ML20100E156

Report to Congress on Abnormal OCCURRENCES.April-June 1995

ML20100E156
Person / Time
Issue date:	10/31/1995
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V18-N02, NUREG-90, NUREG-90-V18-N2, NUDOCS 9602120369
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NUREG-0090 Vol.18, No. 2 Report to Congress on Abnormal Occurrences April - June 1995 l

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AVAILABILITY NOTICE Availabimy of Reference Materials Cited in NRC Publications Most documents cited in NRC publicatio,,:: will be available from one of the following sources:

1.

The NRC Public Document Room, 2120 L Street, NW., Lower Level, Washington, DC 20555-0001 2.

The Superintendent of Documents, U.S. Government Printing Office, P. O. Box 37082, Washington, DC 20402-9328 3.

The National Technical Information Service, Springfield, VA 22161-0002 Although the listing that follows represents the majority of documents cited in NRC publica-tions, it is not intended to be exhaustive.

Referericed documents available for inspection and r ing for a fee from the NRC Public Document Room include NRC correspondence and int,.

' NRC memoranda; NRC bulletins, circulars, information notices, inspection and investigatic notices; licensee event reports; vendor reports and correspondence; Commission papers; and applicant and licensee docu-ments and correspondence.

The following documents in the NUREG series are available for purchase from the Government Printing Office: formal NRC staff and contractor reports, NRC-sponsored conference pro-ceedings, international agreement reports, grantee reports, and NRC booklets and bro-Chures. Also available are regulatory guides, NRC regulations in the Code of Federal Regula-tions, and Nuclear Regulatory Commission Issuances.

Documents available from the National Technical information Service include NUREG-series reports and technical reports prepared by other Federal agencies and reports prepared by the Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission.

Document? vailable from public and special technical libraries include all open literature items, sut books, journal articles, and transactions. Federal Register notices, Federal and State legislation, and congressional reports can usually be obtained from these libraries.

Documents such as theses, dissertations, foreign reports and translations, and non-NRC con-ference proceedings are available for purchase from the organization sponsoring the publica-tion cited.

Single copies of NRC draft reports are available free, to the extent of supply, upon written request to the Office of Administration, Distribution and Mail Services Section, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

Copies of industry codes and standards used in a substantive manner in the NRC regulatory process are maintained at the NRC Library, Two White Flint North,11545 Rockville Pike, Rock-ville, MD 20852-2738, for use by the public. Codes and standards are usually copyrighted and may be purchased from the originating organization or, if they are American National Standards, from the American National Standards Institute,1430 Broadway, New York, NY 10018-3308.

A year's subscription of this report consists of four quarterly issues.

NUREG-0090 Vol.18, No. 2 Report to Congress on Abnormal Occurrences April-June 1995 Date Published: October 1995 Office for Anlysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555-0001

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Abnormal Occurrences,2nd Otr CY95 Previous Reports in Series NUREG 75/090 (January-June 1975), published October 1975.

NUREG-0090-1 through 10 (July-September 1975 through October-December 1977), published March 1976 through March 1978.

NUREG-0090. Vols.1 through 16 (January-March 1978 through October-December 1993), published June 1978 through March 1994.

NUREG-0090, Vol.17, No.1 (January-March 1994), published August 1994.

NUREG-0090, Vol.17, No. 2 (April-June 1994), published October 1994.

NUREG-0090, Vol.17, No. 3 (July-September 1994), published January 1995.

NUREG-0090, Vol,17, No. 4 (October-December 1994), published May 1995.

NUREG-0090, Vol,18, No.1 ((January-March 1995), published July 1995.

NUREG-0090, Vol.18, No. 2 ii

Abnormal Occurrences,2nd Qtr CY95 ABSTRACT Section 208 of the Energy Reorganization Act of unidentified path for the potential release of 1974 identifies an abnormal occurrence (AO) as radioactivity at a PWR nuclear power plant, two an unscheduled incident or event that the Nuclear involved medical brachytherapy Regulatory Commission determines to be misadministrations, and one involved a medical significant from the standpoint of public health or therapeutic radiopharmaceutical safety and requires a quarterly report of such misadministration. Four AOs submitted by the occurrences to be made to Congress. This report Agreement States are included. One involved a provides a description of those incidents and medical teletherapy misadministration, two events that have been determined to be AOs involved medical brachytherapy during the period of April 1 through June 30, misadministrations, and one involved the 1995.

overexposure of personnel at a medical center.

The report also contains an update of one AO This report addresses five AOs at NRC-licensed previously reported by an NRC licensee, and two i

facilities. One involved a reactor coolant system AOs previously reported by the Agreement States.

I blowdown at a pressurized water reactor (PWR)

No "Other Events of Interest" items are being nuclear power plant, one involved a previously reported.

l iii NUREG-0090, Vol.18, No. 2

I Abnormal Occurrences. 2nd Qtr CY95 l

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CONTENTS Page Abstract...................................................................................

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Preface.................................................................................... vii In trod u ction............................................................................. vii The Regulatory System................................................................... vii Reportable Occurrences.................................................................. viii 1

Agreement States....................................................................... viii l

Foreign Information..................................................................... viii l

Reopening of Closed Abnormal Occurrences............................................... viii l

I Report to Congress on Abnormal Occurrences, April-June 1995.................................

1 Nuclea r Powe r Plants....................................................................

1 95-2 Reactor Coolant System Blowdown at Wolf Creek Nuclear Generating Station.......................................................................

1 95-3 Previously Unidentified Path for the Potential Release of Radioactivity at Millstone Nuclear Power Station Unit 2.........................................

2 Fuel Cycle Facilities (Other than Nuclear Power Plants).....................................

3 Other NRC Licensees (Industrial Radiographers, Medical Institutions, I n d ustrial Use rs, etc.)...................................................................

3 95-4 Medical Brachytherapy Misadministration at the University of Virginia. in Charlottesville, Virginia........................................................

4 95-5 Medical Therapeutic Radiopharmaceutical Misadministration of Iodine-131 at Massachusetts General Hospital in Boston, Massachusetts......................

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95-6 Multiple Medical Brachytherapy Misadministrations at Madigan Army Medical Center in Fort Lewis, Washington.......................................

5 Agreement State Licensees...............................................................

6 AS 95-1 Medical Teletherapy Misadministration at an " Unspecified Licensee" in New York, New York....................................................

6 AS 95-2 Medical Brachytherapy Misadministration by Mobile Technology, Inc.,

at Irvine Medical Center in Irvine, California................................

7 AS 95-3 Overexposure of Personnel at Gwinnett Medical Center in Lawrenceville, Georgia....................................................

7 AS 95-4 Medical Brachytherapy Misadministration at Southwest Texas Methodist Hospital in San Antonio, Texas.............................................

