ML20095H622

NMSS Licensee Newsletter.Number 92-1

ML20095H622
Person / Time
Issue date:	03/31/1992
From:	NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS)
To:
References
NUREG-BR-0117, NUREG-BR-0117-N92-1, NUREG-BR-117, NUREG-BR-117-N92-1, NUDOCS 9204300046
Download: ML20095H622 (13)

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U.S. Nuclear OMce of Nuclear NUREGlBR-0117 Regulatory MotorialSslety No.92-1 i

Commission and Sefooverds March 1992

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.x COMMISSION HAS DIREC' LED STAITt TO In the proposed rulemaking presently being developed by

' DEVE1DP AMENDMENTS TO I13 staff, the Comm! salon will restate and emphasize its REOULATIONS FOR ONS!1E STORAOB OP position that it will not look favorably on onsite storage of LOW LEVEL RADIOACITVE WASTE (11W) 11W by generators after January 1,1996, the final mile-AFIER JANUARY 1,1996 stone of the LLRWPAA. Re Commission considers on-site storage to be a last resort. Under the proposed De Nuclear Regulatory Commission (NRC) will propose amendments, onsite storage of ILW would not be per-to amend its regulations contaltdng licensing require-mitted a'ter January 1,1996 (other than reasonable j

meets for reactor, materia!, and fuel cle licensees, to es-short. term storage necessary for decsy or for m!!ection or tablish a regulatory framework setting forth the proce-consolidation for shipment offsite), unless the licensee could document that it has exhausted other reasonable dures and criteria that will apply to onsite storrge of 11W by generators beyond January 1,1996. The Commission waste management options. Such options include the has determined that these changes are required bemuse management of the waste try the State in which the waste i

of potential health and safety concerns associate.1 with generator is located. NRC will propose that the licensee the increased reliance upon onsite storage of i1W and to request that the State take title to, and possession of, the support the eational disposal goals that have been estab.

waste, in accordance with the 11RWPAA. Another op-lished by the Jew. level Radioactive Waste Policy tion is that the licensee contract, either directly or Amendments Act of 1985 (11RWPAA),

through the State, for the disposal of its waste. In addi-tion, reactor licensees would have to document that on-site storage acthities would be consistent with, and not On January 1,1993, the existing 11W disposal sites are compromir.e. the safe operation of the licensee's activi-expected either to close or stop receiving 11W from ou?-

ties, nor decroec the level of safety provided by applica-side their regional cornpacts. Since no new 11W disposal ble regulatory requirements. Rese provisions will be-facilities are expected to be operational by January 1, come standard license conditions for every license issued 1993, many licensees who generate 11W will need to for reactor, materials, and fuel cycle licensees, through store their 11W onsite until disposal capacity is availab!c, amendment of the segulations, ne rulemaking would taless other arrangements for storage or disposal can be amend 10 CFR 30.34,40.41,50.54, and 70.32, which are

- made. Nearly all the State governors have indicated that those sections of the regulations that identify standard their respective States plan on interim storage by waste conditions for byproduct material, source material, pro-generators during the 1993 through 1996 period. Such duction and utilization facility, and special nuclear rnate-Conge is planned to include individuallicensee facilities.

. rial licenses.

Although sonic compacts and States are scheduled to open an 11W disposal facility before January 1.1996, Licensees world not be required to maka formal submit-many others are crpected to miss this deadline.

tal, to NRC, to show compliance with these conditions, but instead would be required to maintain all relevant documentation of the steps taken to satisfy the require.

Although the public health and safety can be adequately ments and to make such documentation availtble for in-protected if 11W is stored, the public health and safety spection by NRC. He Commission may ask for such re-will be enhanced by disposal, rather than long-term, in-ports as might be necessary to determbie whether definite storage of wastes. Dupmal of wastos in a limited additional inspections or other regulatory attention cumber of facilities licensed under the requirements of would be required.

10 CFR Part 61 will provide better protection of the pub-lic health sad safety and environment than storage at ne proposed amendments would supplement, but not multiple sites around the country. Permanent disposal of supersede, the existing regulatory framework applicable 11W has always been the preferred option for managing to storaEc of 11W and the conditions in themselves wastes, as reflected in the 11RWPAA.

would not authorize onsite storage. Onsite storage of

'9204300046 920331 PDR NUREG

-BR-0117 R PDR o

MARCl{ 1992 NMSS IJCENSEE

12. A Sarnpling of Significant Events NEW5LLTITR CON 1ENTS Reported to the U.S. Nuclear Regula.

tory Comminion (NRC)(Contact:

f*

Kathleen Black, 301-492-0631)...........

7 1.

Commission lias Directed Staff t

13. A Sampling of S%nificant Enforcement Develop Amendments to its Regulations Actions against Material Ucensees for Onsite Storage of low level Radio.

(Contact: Joe Delmedico, active Waste (11W) after January 1,1996 301-504-2739).........................

10 (Contact: Nick Orlando,301-504-2566; Bob Nelson. 301-504-?004; James Kennedy, 301-504-3401).................

1 11W at reactors would continue to be subject to 10 CFR 50.59 cvaluations, as well as all other reguistory require.

2.

General Electric Nuclear Fuel Plant ments currently in place. Additionally, licensees nuld Uranium Contamination (Contact:

continue to use appropriate regulatory guklance for on.

Ed Mack, 301-504-2405).................

2 site storage of 11W.

3.

Nuclear Regulatory Commission. (NRC.)

ne low level Waste Branch of tbc D! vision of low.

Certified Packages involved in Springfield, level Waste Management and Decommissioning has the MA, Truck Fire (Contact: Earl Easton.

lead role in developing the proposed rulemaking pack-301-504-2462).........................

3 age.ne proposed rule is scheduled for submission to the Commission by May 1,1992, for its consideration and ap.

4.

Nucleu Regulatory Commission (NRC) proval. The Commission plans to have the final rule in Delays implementation Date for the place by December 31,1992.

Revued 10 CIR Part 20 (Contact:

Cynthia Jones, 301-$04-2629)............

3 For further information, contact: James Kennedy, low.

level waste Management Ilranch, Office of Nuclear 5.

Reconstitution of Liquid Radioactive Material Safety and Edeguanis, U.S. Nuclear Regulatory Commission. Washington, D.C. 20555, telephone Effluent (Contact: Cynthia Jones, 301-504-3401, 301-504-2629)...................

4 6.

NUREG-1324 Published-Pmposed OENERAL ELEC'IRIC NUCLEAR FUEL PLANT Improvements for Regulating Major URANIUM CONTAMINA'110N Materials Licensees (Contact:

Charleu Haughney,301-504-3328).........

