ML20095H634

Report to Congress on Abnormal OCCURRENCES.October-December 1991

ML20095H634
Person / Time
Issue date:	03/31/1992
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V14-N04, NUREG-90, NUREG-90-V14-N4, NUDOCS 9204300058
Download: ML20095H634 (31)

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Nl.'R13G-0090 Vol.14, No. 4 Report to Congress on A3 norma Occurrences October - December 1991

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- A yect's subccription consists of.4 issues for this publication, Single copies of this pub!ication

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NUREG-0090 Vol.14, No. 4 J

Report to Congress on Abnorma Occurrences October - December 1991 Date Published: March 1992 Omce for Analy A and.. valuation of Operational Data U.S. Nuclear Rervir tory '.'ommission Washington, DC 7,1WS

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Previous Reports in Series NUREG 75/090, Janub June 1975, NUREG-0090, Vol 6, No. 3, July-September 1983 pubhshed October 1975 publshed April 1984 NbREG40A1, July-Septer iber 1975, NUREG4V>0, Vol 6, Na 4, October-Decc.nbec 1983 published March 1976 pubhshed May 19S4

- NUREG4XYA2, October-December 1975, NUREG4V>0, Vol 7, Na 1, January-March 1984, published March 1976 published July 1984 NUREG4KrE3, January-March 1976, NUREG4tWO, Vol 7, Na 2, Apnbjune 1984,

- pubhshed July 1976 pubhshed October 1984 NUREG41090-4. ApribJune 1976.

NUREG4iO90, Vol 7. Na 3, July-September 1984, published March 1977 published Apnl 1985 NUREG44.190-5, July-September 1976.

NUREG4UXL Vol 7, Na 4. October-December 1984, published March 1977 pubbshed May 1985 NUREG40A6, October-December 1976, NUREG-WV, Vol 8, No.1, January, March 1985, published June 1977 pubbshed August 1985 NUREG4&&7, January March 1977, NURE04p>0, Vol 8. No 2, ApribJune 19SS, pubhshed June 1977 published November 1985 NUREG-0090-8 Aprildune 1977 NUREG-te>0, Vol 8 Na 3, July-September 1985, published September 1977 published February 1986 NUREG4K190L9, July-September 1977, NUREG40>0, Vol 8. Na 4, October-Deccenber 1965, published November 1977 pubhshed May 1986 NURE04e&10. October-December 1977, NUREG-40X), Vol. 9 Na 1, January-March 1986, published March 1978 pubhshed September 1986 NUREG4WJ0, Vol 1. Na 1 January March 1978.

NUREG-4tWO, Vol 9, Na 2. April-Jt.ne 1986, published June 1978 published January.1987 NUREG-0090, Vol 1. Na 2, April-June 1978.

NUREG-0090, Vol 9. No. 3, July-September 1986 pubhshed Septemter 1978 pubbshed April 1987 NUREG4U10, Vol 1, No. 3. July-September 1978, NUREG41090, Vol 9. Na 4 October-December 19S6, published December 1978 pubinhed July 1987 NUREG-0090, Vol 1 No. 4, October-December 1978, NUR EG4U)0, Vol 10, Na 1, January-March 1987, published March 1979 pubhshed October 1987 NUREG-OtF)0, Vol 2, Na 1, January-March 1979 NUREG-tKM1, Vol 10 Na 2 Apnbjune 1987, published Ju!y 1979

[mblahc6 November 1987 NUREG4U)0, Vol 2 Na2, ApribJune 1979, NUREG-41090, Vol 10, Na 3, July-September 1987, pubbshed November 1979 pubhshed March 1988 NUREG4t190, Vol 2. Na 3. July-Septe mber 1979 NUREG4&>0, Vol 10, Na 4 October December 1987, published February 1980 pubbshed March 1988 NUREG-0090, Vol 2, No 4. October December 1979, NUREG4U)0, Vol 11, Na 1. January-March 1988, published April 1980 pubhshed July 1988 NUREG41090, Vol 3, No.1, January-March 1980, NUREG4elo, Vol 11. Na 2, April-June 1958, puhtished September 1980 published December 1988 NUREG-0090, Vol 3, No 2. Apnbjune 1980, NUREG4W)0, Vol 11, Na 3, July-September 198S.

published November 1980 pubWhed January 1989 NUREG4W)0, Vol 3, Na 3 July-September 19S0, NUREd40)0, Vol 11. Na 4. October-December 1938, published February 19S1 pubhshed April 1989 NUREG4WXt, Vol 3. Na 4, October-December 1980, NUREG40X1, Vol 12. Na 1. January-March 19S9, publshed May 1981 published August 1989 NUREG4M>0, Vol 4, Na 1 January-March 1981, NUREG-0090, Vol 12, Na 2. ApribJune 198+A -

puMished July 19S1 pubhshed October 1969 NUREG4U)0, Vol 4, Na 2, Apribfune 1981, NUREG4n)0, Vol 12, Na 3. July-September 19S9 pubbshed October 1981 pubbshed January 1990 NUREG4p>0, Vol 4, Na 3. July-September 1981, NUREG-009(L Vol 12, Na 4 October-December 1959 pubhshed January 1982 published March 1990 NUREG4XF)0, Vol 4, Na 4, October-Dmber 1981, NURE04U)0, Vol 13 Na 1. January-March 1990, published May 1982 pubbshed July 1990 NUREG4WXL Vol 5. No.1, January-March IW2, NUREG4Uso, Vol 13, Na 2. Apnbjune 199tt pubhshed August 19S2 pubished October 1990 NUREG4&>0, Vol 5, Na L Aprildune 1982, NUREG4XML Vol Na 3, July-September 1990-pubbshed December 1982 pubbshed January 1991 NUREG4W>0, Vol 5, Na 3, July-September 19S2, NUREG-0090, Vol 13, Na 4. October-December 1990, pubbshed January 1983 published March 1991 NUREG4e>0, Vol 5, Na 4, October-December 1982, NUREG-00"O, Vol 14 Na 1. January-March 1991, published May 1983 pubhshed June 1991 NUREG4WA Vol 6. Na 1 January-March 1983, NUREG4xML Vol 14, Na 2 Aprildune 1991, pubbshed September 1982 pubbshed September 1991 NUREG4U10, Vol 6, No. 2. April-June 1983, NUREG41090, Vol 14, Na 3, July-September P)91, published November 1983 pubbshed December 1991 ii

Abnormal Occurrences,4th Qtr CY91 AllSTRACf Section 20S of the 1inergy Reorganization Act of ties are discussed in this report. None of these occur-1974 identifies an annormal occurrence as an un-t ences involved a nuclear power plant, l'our involved scheduled incident orevent that the Nuclear Regula-medie al t herapy misadminist rations and one involved tory Commission determines to be significant from a medical diagnostic misadministration. The NRC's the standpoint of public health or safety and requires Agreement States reported three abnonnal occur-a quarterly report of such evenis to be made to Con-rences. Two involved exposures of ron radiation press. This report covers the period from October I worket s and one involved a medical therapy misidmi-through December 31,1992.

nistrati<.n. The report also contains infonnation that updates some previously reported abnormal occur-Five abnormal occurrences at NRC-licensed facili-tences.

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F iii NURl!G -0090. Vol.14. No. 4

Abnormal Occurrences. 4th Otr CY91 CONTENTS-Pay

' bStract.......................

iii

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. Preface.......

vii introduction..............

vii The Regulato:y System..............

vii R eportable Occu rre r ces.......................................

vii i

Agreement States..............

viii

- Foreign Information.........................

viii Report to Congress on Abnormal Occurrences October-December 1991..

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

1 Fuel Cycle Facilities (Other Han Nuclear Power Plants).......

1

- Other NRC Licensees (Industrial Radiographers, Medical Institutions. Industrial Users, etc.)

1 91-10 Medical Diap,nostic Misadministration ai 1. Gonzaler Martinez Oncologic Hospital in Hato Rey Puerto Rico..

1 91-11 Medical Therapy Misadministration at William Ileaumont Army Medical Center m El Paso, Texas..............

2 91-12 ' Medical Therapy Misadministration at St. Joseph's Hospital and Medical Center m Patenon. New Jersey.........

3 91-13 Medical Herapy Misadministrr; ion at University of Pittsburgh Presbyterian-University Hospital in Pittsburgh, Pennsyhania.................

4 91-14 Medical Therapy Misadministration at University of W6consin Hospitalin Madison.

Wisconsin.................

4 Agreement State I.icensees..

5 AS91-5 Exposure of a Non. Radiation Wor'.er.........

5 AS91-6 Exposures of Non. Radiation Worken 6

AS91-7 Medical Therapy Misadministration at Northridge Hospital Medical Center in Northridge, California......,..

7 Ref ere n ces...........................

9

Appendix A-Abnormal Occurrence Criteria 11 Appendix B-Update of Previously Reported Abnormal Occurrences....

13 Fuel Cycle Facilities _..........

l3 91-6 Potential Criticidity Accident at the General Electric Nuclear Fuel and Component -

Manufacturing Facility in Wilmingem, North Carolina 13 Other NRC 1.icensees...........

14 85-17 Exposure of Radiographic Personnel Due to Management and Procedural Control Deficiencies...........

14 36-28 Immediately Effective Order Modifying 1.icense anJ Order to Show Cause issued to an Industrial Radiography Company 14 87-8 Significant Breakdown of Management Controls for Radiographic Operations 14 v

NUREG-0090, Vol.14, No. 4

1 I

Abnormal Occurrences,4th Otr CY91 CONTENTS (continued)

Page 90-11 Deficiencies in Brachytherapy Program.........,................

15 91 Radiation Exposures of Members of the Public from a Lost Radioactive Source 15 Appendix C-Other Events of interest..

17 N ucl ear Powe r Pla n t s...................,.....................................

17 1.

Emluation of Plant Internal Flcujing Vulnerability for Surry Nuclear Power Station...

17 2.

Catastrophic Failure of Salem Unit 2 Turbine-Generator.......

17 3

Transportation Accident Involving UnliTadiated Fuel 19 References for Appendices................

21 NUREG-0090. Vol.14, Na 4 vi

Abnormal Occurrences,4th Qtr CY91 PREFACE intro <luction NRC. An inspection and enforcement program helps ensure compliance with the regulations.