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NUREG-0090, Vol.18, No. 2

Abnormal Occurrences,2nd Qtr CY95 -

Page Appendix A - Abnormal Occurrence Criteria.................................................. 11 Appendix B - Update of Previously Reported Abnormal Occurrences............................ 15 Other NRC Licensees.................................................................... 15 92-18 Loss of Iridium-192 Source and Medical Therapy Misadministration at Oncology Services Corporation in Indiana, Pennsylvania........................... 15 Agreement State Licensees............................................................... 16 AS 88-5 Medical Teletherapy Misadministration at Sacred Heart Hospital in Cumberland, Maryland.................................................... 16 AS 88-6 Multiple Medical Teletherapy Misadministrations at Sacred Heart Hospital in Cumberland, Maryland.................................................. 16 Appendix C - Other Events of Interest 17 NUREG-0090. Vol.18. No. 2 vi l

Abnormal Occurrences,2nd Otr CY95 PREFACE Introduction description ofits nature and probable consequences.

The Nuclear Regulatory Commission (NRC)

NRC has determined that, of the incidents and l

reports to Congress each quarter, under j

provisions of Section 208 of the Energy events reviewed for this reporting period, only

(

Reorganization Act of 1974, any abnormal those that are described in this report meet the occurrences (AOs) involving facilities and criteria for reporting as AOs. This report covers l

activities regulated by NRC. An AO is defined in the period from April 1 through June 30,1995.

Section 208 as an unscheduled incident or event Information reported on each AO includes date that the Commission determines to be significant and place, nature and probable consequences, from the standpoint of public health or safety.

cause or causes, and actions taken to prevent recurrence.

NRC identifies an AO for the purpose of this Appendix B contains updated information on report using the criteria in Appendix A. The previously reported AOs.

criteria were initially promulgated in an NRC pohey statement that was published in the Federal Appendix C contains information on incidents Register on February 24,1977 (Vol. 42, No. 37, that can be perceived as significant but do not Pages 10950-10952).

i volve a major reduction in the level of protection provided for public health and safety.

This policy statement was published before These events are not reportable as AOs but are provided as *Other Events of Interest."

medical licensees were required to report misadministrations to NRC and few of the examples in the policy statement were applicable The Regulatory System to medical misadministrations. Therefore,in 1984, NRC adopted additional guidance for AO The system oflicensing and regulation by which reporting of medical misadministrations. These NRC carries out its responsibilities is guidelines augment the NRC policy statement implemented through the rules and regulations in examples and are summarized in Table A-1 in Title 10 of the Code ofFederalRegulations. This Appendix A.

includes public participation as an element. To accomplish its objectives, NRC regularly conducts On January 27,1992, new medical licensing proceedings, inspection and enforcement misadministration requirements became effective.

activities, evaluation of operating experience, and As directed by the Commission, the staff is confirmatory research, while maintammg currently developing a new policy statement for Programs for establishm, g standards and issumg rcporting incidents and events to Congress. The techmcal reviews and studies.

policy statement will be published for public comment in the FederalRegister prior to final In licensing and regulating nuclear power plants Commission approval for use m developm, g future and the uses of byproduct nuclear materials, NRC AO reports.

follows the philosophy that the health and safety of the public are best ensured by establishing multiple levels of protection. These levels can be In order to provide wide dissemination of achieved and maintained through regulations information to the public, a Federal Register notice specifying requirements that will ensure the safe is issued on NRC licensee AOs. Copies of the use of nuclear materials. The regulations include notice are distributed to the NRC Public design and quality assurance criteria appropriate Document Room and all Local Public Document for the various activities licensed by NRC. An Rooms. At a minimum, each notice must contain inspection and enforcement program helps ensure the date and place of the occurrence and a compliance with the regulations.

vii NUREG-0090, Vol.18, No. 2

Abnormal Occurrences,2nd Q;r CY95 Reportable Occurrences Agreement States Operating experience is an essential input to the Section 274 of the Atomic Energypct, as amended, authorizes the Commission to enter regulatory process for assuring that licensed activities are conducted safely. Licensees are into agyeements with States whereby the Commission reh,nquishes and the States assume required to report certain incidents or events to regulatory authority over byproduct, source, and NRC. This reporting helps to identify deficiencies and to ensure that corrective actions are taken to special nuclear materials (in quantities not capable of sustammg a cham reaction).

prevent recurrence.

Agreement State programs must be comparable to and compatible with the Commission's For nuclear power plants, dedicated groups have program for such material.

been formed, both by NRC and the nuclear power industry, for the detailed review of operating Presently, information on reportable occurrences experience to help identify safety concerns early; for Agreement State licensed activities is publicly to improve dissemination of such information; available at the State level. For the purpose of and to feedback the experience into licensing, developing a nationwide database, Agreement regulations, and operations. In addition, NRC States are encouraged to provide information to and the nuclear power industry have ongoing NRC on reportable events.

efforts to improve the operational data systems, which include not only the type and quality of In early 1977, the Commission determined that reports required to be submitted, but also the AOs happemng at Agreement State heensed methods used to analyze data. In order to more facilities should be included in the quarterly effectively collect, collate, store, retrieve, and reports to Congress. The AO criteria included in Appendix A are applied umformly to incidents evaluate operational data, the information is maintained in computer-based data files.

and events that occur at NRC and Agreement State b, censed facilities. Procedures have been developed and implemented, and AOs reported Three primary sources of operational data are by the Agreement States to NRC are included in Licensee Event Reports (LERs) submitted the quarterly reports to Congress.

pursuant to 10 CFR 50.73, immediate notifications submitted pursuant to 10 CFR 50.72, and medical misadministration reports submitted Foreign Information pursuant to 10 CFR 35.33.

NRC participates in an exchange of information Except for records exempt from public disclosure with various foreign governments that have by statute and/or regulation, information nuclear facilities. This foreign information is reviewed and considered in the NRC's assessment concerning reportable occurrences at facilities f Perating experience and in its research and licensed or otherwise regulated by NRC is routinely disseminated by NRC to the nuclear yegulat ry activities. Reference to foreign industry, the public, and other interested groups inf rm tion may occasionally be made m these as these events occur.

quarterly AO reports to Congress; however, only domestic AOs are reported.

Dissemination includes special notifications to licensees and other affected or interested groups, Reopening of Closed Abnormal and public announcements. In addition, Occurrences information on reportable events is routinely sent to the NRC's Local Public Document Rooms NRC reopens previously closed AOs if significant throughout the United States and to the NRC new information becomes available. Similarly, Public Document Room in Washington, D.C.

previously reported "Other Events of Interest" are Congress is routinely kept informed of reportable updated if significant new information becomes events occurring in licensed facilities.

available.

NUREG-0090, Vol.18, No. 2 viii

Abnormal Occurrences,2nd Qtr CY95 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES APRIL-JUNE 1995 NUCLEAR POWER PLANTS NRC has reviewed all incident and event reports All of the emergency core cooling system (ECCS) received from licensees for operating nuclear pumps take their suction from the RWST header power plants in the United States (U.S.) through line. If the ECCS pumps were started to mitigate the second quarter of 1995. Using the criteria and the blowdown after the RWST header filled with guidelines in Appendix A of this report, the steam, a common-mode failure of all ECCS following occurrences were determined to be pumps could have occurred as a result of steam significant enough to be reported as AOs.

binding. The ECCS pumps could also have failed as a result of pressure pulses caused by cold RWST water collapsing the steam in the RWST 95-2 Reactor Coolant System and RWST header. If they failed, successful Blowdown at Wolf Creek Nuclear mitigation of such an event would depend on the Generating Station control room operators' cognitive abilities to establish core heat removal via the steam The following information pertaining to this event generators.

is also being reported concurrently in the Fedeml Register: Appendix A (see General Criteria No. 3)

If core damage did occur, then a possibility for a of this report notes that major deficiencies in significant offsite release existed because the

=

design, construction, use of, or management blowdown path in place at the time bypassed the controls for licensed facilities or material can be reactor contamment.

considered an AO.

