ML20114F538

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Report to Congress on Abnormal OCCURRENCES.April-June 1992
ML20114F538
Person / Time
Issue date: 09/30/1992
From:
NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V15-N02, NUREG-90, NUREG-90-V15-N2, NUDOCS 9210130169
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{{#Wiki_filter:_. d i NUREG-0090 Vol.15, No. 2 .. 7 Reaort to Congress on Ainormal C'ccurrences April-June 1992 U.S. Nuclear Regulatory Commission l-P OITice for Analysis and Evaluation of Operational Data en arouq'o,,. +* 9210130169 920930 PDR NUREO 0090 R PDR ,.: -,2.,.. _... -.. -....

.... -.. ~, - _ _ . ~. ~... ~ -.. -. -.. - _ - - -. - ~ -.. d l l; e t a i Availablo from Superintendent of Documents U.S. Government Printing Offico Post Offico Box 37082 Washington, D.C. 20013-7082 A year's subscription consists of 4 issues for this publication. Single copies of this publication + are available from National Technical infortiation Service, Springfield, VA 22161 5 1 1 - ( i ..... -. :.-. ; ; -... ~. ~. -. .. -. - ~...

NUREG-0090 Vol.15, No. 2 Report to Congress on Abnormal Occurrences April - June 1992 Date Published: September 1992 Omce for Analysis and Evaluation of Operational Data U.S. Nuclear llegulatory Commission Washington, DC 20555 f. =a.g

Previous Iteports in Series j NI1111:0 75/tf% Janurydure 1975, Nt fitEG4trM Vol 6, Na 4, October December 1983 pubbshed October 1975 pubbshed May 1984 Nilit! GarAl-1, Ju!y Septernber 197.( NUlti'04RF% Vol 7 Na 1 January March 1954, pubbshtd March 1976 pubbshed July 1984 NUlG104W rAb2, t -)ctoh r December 1975. NUllIXMWrR Vol 7, Na 2, Aptdaune 1984, pubbshed March 1976 pubbshed October 1984 NUlilliarm 3, Janumy-March 1976. NUltEGaru Vol. 7, Na 3. July September 1984, pubbhed July 1976 pubbsheJ Apol 1985 NUlti:04NfM-4 Apnt-June 1976 NllitEGerM. Vol 7. Na 4. October December 1984, pubbshed March 1977 pubbshed May 1985 hUllLG4r>0 5, JulySeptemtsr 1976. NUlt! 04NrAi, Vol 8. No.1. January 4tarch 19SS, pubhshed March 1977 pubbshed August 1985 NUlRGarM4 (ktober-Decemtwr 1970, NUlt LGe rX1, Vol 8. No. 2, Apnbjune 1985, pubbshed June 1977 pubhshed November 1955 NUltl:G4UU -7, January March 1977 Nt11tEG4r4 Vol S, No 3, July-Septcmber 1985, pubbshed Jur c 1971 pubhshed i ebruary 1986 NUltI:0 Dir'ib8, Apnbjune 1977, NUllEG-OrM, Vol. 8, Na 4. October-Decender 1985, publ.shed September 1977 pubbshed May 19S6 NUlti G-tu rAb9, J uly4cptember 1977 NUltl:Garu Vol 9. Na 1, January 4tarch 1986,

ubinhed Novembc r 1977 pubbshed September P66 NUltEG4UAblo, October-Decemtwr 1977, NiiltEGarn Vol. 9. No 2 ApnlJune 1956, publehed Manh 1978 pubbshed January 1987 NUltLGar>0, Vol 1, Na 1. January March 1978.