• lhe Nuclear Regulatory Commission reports to the Congress each quacter under provisions of hedian 1%ortable Occurrences 208 of the linergy Reorganization Act of 1974 on any abnormal occurrences involving facilities and activi-Actual operating experience is an essential input to ties regulated by the NRC. An abnormal occurrence the regulatory procen for assuring that licensed ac-is defined in Sectior 206 as an unscheduled incident tivities are conducted safely. I.icensees are required or event that the Commission determines ir signifi to report certain incidents oir esents to the NRCJlhis cant from the star.dpoint of public health or safety, reporting helps to identify deficiencies early and to ensure that corrective actions are taken to prevent Events are currently identified as abnormal occur-recurrence, rences for this report by the NRC using the criteria listed in Appendix A. These criteria were promul-Fo nuclear power plants, dedicated groups have gated in an NRC policy statement that was punished been formed both by the NRC and by the nuclear in tbc Federa/ Register on February 24,1977 (Vol. 42, power industry for the detailed review of operating No. 37, pages 10950-10952). In order to provide wide experience to help identify safety concerns early; to dissemination of information to the pubbe, a f.dcral improve disseminatvan of such information; and to Register notice is issued on each abnormal occur-feed back the experience into licensing. regulations, renee. Copies of the notice are distributed to the and operations. In addition, the NRC and the nuclear NRC Public Document Room and all Local Public power industry have ongoing efforts to improve the Document Rooms. At a minimum, each notice must operational data systems, which include not only the contain the date and place of the occurrence and de-type and quality of reports required to be submitted, scribe its nature and probable consequences, but also the methods used to analyze the data. In or-der to more effectively collect, collate, store, re-The NRC has determined that only those events de-trieve, and evaluate operational data, the informa-scribed in this report meet the criteria for abnormal tion is maintained in computer-based data files.

eccurrence reporting. This report covers the period from October I through December 31,199L Infor.

Two primary sources of operationa! data are 1.icen-mation reported on each cWnt includes date and see livent Reports (1.l!Rs) and immediate notifica-place, nature and probaNe consequences, cause or tior s made pursuant to 10 CIH 50.72.

causes, and actions taken to prevent recurrence.

Except for records exempt from public disclosure by statute and/or regulation, information concerning re-The Regulatory SystGn portable occurrences at facdities licensed or other-

. wise regulated by the NRC is routinely disseminated The system ofleensing and regulation by w hich NRC by the NRC to the nuclear indust Y, the public, and carries out its responsibihties is implemented other interested groups as these events occur through rules and regulations in Title 20 of the Code offederalRegn!ctions, This includes public participa-Dissemination includes special notifications to heen-tion as an element. To accomplish its objectives, sees and other affected or interested groups. and NRC regularly conducte licensing proceedings, in-public announcements. In addition, information on spection and enforcement activities, evaluation of reportable events is routinely sent to the NRC's more operating expuience, and confirmatory research, than 100 local public document rooms throughout while maintaining proprams for estabhshing stan-the United States and to the NRC Public Document dards and issuing technictd reviews and studies.

R oom in Washington, D.C.De Congress is routinely kept informed of reportable events occurring in li-In licensing and regulating nuclear power plants, the censed facdities.

NRC follows the philosophy that the health and safety of the public are best ensured through the es-Another primary source of operational data is reports tablishment of multiple levels of protcction. These of reliability data submitted by licensees under the multiple levels can be achieved and maintained Nuclear Plant Reliability Data System (NPRDS).

through regulations specifying requirements that will The NPRDS is a voluntary, industry-supported sys-ensure the safe use of nuclear rnaterials. The regula-tem operated by the institute of Nuclear Power Op-tions indade design and quality assurance criteria ap-erations (INPO), a nuclear utility organuation. !!oth propriate for the various activities licensed by the engineenng and failure data are submitted by nuclear vii NU Rl7.G 4XNo. Vol.14, No. 4

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-8 s Abnorrrat Occurrences,4th Ott CY91 power plant licensees for specified plant components in early 1977, the Commission determined that ab-and systems.ne Commission considers the NPRDS

. normal occurrences happening at facilities of Agree-

-.to be a vital adjunct to the LER system for the collee-

- ment State licensees should be included in the quar-tion, review, and feedback of operational experience; terly reports to Congress. The abnormal occurrence

- therefore, the Commission periodically monitors the enteria included in Appendix A are applied uni-NPRDS reporting activities, formly to events at NRC and Agreement State licen-see facilities. Procedures have been developed and i"d'**"'"d' ""d "D"""""I

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TAgreement States the Apeement States to the NRC are !'P "'dD metuded m Section 274 of the Atomic Energy Act, as amended, these quarterly reports to Congress.

authoriles the Commission to enter into agreements with States whereby the Commission relinquishes and the States assume regulatory authority over -

!?oreign Information

byproduct, source, and special nuclear materials (m quantities not capable of sustaining a chain reaction).

Agreement State programs must be comparable to

'lhe NRC participates in an exchange ofinformation and compatible with the Commission's program for with various foreign governments that have nuclear such material.

fa:ihties. His foreign information is reviewed and considered in the NRC's assessment of operating ex-Presently, information on reportable occurrences in perience and in its research and regulatory activities.

' Agreement State licensed activities is publicly avail-Reference to foreign it' formation may occasionally able at the State level Certain information is also be made in these quarterly abnormal occurrence re.

provided to the NRC under exchange of information ports to Congress; however, only domestic abnormal provisions in the agreements, occurrences are reported.

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. NURiiG-Ob90, Vol.14. No. 4 viii

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Abnormal Occurrences,4th Otr CY91 REPORT TO CONGRESS ON ABNORh1AL OCCURRENCES

- OCTOBER-DECEMBER 1991 Nuclear Power Plants

'Ihe NRC is teviewing events reported at the nuclear NRC has not determined Ihat any events were abnor-power plants licensed to o;) crate. For this report, the mal occurrences.

. Filel Cycle Facilities I

(Ottier Tliari Nuclear Power Plants)

'!he NRC is reviewing ev-nts reported by these licensees. For this trport, the N RC has not determined that any events were abnormal occurrences.

-Otlier NRC Licensees (Industrial Itadiographers, Medical Institutions, Industrial Users, etc.)

There are currently over 8000 NRC nuclear material The technologist realized the error nine minutes af.

licenses in effect in the United States, principally for

- ter the dose was administered when the printed dose

- use of radioisotopes in the tnedical, industrial, and label from the. dose calibrator was checked. The

- academic fields. Incidents were reponed in this cate-physician-in-charge promptly administered potas-gory from licensees such as radiographers, medical--

sium iodide solution to the patient to reduce the up _

institutions, and byproduct matenal users?The NRC take of the radioactive iodine. The licensee esti-is reviewing events reported by these licensees. Fct mated, based on 24-hour uptake measurements, that this report, the NRC has determined that the follow-the uptake of radioactive iodine in Ihe thyroid was ap, ing events were abnormal occurrences.

proximately five percent resulting in an estimated dose to the thyroid of 1612 rem. The misadmin-istration was promptly reported to the NRC. 10 Medical Diagnostic M.isadm..inis-tration at I. Gonzalez Martinez

- The beensee contmues to follow the patient's condi-Oncologic Hospitalin Hato Rey, tion and has advised the NRC that the patient has not

- Puerto Rico -

experienced any adverse effects because of the misadministration.

The following information pertairing to this event is -

also being reported concurrently in the FederalRegis-Cause or Causes-The cause is attributed to human ter. Appendix A (see the overall criterion)of this re.

error by the nuclear medicine technologist.'Ihe tech-port notes that an event involvinh a moderate or nologist did_ not verify the dose by reviewing the more severe impact on p ab!ic healtn or safety can be pnnted dose label before administering the dose.

considered an abnormal occurrence.

Actions Taken to Prevent Ilecurrence -

- Date and Place-June 17,1991: 1.- Gonzalez Mar.

tinez Oncologi: Hospital: Hato Rey, Puerto Rico.

Ucensee 'lhe licensee's corrective actions included taking disciplinaryaction against the technologist and i

, Nature and Probable Consequences-On June 17, requiring that the nuclear medicine supenisor check '

' 1991, a patient scheduled to receive a diagnostic dose cach dose before the dose is administered to a pa-of iodine-131 (1-131), was mistakenly administered a tient.

dose of I-131 in the therapeutic range. The misad-ministration occurred wher a nuclear m_edicine tech-NRC-NR C R egion 11 conducted an inspection to re-nologist misread the dose calibrator and admini-view tne circumstances associated with the mis-

- stered 6.2 millicuries rather than 6.2 microcuries, administration, and to review the licensee's correc-1 NUREG-0MO, Voli 14, No;4 e

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Abnormal Occurrences,4th Otr CY91 tive actions. No violatioa of NRC requirements Cause or Causes-The event was attributed to hu-were identified during the mspection, man error as a result of the radiopharmacist's and consulting nuclear medicine physician's inattentive-This item is considered closed for the purposes of this nm and shon npdage at this nacihty. Although

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the prescriting physician s written request was avail-abic at the time the dosage was ordered and admini-stered, both individuals failed to comparc the pic-scribed dosage mth the dose cabbrator assay result or 91-11 Medical Therapy Misadministra-the radio harmaceutical package label. Additionally, c

tion at William lleaumont Army both the radiopharmacist and consulting nuclear Medical Center in El Paso, Texas medicine physician had only been working at the fa-cility for a short time and were unfamiliar with the The followmg information pertaining to this event M use M mioiodine dosages as low as 15 millicuries for also being report ed concurrently in the Federal Regis-the treatment of braves, disease. the physician's tcr. Appendix A (see the ovew'l criterion)of this re-prnious experience and personal preference m.

port notes that an event involvmg a moderate or c'lved a routine dosage of 25-30 milheuiies for a by-more severe impact on public health or safety can be penhn,id disorder,.'od the radiopharmacist had dis-considered an abnormal occurrence.

P#""'d mly a kw Werapeutic raJiotodice dosages, involving high:r dosages, pnor to this particular case.

The licenne also acLaowledged that the consultmg Date and Place-August 30,1991: William Beau-nuclear medicine physician rnay not base realized mont Army Medical Center; El Paso, Texas, that the patient was receiving treatment for Graves' disease rather than a multinodular toxic goiter at the Nature and Probable Co.nsequences-On Augurt 30, time the dosage was administered.