Cause or Causes-This event was attributed to Date and Place-September 17,1994: Wolf Creek the following three causes:

Nuclear Generating Station, a Westinghouse-(1) Unrecognized design vulnerability-An designed pressurized water reactor nuclear power plant, operated by Wolf Creek Nuclear Operatmg RHR-RWST connecting line was designed to Corporation and located about 5.63 kilometers pr vide operational convenience for refillm.g (3.5 miles) northeast of Burlington, Kansas.

the RWST after a refuehng outage, but not for safety purposes. The m, appropriate use of Nature and Probable Consequences-An this line while on RHR cooling could result in inadvertent blowdown of approximately 34,868 a rapid blowdown event and a subsequent liters (9200 gallons) of reactor coolant through the common-mode failure of all ECCS pumps.

residual heat removal (RHR) system to the refueling water storage tank (RWST) occurred (2) Inappropriate use of the RHR-RWST because of incompatible, concurrent RHR valve connecting line-The licensee inappropriately manipulations. At the time of the event, the used the RHR-RWST connecting line to reactor had been shutdown for 28 hours3.240741e-4 days <br />0.00778 hours <br />4.62963e-5 weeks <br />1.0654e-5 months <br /> and was increase the boron concentration of the RHR on RHR cooling (2413 kPa gauge and 149 C [350 train. (Other boration paths existed that psi gauge and 300 F]). The event was successfully would not have resulted in an inadvertent terminated in 1 minute by operator intervention.

blowdown.)

There was only minimal interruption to heat removal processes, and no core damage or fission (3) Inadequate work control-The licensee was product release occurred. However,if the deficient in the control of maintenance and blowdown continued, the licensee estimated that operational evolutions by allowing RHR cooling could have failed in about 3.5 incompatible activities to occur minutes, the RWST header could have filled with simultaneously. The control room crew had steam in about 6 minutes, and uncovering of the ample warning of the potential adverse core could have begun in about 30 minutes.

effects of these activities just prior to the i

1 NUREG-0090, Vol.18, No. 2

Abnormal Occurrences,2nd Qtr CY95 event, but failed to limit the concurrent CFR Part 100 guidelines could result from a manipulation of selected RHR valves.

postulated transient or accident (e.g., loss of emergency core cooling system, loss of control rod The licensee also had previous warnings of system), can be considered an AO.

blowdown events from its experience at Wolf Date and Place-December 6,1994; Millstone Creek and from the following NRC Nuclear Power Station Unit 2, a Combustion Information Notices: 90-55, "Recent Operating Experience on Loss of Reactor Engmeermg-designed pressurized water reactor nuclear power plant, operated by Northeast Coolant Inventory While in a Shutdown Nuclear Energy Company and located about 5.15 Condition"; and 91-42, " Plant Outage Events kilometers (3.2 miles) west-southwest of New Involving Poor Coordination Between L ndon County, Connecticut.

Operations and Maintenance Personnel During Valve Testing and Manipulations."

Nature and Probable Consequences-While the The licensee's response to these warnings was plant was in a refueling outage, a systems that its administrative controls adequately engineer employed by the licensee identified a addressed the concerns.

condition that established a potential unfiltered release path to the atmosphere that could have resulted in offsite doses in excess of 10 CFR Part Actions Taken to Prevent Recurrence 100 gu,dehnes m, the event of a postulated i

Licensee-The licensee implemented the following loss-of-coolant accident (LOCA). The licensee i

actions: (1) chain locked the isolation valve in the immediately declared the enclosure building RHR-RWST connecting line, and made the plant inoperable and promptly reported the condition l

manager and operations manager solely to NRC.

l responsible for access to this valve; (2) removed The Millstone Unit 2 design meludes an the use of the RHR-RWST connecting line from Enclosure Buildm, g around the reactor the RHR boration procedures; and Containment Building to collect all leakage out of (3) approached the Westinghouse Owners Group to address the issue generically.

the containment,dunng a postulated LOCA., He Enclosure Buildmg Ventilation System contams a NRC-NRC issued Information Notice No. 95-03, charcoal bed filtration unit to remove radioactive

" Loss of Reactor Coolant Inventory and Potential iodine prior to discharging the Enclosure Building

(

Loss of Emergency Mitigation Functions While in air out of the 114.4-meter (375-foot) high Unit-1 l

a Shutdown Condition," to inform all reactor stack. The condition identified on December 6, licensees of the circumstances and potential 1994, was that the ventilation system associated consequences associated with the Wolf Creek with the Hydrogen Analyzer cabinet and waste gas sample hood fan, located within the East event.

Electrical Penetration Room of the Enclosure This event is considered closed for the purpose of Building, would not isolate in the event of a this report.

LOCA. During a postulated accident, this ventilation system, which does not contain a charcoal filter unit, would draw Enclosure j

Building air (contaminated with any containment

{

le kage) from the East Penetration Room and 95-3 Previous! Unidentified Path for discharge it through the 45.8-meter (150-foot)

Y the Potential Release of high Unit 2 vent. The lack of a charcoal filter and Radioactivity at Millstone the lower release point would significantly Nuclear Power Station Unit 2 increase the potential of a thyroid dose in excess of the 10 CFR Part 100 guideline at the exclusion The following information pertaining to this event area boundary.

is also being reported concurrently in the Fedemi Register. Appendix A (see For Commercial The Technical Specifications for Millstone Unit 2 Nuclear Power Plants, Criterion No. 3) of this require that the Enclosure Building integrity be f

report notes that a loss of plant capability to maintained to ensure that the Enclosure Building perform essential safety functions, such that a Ventilation System limits the site boundary doses potential release of radioactivity in excess of 10 to within 10 CFR Part 100 guidelines following a NUREG-0090, Vol.18, No. 2 2

Abnormal O currences,2nd Otr CY95 postulated design basis accident. NRC performed NRC-On February 16,1995, NRC exercised a design basis dose calculation which took into enforcement discretion and did not issue a account the lack of charcoal filtration and the violation. In accordance with the " General lower elevation release path which would result Statement of Policy and Procedure for NRC from the noted design deficiency. This calculation Enforcement Actions,"(Enforcement Policy) then indicated that an exclusion area boundary dose to set out at 10 CFR Part 2, Appendix C, this design the thyroid greater than the 10 CFR Part 100 deficiency would normally be categorized as a guideline of 3000 millisievert (mSv)(300 rem)