4 De Oeneral Electric Company (GE) Nuclear Fuel Plant, located in Wilmington, North Carolins, manufactures 7.

Recent Court Decisions / Generator fuel for commercial reactors. During cramination of an croded concrete floor in one of the manufacturing build-Actions May Affect the Environmental ings, the licensee discovered a gap in the cawiction Protection Agency's(EPA's) Regulation joint between it and an adjoining building. Core oinang in of ifazardous and Mixed Waste the area near the gap revealed uranium contamination in (Contacts: Nick Orlando,301-504-2566; e

neat o r, areaa e the commm, a.

Bob Nelson, 301-5062004)..............

4 tion supported tanks containmg uranium nitrate.nere had apparendy been a spill of approximately 700 gallons 8.

Quality Assurance Study for Gamma of nitric acid sometime around the end of October 1991.

Knives (Contact: Dr. Patricia Rathbun, This is not necessarily the only time acidic 11guid has been 301-504-1407).........................

5 9.

Quality Assurance for Brachytherapy Remote Afterloaders(Contact:

Comments, and suggestions you may have for infor.

Dr. Patre, ta Rathbun. 301-504-1407)......

5 restion that is not currently being included, that might be helpful to licensees, should be sent to:

10. Rules Published October 30,1991..

January 27,1992 (Contact: Paul Goldberg.

E. Kraus 301404-2631).........................

6 NMSS Ucensee Newsletter Editor Office of Nuclear Material Safety and Saleguards f

11. Information Notices Published Novem.

One White Flint North, Mall Stop 6-E-6 I

ber 12,1991-March 24,1992 (Contact:

U.S. Nuclear Regulatory Commisskm

(

Paul Ovidberg, 301-504-2631)............

6 Washington. D.C. 20555 2

l l

_.----~__.____._________________,_________m

spilled on the floor. Upon discovery ci the contamination, Carolina, to Vermorit Yonkee Nuclear Power Pbnt in the licensee continued th e investigation, to determine the Vernon, Vermont.He operator of ihe automobile was nature and estent of potential contamination. ne work traveling south in the northbound lanes (and subsc.

included more bore holco in the concrete floor of the quently charged with drhing while intoxicated), in an at.

room. Soil samples were taken and ternporary well points tempt to amid the co'lis.an, the driver of the truck established. No uranium contamination was discovered swerved his vehicle, striking the barrier on the outer t t e other than underneath the slab tank room. ne licensee of the highway.nc truck then rebounded weross the road has employed outside experts to assist it in its recovery, and struck the center median beforo coming to rest. A fire quickly enveloped the tractor trailer and cargo. No As part of its remediation actions, GL has removed see-one was seriously injured, tions of flooring and excavated approximately 100 m8 of contaminated soil from the area. ne final excavation was ne Massachusetts State Police responded to the acd.

about 10 m by 4.5 m and to a depth of 2.4 m. Water was dent within minutes. nc driver of the truck immediately encountered in the excavation at the 2.1 m level, and a prmided the police with the shipping papers.ne Spring.

pumping / drainage system was installed. After excavation, field Fire Department arrived at the scenc shortly there-GE measured concentrations of residual uranium activity after and took command of the emergency response. ne in soil, using gamma spectrometry. Region II intensified Fire Department contacted several organizations. in-its inspection effort and has been closely monitoring the 4 Jed GE, Vermont Yankee, and CIIEM1 REC, for fur-licensee's efforts. He Office of Nudear Material Safety ther information about the contents of the packages. Af-and Safeguards (NMSS) has met with the licensee to dis-ter reviewing this information, along with the information cuss the issue and has supported Ril with a hydrologist provided in the shipping papers and the Emergency Re.

who accornpanied the inspectors onsite and at meetings sponse Guide, the Fire Depa < ment decided to allow the with State of North Carolina representatives.

fire to bum itself out. He o ter wooden boxes on the packages were completely consumed in the fire, ne During one of the earlier inspections, the licensee pro-packages burned until approximately 6:00 a.m. Radiation vided an inspector sa nple splits, to enable the Nuclear surveys were conducted by personnel for the State of Regulatory Commission (NRC) to corroborate the licen-Massachusetts and Vermont Yankee; no contaminatior I,ee's analytical results. nese samples were evaluated at was detected.

the Environmental Survey and Site Assessment Program (ESSAP)of Oak Ridge Associated Universities (OR.AU).

GE notified the NRC Operations Center of the event at ORAU has recently completed a more thorough onsite 4:45 a.m.n Center was not activated for the accident; survey of the excavation. He magnitude of contamina.

however, NRC licadquarters and Region I offices pro-tion reported by ORAU was similar to that reported by vided guidance to State authorities during the meident re-the licensee.

sponse and recovery operations. After the fire was out, the assemblies within the metal inner containers were At present, the licensee, concerned that structural dam-transpotted to nearby Westover Air Force liase, repack-age may occur if further excavation is performed, is filling aged 5y GE, and on December 19,1991, shipped back to in the hole (with NMSS approval). After a thorough re.

GE.Wilmington, without further incident.

view of the licensee's pathway analysis, and increased groundwater monitoring, etc., NMSS will stipulate a NRC has contracted with lawrence Livermore National more formal and lasting solution.

laboratory (LLNL) to study the severity of the accident conditions and the damage sustained by the packages NUCLEAR REGULA1 DRY COMMISSION-(NRC.)

involved in the accident, ne packaging appear to have CER11FIED PACKAGES INVOLVED IN perf rmed es expected. NRC is also reviewing the SPRINGFIELD, MA,1 RUCK FIRE emergency response guidance available to on. scene re-sponders.

On December 16, 1991, at approximately 3:18 a.m., a tractor-trailer truck transporting radioactive materials was involved in a head-on collision with an automobile on NUCLEAR REGULATORY COMMISSION (NRC)

DELAYS IMPLEMENTA110N DATE FOR lilE Interstate 91 (I-91) in Springfield, Massachusetts. The REVISED 10 CFR PAR r 20 truck was carrying 12 Model RA-2 NRC-certified pack.

ages, each containing t~o unitradiated fuel assemblies (uranium dioxide pelled ualed within ritcaloy rods).ne ne Commissm has voted to delay the implementation Mooel RA-2 packagt consists of an inner metal con.

date for the revised 10 CFR Part 20 (20.1001-20.2401) to tainer,11 + inches by 18 inches by 179 inches long, posi.

January 1,1994. His new date is consistent with the date tioned withia an outer wooden boa (30 inches by 31 inches for implementation by Agreement State licensees (the by 207 inches long), separated by cushioning material.

date for implementation by Agreernent States has not been changed), in addition, final versions of Part 20 regu.