1991, a patient referred to the Medical Center for therapeutic radicialine treatment of Graves' die Actions Tul en to Proent Itecurrence ease, mistakenly received a 28.6 thillicurie (mC;) aral dosage of iodine-131 (I-131) instead of the pre.

1.icensee-The radiopharmacist and consulting nu-scnbed oraldosage of l5.0 mCil-131. As a result, the clear medicine physician were counseled and patient's thyroid received about 31,90G rads instead reinstructed as to the proper dose verification tech-of the 16,700 rads intended.

n%ues and safegur.rds. For future therapies usmg radiophatmaceuticals, the counschng nuciear medi-eine physician must visu.dly check tae activity of the Prior to the administration, the radiopharmacist m-radiopharma"cutical dosage, as measured by the rad-volved was informed that a rad,ciodme treatment f or i

iopharmacist or technologist, with Jae written physi-Graves' disease had been requested. He assumed cian prescription. The licensee also intends to re-that it was a 29 mci treatment rather than a 15 mci quire that the consulting nuclear medicine physician treatment. [ At the Medical Center, a 15.0 mci dese is be familiar with the patient's ca e history prioc 19 ad.

routinely used for Graves' disease while a 29.0 mC:

ministering a therapeu"c rathopharmaceutical dos-dosage ts used for thyroid disorders such as multi-age.

nodular toxic goiters.] He then requested a 29.0 mci dose from Syncor, the commercial radiopharmacy.

The actual dose received from Syncor was 28.6 mC.;,

Also, the licensce's Radiation Safety Officer will con-duct a training session in which allImelcar medicine and was labeled as such When the radiopharmacist logged the dosage into the computer, after it had personnel will be required to review the videotape entitied. " Good Practices in Prepanne and Admini-been measured by the dose calibrator, he failed to stcring Padiopharmaceuticals," prepared by the take note of the intended therapy dose as reflected in NRC's Office for Analysis and.Svaluation of dpera-the referring physician's prescript, ion. In addttion, t he tional Data.

counselmg nuclear medicine phystcian did rot verify the dosage to be administered with the intended do?

NRC-NRC Regien IV conducted an mspection to age.The 28.6 mci incorrect dosage was then admmi' review the circumstances associated with this stered to the patient, misadministration and the licensee's corrective ae-tions as described above (Ref.1). The iropection

'lhe referring physician was notified on the day of the tocalert no violations of regulatory requirements misadministration. The licensee stated that no ad-regarding this misadmhistrction, and the licensee's verse effects on the patient were noted. The patient's determim. tion of the cause el the evem was consid-condition will be appropnately followed in the hcen-cred accurate based y sn 4ntervien of the indi-see's Endocrine Clinic, viduals involved. The hcensee hxl implernented NUREG-0@0, Vol.14, No. 4 2

Abnormal Occurrences. 4th Otr CY91 l

corrective actions as reported, and had continued to 1.

The patient should receive a sht-lamp examina-closely observe individuals' performance with regard tion of both eyes immediately and annually to therapeutic radiopharmaceutical dosages.

thereaf ter for the rest of the patient's life, 2.

'lhe iwibility of cataracts is low, and Thisitem is considered closed for the purposes of this 3.

The tr ~ ads to identify patients should be im-prov J.

91-12 Medical Therapy Misadministra-llased on source and geometry considerations, the

t. ion at St. Joseph's llosp,tal and consultant anreed with the licensee's estimate of i

Medical Center in Paterson, New about 1000 rads to the patient's eye. 'lhe consultant Jersey reviewed the beensee's correcuve actions and found them to be appropriat e.The consultant provided sug-

'lhe following information pertaining to this event is gestions to the licensee on how to improve the cot-also being reported concurrently in the Federal Reps-rective actions.

ter. Appendtx A (see the overall criterion)of this re-port notes that an event invoking a moderate or Cause or Causesalhe cause was attributed to fail-more severe impact on public health or safety can be ute to foHow the hospital protocol w hich requires re.

considered an abnormal occurrence, viewing the patient's chart pnor to adnunistering treatment.

Date and Place-October 25,1991;St. Joseph flospt-tal and Medical Center; Paterson, New Jersey.

Actions Taken to Present Recurrence 1.icensee-The licensee's planned corrective actions Nature and Probable Consequences-On Novem-include:

i ber 13,1991, NRC Region I was notified by a letter dated October 30,1991, from the heensee's acting 1.

Patients will only be directed to the treatment

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Radiation Safety Officer (RSO), that a therapeutic area by an aide aho will hand the treatment misadministration involving a strontium 90 (Sr 40) charts directly to the physician, beta applicator, with a nominal activity of 95.5 milli-curies, had occurred on October 25,1991,'lhe thera-2.

All patient's charts will include a polaroid photo-peutie treatment had been administered to the wrong graph of the patiera.

3.

Access to the St-90 beta appheator storage area t

The misadministration involved a 52-year-old male willbe limited to the Physics Department and the who was scheduled for simulation for external beam Chief Tecnnologist.

therapy from a linear accelerator to the head and

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Physics staff will accompany the physicians dur-neck.This occurred when the radiation oncoloev de-mg aH SrM 1 eta applicator treatments and as-panment secretary placed the patient in the Erong 3

c treatment room without the patient's chart.The pa-sist m ueterminmg the treatment times, tient spoke minimal linglish and the radiation on-5.

Staff training and reenforcement of appropriate cologist did not speak the patient s language. The patient processing procedures and N RC notifica-physician questioned the patient more than once as tion and reporting icquirements will be con-to which area of his body was being treated. The pa-ducted.

tient pointed toward his head as the area to be treated. llased on this pmr exchange of information, NRC-An NRC Region I inspector was dispatched to and without benefit of review of the patient's chart, conduct a special inspection on November 15,1991, the oncology physician then proceeded to administer of the circumstances surrounding this misadmin-a St-90 dose to the patient's eye.The licensee esti-istration (Ref. 2).

mates that about 1,000 rads were delivued in 11 sec-onds to the surface of the right eye.The licensee esti-On December 26,1991,ihe NRC transmined to the mates that no harmful effects occurred to the patient licensee a Notice of Violation and Proposed Irnposi-as a result of this event.

tion of Civil Penalties in the amount of $6.250 (Ref.

3). Two violations were identified. (1) the failure to An NRC medical consultant was retained to review review the patient's prescription which resulted in the licensee's dosimetry, the possible biological ef-the misadmimstration ($3,750); and (2) the failure to fects of the dose, and the actions to prevent recur-report the misadmiristration to the NRC.ithin 24 rence. The consultant concluded that:

hours J its Jiscovery ($2.500). Iloth wolations were 3

Nt !RR LOO 90. Vol.14, No. 4

- Abnormal Occurrences,4th Qtr CY91

~ lassified as Severity Level 111 on a scale in which Se-Actions Taken to Prevent Recurrence c

verity Levels I through V range from the most signifi-cant to least significant, respectively. The licensee Licensee-Corrective acilons included stressing to admitted the violations and paid the civil penalties in the radiation technologisu the need to carefully read

full, patients' charts and to recogni7e notations of changes in the fields to be treated. When a field is completed This item is considered closed for the purposes of this on a patient, the administered dose is to be written report.

down m the patient s chart using a different color mk.

NRC--NRC Region I will examine the licensee's 91-~13 Medical Therapy Misndministra-

[#[$s*

d"d conective acti ns at the next sched n

tion at University of Pittsburgh Presbyterian University llospital Unless new, significant information becomes avail-in Pittsburgh, Pennsylvania able, this item is considered closed for the purposes of this report.

'1he following information penaining to this event is also being reported concurrently in the federa/ Reda-91-14 Medical Therapy Misadministra-ter. Appet dix A (see the overall criterion)of this re-port notes that an event mvolvmg a moderate i tion at University of Wisconsin more severe impact on public health or safety can be llospital in Madison, Wisconsin ctmsidered an abnormal occurrence.

The following information pertaining to this event is alsotwin ter.. ape'g reported concurrently in the FederalRcgi Date and Place-November 22,1991: University of ndix A (see the overall criterion)of this re-Pittsburgh Presbyterian-University llospital: Pitts-port rhtes that an event invohing a moderate or burgh, Pennsyhania.

more severe impact on public health or safety can be couidered an abnormal occurrence.

Nature and Probable Consequences-On November 22,1991, NRC Region I was notified by the licensee's Date and Piare-November 27,1991; University of Radiation Safety Officer (RSO) that a therapeutic Wisconsin; Madistm. Wisconsin.

misadministration invohing a cobalt-60 teletherapy unit had occurred at their Presbyterian-University Nature and Probable Consequences-A patient was Hospital facility on November 21,1991. The Ihera.

undergoing a series of five treatments for a cancer of ocutic treatment had been administered to the wrong the nasal septum using a high dose rate iridium 192

' art of a patient's Imdy, afterloading unit. In this type of treatment, a p

hrachytherapy catheter was positioned in the pa-The technologist had looked at the patient's chart but tient's nasal passage. The computerized device then set up the wrong treatment field. The patient re-m ved the source through the catbeterinto the treat, ceived 287 rads to the thoracic vertebrac (upper ment ama. The source had a nomm, al strength of 4 hack)instead of the prescribed 300 rads to the eersi-curies.

cal settebrae (lower neck). liecause the patient had previously undergone thoracic vertebrac treatment, The initial four treatments were completed without the technologist erroneously assumed that the thm ncident, llowever, prior to the fifth treatment on racie treatment was continuing and admimstered the November 27,1991, the operating physicist picked up treatment without adequately reviewing the patient's the wrong patient chart located next to the device's chart which indicated the correct treatment area (cer-control panel and entured the % ment program in-vical).

formation into the computenzed device. While the treatment was underway, a student technologist in-The licensee has determined that the treatment will -

quired about the length of time to complete the treat.

ment, The prescribing physician and the operating not have any sdverse effects on the patient. De pa-physicist indicated different lengths of time. The phy-tient is suffering from metastaticcancer of the breast sician, realizing there was an error, directed that the and was receiving palliative radiation treatments to the spine.

treatment be stopped immediately. Subsequently, it was discovered that the physicist had used the wrong patient chart and, therefore, entered incorrect treat.