Severity Level III violation and enforcement would occur. It also indicated that the whole action would normally be considered because it body dose would not exceed the 250 mSv (25 rem) involved a violation of the Technical Specifications 10 CFR Part 100 guideline. He NRC calculation and could have resulted in 10 CFR Part 100 was very conservative in that it assumed that all guidelines being exceeded in the event of a l

of the designed allowable containment leakage, LOCA. However, the exercise of discretion for following the design basis accident, would be the apparent Severity Level III violation was through the penetrations in the East Electrical determined to be warranted in this instance Penetration Room and released from the because: (1) the condition was identified by the Enclosure Building through the Hydrogen licensee's staff as a result of a questioning attitude Analyzer Ventilation system.

by a system engineer and was promptly reported to the NRC;(2) the condition, which existed since Ccuse or Causes-The cause cf this condition initial startup, was difficult to discover and such was an original design deficiency of the hydrogen identification was not likely by routine inspection, analyzer cabinet exhaust system, surveillance and quality assurance activities;(3) comprehensive corrective actions were taken within a reasonable time period that involved an Actions Taken to Prevent Recurrence adequate root cause determination and a review for failures caused by similar root causes; and (4)

Licensee-The licensee modified the design to the condition was caused by an old performance route the exhaust path from the hydrogen analyzer failure that is not reasonably linked to present cabinet into the enclosure building ventilation performance."

system, thereby going through the appropriate filtration,in order to reduce any post-LOCA This event was determined to be plant specific radioactive release to below 10 CFR Part 100 due to the unique design of the ventilation system.

guidelines. The waste gas sample sink was relocated from the enclosure building to the This event is considered closed for the purpose of auxiliary building. His design modification was this report.

implemented prior to the start up of Millstone Unit 2.

FUEL CYCLE FACILITIES (Other than Nuclear Power Plants)

NRC has reviewed all incident and event reports the occurrences reviewed for this reporting period received from licensees for the milling, processing, were determined to be significant enough to be and fabrication of nuclear fuel in the U.S.through reported as an AO.

the second quarter of 1995. Using the criteria and guidelines in Appendix A of this report, none of OTIIER NRC LICENSEES (Industrial Radiographers, Medical institutions, Industrial Users, etc.)

There are approximately 22,000 active material Agreement States, have entered into agreements licenses for the use of byproduct materials in with NRC to assume regulatory authority for industrial, medical, and academic applications in approximately 15,000 of these licensees within the U.S. T\\venty-nine States, known as their States. NRC is responsible for regulating 3

NUREG-0090, Vol.18, No. 2

Abnormal Occurrcnces,2nd Qtr CY95 approximately 7000 licensees located in the Cs-137 sources. Also, because of anatomic remaining 21 States, the District of Columbia, and characteristics of the patient, the physician had all U.S. territories. NRC has reviewed all incident difficulty inserting the source carrier into the and event reports received from NRC licensees applicator.The design of the afterloading device through (Se second quarter of 1995. Using the allows the source to slide out of the carrier if any criteria and guidelines in Appendix A of this unusual manipulation of source carrier is report, the following occurrences were determined required. The difficulty experienced by the to be significant enough to be reported as AOs.

physician in inserting the source in the applicator and the design of the source carrier resulted in the source falling out of the carrier during the 95-4 Medical Brach}' therapy msertion process.

Misadm.. tration at the mis University of Virginia, in Actions Taken to Prevent Recurrence Charlottesville, Virginia Licensee-The b.eensee provided traimng for its The following information pertaining to this event staff, involved in brachytherapy procedures, is also being reported concurrently in the Fedcral concerning the precautions which must be taken Registcr. Appendix A (see Event Type 3 in when handling an applicator such u, the one used Table A-1)of this report notes that a therapeutic in the subject procedure. Also, emphasis was exposure to any part of the body not scheduled to placed on the need to be more attentive during receive radiation can be considered an AO.

the source insertion process in order to account for all prescribed sources.

Date and Place-March 14,1995; University of Virginia Medical Center; Charlottesville, Virginia.

NRC-NRC conducted a special inspection on March 23-24,1995, to review the circumstances Nature and Probable Consequences-A patient surrounding the misadministration. The was prescribed a manual brachytherapy inspection report was issued on May 2,1995.

procedure using cesium-137 (Cs-137) sources Enforcement action will be taken as appropriate.

loaded in an applicator, for a total gynecological treatment dose of 3000 centigray (cGy)(3000 rad).

This event is considered closed for the purpose of this report.

During insertion of the applicator into the patient, one of the sources fell onto the patient's bed and was unnoticed by the licensee staff involved in performing the procedure. A nurse found the 95-5 Medical Therapeutic source in the bed on March 15 and removed it.

Radiopharmaceutical The source was reloaded into the applicator and Misadministration of lodine-131 the physician revised the prescribed dose to 2500 at Massachusetts General cGy (2500 rad). The licensee estimated that the IlosP tal in Boston' i

source remamed at approximately 10 centimeters (4 inches) from the patient's foot for 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> and Massachusetts delivered a dose of about 13 cGy (13 rad) to the The following information pertaining to this event foot.

is also being reported concurrently in the Fedeml RcKSter Appendix A (see Event Type 5 [a] in i

The licensee notified the referring physician and Table A-1) of this report notes that admimstering the patient of the misadministration. An NRC a thrapeutic dose of a radiopharmaceutical medical consultant was obtained who concluded differm, g from the presenbed dose by more than that the patient was receiving appropriate 10 percent and the actual dose is greater than 1.5 follow-up care. In addition, the b,censee and the times the prescribed dose can be considered an medical consultant concluded that the patient will AO' not experience any adverse health effects as a result of the misadministration.

Date and Place-May 9,1995; Massachusetts Cause or Causes-The licensee's staff involved in the brachytherapy procedure were not familiar Nature and Probable Consequences-A patient with handling of the applicator that contained the was prescribed a 296 megabecquerel(MBq)(8 NUREG-0090, Vol.18, No. 2 4

AbnorniaY Occurrences,2nd Otr CY95 millicurie [ mci]) dosage of iodine-131 (I-131) for Violation at the Severity Level IV on June 26, hyperthyroidism; however, a dosage of 1106.3 1995.

MBq (29.9 mci) was administered.

This event is considered closed for the purpose of Representatives of the hospitalinformed the this report.

referring physician and the patient of the misadministration. An NRC medical consultant was obtained to evaluate the event and stated that the higher dosage given to the patient will result 95-6 Multi le Medical Brach) therapy P

m a more likely achievement of the mtended therapeutie goal to eliminate the patient's Misadministrations at Madigan hyperthyroidism. Additionally, the consultant Army Medical Center in Fort determined that it is unlikely that the patient is at Lewis, Washington significant risk of experiencing long-term consequences from receiving the higher dosage The following information pertaining to this event beyond the risk associated with the prescribed is also being reported concurrently in the Federal dosage. Therefore, the impact on the patient's Register. Appendix A (see Event Type 5[d] in health is expected to be negligible with no Table A-1) of this report notes that administering expected long-term disability. (The intent of the a therapeutic dose from a sealed source such that prescribed dose was to ablate the portion of the the treatment dose differs from the prescribed thyroid remaining after surgery and then support dose by more than 10 percent and the event the patient with thyroid supplement the rest of (regardless of health effects) affects two or more her life. This did not change with the patients at the same facility can be considered an administered dose.)