He truck was traveling north on I-91, cruoute from latory guides will be available to the public for 1 year be-General Electric (GE) Company in Wilmingtor. North fore the implementation date.

3

A change in the implernentation date is considered c mo-NUREO-1324 PUlll_lSilliD-PROPOSI:D jor change to the rule; therefore, a delay in the implemen-th1PROVEhtENIS l~OR RI: OUI.A11NG h1 AJOR Lation date must be enacted through the rulemaking pro-ht ATl!RIA1.S 1JCENSPliS cess. lhe Commission has instructed the NRC staff to initiate this process. In addition, the Commission has in.

In l'ebruary IW2, NURiiG-1324,* Report of the htateri-structed the staff to notify and consult with the linviron.

als Regulatory Review Task I'orce," was sent for com-menad Protection Agency (EPA) about the change.

ment to all major materials licensees. NURiiG-1324 propses improved methods for regulating major materi-als licensees.The NUREO was developed by a task force lhe proposed rule to delay the img'amentation date will w hose charter was to des clop an ideal rnethod of regulat-be published iri the federal Regurer, with at least a 30-day ing major malettallicensees/lhe task force was to be un-mmment period. Individuals or organizations with com-fettered by any existing regulations or regulatory guid.

ments on delaying the implementation date are enmur-ance, concerns aluut backfitting, or limitations on aged to respond during the comment pernd. After the tesources of the U.S. Nuckar Regulatory Comminion comment period has expired, the NRC staff will review (NRC) or the licensees.

the submitted comments. mj the Commission wtll make a final decaion on the delay.

In the letter transmitting NUI EG-1324, the NRC staff requested that comments be provided within 60 days (or aluut April 30, lW2) and that the followmg types of RECONSTilV110N OF L10UID RADIOAC11Vli questim be addressed:

EFI LUENT 1,

viuh 4

- w.*ndations should, or should Tais article is.ntended to alert Nuor at Regulatory Com.

% L nt d:

mission (NRC) licensees to the potutial for chernical re-constitution or reconcentration of radioactive materials 2.

Wh, 2 t mommendasions should be enoJified, released to the sanitary sewer, se liquid effluent, when how, and wh/?

processed by sewage treatment tacthties.

3.

What priorit saould be auiped each recomnanda-tion to be implemented, and why?

In hme 1991, Region ill was notified that Iwo loads of m..

cinemted sludge ash from a waste water treatment facil-ity were rejected from a commercial landfill because of Rl! CENT COURT Dl!CISIONS/GliNiilu. TOR elevated radiation readings from the ash. NRC review of ACTIONS h1AY AITECI'TilliliNVIRONMiiNTAI.

the incident revealed that the ash was generated from the PRoll!CI10N AGENCY'S (l!PA'S) RiiGUI.A'110N OFllAZARDOUS AND hilXED WASTl!

meincration of sewage sludge, which was also a product of the sewage treatment process. Analysis of the rejected ash revealed detectable concentrations of several rash-A December 6, lWl, decision by the U.S. Court for Ap-I>eals of the District of Columbia could affect the wa} that onuclides; however, the concentrutions were below those requiring a license. pursuant to l') CFR 30.14, and posed EPA regulates hasardous and mined waste. Iate IW1 no signtficant health hazard. Inspection of the originator's and early IW2 also saw increased efforts by the electric disposal practices, that resuhed in the radioactive sludge, utilities to compel EPA to change the current regulations showed all icleases during the previous 18 months to be in for the management of mixed waste. 'lhese efforts m-accordance with 10 CI R 20.303 sanitary sewer release cluded petitions to both EPA and the U.S. Loust of Ap.

criteria. The sewage treatment process appeared to con-peals to amend or revise the Resource C,onservation and centrate the radioactive material in the sewage sludge. In-Recmery Act @G A) egulasns, as they penain to ec cinemtion of the sludge resulted in further concentration storage and dihptsal of mixed waste.

of the radioactive material in the ash. In tnis case, a total On December 6, IWI, the D.C. Court of Appeals de-concentration factor of 1014 was observed.

cided that EPA had inued the " mixture" and "deriveu-from" rules (40 CFR 261.3 (a X2 Xiv) and (cK2 Xi)) without With the. installation of sensitive radiation-nonitoring adequate notice and opportunity for public comment be-equipment at many landfills across the country, the rejec-fore their proinulgation in 1980 (see Shell Od n EPA, tion of waste shipments because of elevated radiation No. 80-1532, slip op, D.C. Cir., December 6,1991). 't he readings is becoming a more common occurrence. Al-

" mixture" rule states that any mixture of a listed haiard-though release to sewers is currently allowed by 10 CFR ous waste and a non hazardous solid waste is a harardous 20.303(20.2003 0f the revised 10 CI R Part 20), licensees waste.1hc " derived.from" rule states that any waste re-thould be aware of gutential problems associated with the sulting from the storage,it catment, or dispWil of a listed release of radioactive materials, readily soluble or dis-hatardous waste is a haiardous waste. The Court's deci-persible in water, to the sanitary sewer. Af ter or w hile un-sion would vacate these two provisions in the regulations dergoing sewage treatment, these releases may be subject that EPA uses to defme a haiardous waste. As much as 25 to chemical reconstitution or reconcentration.

percent of waste that is currently regulated as hazardous 4

waste could be affected by the Court's decision, it is un-focus et a predetermined point about which the patient's certain how the Court's decision will affect " mixture and lesion needs to be kwated. *Ihe Office of Nuclear Mate.

" derived from" harardous waste in EPA Authorned rial Safety and Safeguards (NMSS) has contracted with States, as the States may have aheady promulgated their the Nuclear Systems Safety Pror, ram at lawrence IJver.

harardous wate regulatkms in accordance with applica-more Natio ial laboratory (LLN L) to perform a res. arch ble State procedural requirements. On March 3,1992, project on quality assurance for gamma knives. He ob-LPA announced, in the redera/ Regbirr ($7 IV 7628), that jective of this project is to provide information, to the Nu-it had reinstated these rules, as interim rules and that it clear Regulatory Commission (NRC), that will enhance would reissue the rules, as final rules, rJter the public was the safe and reliable use of gamma knives. 'lhe project given the opportunity to comment on the proposed (re-will not irnpact or delay license processing for facilitics issued) rules. The effective date of the interim rules is wit.hing to acquire a gamma knife.

February 18,1992, and they will expire on April 28,1993.