Cause or Causes-The cause was attnbuted to fail-ment program information into the computer. The l'

ure to follow the wntten prescription in the patient's correct treatment information was then entered into chart.

the computer and the treatment senes completed.

l NURiiG-0090 Vol.14, No. 4 4

l

_.. y Abnormal Occun ences,4th Otr CY91 The erroneous treatment information positioned the treat.nent, using patient pnotos or other means of-iridium 192 source so that the patient's lips received verification, Patient charts for ueatment sedes will an unintended exposure for about one minute, The -

be placed in a specifica location. Na eteeptions will dose calculation by the licensee indicated the patient be made to the training teuuired of a user. In the fu-

- received approximately 73 rads to the lips. According ture, training will include a pencral section on high to the licensee, the radiation exposure received 7 dose rate afterloa< Jing devices.

t he lips, for a correctly administered treatment Io Ihe nasal septum, y auld be about 25 rads,'Ihe licensee

. does not expect any consequences resulting from the NRC-A special inspection was conducted on De-additional exposure to the patient's lips from this cembcc 17, 1991, to review the circumstances sur.

misadministration.

roundmg the misadmimstration and to review the li-censee's corrective actions (Ref. 4). No violations of Cause or Causes 'ne physicist failed to verify the NaC requireNnts were identified. 'the conective identity of the paticnt and assumed incorrectly that actions appeared sufficient to prevent a recunence the chart at the control panel was for the patient un-of the misadministration. While tha licensee has a vi-dergoing treatment.

able quality assurance pr ogram hg lace, the changes adopted will strengthen the previous pmeedures.

Actions Taken to Present Recurrence Licensee-The licensee has directed that the operat-

'lhis item is considered closed for t he purposes of this ing physicist check the identity of each patient before report.

Agreement State Licensees Procedures have been developed for the Ar;rectnent After the pmcedure was completed, the physician re-States to screen unscheduled incidents or events us-mc.ved the devices and pLiced them in a lead con-ing the same criteria ns the NRC (see AppendN A) tniner The container was then transponed to the?

and report the events to the NRC for inclusion in room ehere the cesium stomge safe was located; these quarterly reports to Congress. For 'his period, however, the sources were not removed from the in-the Agreement States reported the following events scris hnd placed in the safe as they should has e been.

as abnormal occurrences.

On September 1, an employee of the Medical Center removed tne inserts, still containing the sources, AS91-5 Exposure of a Non-Ratliation fr m the icad transport container, and thinking they Worker were empty, placed thern in an envelope to be trans.

perted to Methodist Hospital where they were in-Appendix A (see Example 5 of "I,or All Licensees")

tended to be used. The envelope was placed in the of this report notes that any loss of heensed traterial Radiology Department where it was picked up by an m such quantities and under such circumstances that employee of a private medical group a few days later.

substantial hazard may result to persons in unre' This individual placed the enveh)pe in his private car stricted areas can be considered an abnormal occur-and drove to Methodist Ilospital uhich teok approxi-mately 25 minutes.

rence, When the inserts were received by Methodist Hospi-This writeup is based on information provided to the tal, the envelope was opened immediately and the i

NRC in December 1991 by the Agreement State of sources were discovered inside.'Itey were placed in a California for inclusion in this report.

lead transport container and remm ed to the storage safe by staff of the hospital

[

Date and Place-September 1,1989; exposures to sources occurred at San Gabriel Valley Medical Cen-San Gabriel Valley Medical Center hired a medical ter in San Gabriel, California, and during delivery to physicist to evaluate and detennine the extent of ex-Methodist Hospital of Southern California in Ar-posures that individuals had received as the result of i

cadia, California.

this incident. Extensive time and motion studies were l.

conducted, as well as the processing of personnel

'~

Nature and Probable Consequences-On August 1, monitoring devices, to determine doses received.The 1989, an intracavitary procedure was performed at individual who had transported the sources from one San Gabriel Valley Medical Center. Two cesium-137 hospital to the other was a non-radiation worker and sources, 42.2 mci cach, were loaded into colpostat therefore did not wear a personnel monitoring de-devices and inserted into the patient for treatment.

vice. It was estimated that he received about 106 rem 5

NURl!G-0090, Vol.14, No. 4

Abnormal Occurrences,4th Qtr CY91 to his rig ht hand and 0.168 :em w ho!c. body exposure.

AS91-6 Exposures of Non-Itadiation All others w ho came in contact w,th the sources wore Workers pen.onnel monitorior devices. It was estimated tb-t their exposures were within the occupational d0se Appendnt A (see Sample 5 of "I or All 1.icensees")

limits specified by the State's Radiation Control notes that any loss of licensed matctialin such quan-Regulations.

tities and under such circumstances that substantial ha/ard may result to persons in unrestricted areas can The Medical Center was cited lor caus ng the dehw be conridered an abnormal occurrence. In addition, i

cry man to receive 106 rem to his tight hand as a re-lixampic 2 of "I'or All 1.ieensees" 'n Appendix A sult of this event. Ile was notified in wTiting by the notes that an exposure to an mdividual in an are-hospital of the nature and extent of his exposure and stricted arca such that the w hole boJy dose received was provid J a medical review. A medical examina-exceeds 0.5 rem in one calendar year can be consid.

tion of hk hands on the day after the nposure and cred an abnormal occurrence.

three weeks later did not reveal any evidence of skin changes or other symptoms. Also, his blood count

.this writeup is based on information provided to the showed no significant abnormalities.

NRC in December 1991 by the Agreement State of California lor inclusion in this report.

Cause or Causes-.The apparent cause of thts expo-sure was the failure of hospital employees to follow Date and Place-November 1990; exposures to em-proper procedures for storage of brachytherapy ployees at Federallixpiess I ns Ange:es Airport Ilub sources !ollowing their use. Th5 individual w ho trans.

Sort Facility at los Angeles, California, from sources f

ported the sources from the p.tient's room to the ec-shipped from Anaheun Memonal Hospita. in sium stor..ge location at the Medteal Center did not Anahetm, Cahfornia.

rc:nove them from the colpostat source holders and place them in the storage safe By leaving the sources Nature and Probable (,onsequences-On Nosem-in the holders, other personnel were easily expmed her 2,1990, Anaheim Memorial Hospital, Anaheim, because the sources were invisible and could only be Caliform,a, shipped 7 cesium.137 sources the.t had detected by careful examination or use c,f a survey been usQfor a brachytherapy implant back to the meter.

supplier, I heraper: tic h uelides. Inc., Valencia, L ali-forma. Ihe sources consisted of two 50 mCt, threc 25 mci, and two 12 mci si/es.

Actions Taken to Prevent Recurrence The Type 7 A package used for shipment consisted of Licensee-The Medical Center purchased a bench a plastic source retainer, fitted into a lead pig that was top Geiger-Mueller detector equipped with an audi-then placed inside a metal can. This metal can was ble alarm and installed it at theircesium storage loca^

placed inside a 5-gallon metal containct and was sur-tion. The detector wdl alarm if sources are not se' rounded on all sides by a high density polyurethane cured inside the storage safe. Also, a refre. sher foam. the inside container was secure'd with a tid and training was held for all staff covering the proper a snap ring.Thc outside container was secured with a handling of brachytherapy soutecs held under the li-lid and level hack ring.

eense. This training included removat and replace-ment of sources from the storage safe as well as quar-The package was picked up by Federal F.xpress on terly inventories. Methods for surveying devices that November 2,1990, and was taken first to the Fuller-comained cesium sources prior to taking ihem out of ton, California, sort facdity and then to the 1 os Ange-service war emphasized.

les Airport (LAX) Hub Sort Facility. At 1.AX, the package came open while descendmg 8 feet on a Agency-The inspection agency cited the Medical 45-decree angle conveyor belt. At the bottom of the Center for six :tems of noncomphance. The licensee desce'nt, all contents of the package became sepa-responded to the Notice of Violation on Novem-rated and scattered on the conveyor belt and around ber 14,1989, and the investigation was closed on No-the work area.

vemiv r 30, 1989. A follow-up inspection was con-duc,. in October 1900, and no similar type A Federal lixpress employee noticed th;.t the pack-personnel exposures were found: therefore, the cor-age had a radioactive label and immediately re packed rcctive actions appeared to be effective in preventing the 5-gallon container; however, he did not realize further similar incidents.

that tne sources had fallen out. The employee re-ported the incident to his supervisor who called m a I%iess new significant information becomes avail-hazardous materials specialist to examine the con-

. se, this item is considered closed for the purposes tainer.The speciahst used a survey meter and deter-of this report.

mined that there was no radiation level at the surface NURiiG-0090, Vol.14, No. 4 6

. Abnormal Occurrences,4th Otr CY91

- of thedrum.Ratherthanquestionwhyhedidnot reg-Other 'Iherapeutic Nuclides has redesigned their ister any reading, he assumed that all items inside the container to prevent this type of spillin the future.

package had been properly secured and he allowed it to continue on to its destination,

-Unless new, significant information becomes avail-able, this item is considered closed for the purposes tMs n poa

' Die package arnved at Therapeutic Nuclides on Monday,- Novembcr 5,1990, but it was not opened AS9b7 Med.ical Therapy Misadm.. tra-inis until the following day. When the package was opened and dixovered' empty, the Radiation Safety tion at Northridge Ilospital Officer for "Iherapeutic Nuclides immediately noti-Medical Center in Northridge, fied the Los Angeles County Radiation Control of-California fice (Agency) and an investigation was begur. An Agency inspector contacted Federal lixpress in an at.

Appendix A (see the overall criterion) of this report tempt to backtrack the route the package took from notes that an event mvolving a moderate or more se-

. the time it was picked up at the hospital. She was able vere impact on public health and safety can he consid-to focus her search on the Hub facility at LAX and cred an abnormal occurrence.

discovered the sources there as soon as she entered the facility.

This writeup is based on information provided to the NRC in December 1991 by the Agreement State of All'seven sources were kiented in various places California for inclusion in this report.

throughout the facility by the inspector. Federal Ex' Date and Place-May 3,1991; Northridge Hospital press personnel who came in contact or worked near Medical Center in Northridge, California.

where the sources were found were interviewed.