AO.

Cause or Causes-The licensee stated that this Date and Place-February 1994 through May event occurred because of a human error. The 1995; Madigan Army Medical Center (MAMC);

technologist involved in this procedure Fort Lewis, Washington.

inadvertently switched the labeled lids on the vial shields containing the I-131 dosages prescribed Nature and Probable Consequences-Four for different patients. Additionally, the technician p tients were presenbed brachytherapy failed to check for the correct dosage on the vial procedures, usmg indium-192 seeds of different label, and the wrong dose was administered to the s urce strengths, and received doses other than intended patient.

those presenbed because of the same computer mput error. (The same computer mput error could cause either underdoses or overdoses Actions Taken to Prevent Recurrence because the algorithm used was dose dependent.)

Details of the misadministrations are as follows:

Licensee-The licensee instituted a procedure for checking the viallabel before giving a dose. In Patient A: The patient was prescribed a dose of addition, the licensee is obtaining a second dose 2800 centigray (cGy)(2800 rad) for a calibrator which will be used in the out-patient gynecological brachytherapy dosing room of the Thyroid Clinic. Each dose treatment, but received a dose of will be re-assayed immediately before the I-131 is about 1680 cGy.(1680 rad)instead.

administered to the patient, rather than relying on the assay which was performed in the Thyroid Patient B: Event 1 - The patient was prescribed a Lab before the dose was transported to the dose of 1600 cGy (1600 rad) outpatient dosing room.

for lung treatment, but received a dose of about NRC-NRC performed an inspection on May 12, 2128 cGy (2128 rad)instead.

1995, to learn about the event and determined that it constituted a misadministration as defined Event 2 - On another day, the same in 10 CFR 35.2. NRC determined that this was an patient was prescribed a isolated violation of the licensee's Quality dose of 1500 cGy (1500 rad)

Management Program and issued a Notice of for lung treatment, but 5

NUREG-0090, Vol.18, No. 2

~

~

Abnormal Occurrences,2nd Otr CY95

]

received a dose of about check of dose rate calculations generated by the 2350 cGy (2350 rad)instead.

treatment planning system.

Patient C: 'Ihe patient was prescribed a dose of Actions Taken to Prevent Recurrence 3000 cGy (3000 rad) for gynecological treatment, but received a dose of Licensee-The physics staff at MAMC promptly about 5142 cGy (5142 rad)instead, corrected the data entered into the computer treatment planning computer, recalculated the doses received by the patients, and took steps to Patient D: The patient was prescribed a dose of ensure that appropriate data will be used for 1500 cGy (1500 rad) f ir a biliary tract future treatment plans.

treatment, but received a dose of about 2050 cGy (2050 rad)instead.

NRC-NRC initiated an inspection on June 6, 1995, to review the circumstances associated with the misadministrations and to review the The licensee does not expect the patients to experience any adverse health effects as a result of licensee s corrective actions. (As of the date of the misadministrations.

this report, the mspection is ongoing.) An NRC medical consultant will review each case m order to provide an independent assessment of the Cause or Causes-Based upon NRC's initial potential consequences of the overdoses.

review of the misadministrations, it appears that the probable causes of the treatment errors were This event is considered closed for the purpose of failures to: (1) independently review or check the this report.

data input to the computerized treatment planning system, and (2) perform an independent AGREEMENT STATE LICENSEES The 29 Agreement States have approximately Date and Place-May 23-26,1993; " Unspecified 15,000 active material licenses for the use of Licensee; New York, New York. (New York State byproduct materials in industrial, medical, and law prohibits disclosure of the licensee's name.)

academic applications. Procedures have been developed for Agreement States to screen Nature and Probable Consequences-A patient incidents and events using the same criteria and was prescribed a total dose to the right guidelines as NRC, and to report those superclavicular area and spine of 2400 centigray occurrences that have been determined to be (cGy)(2400 rad) using cobalt-60 teletherapy significant enough to be considered as AOs.

equipment. During simulation, the technologist Using the criteria and guidelines in Appendix A erroneously placed the preparatory tattoo marking of this report, the following occurrences were the treatment area on the wrong side of the determined to be significant enough to be patient. The patient consequently received a dose reported as AOs.

of 900 cGy (900 rad) to the left superclavicular area which was the wrong treatment site. The patient was then resimulated and the treatment to AS 95-1 Medical Teletherapy the correct site was administered as prescribed.

Misadministration at an The licensee informed the referring physician of

" Unspecified Licensee" in the misadministration, and the referring physician New York, New York chose not to inform the patient. The licensee also stated that no adverse health effects resulted from Appendix A (see Event Type 3 in Table A-1) of the misadministration.

this report riotes that a therapeutic exposure to any part of the body not scheduled to receive Cause or Causes-The misadministration radiation can be considered an AO.

occurred because the licensee staff marked the NUREG-0090, Vol.18 No. 2 6

1

Asnorms Nedrrences,XnfiQtrTMFJ wrong treatment area on the patient during a significant change in lung function could be simulation in preparation for treatment.

measured with the dose given to the right lung. A dose of this type may eventually cause a drying out of the lung mucosal cells in that region, Actions Taken to Prevent Recurrence result,ng m a " dry cough.

i Licensee-The licensee issued a notice to all of its personnel concerning the importance of accurate Cause or Causes-A chest x-ray showing that the marking of treatment areas. Also, residents, HDR remote afterloading unit's positioning physicists, technologists, and attending staff were catheter was erroneously placed in the right lung reminded that the treatment remarks in patient was not reviewed by either the pulmonologist or charts should accurately reflect the original the radiation oncologist.

prescription. In-service training was held concerning the issues, and the applicable Actions Taken to Prevent Recurrence procedures covering treatment prescriptions and Licensee-The licensee took the following actions field markings were revised.

to prevent recurrence: (1) real-time fluoroscopy State Agency-Acting under authority granted by will be used at the time of the bronchoscopy;(2) a the State Agency, the New York City Bureau of guide wire will be utilized within all bronchial Radiological Health investigated the catheters at the time of the bronchoscopy;(3) a misadministration and submitted its investigative chest x-ray will be obtained and reviewed by the reports to NRC. The reports contained participating physicians immediately following the information about the licensee's actions to prevent bronchoscopy and catheter insertion, and prior to patient transport to the brachytherapy unit; and recurrence, (4) confirmation of the intended treatment site This event is considered closed for the purpose of will be obtained from the patient consent form this report.

and through verbal communication with the pulmonologist, radiation oncologist, patient, and unit staff members.

State Agency-The State Agency requested that AS 95-2 Medical Brachytherapy the licensee take the above corrective actions.

Misadministration by Mobile Technology, Inc., at Irvine TIiis event is considered closed for the purpose of Medical Center in Irvine, this report.

California Appendix A (see Event Type 3 in 'Ihble A-1) of this report notes that a therapeutic exposure to AS 95-3 Overexposure of Personnel at any part of the body not scheduled to receive Gwinnett Medical Center in radiation can be considered an AO.

Lawrenceville, Georgia Date and Place-March 14,1995; Irvine Medical Appendix A (see For All Licensees, Criterion Center; Irvine, California.