NUllEG4Wr% Vol 9.Na 3 July-September 1986 pubh*.hed June 1978 pubbshed Apnl 1987 NUltE0 4Kr>0, Vol 1. Na 2 Apnl4une 1978, NUlt1-Garn Vol 9, No 4, Octcher-December 1986, published beptcmber 1978 pubhshed July 1987 NUltE04r4 Vol 1, No 3. July-September 1978 NUllEG4fAI, Vol.10 Na 1, January 41 arch 1987, pubhshed December 1978 pubbshed October 19S7 NUlli Germ, Vol 1. Na 4. October-December 1978. NUitEGara Vol 10. Na 2 ApnlJune 1987, pubbshed Much 1979 pubhsheJ November 1987 NUltliG4f>0, Vol 2 No 1. JanuarpMarch 1979. NUltl"G4r4 Vol 10, Na 3. July September 1987, pubhshed July 1979 pubhshed March 1988 NUltEGarR Vol 2. No 2. Apnidune 1979, NUlmO4Wr>0, Vol.10, No 4. October December 1987, puhhshed Nosember 1979 pubbshed March 1988 NUlEGars Vol 2 No 3. lulpSeptember 1979, NUlEG4r4 Vol 11, No 1, January 4tarch 1988, pubbhed i ebruary 1960 pabbshed July 1958 NUldGer% Vol 2 No 4, October December 1979 NUlE04WrMI, Vol 11. Na 2 Aptd-June 1988, pubbhed Apol 1930 pubhshed December 19S8 NUIRO Dru Vol 3 No 1, JanuarpMarch 1%0, NUIEG4WAt Vol 11, No 3, July-September 1988, pubbhed September 1980 pubb6ed January 1989 NUlWGer% Vol 3, Na 2. Apollune 1980, NUIEG4rn Vol 11, Na 4, October-December 19S3, puhhshed Nosember 1980 pubhsheJ Apnl 19S9 N1Illi: Gar % Vol 3 No A JulySeptember 1980, NUlt! 04Wrn Vol 12, No 1. January 41 arch 1989, pubbshed I ebrumy 19sI pubhshed August 1989 NUlmG ern Vol 1 No 4. October-December 19so, NUlmO4in90, Vol 12, No 2, Aprillene 19b9, pubhshed May 1981 pubbhed October 19S9 NUIEGern Vol 4, No 1, January-March 1%1, N1110 G4Wf% Vol 12, Na 3, July-September 19S9 pubbsbed July 1981 pubushed January 1990 NUlWGarAi, Vol 4, No 2. Apnl June 1951. NUIEGarn Vot 12, Na 4. Ociober December 1989 puhhshed October 1951 pubbthed March F/M NUlmGar% Vol 4, No 3, hdy September lost. NlIlWG4UR Vol 13, Na 1. January 41 arch prM, pubbshed January 19S2 pubhshsd.luly U/M NUlWGar% Vol 4, Na 4, Octobi r-Decender 1981, NUlWG4NrML Vol 13. Na 2, Aprildune 19%t pubbshed May 19M2 pubhshed October 1990 NUl&G4F4 Vol 5. No 1, January 40uch 1%2. NUIEGarn Vol 13, No 3, July-September IVA pubbshed August "!S2 pubbshed January 1111 NUlu Germ, Vol 5, No. 2 Apubjune 10 2, NUlti!Garn Vol 13 No 4. October-December 190, 3 pubbshed December 1982 pubhshed March Pr>l NUlWGaru Vol 5, N t 3, July Septemtwr 19S2. NUl&Gerd Vol 14 Na 1, January 4tarch p>91, pubbshed Janusy 1983 pubh ed June 1991 NUlti Garu Vol 5, Na 4 tictober. December 1982 N1ilWG tarM Vol 14, Na 2. Apnidune P/11, pubbshed May 9S3 published Seriember l?>l NUIRG OtrA Vol 6, Na 1. January 41 arch 19S3, N1:ltFGerM, Vol 14. Na 3. July September 1991, pubbshed September 1983 pubbshed December Pr>l NUIRGaru Vol 6 Na 2. Apuldune 1981 Nid&Garu Vol.14. No 4, October-December 1711, pubbshed elovembei 19X3 pubbshed March P192 NUlWG4 nrm Vol 6. No 3. JulySeptember 1953 NURFG4WM, Vol 15. Na 1 January 41 arch 1712, puhhshtd Aprd 19n4 pebbshed July 1992 li