Those individuals who came in close contact with the Nature and Probable Consequences-On May 3, sources were sent for medical evaluation and fol-1941,15 mci of iodine.131 intended for patient "A" lowup Dose estimates were established foi allwork-was administered in error to patient "B" w ho had the ers and ull were notified of their estimated doses. In-same first and last names as patiem "A." The admini-dividual dose estimates for the 24 employees stration was made by the hospital's Certified Nuclear involved ranged from 10 mrem to 1810 mrem whole Medicine Technologist without the responsible phy-body. Also, three individuals who said they touched sician present, which is a violation of she California the sources had estimated extremity doses that Radiation Control Regulations. Patient "11" had re-ranged from 90 to 260 rem.

ported to the hospital's Outpatient Department for a preoperational chest x-ray instead of reporting to her The U.S. Department of Transportation (DOT)in, doctor's private office as she was instructed. Patient vestigated whether the package of sources was prop.

"A" was scheduled to receive a byperthyroidism erly securcJ prior to pick-up by Federal Express.

treatment that same morning.

There is strong evidence that the package was not gg g ;

g..go g

properly scaled; therefore, w hen it fell down the con-veyor belt it easily sptiled open. The hospital staff and siened the coraent form. She asked questions of

~

her technologist about thyroid disorders and was supplied sworn statements to Radiation Contro: Pro-given answers.De dose of 15 mci was administered.

grarn staff that they had followed all procedures when they packaged the sources; however, DOT has later that same day, patient "A" presented herself run extensive tests on the container and has con'

- for the treatmem. It was then that the hospital dis-cluded that if it had been sealed properly, it woul t covered that they had admmistered the dose to the not have spilled its ccmtents.

wrong patient. I atient " irs" doctor was contacted I

and consulted with the Chief Nuclear Medicine phy.

Actions Taken to Present Recurrence sician.They decided to give patient "U" 15 dmps of a potassium iodine solution three times daily for three llospital-After long delays, the hospital complied dap plus forced fluids to reduce Ihe uptake of the m-dioactive iodine. She underwent the previously

. with the dose notification requirements.

scheduled surgical procedure three days after the dose was administered without any regard for the State Agency-A Notice of Valation was issued to possible exposure of surgical room staff from the pa-the hospital for failure to report the incident and also tient.

for the exposures to personnel in excess of permissi-ble levels. The case was closed on November 13, This meident was reported to the wrong !irut of

-1991.

California's Department of Health Services by the 7

NUREG-0040, Vol. '14, No. 4

_.m._

Abnormal Occurrences,4th Otr CY91 l

hospital five days after it occurred. Not realizing the Cause or Causes Jihe administration was made by

- significance of the error, Radiologic ilcalth was not the hospitars Certified Nuc1 car Medicine Technolo.

- contacted tmtil May 31, 1991, 28 days after it oc.

gist without the responsible physician present.

eurred. An investigation was begun by the Radiologic Ilealth Un t of th_e les Angcles County licalth De-Activms Taken to Present Herurrence partment,~ the inspection agency for this licensee.

The inspector discovered that the hospital had origi-Licensee-- An enforcement conference was held at nally estimated the patient's thyroid dose to be much the los Angeles County Ilealth Department be-lower than it actually was.'lhe agency retained a con-tween members of the hospital administrative staff sultant w ho performed a complete workup of the pa.

and representatives of the County and State Radia, tient. The patient's dose was established at 3000 rem tion Control Progtam staff. The hospital presented to the thyroid and she was informed of this in writing an extensive corrective action plan and explained by the hospital. She was placed into a treatment fol.

new controls that would be put in place.

lowup program.

Agency-Representatives of the. Radiologic Ilealth liranch accepted the plan and the case was referred to the city attorney's office for determination if An evaluation of exposures to the surgical room staff charges should be filed.

. was also made by the consultant. Their exposures were determined to be miruma and : hey were also This item is considered closed for the purposes ofIhis.

- notified by the hospital.

report.

t 9

l NUREG-0090, Vol.14, No. 4 8

1.

-. a.

1 Abnormal Occurrences 4th Otr CY91 REFERENCES 1.

Letter from LJ, Callan Director, Division of 02526/91-003, License No. 29-10191-02, Dock.

Radiation Safety and Safeguards, NRC Region et No. 030-02526, December 9,199 L' IV, to LTC Albert htoreno, Department of the Army, William lleaumont Army Aledical Cen.

3.

Letter from Thomas T. h1artin, Regional Ad.

ter, forwarding Inspection Report No, ministrator, NRC Region I, to Sister Jane 030-03260/91-02 and Notice of Violation. Li.

Frances Ilrady, President, St. Joseph's Hospital cense No. 42-05255-07, Dxket No. 030-03260, and hiedical Center, forwarding Notice of Viola.

January 30,1992.*

tion and Proposed Imposition of Civil Penalties (Notice)-56250, License No. 29-10191-02, 2.

Letter from hialcolm R. Knapp, Director, Divi.

Docket No. 030-02526, December 26,1991.*

sion of Radiation Safety and Safeguards, NRC Region I, to Sister Jane Frances llrady, Presi.

4.

Letter from Wiiliam 11. Schnitz, Chief, Nuclear dent, St. Joseph's !!ospital and h1edical Center, Materials Inspection Section 1, NRC Region Ill, forrarding Inspection Repert No. 030-to Abdul llen Zttri, Radiation Safety Officer, Uchersity of Wisconsin-Madison. forwarding Inspection Report No. 030-03465/91-002, Li.

• A co is avahNe he impectkm or copymg for a fee in the NRC Cense No. tS-09S43-18, Docket No. 030-03465, Publ Document Romn. 21201. Siteet. NW., Icaer trsel, waunngton.Dc 20555.

February u,,1992.*

l i.

I l

1 l-I l

l l_

9 NURIiG-0090, Vol.14, No. 4

i i

Abnormal Occurrences,4th Otr CY91 1

APPENDIX A ADNORMAL OCCURRENCE CRITERIA The followmg criteria for this repcrt's abnormal oc-dioactive material, or (b) release of radioactive cur <cLee detenninations were set forth in an NRC material frorn a package in amounts greater than policy statement published in the Federal Recister on the regulatory limit.

February 24,1977 (Vol. 42, Nc. 37, pages 10950-10952).

5.

Any loss of licensed material in such quantities and under such circumstances that substantial An event will be considered en abnormal weerrence hazard may result to persons in unrestricted ar-if it involves a major reduaion in the degree of pro-eas.

tectior. of the public health or safety. Such ari event would involve a moderate or more severe impact on 6.

A substantiated case of actual or attempted theft the nublic health or safety and could include t at need or diversion of licensed material or sabotage of a not be limited to:

facilny.

7.

Any substantiated loss of special nuclear mate-1.

Moderate exposure to, or release of, radioac:ive material licensed by or othuwise regulated by rial or any substantiated imentory dtscrepancy the Commission:

that is judged to be significant relative to nor-raally expected performance and that is judged to 2.

Major degradation of essential safety related be caused by theft or diversion or by substantial equipment: or breakdown of the accountabihty system.

8.

Any substantial breakdown of physical security 3.

Major deficiencies in desigr, construction, use of, or uanagement controls for licensed facilitics or material control (i.e., access control, contain-or material.

ment, or accountability systems) that signifi-cantly weakened the protection against theft, di-version, or sabotare.

Examples of the types of events that are evaluated in detail using these criteria are:

9.

An accidental cnticality [10 CFR 70.52ta)].

For All Licensees

10. A major deficiency in design, construction, or op-eration havmg safety implications requiring im-1.

Exposure of the whole body of any individual to mediase remedal action.

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

11. Serious deficiency in management or procedural more of radiation; or exposure of the feet, an~

controls in major areas.

kles, hands or forearms of any individual to 375 rem or more of radiation [10 CFR 20.403(a)(1)],

12. Series of events (where individual events are not or equivalent exposures from internal sources.

of maior importance), recurring incidents, and incidents with implications for similar facilities 2.

An expasure to an individual in an unrestricted (generic inciderits) that create major safety con-area such that the whole body dose received ex' ecrn.

ceeds 0.5 rem in one calendar year [10 CFR 20.105(a)].

For Commerrial Nuc! car Power Plants 3.

The release of radioactive material to an unre-1.

Exceeding a safety limit of license technical stricted area in concentrations which, if averaged specifications I10 CFR 50.36(c)].

over a period of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, exceed 500 times the

- regulatory limit of Appendix 13, Tab!c lI,10 CFR 2.

Major degradation of fuel integrity, primary Part 20 [CFR 20.403(b)(2)].

coolant pressure boundary, or primary contain.

l mera boundary.

4.

Radiation or contarnination levels m excess of design values on packages, or loss of confine-3 loss of plant capabihty to perform essential

(

ment of radioactive material such as (a) a radia-safety functions such that e potential release of tion dose rate of 1000 mrem per hour three feet radioactivity in eyeess of 10 CFR Port 100 guide-from the surface of a package containing the ra-lines could result from a postulated transient or i

l 11 NIIRI60040, Vol. I4, No. 4

Abnormal Occurrences,4th Ott CY91 accident (c.g., loss of emergency core cooling sys-For Fuel Cycle I.lcensees tem, loss of control rod system). _

1.

A saf ty limit oflicense technical specifications is 4.

Discovery of a major condition not specifically a plant shutdown is required [10 considered in the safety analysis report (SAR) or fg yhn technical specifications that requires immediate remedial action.

2.

A major condition not specifically considered in 5.

Personnel error or procedural deficiencies that the safety analysis report or technical specifica-result in loss of plant capability to perform essen-tions that requires immediate remedial action.

tial safety functions such that a potential release of radioactivity in excess of 10 CFR Part 100 guidelines could result from a postulated tran-3.

An event that seriously compromised the ability sient or accident (e.g., loss of emergency core of a confinement system to perform its desig-cooling system, loss of control rod system).

nated function.

NUREG-0090, Vol.14, No. 4 12

Abnormal Occurrences,4th Qtr CY91 APPENDIX 11 UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES During the October through December 1991 period, subsequent updating information on ihe abnormal NRClicensees, Agreement States, Agreement State occunences discussed. (the updating provided gen-licensees, and other involved parties, such as reactor crally covers events that took plaec during the report vendors and architect-engineering firms, continued period; some updating, however, may be more cur-with the implementation of acticms necessary to pre-rent as indicated by the associat ed event dates.) Open veut recurrence of previously reported abnormal oc-items will be discussed in subsequent reports in the currences. The referenced Congressional abnormal series.

occurrence reports below provide the initial and any Fuel Cycle Facilities 91-6 Potential Criticality Accident at the corrective actions for apparent violations identified General Electric Nuclear Fuel and as a resuh of the "ll and NRC followup inspections.