No.1) of this report notes that exposure of the feet, ankles, hands or forearms of any individual Nature and Probable Consequences-A patient to 375 rem or more of radiation can be considered was prescribed a brachytherapy treatment to the an AO.

left lung using a high dose rate (HDR) remote afterloading unit. However, because of an error Date and Place-April 6,1995; Gwinnett Medical the patient received 800 centigray (800 rad) to the Center; Lawrenceville, Georgia.

right lung.

Nature and Probable Consequences-Licensee The patient and the referring physician were personnel involved in a brachytherapy treatment informed of the misadministration. The patient's using iridium-192 seeds received exposures above physician stated that based on a five-year survival minimum as a result of handling what they rate the chance of clinically noticeable assumed was a dummy source. The personnel complications would be extremely low, and no included physicists, physicians, technologists and 7

NUREG-0090, Vol.18, No. 2

Abnormal Occurrences,2nd Qtr CY95 nursing staff. One of the physicists was pregnant received inservice training and were advised not (estimated at 11 weeks), but did not receive any to handle any radioactive material until May 1996.

significant overexposure. The most significant case was an overexposure to Physicist A who State Agency-The Department of Natural received 8.83 millisievert (mSv)(883 millirem Resources of the State of Georgia investigated the

[ mrem]) effective dose equivalent and 12,560 mSv incident. The corrective and preventative actions (1256 rem) to the hands. Exposures for other submitted by the licensee will be reviewed during involved individuals were as follows:

the next inspection by the Department.

Enforcement action will be taken as appropriate.

Physicist B: 1.15 mSv (115 mrem) effective dose The event is considered closed for the purpose for equivalent and 433 mSv (43.3 rem) this report.

to the hai ds Physician A: 1.08 mn (108 mrem) effective dose equ ent and 54 mSv (5.4 rem) t AS 95-4 Medical Brachytherapy Misadministration at Physician B: 0.31 mSv (31 mrem) effective dose Southwest Texas Methodist equivalent and 108 mSv (10.8 rem)

Ilospitalin San Antonio, to the hands Texas A pene.r

.'see Event 'Iype 5[d] in Table A-1) of P

Technologist: 1.55 mSv (155 mrem) effective dose this rc w ates that admm,istermg a therapeutic equivalent dose ft a a scaled source such that the treatment dose differs from the prescribed dose by more It should be noted that physicist A has not shown than 10 percent and the event (regardless of any signs of erythema' health effects) affects t.wo or more patients at the same facility can be considered an AO.

Cause or Causes-The licensee stated that the overexposures occurred because:(1) the hospital Date and Place-July 28,1994; Southwest Texas procedures were not followed when ordering the Methodist Hospital; San Antonio, Texas.

radioactive material: (2) the personnel handling the iridium-192 seeds assumed that they were Nature and Possible Consequences 'I\\vo patients l

dummy sources; (3) the physicist 6 t>rimarily were prescribed brachytherapy procedures using j

handled the sources did not have proper training manual loading for prostate treatment. One was and experience, or adequate supervision during prescribed to receive a dose of 160 gray (Gy) the performance of the treatment; (4) a survey (16,000 rad) of iodine-125 and the other was meter was not used while opening the shipping prescribed a dose of 115 Gy (11,500 rad) of container; (5) film badges were not worn or were nalladium-103. However, because of an error the worn improperly;(6) there was confusion among implant sources of the two patients were switched.

the physicists as to whether a dummy source was ordered; (7) there were problems in identifying the The patients and their referring physician were dummy source from the radioactive seeds, and notified of the misadministration. The licensee (8) the source was left unshielded after being staff indicated that the two doses were biologically returned to the shipping container.

equivalent and stat.ed that the only effects expected are those that would result if the prescribed doses were administered to the correct Actions Taken to Prevent Recurrence patients.

Licensee-The licensee addressed the issues Cause or Causes-The licensee was unable to involving the incident, and either has or will determine how the misidentification occurred.

implement corrective actions to prevent recurrence. Exposure dose calculations have been Actions Taken to Prevent a Recurrence made by a certified health physicist. The personnel training and accreditation program has Licensee-The Radiation Safety Committee been modified. Physicist A and Physicist B have immediately implemented new procedures for NUREG-0090, Vol.18, No. 2 8

Abnormal Occurrences,2nd Qtr CY95 ordering, receiving, loading, sterilizing, a.'d This event'is considered closed for the purpose of implanting prostate implants.

this report.

State Agency 'Ihe State agency investigated the incident and reviewed the new procedures for prostate implants. No violations were cited, i

l l

I-l l

9 NUREG-0090, Vol.18, No. 2

Abnormal Occurrences,2nd Qtr CY95 APPENDIX A ABNORMAL OCCURRENCE CRITERIA 1 The following criteria used to determine an averaged 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 abnormal occurrence (AO) were set forth in an 500 times the regulatory limit of Appendix B, NRC policy statement published in the Fedeml Table II,10 CFR Part 20 [CFR 20.403(b)(2)].

Register on February 24,1977, (Vol. 42, No. 37, 4.

Radiation or contamination levels in excess of pages 10950-10952).

design values on packages, or loss of An event will be considered an AO if it involves a confinement of radioactive material such as major reduction in the degree of protection of the (a) a radiation dose rate of 1000 mrem per public health or safety. Such an event would hour three feet from the surface of a package mvolve a moderate or more severe impact on the containing the radioactive material, or (b) public health or safety and could include but need release of radioactive material from a not be limited to:

package in amounts greater than the regulatory limit.

1.

Moderate exposure to, or release of, radioactive material licensed by or otherwise 5.

Any loss of licensed material in such regulated by the Commission; quantities and under such circumstances that substantial hazard may result to persons in 2.

Major degradation of essential safety-related unrestricted areas.

equipment; or 6.

A substantiated case of actual or attempted 3.

Major deficiencies in design, construction, theft or diversion of licensed material or use of, or management controls for licensed sabotage of a facility.

facilities or material.

7.

Any substantiated loss of special nuclear Examples of the types of events that are evaluated material or any substantiated inventory in detail using these criteria are:

discrepancy that is judged to be significant relative to normally expected performance For All Licensees and that is judged to be caused by theft or diversion or by substantial breakdown of the 1.

Exposure of the whole body of any individual accountability system.

to 25 rem or more of radiation; exposure of the skin of the whole body of any individual 8.

Any substantial breakdown of physical to 150 rem or more of radiation; or exposure security or material control (i.e., access of the feet, ankles, hands or forearms of any control, containment, or accountability individual to 375 rem or more of radiation systems) that significantly weakened the

[10 CFR 20.403(a)(1)], or equivalent protection against theft, diversion, or exposures from internal sources.

sabotage.

9.

An accidental criticality [10 CFR 70.52(a)].

2.

An exposure to an individual in an unrestricted area such that the whole body

10. A major defic.iency in design, construction, or dose received exceeds 0.5 rem in one calendar operation having safety implications year [10 CFR 20.105(a)].

requiring immediate remedial action.

3.

The release of radioactive material to an

11. Serious deficiency in management or unrestricted area in concentrations which, if procedural controls in major areas.

