaluate the NRC's process for assessing exposures and consequences, and notifying individuals and authorities following an elevated exposure. (Responsible Office: NMSS/NRR/ Office of the General Counsel) Disposition: Ongoing The staff has developed guidance to address this recommendation for materiallicensees based on the experience of the Amersham source incident. This guidance was previously approved by the EDO; however, it is being revised to incorporate the lessons learned from the IIT, and will be issued as Inspection Manual Chapter 1302. The staff is in the process of resolving comments and expects to issue the manual chapter by February 28, 1994. Action 2b: Evaluate the need to further define licensee responsibility for assessing radiation exposure and notifying members of the public and authorities. (Responsible Office: NMSS/NRR) l l 11 NUREG-1272, Appendix E

Disposition: Ongoing The staff received guidance from OGC regarding the applicability of 10 CFR Parts 19 and 20 to licensees for assessing radiation exposure and notifying members of the public and authorities. 'Ihis guidance was forwarded to RES for incorporation into a final rule package on 10 CFR Parts 19 and 20. The final rule package was submitted to the EDO on December 17,1993, for his signature and for Commission review. The final rule makes minor clarifications to 10 CFR Parts 19 and 20 to make such reports required by Part 20. The expected completion date was March 31,1994. Item 3: Adequacy of Regulatory Oversight of Scaled Sources and Devices and Medical Licenses Action 3a: Evaluate the need to update licensing and inspection guidance and requirement for high-dose-rate afterloaders. (Responsible Office: NMSS/RES) Disposition: Ongoing The staff has undertaken several efforts with regard to evaluating the need to update licensing and specific guidance and regulations for high-dose-rate afterloaders. The staff revised Policy and Guidance Directive 86-4 to incorporate the requirements of the two bulletins. A Temporary Instruction was issued in September 1993 to provide guidance on routine inspection of high-dose-rate afterloaders. In addition, research efforts are continuing into quality assurance plans for remote afterloaders and human factors related to brachytherapy. RES will document the results of these various efforts into a user need memorandum to revise 10 CFR Part 35. The expected completion date for this memorandum is March 31,1995. The staff continues to monitor and evaluate contractors' findings regarding quality assurance and quality control and human factors research studies on remote afterloader procedures. NMSS and RES will document these findings in a final report to be issued on June 30,1994. The expected completion date to revise 10 CFR part 35 is December 31,1997. Action 3b: Evaluate the relative merits of a performance-based approach versus schooling or certification to verify the radiation safety knowledge of high-dose-rate afterloader users. (Responsible Office: NMSS/NRR) Disposition: Ongoing The staff will conduct an evaluation as requested, and continue to discuss this issue with the ACMUI. The staff will incorporate this issue into the user need memorandum described in 3a above, as appropriate. This issue was discussed with the ACMUI in May 1993, and will be discussed at future meetings. The ACMUI advised the staff that there are no simple methods or prescriptive requirements to determine if a physician has achieved the necessary competency to independently supervise the use of byproduct material for diagnosis or therapy. The ACMUI noted that the staff does not have statistical data to demonstrate that the current system is not working. However, the ACMUI did recommend a paradigm shift in the methods used by the NRC to access the adequacy of training and experience in order to remove the NRC from disputes between competing specialties within the medical NUREG-1272, Appendix E 12 l

~ ' EucMarWaVriaEs-staff Actions community. The paradigm shift would involve preceptoring by a qualified physician, attestation of the competency of the candidate by the preceptor, and independent testing on behalf of the NRC. The staff's plan to evaluate all current training and experience criteria will include a determination regarding the relative merits and resource costs of different training approaches to ensure adequate radiation safety knowledge of all users. These findings will be incorporated into the user need memorandum. Action 3c: Evaluate the licensing interface among the NRC, the U.S. Food and Drug Administration (FDA), and the Agreement States for sealed sources and devices, including licensee requirements for design reviews and quality assurance and quality control. Develop a Memorandum of Understanding with the FDA to further clarify respective roles. (Responsible Office: NMSS/OSP/OGC) Disposition: Ongoing The staff reviewed the FDA's description of its regulatory review of devices such as the Omnitron 2000, and met with FDA staff to clarify the NRC/FDA interface agreement which was signed on August 26,1993. NMSS procedures for implementation of the Memorandum of Understanding were drafted and circulated for comment on October 15,1993. The procedures will be issued as an Inspection Manual Chapter by March 31, 1994. The staff will also review the interface between the NRC and the Agreement States with respect to approval of sealed sources and devices, and will make appropriate recommendations for improving the definition of that interface. Action 3d: Revise the inspection guidelines to trigger consideration for licensees whose programs have significantly expanded or changed. (Responsible Office: NMSS) Disposition: Ongoing A task force composed of headquarters and regional staff has been formulated and was scheduled to meet during February 1994 to make significant changes to the inspection guidance in Manual Chapter 2800, " Materials Inspection Program." Areas to be addressed include guidance on inspection of satellite facilities; field offices and temporary job sites; adjustment of inspection frequency based on performance; and emphasis on programs that have significantly expanded or changed. To provide guidance to license reviewers in advance of issuance of Inspection Manual Chapter 2800, the staff will issue a Policy and Guidance Directive by June 30,1994. This directive will provide criteria for licensee reviewers to use in determining if licensee's programs have significantly expanded or changed. The expected completion date is January 29,1995. Action 3e: For near-term, and where indicated, conduct inspections of licensees whose programs have significantly expanded or changed since the last routine inspection. (Responsible Office: NMSS/ Regions) Disposition: Ongoing The staff issued a memorandum to the Regions requesting that they poll the licensing staff to identify licensees whose programs (i.e., number of sites, scope of licensed activities, and/or possession limits) have significantly expanded or changed within the last two years. 13 NUREG-1272, Appendix E