NRC has asked LLNL to gather information on relevant On November 27, 1991, the Edison Electric Institute quality assurance guidelines and procedures from m rdi-(EEI), the American Public Power Association, the Na-cat associations, standard-setting organizations, the tional Rural Electric Cooperative Association, and sna9y rnsnufacturer, and gamma knife users. This information individual electric utilities petitioned the U.S. Court of will be analyzed and compared to existing regulations and Appeals for the District of Columbia, to review EPA's de-guidelines (primarily 10 CFR Part 35 and the Quality cision on storage of mixed waste In this decision, EPA de-Management Rule, effective January 27,1992). In addi-termined that generators forcul to store mixed waste, be-tion, LIRL is developing a risk analysis methodology to cause of lack of adequrte disposal capacity, are in identify and araess high risk human initiated actions and violation of the land <!isposal. restrictions prohibition on most hkely failure rnodes. This project thus provides an hazardous waste ste age found at Section 3004 0) of opportunity to update regulations and develop model RCRA. According to the petitioners, EPA's decision safety procedures grounded on a systematic and analyti+

forces them into immediate non-compliance, with no cal risk assessment methodology. He approach being means to come into compliance, because adequate dis-used may prv> vide a prototypic regulatory model for a posal capacity for mixed waste does not currently exist.

broader claas of nuclear medical desices.

He petitioners also requested that the Court crpedite its cxmsideration of the petition, but this has since been de-Lt.NI, working closely with NRC, has put together a re-nied by the Court.

search team of physicians and medical phpicists y !!h ex.

pertise in teletherapy, risk assessment experts, and scien-In addition, on January 13,1992, the Utility Solid Waste lists and engineers with extensive knowledge of quality Activities Group submitted a rulemakirg petition, to control and regulatory compliance issues. De team has EPA, requesting that EPA arner d its regulations, to es-acxtuired quality assurance documentation from over 20 tablah a separate exemption for small quantity genera-medical and standards organizations.'lhe man ufact urer's tors of mixed waste. The petitioners also rcquested that U.S. represcr;tative, Elekta Instruments, Inc., has pro.

EPA declare that the storage of mixed waste, pending the vided the team with technical information on the camma development of adequate treatment and dispmal capac-knife, as well as with gamma units and results of accep-ity, is a legitimate practice under Sectbn 3004 0) of tance tests. LLNL has visited five gamma knife facilitics, RCRA. Finally, the petitioners requested that EPA so far, to interview users about quality assurance prae-cmend its regulations to allow qualified facilities to accu-tices and to collect information needed for the risk analy-mulate mixed waste onsite until adeocate treatment and sis. Since the current gamma knife community is so small, disposal capacity become availabic. At press time, EPA 11NL hopes to receive data for this project from all was considering both this petition for rulemaking and its garnma knife licensees.

response to the EEZ petition, to review its determination on waste storage.

De NMSS project manager is Dr. Patricia A. Rathbun.

She can be reached at 301-504-1407.

If you have any questions on these actions, please contact Nick Orlando, NRC Mixed Waste Project Manager, at QUAUrY ASSURANCE FOR IIRACIWillERAPY 301-504-2566.

REMOTE AITERLOADERS QUALITY ASSURANCE STUDY FOR OAMMA He Division of Industrial and Medical Nuclear Safety KNIVES (IMNS), Office of Nuclear Material Safety and Safe-guards (NMSS), has contracted with Idaho National En-The teksell Gamma Unit (LGU) or gamma knife is a gineering 1.aboratory (INEL) to identify regulations, relatively new (1987) radiation medical device in the standards, guidelines, and current practices for quality as-United States. It is used for gamma stetwtactic radiosur-surance in remote af terloading brachytherapy and to cor-gery of intracranial lesions, it differs from conventional relate them against existing regulations in 10 CI'R Part 35 cobalt teletherapy in that its 201 cobalt-60 sources do not (in particular, Subparts O and 1). The quality assurance move but are arranged so that gamma ray beams sharply areas specifically addressed by this study include:

5

1 (a) safetyieview and registrolion of remote ofterloaders:

PROPOSED RULES

'9 " * * *"I' (b) acceptance testing, toutine calibration, and safety checks of remote afterloaders and anociated facility 1.

Published: December 27,1991 systerns; and 2.

Contact:

Joseph Mate,301-492-3795 (c) nice and preventative maintenance of remote af.

Criminal Enforcement" llased on the data collected, INEL will develop a recom-1.

Published: January 3,1992 mended malel for acceptance testing. routine calibra-tion, and safety checks of remote afterloader devices and 2.

Contact:

James lieberman,301-504-2741 associated safety systems. In addition, INEL will aness the risk signifka' ice anociated with the use of remote af-INFORMA'I10N NO11CilS PUlilJSilED terloaders, to identify entical human actions and cornpo' November 12,1991-March 24,1992 nents that could be significant contribu'on to risk.

A. Training and Supervision of Individuals Supenised To accomplish t he program's objectives, INEL has auem*

by an Authorized User-IN No. 91-71, dated bled a team of medical experts and scientists, including November 12,1991 physicians and medical physicists with expertise in remote Technical Contacts:

afterloading brachytherapy, and scientists with ( pertise Janet R. Schlueter,301-504-2633 in risk assessment.

Roy Caniano,312-790-$721 Selected standard-setting txnlies, medical organizations.

This notice reminds licensees of the importance of pro-and government agencies are being inteniewed. In addi-viding adequate instructkm and supenision to individuals tion, INEL is obtaining information, relevant to quality working under the supervision of an authorized user *Ihe assurance, from thice manufacturers of remote after-regulatory requirements for the instruction of workers loaders represented in the United States, and from five are described in 10 CFR 35.25,"Supenision." Additional medical institutions, performing brachytherapy, using re-requirements for the instruction of workers are described mote afterloaders. 'Ihe three manufacturers include in 10 CFR 19.12, " Instruction to workers.' 'the State.

Nucletron, RTS Technology, and Omnitron. Of the five ment of Considerations for Part 35, which is discussed in medical institutions participating in this study, three are this notice, contains additional information on instruction needical centers associated with large teaching universi-and supenision. Supenised individuals who infrequently ties, one is a large private clinic, and one is a medium site use radioactive materials, such as part. time cross trained radiation oncology center at a private hospital.

and contractor technologists, are of particular concern.

NRC has received reports of recent events: that led to misadministrations or violations, that indicate that some

'Ihe NMSS project manager is Dr. Patricia A. Rathbun, She can be reached at 301-504-1407.

licensees are not providing adequate mstruction or super-vision to individuals working under the supervision of authorized users. Six recent cases are discussed.