12. Series of events (where individual events are I n Janu ry 1.1994, changes to Title 10 of the Code of Federal not of major importance), recurring incidents, Regidarons Part 20 were promulgated. At the Commission s direc-tive, the staff is currently developmg a policy statement revising and incidents with implications for s.imilar critena for various types of Aos. The changes pertinent to the 10

[acilities (generic incidents) that create major CFR 20 revision will also be included in that draft policy state-safety concern.

ment. Upon Commission's approval. the appropriate changes to this Appendix will be pubhshed.

I1 NUREG-0090, Vol.18, No. 2

Abnormal Occurrences,2nd Otr CY95 For Commercial Nuclear Power Plants For Fuel Cycle Licensees 1.

Exceeding a safety limit of license Technical 1.

A safety limit oflicense Technical Specifications [10 CFR 50.36(c)).

Specifications is exceeded and a plant 2.

Major degradation of fuel integrity, primary coolant pressure boundary, or primary 2.

A major condition not specifically considered containment boundary.

in the safety analysis report or Technical Specifications that requires immediate 3.

Loss of plant capability to perform essential remedial action.

safety functions such that a potential release of radioactivity in excess of 10 CFR Part 100 3.

An event that seriously compromised the guidelines could result from a postulated ability of a confinement system to perform its transient or accident (e.g., loss of emergency designated function.

core cooling system, loss of control rod system).

Medical Misadministrations 4.

Discovery of a major condition not As discussed in the Preface to this report, the specifically considered in the Safety Analysis NRC policy statement on AOs was published Report (SAR) or Technical Specifications that before licensees were required to report medical requires immediate remedial action.

misadministrations to the NRC. Therefore, during 1984, NRC developed guidelines for 5.

Personnel error or procedural deficiencies selecting such events for AO reporting. These that result in loss of plant capability to guidelines, which are summarized in Table A-1, perform essential safety functions such that a augment the NRC policy statement.

potential release of radioactivity in excess of 10 CFR Part 100 guidelines could result from As noted in the Preface, revised guidelines are a postulated transient or accident (e.g., loss currently being developed because new medical of emergency core cooling system, loss of misadministration definitions became effective on control rod system).

January 27,1992.

NUREG-0090, Vol.18, No. 2 12

Abnormal Occurrences,2nd Otr CY95 l

Table A-1 NRC Guidelines for Selecting Medical Misadministration Events for Abnormal Occurrence (AO) Reporting l

AO Reporting Threshold Event Type Diagnostic Exposure Therapeutic Exposure (1) Administering a radiopharma-If the improper administration If the improper administration ceutical or radiation from a results in any part of the results in any part of the body sealed source other than the body receiving unscheduled receiving unscheduled radiation, an one intended.

radiation, an AO report should AO report should be proposed for be proposed if:

any such event.

(a) the actual dose to the If the parts of the body wrong body part is receiving radiation greater than five times improperly would have the upper limit of the received radiation anyway, normal range of had the proper administration exposures prescribed been used, an AO report for diagnostic procedures should be proposed if:

involving that body part, or (b) there are clinical (a) the actual dose is greater indications of any than 1.5 times that intended adverse health effects to the above described body to the wrong body part.

parts, or, If the parts of the body (b) the actual dose is less than receiving radiation 0.5 times that intended to the improperly would have above described body parts, or, received radiation anyway, had the proper administration (c) the above described bodyparts been used, an AO report should show signs of adverse health be proposed if:

effects greater than expected had the proper administration been used, or (a) the actual dose is greater (d) the event (regardless of any than five times that intended health effects) affects two or to the above described body more patients at the same parts, or, facility.

(b) the above described body parts show signs of adverse health effects greater than expected had the proper administration been used.

(2) Administering a radio-An AO report stould be An AO report should be l

pharmaceutical or radiation proposed if:

proposed for any such event, to the wrong patient. or (a) the actual dose to the wrong patient exceeds five times the prescribed dose for the intended patient, or (b) the event results in any adverse health effects.

(3) Administering a radiophar-Same guidelines as for Same guidelines as for maceutical or radiation by a Event Iype 1.

Event Type 1.

13 NUREG-0090, Vol.18, No. 2

Abnormal Occurrences,2nd Qtr CY95 Table A 1 (Continued)

AO Reporting Threshold Event Type Diagnostie Exposure Therapeutic Exposure route of administration other than that intended by the pre-scribing physician.

(4) Administering a diagnostic An AO report should be Not applicable.

dose of a radiopharma-proposed if:

ceutical differing from the prescribed dose by more than 50 percent.

(a) the actual dose is greater than five times the prescribed dose, or, (b) the event results in adverse health effects worse than expected for the normal range of exposures prescribed for the diagnostic procedure.

(5) Administering a Not applicable.

An AO report should be therapeutic dose of proposed if:

a radiopharmaceutical differing from the prescribed (a) the actual dose is greater i

dose by more than 10 percent; than 1.5 times the prescribed or administering a therapeutic

, dose, or, radiation dose from a sealed source such that errors in the (b) the actual dose isless than source calibration, time of 0.5 times the prescribed exposure, and treatment dose, or geometry result in a calculated total treatment dose (c) the event results in adverse from the final prescribed health effects worse than total treatment dose by more wo':Id be expected for the than 10 percent.

normal range of exposures prescribed for the therapeutic procedure,or, (d) the event (regardless of any health effects)affects two or more patients at the same facility.

(6) Recur.ing or series of For either diagnostic or therapeutic exposures, an AO report should be events (regardless of the proposed for recurring events or a series of events (in which each individual number of patients or misadministration is not of major importance) that create a significant facilities i.1volved).

public health or safety concern.

J (7) Gene:ic events.

For either diagnostic or therapeutic exposures, an AO report should be proposed for misadministrations with generic implications that create a significant public health or safety concern.

NUREG-0090, Vol.18, No. 2 14

Abnormal Occurrences,2nd Qtr CY95 APPENDIX B UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES j

During April through June 1995, NRC licensees, below contain a summary of information 1

Agreement States, Agreement State licensees, and presented in previous reports and any subsequent other involved parties, such as reactor vendors updated information provided during the and architect-engineering firms, continued with reporting period. Those updated events which the implementation of actions necessary to still require additional information will be i

prevent recurrence of previously reported discussed in future reports.

abnormaloccurrences(AOs). The AOs discussed OTHER NRC LICENSEES 92-18 Loss ofIridium-192 Source and (40 millirem to 22 rem). The source was Medical Therapy eventually mixed by accident with medical Misadministration at OncoloU biohazard waste and was subsequently found and Services Corporation in Indiana, recovered at the site of a company that had been contracted to dispose of biological waste material.

Pennsylvania This abnormal occurrence (AO) was origmally The AO report is updated as follows:

reported in NUREG-0090, Vol.15, No. 4, " Report The licensee submitted information in letters to Congress on Abnormal Occurrences, dated August 31,1994 and October 4,1994 in October-December 1992," under the title " Loss of response to the NRC's Notice of Violation and Iridium-192 Source and Medical Therapy Proposed Imposition of Civil Penalties dated May Misadministration at Indiana Regional Cancer 31,1994. After consideration of the licensee's Center in Indiana, Pennsylvania."

responses, NRC concluded that ar JGequate basis was not provided for withdrawal of any of the The AO criten.a used were:

violations or for mitigation of the civil penalties.