ComEonent Manufacturing Facilit}-

I "" ""'" d*

• d " d'd "* *'* P " "' *" " " '

I for the facility, who officially assumed this position on

.in Wilmington, North Carolina February 9,1992.

This abnormal occurrence was originally reported in

'lhe licensee continues to evaluate 'its nuclear NUREG-0090. Vol.14, No. 2 " Report to Congress criticality safety program; as areas for improvement on Abnormal Occurrences: April-June 1991," and are iJentified, they are being added to the beensee's updated in Vol.14, No. 3. He event, involving de_

Performance Improvement Program (PI P). Status re-graded nuclear criticality safety controls, was investi.

ports on the PIP have been submitted monthly by the gated by an NRC Incident Investigation Team (llT).

licensee to the NRC. The NRC wili be meeting with As mentioned in the previous reports, the NRC IIT the licensee on a quarterly basis to review the been, formal report was pubHshed in August 1991 as see's progress m completing the elements specified NUREG-1450 (" Potential Criticality Accident at the in the licensee's PIP. The first such meeting is sched.

General Electric Nuclear Fuel and Component uled for March 4 W)2.

Manufacturing Facility, May 29,1991"). Also, as pre-

~

viously mentioned, the licensee's solvent extraction As mentioned in the previous reports the NRC staff system remained shutdown until October 16,1991, developed a Staff Action Plan in response to the IIT when the NRC authorized the licensee to restart op-report findings. Some of the short term Staff Action cration of the system. The abnormal occurrence is Plan items were compicted during the latter part of updated as follows:

1991. In addition, responses to NRC Bulletin 91-01

(" Reporting less of Criticality Safety Controls"),

Sigmficant NRC inspector presence was maintaine<l which requires all fuel cycle and uranium fuel re-at the site during the mul-October to mid-November search and development licensees to evaluate and 1991 time penod. The inspectors reviewed opera-modify as necessary their criticality safety criteria and procciJures, are due by the end of January 1992 (Ref.

tions in progress as the licensee restarted the solvent extraction process, and reviewed actions being taken B-1).Dese responses will be revicwed by the NRC's by the licensee to improve its performance in the area Office of Nuclear Material Safety and Safeguards of nuc! car criticality safety. The licensee's solvent ex' (NMSS): then the licensees' implementauon of any traction process has been operated % i safe manner needed iroprovements will be reviewed durmg NRC inspections.

stnce operation was resumed m mid-October. In an emergency exercise on December 18,1991, the licen-Also as previously mentioned, NMSS established a see demonstrated effective corrective actions for problems in the licensee's emergency response pro' Materials Regulatory Review Ta;k Force. The pur-pose of theTask Force was to conduct a oroad-based gram.These problems were identified by the IITand review of the Commission's current licensing and NRC followup inspections.

oversight programs for luci eycle and large material plants.The Task Force was requested to define the The NRC held an enforcement conference with the comp (ments and subcomponents of an ideal regula-licensee on February 7 1992 to discuss causes and tory evaluation system for these types of heensed 13 NtJRIE0090. Vol.14, No. 4

- j i

Abnormal Occurrences,4th Otr CY91 1

1 l

plants and compare them to the components and

.This report (Draft NUREG-1324) was issued for subcomponents of the existing regulatory evaluation public comment during 17ebruary 1992 (Ref. B-2).

system. 'the Task I'orce prepared a report which dis-cusses the findings from this comparison and pro-Funher updating of this item will be made as appro-poses recommendations on the basis of the findings.

priate.

Otller NRC Licensees 85-17 Exposure of Radiographic Person.

This item is considered closed for the purposes of this nel Due to Management and Proce.

reimn.

dural Control Deficiencies 86-28 Immediately Effective Order Modi-This abnormal occurrence was originally reported in fying License and Order to Show NU."EG-.0090, Vol. 8. No. 3, " Report to Congress Cause issued to an Industrial Ra-on Abnormal Occurrenes: July-September 1985."

diography Company The event mvolved Westere Stress, Inc., with offices in Evanston, Wyoming and Heuston, Texas. The &

This abnormal occurrence was originally reported in normal occurrence is updated, ai A closed out, as fol' NUREG -0090, Vol. 9, No. 4, " Report to Congress lows:

an Abnormal Occurrences: October. December 1986." The Order involved an employee of Met-An investigation by the NRC Office of investigations Chem Testing laboratories of Utah, Inc., of Salt

~

(01) was initiated to determine whether employees l_ake City, who had also been employed thhe prede-of Western Stress, Inc., had intentionally withheld in-cenor company Met Chera Engineering labooto-tormation from the NRC concerning radiation over-rics, Inc. (The predecessor company's assets were exposures to Western Stress employees and the gere purchmed by Met. Chem Testi,g Iaboratories of cral public. The result of this investigation Utah. Ines on September 10,1984, and a n"w license demonstrated that the Weste.a Stress District Op-was issued on July 31,1986.) The abnormal occur-erations Manager for the Evanston office, the Radia-rence is updated, and closed out, as follows:

tion Safety Officer (RSO) for the Evanston office, two radiographers, and a radiography assistant con-An investigation by the NRC Office ofInvestigations spired to make false verbal and written statements.

(01) was initiated to determine whether the em-The results of this investigation further demon-ployee, while emphived by the predecessor comp;my, strated that the REO, the two radiographers, and the deliberately forged a letter to cever up a radiatian ed radiography nssistant knowingly and intentionally posure of a radiographer lhe results of this investi-made false verbal and written statements to the gation demonstrated that the employee knowingly

NRC, ar.d willfully wrote a fictitious letter to suppress and/

or conceal information about the overexposure.

These investigation findings were referred to the U.S. Department of Justice (DOJ) for potential This 'trea was referred to the U.S. Departruent of prosecution on July 9,1986. In an indictment on Sep.

Justice for potenpal prosecution. The U.S. District tember 16,1987, a Grand Jury for the U.S. District Court for the District of Utah sentenced the mdivid-Court, for the District of Wyoming, charged the five ual for violation of 10 USC 1018, " making a false employees of Western Stress, Inc. with " making of statement," on May 25,1989.

false, fictitious, and fraudulent statements"(18 USC 1001), " aiding and abetting" (18 USC 2), and " con.

By request of the licensee, on May 28,1987, the NRC spiring"(IS USC 371). All five individuals were con.

retired License No. 43-19662-01, which had expired victea for the violations stated in the 01 investigation.

on March 31,1987.

The fmal DOJ judgrnent was made March 16,1989,

- This item is considered closed for the purposes of this By request of the licensee, the NRC terminated U.

repon.

cense No. 49-23490-01 on April 30.1986.

87-8 Significant lireakdmvn of Manage-In 1986, Western Stress was purchased it MrfEC in.

ment Controls for Radiographic ternational A nevt license was issued which specifi-Operations cally prohibited any of the five individuals from acting as radiographers or radiography assistants without This abnormal occurrence was originally reponed in written permission from the NRC.

NUREG-0090, Vol.10, No.1, " Report to Congress

- NIJREG-0090, Vol.14. t'o. 4 14

' Abnormal Occurrences. 4th Otr CY91 3

g on Abnorrnal' Occurrences: January-March 1987."

previous ly submhted December 27,1990,identi-7the _ event involved: A-1 Inspection loc., of fied no misadministiations identified dming the Evanston, Wyoming.'lhe abnormal occurrence is up-aud;t of brachpherapy procedures, In the latter dated, and closed out, as follows:

part of 1991, the licensee submitted a therapy i uality m:magunent program to be incorporated l

L As previously mentioned, the NRC issued an Order into its license. Irupection findings have also on April 10,1987, suspending this byproduct material been favorable.

- license e.nd requiring the licensee to show cause why the license should not be revoked (Ref. Il-3). '!he 11-Unless new, significant information becomes avail.

censee responded in a letter dated April 27,1987.

able, this item is considered closed for the purpmes lhe NRC deferred consideration of this matter of this report.

pcnding the completion of an investigation of related matters conducted by the NRC's Office of Investiga.

tions, 91-8 Itadiation Exposures of Me:nbers of the Public from a Lost fladioac-In view of the fact that this license expired on May 31, tive Source l'

~1989, and in vicW of the actions already taken in this L

_ cas4 the NRC concluded that no purpose would be

'Ihis abnormal occurrence was origmally reported in U

served by considering additional enforcement action,

. NUREG -0090, Vol.14, No,3, "Rc] ' to Congress Therefore, NRC terminated A-1 Inspection, Inc 's li-on Abnormal Occurrences: July-Seguember 109L" cense effective July 10, 1989, and NRC's enforce-Tihe abnormal occurrence is updated as follows:

ment actions in this case were considered closed, As previously mentionel on September 5.1991, the This item is considered closed for the purposes of t his licensee (Western Atlas International) reported the-i repor',

loss of a 2-curie cesium-137 scaled well logging source from a vehicle en route from the licensec's 90-11 Deficiencies in Ilrachytherapy Pro.

Tukon, Oklahoma, facility to its Ilouston, Texas, fa.

gram cility. As a result, two members of the peacral public receved unnecessary radiation exposures.

This abnormal occurrence was originally reported in

< NUREG-0090, Vol.- 13, No. 2, " Report to Corgress On December 20i1991, the NRC issued a Notice of on Abnormal Occurrences: April-Joac 1990."= As

-%alation and Proposed imposition of Cnil Penalty in previously mentioned. Orders suspending the the amount of $10,000 for violating NRC require-brachytherapy procedures <,tre issued to the Sc ments in the low ofIhe radioactive source (Ref. Ib6)-

u Mary Medical Center facilities in Gary and Ikitart, The proposed civil peralty was based on two viola-Indiana, Land to Porter Memorial Hospital in Val, tions: (1) faikre to block and brace the radioactive

> paraiso, Indiana. The Order to the St. Mary Medical.

source cortniner adequately during *tansportation; Center facuities was issued en April 27,1990 (Ref.

and (2) failure to ensure that the container's closure U

H-4) and the Order to Porter Memorial Ilospitahvas devicms properly installed, secured, and free of de-issued on May 1 1990 (Ref. B-5). The abnormal oc-fccts The NRC also cited the licensee for five other currence is updated, and closed out, ng follows:

violations which dere not assessed a civil penalty.