RULES PUllLISilED, October 30.1991-Towy 27, 1992

11. Problems with Criticality Alarm Components /Sys-tems-IN No. 91-84, dated December 26, 1991 Technical Contacts:

FINAL RULES Scott Pennington,301-504-2693

• "Matenal Control and Accounting Requirements for Gerald Troup, 404-331-5566 Uranium Enrichment Facilities Producing Special Nuclear Material of low Strategic Sigmficance,

.Ihis notice reminds licensees of the irnportance of ade.

quate reviews of plant modification, installation, mainte-1.

Published: 10/31/91 nance, and resporne actions, to ensure that required criti-cality alarm systems meet their intended purpose. It 2.

Contact:

Sher llahadur,301-492-3775 discusses six recent cases of problems with criticality alarm systems, llecause physical and electrical modifica-

• " Revision of Fee Schedules,100% Fee Recovery, tions have the clear potential to degrade or disabic all or Clarification of Site Standards" part of this system, licensees should ensure that they know the system's configuration and the routing of detec-1.

Published: 11/13/91 tor or power circuits, in detail, and that they have a com-prehensive testing program and continuous monitoring 2.

Contact:

James Holloway, Jr.,301-492-4301 of the system's integrity.

6

i C. NRC Reporting Requirements for Contamination A SAMPIING OP SIGNIFICAMrilVENTS Events at Medical Facilities (10 CFR 30.50)-IN No.

REPOR111D TO Tl111 U.S. NUCLEAR 91-86, Gated December 27,1991 REGULATORY COMMISSION (NRC)

TechMcal

Contact:

Roben L Ayres,301-504-3423 His neti ;e explains more futly the Linds of contamination Event 1: Medimi Diagnostic Misadministration evetst involving byproduct material, as described in 10 Date Notified: June 17,1991 CFR 30.50, that might be considered reponable to the U.S Nuclear Regulatory Commission (NRC) by a inedi.

Ikensee: 1. Gonzalez Maninez Oncologic llospital al tacility performing pmcedures with byproduct mate-Ilato Rey, Pueno Rico rial, panicularly latine.131.

On June 17,1991, a patient scheduled to receive a diag.

D. Revised Protective Actk>n Guidance for Nudear In-nostW oNW31 N31)was mhtakny a&ninb cidents-IN No. 92-08, dated January 23,1992 stered a d(ac of I-131 in the therapeutic range. the mis-Technical Contacts:

administration occurred when a nuclear rnedicine Kevin M. Ramsey,301-504-2534 technologist rnisread the dose calibrator and admin.

W. Scott Pennington,301-504-2693 tstered 6.2 millicuries rather than 6.2 microcuries. He technologist reallied the error 9 minutes after the dose his notice informs licerisces of recent rettsions to the was administered, when the printed dose label from the "U.S. Environmental Protection Agency (EPA) Manual dose calibrator was checked. He physician in. charge of Protective Action Ouldes and Pro'ective Actions for promptly administered potassium lodide r,olution to the Nuclear !ncidents." De revisions include the use of com.

patient, to reduce the uptake of the radioactive hidine.

mitted effcetive dose equivalent units rather than whole, ne licensee estimated based on 24. hour uptake meas-body dose units, a clarification of the most suitable offsite urements, that the dose to the thyroid was 1612 tem, protective actions, and guidance for controlling doses to emergency workers onsite.

The licensee continues to follow the patient's condition and has advised the Nuclear Hegulatory Commission (NRC) that the patient has not experienced any E. 13rachytherapy incidents involving Iridium 192 Wire adverse effects because of the misadministration.

Used in Endobronchial Treatments-IN No. 92-10, dated January 31,1992 De muse is attributed to human error by the nuclear Technical

Contact:

medicine technologist.ne technologist did not verify the Intrict Karagiannis,301-492-4258 dose by reviewing the printed dose label before admini-His notice describes two recent events where iridium 192 wire attached to an unitradiated flexible ne licensee's corrective actions included taking discipli-guide wire became detached from the guide wire, and nary action against the technologist and rcquiring that the what measures the licensees took to prevent such recur

• nuclear medicine supervisor check each dose before the rences.

dose is administered to a patient.

F. Uranium Oxide Fires at Fuel Cycle Facilities-IN Event 2: Medical Therapy Misadministration No. 92-14, dated February 21,1992 Technical Contacts:

Date Notified: August 30,1991 rics i R I-504-2576 El 1 aso, Texas his notice describes two incidents of fire, at licensee fa-On August 30,1991, a patient referred to the Medical cilities,invohing urniurn at various stages of oxidation, Center for therapeutic radioiodme.rea',nent of Oraves' and alens licensees to the potential for these fires. It dis-disease mistakenly received a 28.6 nilheurie oral dosage cusses measures for preventing such fires and for upgrad-of I-131, instead of the picscribcd cral dosage of 15.0 ing fire detection, alarm, and suppression systems, millicuries I-131. As a res.ilt, the patient's thyroid re-ceived about 31,900 rads, instead of the 16.700 rads in.

O. Spent Fuel Pool Reactivity Calculations-IN No.

tended.

92-91, dated March 24,1992 Technical Contacts:

Hefore the administration, the mdiopharmacist involved Jack Ramsey,301-504-1167 was informed that a radiciodine treatment for Graves' l

l2rry Kopp,301-504-2879 disease had been requested. Ile assumed that it was a l

29.millicurie treatment rather than a 15-millicurie treat-l Dis notice alens addresses to potential errors in reactiv-ment. (At the Medical Center, a 15-millicurie dose is rou.

ity calculations for spent fuel pools.

tinely used for Graves' disease, whereas a 29.millicurie t

w

-m

=

dosage is used for thyroid disonien such es multinodutor of his body was being trected.%e patient pointed teard toxic gohers.) When the radiopharmacist logged the dos-his head as the area to be treated. liased on this poor ex.

age into the computer, aher it had been measured by the change of information and without the benefit of a review dose calibrator, he failed to note the intended therapy of the patient's chart, the oncology physician then ad-

&>se in the referring physician's prescription. In addition, ministered a St-90 dose to the patient's eye, without wait.

the consulting nuclear medicine physician did not verify ing to review the patient's chart. He licensee estimates the dosage to be administered with the intended dosage.

that about 1000 rads were delivered in 11 seconds to the

%c 28.6 millicurie incertreet dosage was then admin-surface of the right eye.%e licensee estimates that no istered to the patient, hannful effects ocrurred to the patient as a result of this event.

Me referring physician was notified on the day of the misadministration.ne licensee stated that no adverse ef.

An NRC medkal consultant wa retained to revicw the fects on the patient were noted.

licensee's dosimetry, the possible biolorcal cffects of the dose, and the actions to prevent recurrence. ne consult.