(1) Event TyPC 5,in Table A-1-A An Order Imposing Civil Penalties - $280,000 therapeutic dose that is greater than 1.5 (Order)was issued on April 24,1995. The licensee had 30 days after the Order was issued to times the prescribed dose; and pay the civil penalties. The licensee also had 30 (2) For All Licensecs, Criterion No. 2-An ys aner th Or&r was issd to requst a heanng on the Order, and it did so via a letter exposure to an individualin an dated May 18,1995.

unrestricted area such that the whole body dose received exceeds 0.5 rem in Concurrent with the enforcement process, the one calendar year.

licensee requested the termination of its license on December 13,1993, with the license to be On November 16,1992. Oncology Services replaced by individual licenses issued to the Corporation lost a 159,000 gigabecquerel (43 facilities named as locations of use on the curie) sealed iridium-192 source from a high dose Oncology Services Corporation (OSC) license.

rate (HDR) remote afterloader brachytherapy unit The OSC license was terminated on August 24, at its Indiana Regional Cancer Center in Indiana, 1994, concurrent with new licenses being issued to Pennsylvania. The source had:(1) broken off of five of the six facilities which were previously the 11DR unit while in service; (2) subsequently listed as locations of use on the OSC license.

killed a patient with a 1,600,000 centigray (1,600,000 rad) absorbed dose, after remaining on This event is considered closed for the purpose of the patient's body for almost 4 days; and (3) this report.

caused 94 other people to receive radiation ranging from 400 microsievert to 220 millisievert 15 NUREG-0090, Vol.18, No. 2

Abnormal Occurrences,2nd Otr CY95 AGREEMENT STATE LICENSEES AS 88-5 Medical Teletherapy AS 88-6 Multiple Medical Teletherapy Misadministration at Sacred Misadministrations at Sacred Heart Hospital in Heart Hospital in Cumberland, Maryland Cumberland, Maryland This AO was originally reported in This AO was originally reported in NUREG-0090, Vol.11, No. 4, " Report to NUREG-0090, Vol.11, No. 4, " Report to Congress on Abnormal Occurrences, Congress on Abnormal Occurrences, October-December 1988."

October-December 1988."

The AO criterion used was a moderate or more The AO criterion used was a moderate or more severe impact on public health or safety, as stated severe impact on public health or safety, as stated in the second paragraph of the General Criteria.

in the second paragraph of the General Criteria.

Over a 13-month period 33 patients undergoing, On September 2,1988, an 81-year-old patient bram cancer treatments had received therapeutic received a therapeutic dose of 1400 centigray radiation exposures from a cobalt-60 teletherapy (1400 rad) to a part of the body not scheduled to machine that exeeeded the prescribed dose by at receive radiation. The event was reported as an least 10 percent m each case. The event was AO because it involved a moderate or more reported as an AO because it involved a moderate severe impact on public health or safety.

or more severe impact on public health or safety.

The AO report is updated as follows:

The AO report is updated as follows:

NRC is continuing to work with the State of NRC is continuing to work with the State of Maryland to obtain more information regard.mg Maryland to obtain more information regarding this meident.

these incidents.

This event will be updated when additional This event will be updated when additional information becomes available.

information becomes available.

NUREG-0090, Vol.18, No. 2 16

Abnormal Occurrences,2nd Qtr CY95 APPENDIX C OTIIER EVENTS OF INTEREST "Other Events of Interest" are reported because During the period from April 1 through June 30, they can be perceived as being significant but 1995, no "Other Events of Interest" items were have been determined not to involve a major reported.

reduction in the level of protection provided for public health or safety; therefore they are not reportable as abnormal occurrences.

17 NUREG-0090, Vol.18, No. 2

_-_-_-_-.m____

NRC FORM 336 U.S. NUCLEAR REGULATORY COMMISSICN MPORT NUMBER 3

M 1102, u

Rev and Num-3201. W BIBLIOGRAPHIC DATA SHEET b"* -

l' ""Y 3 (S Instructiens on the r rs.)

NUREG-0090

2. TM AND SUBTm Vol.18, No. 2

(

3. DATE REPORT PUBUSHED

(

Report to Congress on Abnormal Occurrenc:es:

uoNTH I

vEm April-June 1995 I

October 1995 y

4. FIN OR GRANT NUMBER l

6. AUTHOR (5)

6. TYPE OF REPORT l

Quarterly

7. PERIOD COVERED (incluelve Dates)

January-March 1994

8. PERFORMING ORGANIZATION - NAME AND ADDRESS (if NRC. prov6de Diviolon, Office or Reg 6cn U.S. Nuclear Regulatory Comrnission, and malling address; if contractor, provide name and rnalling address.)

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

9. SPONSORING ORGANIZATION - NAME AND ADDRESS (if NRC, type *Same as above"; if contractor, provide NRC Division. Offloe or Region, U.S. Nuclear Regulatory Commission, and malling address.)

Same as 8., above.

10. LUPPLEMENTARY NOTES f

d

11. ABSTRACT (200 words or less)

Section 208 of the Energy Reorganization Act of 1974 identifies abnormal occurrence (AO)as an unscheduled incident or event that the Nuclear Regulatory Commission determines to be significant from the standpoint of public health orsafety requires a quarterly report of such occurrences to be made to Congress. This report provides a description of those inci-dents and events that have been determined to be AOs during the period of April 1 through June 30,1995.

'Ihis report addresses five AOs at NRC-licensed facilities. One involved a reactor coolant system blowdown at a pressur-ized water reactor (PWR) nuclear power plant, one involved a previously unidentified path for the potential release of radioactivity at a PWR nuclear power plant, two involved medical brachytherapy misadministrations, and one involved a medical therapeutic radiopharmaceutical misadministration. Four AOs submitted by the Agreement States are incuded.

One involved a medical teletherapy misadministration, two involved medical brachytherapy misadministrations, and one involved the overexposure of personnel at a medical center. The report also contains an update of one AO previously reported by an NRC licensee and two AOs previously reported by the Agreement States. No "Other Events ofInterest" items are being reported.

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

13. AVAILA8iUTY STATEfENT Unlimited Nuclear; Reactor; Coolant System Blowdown; Wolf Creek; Path for Release of Radioac-

'* h*'

tivity; Millstone; Medical; Misadministration; Brachytherapy; 'Ibletherapy Unclassified (This Report)

Unclassified

15. NUMBER OF PAGE8 to. PRICE NRC FORM 336 (2-80;

Printed on recycled paper Federal Recycling Program

NUREG-0090, Vol.18, Nr. 2 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES OCTOZER 1995 APRIL - JUNE 1995 UNITED STATES NUCLEAR REGULATORY COMMISSION FIRST CLASS MAIL WASHINGTON, D.C. 20555-0001 POSTAGE AND FEES PAID USNRC PERMIT NO. G-67 OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300 hs,555139531 0

DTV.$f7,0^DM 1ANico3(

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20555 i

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