L St. Mary Medical Center facilities-in a leuer The letter informing the licensee of the action indi-dated October 15,1991, the licensee indicated it L cated NRC's concern that a responsible licensee-plans to seek reinstatento. ofits radiation ther-manager had disregarded findings of an August 1991 apy program. It has not, however, submitted a

_ safety audit which had directed that the containers formal request for the necessary license amend.

not be used until identi.fted defects had been fixed.

ments.

The letter noted that the violations resulted in an in-cidant which had posed a significant threat to the -

L 2.

Porter Memorial Hospital-On January.10, health and safety of the general pubhc.

1992,' the NRC rescinded the Order suspending radiation therapy' activities. 'lhe licensee-has This item temains open pending the licensee's re-

- complied wit _h the terms of the NRC Order. An sponse to the December 20,1991, letter and pending audit report from an independent consultant, further review of the company's licensed activities.

15

. NUREG-0090, Vol.14, No. 4

Abnormal Occurrences,4th Qtr CY91 s

APPENDIX C L

OTIIER EVENTS OF INTEREST The following items are described because they may volve major reductiom in the level of protection pro-possibly be perceived by the pubhc to be of public vid<.d for public health or safety; therefore, they are health or safety significance. nc items did not in.

not repostable as abnormal occurrences.

Nuclear Power Plants L Fxaluation of Plant Internal Flooding appropriate, hardware and procedures that Vulnerability for Surry Nuclear Power would help to prevent or mitigate cevere acci-dents.

Station _

On August 30, 1991. Vltgmia Electric and Power Discussion Company (the licensee) submitted its Inoividtd Plant Examination (IPil) report for Suny Units I and The specific internal flooding vulnerabih.ty identified

-2 (Ref. C-1).The report identifit.d an unexpectedly by the hcansee for the Surry facilityis a rupture in an high core damage frequency (CDF) estimate of 8-foot water mtake pipe m the Unit 1 or Unit 2 tur-t.1E-03 per reactor year (i.e., about 1 in 1,000 reac-bine building which could flood and damage the com-tor years) for intental floodmg events. durry Units I m n emergency switchgear room. This might poten-and2 ard Westinghouse-designed pressunzedmnter ti lly lead to disabling of important safety equipment, reactors located in Surry County, Virginia, me damage, and possible release of mdiation.

The licensee believes the vulnerability has been over-

Background

estimated because of various conservatisms assumed On August 8,1985, the Commission issued a policy in the r,21yses. Nevertheless, the licensee has imple-mented plant modifications and mterim measures to statement on severe accidents appheable to f uture reduce thc likelihood of flood event initiation, which designs and existing plants. Although the policy statement concluded that existing plants posed no tk hmee Mmates to reduce task byabout a factor undue risk to pubhc health and safety, the Commis-of 10. Such steps m, elude sump pumpimprovements, sion recognized the need for a syste'matic examina-replacement of selected motor operated valves and tion of each nuclear power plant for planbspecific expansion joints, and inspection of valve bollmg. Ad-vulnerabilities.

ditional enhancements that were implemented, but not taken credit for in the flooding analysis, melude On November 23, 1988, the NRC issued Generic inst llation of flow limiters, improvements of a de-Letter 88-20. " Individual Plant Examination for Se-vice to prevent the backflow of water, round.the.

vere Accident Vulnerabilities," which stated that li-clock Dood watches, quicker flood response, and censees of existing plants should perform a system-installation of diesel-dnven sump pumps not depend-atic examination, IPE, to identify any plant-s'pecific ent on e!cctric power. The hcensee is currently evalu-vulnerabilities to severe accidents and report the re-ating ther possible modifications and measures to suits to the Commission.nc specific purpose of the I"".her reduce the potential forinternal flooding sce-

"^""S' IPE is to have each licensee of a nuclear power plant do the following:

The issue remains under NRC review and the licen-see ons will e ntinue to be closely monitored and

1. ' Develop an appreciation of severe accident be-evalu ted.

havior;.

2. ' Understand the most likely severe accident se-2, Catastrophic Failure of Salem Unit 2 quences that could occur at its plant:

Turbine-Generator 3.

Gain a more quantitative understandii, af the On November 9,1991, Public Service Electric and overall probabilities of core damage and fission Gas Company (the licensee) experienced a cata-product releases: and, if necessary, strophic failure of its Salem Unit 2 turbine-generator. Because of the failure, the plant is 4.

Reduce the overall probabilities of core damage expected to be out of service for an extended period and fission pnxluct releases by modifying, where of time. Salem Unit 2 is a Westinghouse-designed 17 NUREG-0090, Vol.14 No. 4

Abnannal Occurrences,4th Qtt CY91 i

pressurized water reactor, tomted in Salem County, relance was placed on the backup emergency turbine New Jersey, h a equipped wu h a Westinghouse tur-trip system involving solenoid vahe IT-20.

bine~ assembly, a Westinghouse Electro-llydraulic Control (EllC) system, and a General lilectric gen.

Hy design, opening of the RTils caused ET-20 to be

- erator and exciter. The event was resiewed by ar, elect rically energized.The reactor trip also initiated a NRC Augmented Inspection Team (Al'l). The' fel.

30+ccond delay for opening the output breakers I

which wm issued on January 7,1992 (Rel. C-2).

lit-20 solenoid valve failed to open to assure relief lowing details are generaHy based on the AIT report from the main generator. 'lhough energized, the of HTF pressure to maintain the turbine steam ad-nms w&es ched.

At about 11:00 a.m., with Unit 2 opers tiag al 100 per-cent reactor power, plant operators inhiated a rou~

When the ASToil pressure retumed to normal,after tine test procedure to yerify the operabGity of the the momentary petturbation, the AST interface steam turbmc automatic mechanical trip mecha-valve closed (by design) llecause tbc lit-20 solenoid nisms.,the test procedure myolved the mam,putation valve, thoueh energized. did not function, liTl' pres-of mechame:d trip devices m the turbme auto stop oil sure was re' turned to the pilot valves which imtit:cd (AST) systes the primary turbine protection mecha' reopening of the turbine steam admission valves.

nism. Ily design, the test procedare required the com-Steam may have also been admitted to the turbine plete ismation of the AKt system from any turbine through the bypass vahe associated with each stop control or top function (includmg the mechanically-valve. Apparently, steam was admitted to the turbine actuated turbme overspeed trip device)in order to at about the same time that the output breakers Inm prevent an actual turbine trip during testing of the the main generator openedflhe disconnection of tne mechae al devices' min gnerator from the prid effectively removed all hiad resistance from the turbine-generator system.

. A redondant backup system for turbine overspeed Consequently, as hign energy steam was readmitted g

protection and emergency trip funeuons was as-

. to the turbine, the turbine began te overspecdc surned to be operational The backup system consists of three electrically; actuated solenoid v:dves de.

At the normal overspeed control setpoint (103% of signed to pmvide reddndant automatic control and the normal rated turbine speed of 1300 rpm), the trip of the tuybine in an e-crspeed condit;on (by reli-

OPC40-1 and Ol C40-2 solenoid 5alves were e!ec-ance on the two redundant overspeed protection so-t ricany energized. However, the valves failed to open tenoid.vahn OPC-20-1 and OPC-20-2) and to to reheve the lilF pressure that was rnaintaining the 1

1 cause a surbine trip on a reactor trip thy reliance on govea 't nnd intercept vahes open. Therefore, the l:

the luckup emergency trip solenoid valve ET-20).

turbine.geneta:or umt continued to overspeed.

t l

The turbine speed reached approximattly 2900 rpm -

During the pertormance of the test, a momentary oil.

and several blades m the ho 22 low pressure turbme prusure pertwbation (a pronounced Jecrease last-section separated from tl c rotor disc, penetrated the 7

ing about 1,5 seconds) occurred in the AKF system.

Though of short duration, the oil pressure decrease jl.25 meh thick steet tutbint.asmg and became pro-

~

was sufficient to open the AST interface valve. This jecides from the turbine, llecause the Salem turbine gnum am out. side on the turbmc building roof, vahe functioned to reheve the emergency trip Ouid WSF) prest.ure from the pilot valves affecting opera-the prcjectiles Imded on the roof and the ground tion of tmbine steam admission valves, i.e., stop around the turbine building. No nuclear safety sys-tems were affected by the turbme projectiles.

l valves,. pos ernor vah es, reheat stop vah es. and inter-

. cept vahes. Consequently, those valves closed and

'lhe resulting eccentric motion of the rotor shaft -

tsotated steam flow to the high and low pressure tur-c:msed severe vibrittlim at the main generator. Con-bmen sequently, the generator's hydrogen seals failed and seal oil lines ruptured. Hydrogen gas (used for gen-l' The oil pressure perturbation also resulted in the ac-erator cooling) and seal oil (used to pressuriec the

tivanon er three low AST pressure signals to the reac-generator hydrogen seals) w cre released and ignited.

l.

' tor protection systemfitPS). In accordance with the A fire erupted in the immediate area of the genera-L

-- design of the RPS lopc, two cut o{ three loiv AST

lor, j-pressure signals are considered as indwative of a tur-bme trip. Consequently, the reactor inp breakrs When the opemtors pert'orming the turbine test see-(I!TDs) opened to cause an immediate reactor phmt ogmied the situation (about 70 seconds af ter the re.

l trip. Because of *he test in progress.The primary tur-actor trip), they restored the ASTsynem to normat bine trip system (auto stop oil) was isobted and mea-An operator also manuauy inpped the turbine to pable of providing turbine trip anuranceJ!herefore, assure tha; the AST system functioned to open the

. NUREG-0040; Vol 14, No. 4 lb

~

Abnormal Occurrences,4th Otr CY91 V

i

. interface valve and relieve the in F pressure that was

- deficiency in commitment tracking. Additionally, on maintaining the steam admission valves open.'Ihese -

October 20, 1991, operators and their supervisors actions isolated the turbine irom further steam au-permitted turbine startup without resolving a turbine mission.The event duration was about 74 seconds.

sptem test discrepancy which indicated that the tur-bine overspeed protection system was not function.

In accordance with its emergency plan, the licensee ing properly.

declared an Unusual Event, 'the event was later briefly upgraded to an Alert until the licensee deter.