He event was attributed to human error as a resuh of the an! agreed with the licensee's estimate of dose to the pa.

radiopharmacist's and consultmg nuclear medicine phy-tient's eye and concluded that the possibility of cataracts sician's inattentiveness and brief experience at the facil-was low,

ity, He cause was attributed to failure to follow the hospital

%c radiopharmacist and consulting nuclear. medicine protocol, which requires reviewing the patienl's chart be-physician were advised and reinstructed on proper draw-fore administering treatment.

ing techniques and safeguards. For future therapies using radiopharmaceuticals, the consulting nuc! car medicine

%e Ikensee's planned conective actkms include:

physician must visually check the amount of drawn radio-pharmaceutical, as measured by the radiopharmacist or 1.

Patients will only be direct ed to the treatment area by technologist, with the amount intended for the therapy.

an aide, who will band the treatment chartti directly He licensee also intends that the consultir'g nuclear-to the physician, medicine physician be familiar with the patient's case his-tory before administering a thenipeutic radiophar na-2.

Each patient's chart will include a polaroid photo-ceutical dose.

graph of the patient.

Also, the licensee's Radiation Safety Officer (RSO) will 3.

Access to the Sr-90 beta applicator storage area will conduct a training se6sion in which all nrclear medic"ic be limited to the Physics Department and the Chief personnel will be required to review the videotape en-Technologist, titled *0 Sod Practices in Preparing and Administcring Rae.jnarmaceuticals," prepared by NRC's Office for 4.

Physics staff will accompany the physicians during all Analysis and Evaluation of Operational Data.

St-90 beta applicator treatments and assist in deter-mining the treatment times.

Event 3: hiedical%crapy Misadministration 5.

Staff training and reenforcement of appropriate Date Notified: November 13,19h patient processing procedures and NRC require-Licensee St. Joseph's liospital and Medical Center Paterson, New Jersey NRC Region I conducted a special inspection on Noverr-ber 15,1991, of the circumstances surrounding this mis.

On November 13,1991, NRC Region I was notified by a administration. He incident was reviewed by an NRC lett.r dated October 30,1991, from the licensce's acting medical consultant. On December 26,1991, NRC trans-RSO, that a therapeutic misadministration invohing a mitted to the licensee a Notice of Violation and Proposed strontium-90 (Sr-90) beta applicator, with a nominal ac-Imposition of Ch'il Penalties, hmiolations were identi-thity of 95.5 millierMes, had occurred on October 25, fied: (1) the failure to review the patient's presenption, 1991. He therapeutie treatment had been admmistered which resulted in the misadministration; and (2) the fail-to the wrong patient.

ute to report the misadministration to NRC within 24 De misadministration involved a 52 year old male who was scheduled for a simulation for external beam therapy 1, vent 4: Medical %crapy Misadmm.. tration is to the head and neck. His occurred when the radiation oncology department secretary directed the patient to Date: November 22,1991 i

l wait in the wrong treatment room without his chart.The patient spoke minimal English, and the radiation oncolo-I.icensee: University of Pittsburgh Prest 1erian-3 I

gist did not speak the patient's language. The physician University liospital

(-

questioned the patient more than once as to which area Pittsburgh, Pennsylvan,ai 8

l l

~-

1 De licensee's RSO nottfied NRC that a therepeutic radiation crpe:ure received by the lips, for a correctly ed-misadmini6trabn involving a cobalt 60 teletherapy unit minidered treatment to the nasal septum, would be had ocruned at its Presbyterian University llospital facil-about 23 rads. De bcent.ee does not expect any conse-ity, on Noverober 21,1991. He therapeutic treatment quences from the edditional exposure to the patient's had been administered to the wrong part of a ptient's tip.

tway.

He physicist fallal to verify the identify of the patient De technologist had looked at the patient's chart, but set and assumed incorrectly that the chart at the control I

vo the wrong treatment field. He patient received 287 panel was for the patient undergoing treatment, rads to the thoracic vertebrae (upper back)instead of the prescribed N10:3ds to the cervical vertebrac (icmcr neck).

He licensee has onected that the operating physicist Because the patient had previously undergone thoracic check the identity of each patient before treatment.using veitebrae treatment, the technologist ermneously as-patient photos or other means of venfication. Patient rumed that the thoracic treaiment was continuing and ad-charts foe treatment series will be placed in a specified no-ministered the treatment without adequately reviewing cation. No exceptkms will be made to the trainiag re-the patient's chart, which indicated the correct treatment quired of a user. in the future, training willinclude a gen-area.

cral section on high-dose. rate afterloading &vkes.

ne licensee has detennined that the treatment will not have any adverse effects on the patient.uc patient is suf-Event 6: Expusure of a Non radiation Worker fering from metastatic cancer of the breast and was re-Date: September 1,1%9 ceiving palliative radiation treatments to the spine.

lkensee: San Gabriel Valley Medical Center De cause was attributed to failure to follow the written San Gabriel, California prescription in the patient's chart. Corrective actions in' (Cahfornia tiensee) cluded stressing to the radiation technologists the need to tarefully read patients' charts and to recognize notations On August 1,1989, an intracavitary procedure was per-of changes in the fields to be treated. When a field is com.

fonned at San Gabriel Valley Medical Center. 'Two pleted on a patient, the administered dose is to be written cesium 137 sources,42.2 milheunes each, were loaded down in the patient's chart, using a different color ink.

into colpostat devices and inserted into the patient for treatment. After the procedure was completed, the phy.

Event 5: Medical nerapy Misadministration sician removed the devices and placed them in a lead con-

)

tainer. He container was then transported to the room Date Notified: Novernber 27,1991 w here the cesium storage safe was hicated, however, the Ikensee: Madison, Wisconsin sources were not removed from the inserts and placed in the safe as they should have been. On September 1, an A patient was undergoing a series of five treatments for a employee of the Medical Center removed the inserts still cancer of the nasal septum, using a high-dose rate containing the sources from the lead transport container, iridium 192 afterloading unit. He initial four treatments and, thinking that they were empty, placed them in an en-e cre completed without incident. For the fifth treatment, velope to be transported to Methodist llospital, where on November 27,1991, the operating physicist peked up they were intended to be used. He envelope was placed the wrong patient's chart kicated next to the device's con-in the Radiology Department, where it was picked up by trol panel and entered the program infonnation into the an employee of a private inedical group, a few days later.

computerized device.While the treatment was underway, nis individual placed the envelope h his private car and a student technologist inquired about the length of time drove to Methodist Hospital, which took approximately to complete the treatment.De prerienbing physician and 25 minutes.

the operating physicist indicated different lengths of time.ne physician, realizing there was an en or, directed When the inserts were received by Methodist Ilospital, that the treatment be stopped immediately. Subsc-the envelope was opened immediately, and the sources quently, it was discovered that the physicist had used the were discovered inside.ney were placed in a lead trans-chart for the wrong patient and, therefore, entered incor-port container and removed to the storage rafe by staff of rect treatment program information into the computer, the hospital.