AEOD Annual Report,1993 The Regions proposed a schedule for the conduct of inspections by March 31,1994. The expected completion date is May 9,1994. Item 4: Lack of guidance for nonradioactive waste collectors and brokers for handling highly radioactive material. Action: Evaluate the need for assisting the nonradioactive waste processing industry in establishing guidance for detecting, and obtaining expert assistance for handling, radioactive materials. (Responsible Office: NMSS/OSP) Disposition: Ongoing The staff has initiated efforts to prepare guidance. Specifically, the staff met with representatives from the Agreement States and the waste processing industry on June 29, 1993, to develop the guidance which will incorporate lessons learned from the IIT. During October 1993, the staff received diverse comments from the industry and Agreement States concerning its draft guidance. Addressing these comments resulted in a slip of the due date from January 31,1994, to March 31,1994. Two forms of guidance will be issued: (1) emergency response information to be distributed to facility workers, and (2) more detailed technical guidance for managers of waste processor facilities. The guidance will incorporate lessons learned from the IIT. The expected completion date is March 31,1994. Item 5: Cause of Source Wire Failure Action: Evaluate Southwest Research's final report on the source wire failure and document the findings. (Responsible Office: NMSS/OSP) Disposition: Resolved (Pending AEOD independent review) The staff received the final report from Southwest Research which confirmed the staff's hypothesis regarding the cause of the source-wire breakage. The contractor's final report was transmitted to the Commission via a memorandum dated October 27,1993. The responsible office considers this item resolved.

References:

j 1. NUREG-1480, " Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16, 1992," February 1993. 2. Memorandum from J. Taylor to Office Directors and Regional Administrators, " Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16,1992," dated March 12, 1993. 3. Memorandum from R. Bernero to J. Taylor, " Status Report on Staff Action Plan Responding to the Investigation of the Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16,1992"(NUREG-1480), dated February 6,1994. NUREG-1272, Appendix E 14

NRC FORM 335 U S. NUCLEAR REGULATORY COMMISSION

1. REPORT NUMBER (249)

(Assigned by NRC. Add Vct., NRCM 1102 Supp., Rev., cnd Addendurn M.am-320i,3202 BIBLIOGRAPHIC DATA SHEET b"$- " ar 3 (See instructions on ine reverse) NUREG-1272, Vol. 8, No. 2

2. THM AND SUBMLE

3. DATE REPORT PUUUSHLD Office for Analysis and Evaluation of Operational Data uoy7g l

ye,n 1993 Annual Report - Nuclear Materials i May 1995

4. FIN OR GRANT NUMBER

b. AUINUNb)

6. TYPE OF REPORT Annual summary of regulatory activities for nuclear materials

7. PERIOD COVERED (inclusive Dates)

CY 1993

8. PERFORMING ORGANIZATION - NAME AND ADDRESS (if NRC, provide Division. Office or Region. U.S. Nuclear Regulatory Commission, and malling address; if contractor, provide name and malhng address.)

Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555-0001

9. SPONSORING ORGANIZAllON - NAME AND ADDRESS (if NRC, type "Same as above"; if contractor, provtde NRC Division, Office or Regicn, U.S. Nuclear Regulatory Commission, and malhng address.)

Same as in item 8

10. SUPPLEMENTARY NOTES

11. ABSTRACT (200 words or less)

The annual report of the U.S. Nuc! car Regulatory Commission's Office for Analysis and Evaluation of Operational Data (AEOD)is devoted to the activities performed during 1993. The report is published in two separate parts. NUREG-1272, Vol. 8, No.1, covers power reactors and presents an overview of the operating experience of the nu-clear power industry from the NRC perspective, including comments about the trends of some key performance measures. The report also includes the principal findings and issues identified in AEOD studies over the past year and summarizes information from such sources as licensee event reports, diagnostic evaluations, and reports to the NRC's Operations Center. NUREG-1272, Vol. 8, No. 2, covers nuclear materials and presents a review of the events and concerns during 1993 associated with the use of licensed material in nonreactor applications, such as personnel overexposures and medical misadministrations. Note that the subtitle of No. 2 has been changed from "Nonreactors" to " Nuclear Materials." Both reports also contain a discussion of the Incident Investigation Team program and sum-marize both the Incident Investigation Team and Augmented Inspection Team reports. Each volume contains a list of the AEOD reports issued for 1981-1993.

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

13. AVAILA8luTY STATEMENT Unlimited

14. SECURITY CLASSIFICATION nuclear materials (This Page) operating experience abnormal occurrences Unclassified IIT staff action status (This ReporO AEOD recommendations Unclassified AEOD report listing

16. NUMBER OF PAC.ES

w. eRICe NRC FORM 335 (2-89)

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