'Ihe licensevs actions subsequent to the event were mined that turbme projectiles had not affected any effective and correct. Ilowever, the circumstances safety-related system. All reactor plant systems oper, leading up to the event remain under review by the ated normally and the reactor was brought to a safe NRC and enforcement action is pending.

shutdmin condition. No radiological releases oc curred and no safety injection was required. The fire 3.

Transportation Accident Involving was extinguished within 20 minutes by a combination Unirradinled Fuel of automatically actuated fire suppression systems and rapid response from the on site fire brigade.

At about 4.00 a.m., en December 16,1991, a flatbed trailer truck loaded with 12 shipping containers (each Licensee management representatives immediately containing two new, unitradiated, low-enriched fuel responded to the site to provide oversight, direction, assemblies) was traveling north on Interstate 91 in and control of recovery efforts. Actions were initiated Springfield, Massachusetts, when it was struck head.

to comprehensively investigate the event and deter.

on by an automobile traveling south in the wrong mine causal factors. No significant personnelinjuries lane, The truck driver and his nssistant were trans-occurred. NRC Resident inspectors reported to the ported to a local hospital with minor irsjuries. The site to begin evaluation of the event and the licen.

automobile driver was apparently uninjured. The see's response,Thc Unusual Event was tenninated in truck was enroute from the General liiectric (GE) about tlace hours.

fuel fabricating facility in Wilmington, North Caro-lina, to the Vermont Yankee nuclear power plant at The proximate cause of the event was the failure of Vernm, Vermont.

all the backup emergency and overspeed protection tnp devices to function as a result of mechamcal bind-Each steel,11.5" X 18" X 179" shipping container ing of the three solenoid valves ihe mechanical was positioned inside an all-wooden outer container, binding was a result of foreign debris and sludge in FoHow ng the col.:sion, a fire ensued which ignited the outer containers. Four containers remained on the two OPC solenotd valves; and foreign debris, rust' and corrosion in the ET-20 solenoid valve.

the trailer while the other eight fell to the ground during the accident or the ensuing fire.The local fire Several contributing causes and precursor events P#"*** *E"M C"'

IO

1. 82 "E ##~

were identified. The principal findings included the determination that there was no preventive mainte-dioactive material, they chose to let the containers nance performed on the thtee solenoid valves since urn 3e Dre caused mymg amants ONamagdo installation, and the periodic operational testing of the inner containers and their contents. Representa-0" "S""

the same valves was insufficien, to effectively verify the hydranlic performance of sch device. Further, setts, and Vermont Yankee were dispatched to the by design, the majority of the automatic turbine trip -

accident site.They dctected no release of radioactive niaterial.

features were bypassed when the mechanical trip testing procedure was performed. In this configuru-At about 4:00 p.m., on Decembcr 16,1991, the metal tion, the turbine trip capability is principally depend-inner packages were taken to Westover Air Force ent on the proper functioning of a single backup Base. When GE representatives arrived, they super-emergency turbine trip solenoid valve, ET-20.

vised repackaging of the containers into new wcoden outer packages /the repackaged fuel was then trans-Potentially, this event was preventable. In a Licensee ported by tt Nr truck back to the GE-Wilmington

- Event Report, the licensee committed to replace the facility. 'Ihe shipment ardved safely at the GE-ET-20. OlG20-1, and OPC-20-2 solenoid valves Wilmington facility on December 19,1991.

-in Unit 2 after discovering on September 10, 1990,

.that similar components in Unit 1 were defective. An During the week of Januaiy 13,1992, the licensee re-opportunity was available in May 1991 to effect re, moved the burned containers from their outer pack-placement. Ifowever, the work was deferred to the ages and moved them into a radiologically controlled planned January 1992 refueling outage because of a area where the fuel assemblies were disassembled

)

management icision that may have been caused by a and a preliminary inspection conducted. The licensee i

19 NUREG-0WO. Vol.14, No. 4

f~

Abnormal Occurrences. 4ih Otr CY91 '

?will perform further evaluations before it; moving the :

This incident rest.ited in widespread media and pub-

a indhidsal fuel pellets from theirl rods for examina.

lic interest.' llowever, the damaged fuel ak.cmblics tions. lawrence Livermore ' National: laboratory,

-yhich is conducting an investigation of the event for_

_ posed no threat to public health or safety, and no re.

- lease of radioactive material from the containers was the NRCiobsened the opening of the packages. No.

detected.

. contamination was detected during the disassembly.

i

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M-1 4

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4

- _NU_ REG-0090, Vol.14, No._4 20.

Abnormal Occurrences,4th Qtr CY91 REFERENCES FOR APPENDICES W1 U.S. Nuclear Regulatory Commission, NRC B-5 1.etter from ilugh I Thompson, Jr., NRC Bulletin 91-01, "Reponing Loss of Criticality Deputy Exemtive Director for Nuclear Mate.

Safety Controls," October 18, 1991,*

rials Safety, Safeguards, and Operations Sup-port, to Wiley N. Carr," Administrator and B-2 U.S. Nuclear Regulatory Commission, Draft Chief Executive Officer, Porter Memorial NUREG-1324, " Proposed Method for Regu-Hospital, forwarding " Confirmatory Order lating Major Materials License:s," issued for Suspending Brachytherapy Activities and public comment during February 1992."

Modifying License," License No.13-17073-01, B 3 letter from James M. Taylor, Director, NRC Office of Inspection and Enforcement, to G.W.

11-6 Letter from Robert D. Martin, Regional Ad-Wyrick, President, A-1 Inspectiori, Inc., for-ministrator, NRC Region IV, to Bill Rose, warding Order Temporurdy Suspending Li-Radiation Protection Officer, Western Atlas

. cense (Effective Immediately) and Order to International, forwardiag Notice of Violation Show Cause, License No. 49-21496-01, and Proposed Imposition of Civil Pen-Docket No. 30-20S66, April 10,1987

• alty-510,000, License No. 42-02964-01, Decket No. 030-06402, December 20,1991.'

B-4 Letter from James 1.ieberman, NRC Director o, Enforcement, to Scott liardtman, Vice C-1 Letter from W,L Stewart, Senior Vice Presi-President, Operations, St. Mary Medical Cen-dent-Nuclear, Virginia Electric and Power ter-Hobart, Indiana, and St. Mary Medical Company, to Document Control Desk, Center-Gary, Indiana, transmitting, " Order USNRC, " Virginia Electric and Power Come Suspending Brachytherapy Activities and pany Surry Power Station Units 1 and 2 Re-Modifying Ikenses," License - Nos, 13-sponse to Generic Letter 88-20 and Supple-03459-02 and 13-03459-40, Docket Nos.

ment i ladividual Plant Examination (IPE) for 030-01615 and 030-31379, April 27,1990.*

Severe Accident Vulnerabilities " Docket Nos, 50-2S0 and 50-281, Augtst 30,1991,*

lSUIEu$$$N[nNSES$N.YEfY$$N't$v[

C-.2 Letter from Charles W. Hehl, Director, Divi.

wuhmston, DC 20$55.

sion of Reactor Proj,ects. NRC Region I, to "A tree engle co$e office of Administration. IIutribution andis avaaable. io the cuer.1 of au ply, upon wni-Steven E, Miltenberger, Vice President and ten requen to Chief Nuclear Officer, Pul:lic Service Electnc Man Seni es Scenon, U.S Nuclear Regulac v Commission, and Gas Company, forwarding NRC Region i Ichnd'[aS[e [th $5NuNe tEuIN$kN$,7[N[

Augmented inspection Team Report 50-311/

Street. NW., lower [ > vet, Washinpm, DC 20555.

91-81, Docket No. 50-311 January 7,1992,*

21 NUREG-0090, Vol.14, No. 4

-7 4 _

P#4C FORM SN U8 UCLEAR HrGULA10RY eOMMISSION

1. RLPORT NUMBER (2-80)

(Ass 6 N RC M 1102.

Supp.grtx1 t,y NRC, Add Vol,

, Rev,, and Addendum f4Jm.

a20s. 32c2 -

BIBLIVGRAPHIC DATA SHEET t*. eM wee instructions on u. re"$*)

NUltl30-0090 2 Tirte Arc suannt Vol.14, No. 4

~~

• ^""""'^ **""

lleport to Congress on Abnormal Occurrences:

October - December 1991 l

uOmu ytAR March 1992

4. FIN OR GRANT NUMBER

b. Avirtue468

6. TYPE OF HU50RT Quarterly

v. nRoo covento circiusive estes)

October - December 1991 0, PERFORMNG ORGAN 12ATION - NAME AND ADDRiiSS Uf NRO, provgie Divisa>n, Office y Hegon, U $ Nuclear Hegdatwy Commisse and mathng address: 11 CCntractor, provnte name and mahng ad(3ress )

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

9. 6PONSOMG ORGAN 2Af TON - NAME AFC ADOR8iSS Of NRC, tpa Same as ahe" it cont

• actor, provide NRC ow.sm, Off ce or Reg ott U.S t AJulear Regulatory Commissen, and mailmg address-)

Same as S., above

10. SLPPLEMENTARY NOTES

11. ABSTRACT (200 wrvot or Miss)

Section 208 of the Energy Reorganization Act of 1974 identifies an abnorrnal occurrence as an unscheduled incident L or event that the Nuclear Regulatory Commission determines to be significant trom the standpoint of public heahh and safety and reqtires a quarterly report of such etents to be n.ade to Congress. This report covers the pericwi Oc-tober through December 1991. Five abnormal occurrences at NRC licensed facilitics are discussed in this report.

. None of these occurrences involved a nuclear power plant. Four involved medical therapy misadministrations and one involved a medical diagnostic misadministration. The NRC's Agreement States reported three adnormal occur-rences. Two involved exposures of non radiation workers and one involved a medical therapy misadministration.

The report also contains infortnation that updates some previously reported abnormal occurrences.

12. KEY WORoSCESC91PTORS (List worcs er phrases that wii assrst researchers 'n krating the report) 13 AVAILADtLITY ETATEMENT Unlimited

14. SECURITY CLASSIFICATION

- Medical Therapy Misadmin& : rations cru rw Medical Diagnostic Misadministration Unclassified Exposures of Non Radiation Workers

%, upg Surry Units I and 2 Internal Flooding Vulnerability Unclassified Catastrophe Failure of Salem Unit 2 Turbine-Generator

• * ""'" * " ^ " "

Tvansportation Accident involving Unitradiated Fuel 16 PROE NRC FORM 335 (2-89) i J

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