He correct treatment information was then entered into the computer and the treatment series completed.

San Gabriel Valley Medical Center hired a medical physicist to evaluate and determine the extent of crp+

ne erroneous treatment information positioned the sures that individuals had received as the result of this in-l iridium 192 source so that the patient's lips received an cident. Extensive time and motion studies were con-i exposure for about 1 minute.ne dose calculation by the ducted, as well as the processing of personnel monitoring licensee indicated that the patient recched approxi-devices, to determ'nc doses received.ne individual who mately 73 rads to the lips. According to the licensee, the had transported the riources from one hospital to the

(

9

l other was a non radiation worker and therefore did not When her name wcs celled, patient "11" anseered and wear a personnel monitoring devi c. It was estimated signed the consent form. She aded questions of her tech.

that he received about 106 rem to his nght hanJ and 0.168 nologist about thyroid disorders and was given answers.

tern w hole-body exposure. All others who came in contact 1he (kt.e of 15 millicuries was administered, with the sourtes wore personnel. monitoring devices. It was estimated that their exposures were within the oxu.

later that same day, patient "A" presented herself for pational dose limits specAfied by the State's Radiation the treatment. It was then that the hospital dixovered Control Regulations.

that perwr.ncl had administered the dose to the wTong patient. Patient *ll"'s doctor was centacted and consulted

'lhe Medical Center was cited fot causing the delivery with the Chief Nuclear Medicine physician.'lhey decided man to receive 106 rem to his right hand, as a result of this to give patient "11" 15 drops of a potassium iodide solu-cvent.*Ihe hospital notified him in writing, of the nature tion three times daily for 3 days, plus forced fluids to re.

and extent of his expasure, and previded him with a medi.

duce the uptake of the radioactive kdine. She underwent cal review, A medical examination of his hands, on the day the previourJy scheduled surgical procedure 3 days after after the caposure, and 3 weeks later, did not reveal kny the dose was administered, without any regard for possi-evidence of skin changes or other symptoms. Also, his ble patient exposure of surgical room staff, blood count showed no significant abnormalities.

1his incident was reported to the wrong unit of Califor.

The apparent cause of this exposure was the failure of nia's Department of flealth Services, by the hospital,5 hospital employees to follow proper procedures for stor-days after it occurred. Radiologic licalth was not con-age of brachytherapy sources after their use 'Ihe individ-tacted until May 31,1991,28 days after the incident oc-ual who transported the sources from the patient's room curred, since perwnnel did not realize the significance of to the cesium storage location at the Medical Center did the event. An investigation was begun by the Radiologic not remove them from the colpostat source holders and licalth Unit of the los Angeles County llealth Depart-place them in the storage safe. Ily leaving the sources in ment, the inspection agency for this licensee. The inspec.

the holders, other personnel were casily exposed, be-tor discovered that the hospital had originally estimated cause the sources were invisible and could only be de.

the patient's thyroid dose to be much lower than it actu-tected by careful examination or use of a survey meter, ally was. The ag':ncy retained a consultant, who per-formed a complete workup of the patient.*Ihe patient's The Medical Center purchased a bench top Geiger-dose was established at 3000 rem to the thyroid, and she Meuller detector equipped with an audible alarm and in-was informed of this in wating by the hospital. She was stalled it at its cesium storage hication.1hc detector will placed into a treatment followup program.

alarm if murces are not secured inside the storage safe.

Also, a refresher training was held for all staff, covering 4

the proper handling of brachytherapy sources held under The consultant also evaluated exposures to the surgical room staff.'Iheir exposures were determined to be mini-the license. This training included removal and replace-ment of sources from the storage safe, as well as quarterly mal; they were also notified by the hos') ital.

inventories. Methods of surveying devices that contained cesium sources, before taking them out of service, were An enforcement conference us held at the los AnEcles emphasized.

County llealth Department, between members of the hospital administrative staff and representatives of the Event 7: Medical'lherapy Misadministration County and State Radiation Control Program staff.'Ihe hospital presented an extensive corrective action plan Da?c: May 3,1991 and explained new controls that would be put in place.

IJcensee: Northridge liospital Medical Center Northridge, California Representatives of the Radiologic Ilealth firanch ac-(California ljcensee) cepted the plan, and the case was referred to the city at.

torney's office, for determir. 4on of whether charges On May 3,1991,15 millicuries of iodine 131 intended for should be filed.

patient "A" were administered in error to patient *II,"

who has the same first and last names as patient "A." 'Ihe administration was made by the hospital's Certified Nu-A SAMP!JNG OF SIGNII1 CANT ENFORCEMENT clear Medicine Technologist, without the responsible ACTIONS AGAINST MNITIRIALIICENSEES physician present, which is a violation of the Califorma Radiation Control Regulations. Patient *II" had reported One way to avoid regulatory problems is to be aware of to the hospital's Outpatient Department for a preo.

enforcement pivblems others have faced.Thus, we have perational chest x ray,instead of reporting to her doctor's included here a sampling of some representative enforce-private office, as she was instructed. Patient "A" was ment actions against materials licensees. 'Ihesc enforce.

scheduled to receive a hyperthyroidism treatment that merd actions can include civil penalties, orders of various same morning, types, and notices of violations.

10

-~

A. Civil Penalties and Orden aethities. A letter was issued October 18,1991, that 1.

Consolidated NDE, incorporated. Woodbridge, New Jersey 4.

P.X. Engineering Company, Inc., Iloston, Supplement Vil, EA 91-058 Massachusetts A Notice of Violation and Confirmatory Order Modi.

fying ucense (Effecth e lmmediately) was issued Oc-A Notice of Violation and Propsed impsition of tober ll,1991. ne order confirms that an individual Civil Penalty was issued February 21,1991, to em-would be allowed to act only as an assistant radiogra-phasite the importance of the licensee's resp msibil-pher, and not as a radiographer, until such time as the sty for ensuring that: (1) licensed aethities ate con-licensee submits, and the Nuclear Regulatory Com-ducted safely and in acmrdance with the conditions mission (NRC) accepts, the licensee's basis for being of the license; and (2) all information communicated satisfied that the indhidual should act as a radiogra-to NRC is complete and accurate in all material re-pher, as defined in 10 CFR 34.2.ne action was taken spects. De action was tmed on the licensce's former because the indhidual, wh:n he was acting as a radi-RSO, who was also the licensee's radiographer, fail-otrapher, failed to provide complete and accurate in-ing to provioe adequate supcivision of an individual r

formation to NRC dunng and after an NRC inspec-acting as a radiographer's assistant, on a number of tion and created an inaccurate utilizatkm record. A occasicms between November 1987 and June 28, civil penalty was not proposed in this case, because a 1988. Also, the action was based on the RSO's failure Confirmatory Action letter, a civil penalty, and an to provide accurate information in response to an in.

Order Suspending Operation had previously been is-spector's questions about his physical presence dur-sued for the underlying problem.

ing the performance of radiography,%c licensee re-sponded in letters dated April 5,1991, and May 29, 1991. After consideration of the licensce's re.

2.

Construction Engineering Consultants, Inc.,

sponses, the staff concluded that the violations did Pittsburgh, Pennsyhania occur as stated, and an Order Impning Civil Penalty Supplement VI, EA 91-077 was issued October 1,1991.

A Notice of Violation and Ptoposed imposition of 5.

St. Joseph's Hospital and Medical Center, Paterson, Civil Penalty was issued July 30,1991, to emphasize

• C* C the importance of the use of ths alarm ratemeters y

9 g

dun,ng the performance of radiographic operations.

9I~Ig De action was based on a violation involving the fail-ute of licensee radiographers to wcar alarm rate do-A Notice e,f Violation and Proposed Impsition of simeters while petforming radiography. He base Chil Penalties and Order Modifying 1.icense and De-civil penalty was escalated because NRC identified mand for Information were issued December 3, the violations and mitigated for the licensce's correc-1991, to emphasize the need for management to en-tive action and good past performance. The licensee sure that: (1)all employees provide complete and responded and requested termination of license; accurate information to NRC: and (2) activities at the therefore, a letter withdrawing the civd penalty was facility are conducted safely and in accordance with issued November 6,1991, concurrent with the termi.

Hb i

on nation of the license, the failure of the individual sening as Chairman of the Radiation Safety Committee and acting RSO to 3.

Fewell Oeotechnical Engineering, Ltd., Pearl City, provide complete and accurate information to NRC, llawaii unauthorized movcment of a liigh Dose Rate after.

Supplements IV, V, VI, and V, EA 90-l%

loader, and failure to have interlocks on the door to the linear accelerator room. De Order Modifying A Notice of Violation and Proposed imposition of License precludes use of the wsponsible indhidual Civil Penalties was issued February 7,1991, to em-as RSO or from sening on the Radiation Safety phasize the importance of complying with license and Committee for 3 years, regulatory requirements, and of ensuring manage-ment ovenight of the licensed program. The action 6.

University of Missouri-Columbia, Columbia, was based on multiple willful radiation safety viola-Missouri tions by a radiographer, including failure to survey af-Supplements V and VI, EA 91-113 l

ter exposures, failure.to adequately post the re-l stricted area, failure to secure the source after A Notice of Violation and Proposed imposition of exposures, and failure to prevent entry into the Chil Penalty was issued October 29,1991, to em-restricted area. In addition, the radiographer pro-phasite the importance NRC places on attention to vided false information to NRC personnel as to his detail while preparing byproduct material for 11

distribution, and cn;uring that typmduct mat: rial 6 l leak tests of a se. led source; (c) survey et the end of properly shipped in accordance with NRC and DOT cach day the areas where radiophannaceuticals are requirements. ne action was based on two incidents used;(d) check the operation of the radioactive gas in which a shipping technician inadvertently switched collection system and measure the ventilation rates containers. As a result of these errors, packages were in areas where radioactive gases atc used; (c) hold shipped with the wrong contents listed on the ship-quarterly meetings of the Medkalisotopes Commit-ping papers an( the radiontive labels, and recipients tee and have the RSO in attendance in such meet-received the wrong typroduct material.

ings: (f) post certain required documents;.md (g) re-7.

Veterans Administration Medimi Center, Albany, New York

10. Wrangler lateratories,12rsen lateratories, and Supplements VI and V11. EA 91-050 Orion Chemk:al Company, Prom, Utah EA 87-223 A Notice of Violation and Proposed Impwition of Chil Penalty was issued November 4,1991, to em-An Order Suspending LJcenses (Effective immedi-phasize to licensee management that it has a funda-ately) was issued February 25, 1988, to the above mental responsibility in ensuring that NRC require-firms.nc action was based on an NRC investigation ments are met, including the accuracy of required that indicated that the firms had: (1) failed to fulfill records; and that trained and qualified staff, as well as commitments made to NRC;(2) made contradictory adequate resources, are essential to maintaining such statements to NRC and the State of Utah authori.

assurance.ne action was based on the failure to per-ties; and (3) pnwessed uranium in an unsafe manner, form required physical inventories of scaled sources with inadequate contamination controls. He licen-and creation of inaccurate records indicating that the see responded to the Order on March 18,1988, Ntcr inventories had, in fact, been performed.

consideration of the response, an Order Revoking

1) cense was issued August 15,1988. A licaring was 8.

Westinghouse Environmental & Geotechnical Serv-requested and, after an initial decision, a Memoran-kes, Inc., Raleigh, North Carolina dum and Order (Terminating Proceeding) was issued Supplements IV, V, and VI. EA 91-140 September 26,1991.

A Notice of Violation and Proposed imposition of H. Severity level Ill Violation, No Civil Penalty Civil Penalty was issued November 14,1991, to em-phasize the importance of adequate program over.

1.

ljppincott Engineering Associates, Riverside, sight and compliance with regulatory requirements New Jersey and license conditions. ne action was based on seven Supplements IV, V, and VI, EA 91-150 violations invohing the licensee's radiation safety program. One of the more significam violations in.

A Notice of Violation was issued November 25,1991, volved the licensee establishing a permanent com-based on violations invohing the failure to maintain merrial operation without obtaining a license amend-proper security of licensed radioactive material k)-

ment for that establishment.

cated at the field site in Willow Grove. Specifically, an OSilA inspector observed a moisture / density 9.

Winona Memorial liospital, Indianapolis, Indiana gauge unattended within the perimeter of the fence Supplement VI, EA 91-12A of the field site. In addition, NRC inspectors deter-mined that the gauge did not have a kick or an outer A Notice of Violation and Proposed imposit!on of container that was htked, so as to prevent unauthor.

Civil Penalty was issued October 16,1991, to empha-ized or accidental removal of the sealed source from size the need for effective management and oversight its shielded position. Other violations were also of NRC licensed activities. He action was based on noted in the radiation safety area. A civil penalty was violations involving the r : iodic failure to: (a) per-not proposed because of the licensee's prompt and form the quarterly lineanty and the annual accuracy comprehensive corrective actions, as well as its past tests of the dose calibrator;(b) conduct seMannual goal history.

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