..__m .m. Abnotmal Occurrences,2nd Otr CY92 AllSTRACT Section 208 of the linerfy iteorganiiation Act of 1974 tion capability at the Shearon liarri; Nuclear Power identifies an abnormal occur rence as an unscheduled inci-I'lant. 'Ihe other four involved medical misadministra. dent or event that the Nuc! car llegulatory Commission tions (three therapeutic and one diagnostic) at NitC-determines to be significant from the standpoint of public licensed facilities. No abnormal occurrences were re-health or safety and requires a quarterly report of such ported by NitC's Agreement States. The repor1 also events to be made to Cogress. 'lhis report covers the contains information updating a previously reported ab-period from April I through June 30,1992. normal occurrence. Itive abnormal occurrences are discussed in this report. One involved on extended loss of high head safety injec-l I ( t i ist NUlti!G -0090, Vol.15. No. 2

.t.bnormal Occurrences,2nd Otr CY92 CONTENTS Page Abstract... iii Preface vil Introduction..... vii 'the Regulatory System vii Reportable Occurrer vii Agreement States.. viii Foreign Information vili Report To Congress On Abnormal Occurrences, April-June 1992 1 N uclear Power Plants............................. I 92-4 less of liigh-f lead Safety injection Capability at Shearon liarris Nuclear Power Plant..... 1 Fuel Cyc!c Facilities (Other than Nuclear Power Plants)............................ 3 Other NRC ljcensees (industrial Radiographers. Medical Institutions, Industrial Users, etc.). 3 92-5 Medical Therapy Misadministration at lieth Israel 11ospital in Passaic, New Jersey.. 3 92 4 Medical Therapy Misadministration at llospital Metropolitano in Rio Piedras, Puerto Rico.. 4 92-7 Medical Diagnostic Misadmmistration at llaystate Medica! Center, Inc.'rporated, in Springfield. Massachusetts. 5 92-8 Medical'lherapy Misadministration at The Chrbt llospital in Cmcinnati. Ohio..... 6 Agreement State 1.icensees.. 7 References. 9 Appendix A-Abnormal Occurrence Criteria...... I1 Appendix Il-Update Of Previously Reported Abnormal Occurrences.......... 15 Other NRC Licensees.. 15 91-8 Radiation lixposures of Members of the Public from a lost Radioactive Source.. 15 Appendix C-Other livents Of Interest. 17 Other NRC Licensees. 17 1. improper Movement of Fuel at the University of Michigan Research Reactor 17 References it.ppendices 19 v NURl!G-0090. Vol.15, No. 2

i l 1 Abnormal Occurrences. 2nd Otr CY92 PIWFACE i I Ilitrodiletioll rules and regulations in Title 10 oi the Code ofIrderal Rcgulations. Bus includes public participation as an cle- 'the Nuclear llegulatoiy Commission r eputs to the Con. ment. To accomplish its olyc(tives. NitC regularly con. gress each quarter under provisions of Section 20S of the ducts liceming proceedmgs inspection and enforcement linergy lleorganization Act of l'U4 on any abnonnal oe-activities, evaluauon of operating experience, and confir-i currences involving facilities and activities regulated by matory rescaich, while rnaintaining programs for estab-the NitC. An abnormal occurrence is defined in Sec. lishing standards and inuing technical reviews and stud-tion 208 as an unstheduled incident or esent that the ict Comminion deter mines is signiheant fr om Ihe standpunt of public he dth or safety. In licensing and regulating nuclear p>wer plants and the uses of byptoJuct nuclear rnatcrials the NltC follows the I! vents are currently identified as ubnorinal occurrences philosophy that the health and safety of the public nre for this repor t by thi NitC using t he criteria and accompa. best ensured through thc establishment of multiplclevels nying exampleslisted in Appendix A.These crueria were of protection.'these multiple levels can be achieved and promulgated in an NltC policy statement that was pub. rnaintained through regulations specifying seguirements lished in. the federal Registcr on February 24, 1977 that wdl ensure the safe use of nuclear materiW 'lhe (Vol. 42, No. 37 pages 10950-19952). regulations include design and quidity anurance criteria appropriate for the various activities hcensed by the 'the NitC pobey statement was published before liten. NltC, An inspection and enforcement program helps en-sees were required to report medical misadministrations sme compliance with the regulations. to the NitC.1:cw of the examples in the policy statement are applicable to medical misadministrations. 'therefore, Ikprbllie Oedtrrel100S during 19M, Ihe NltC developed guidehnes for selectmg such events for abnoimal occurrence reporting. 'ihese Actual operatmg experience is an essential input to the guidelines, which have been used by the N:tC since the regulatory process for anuring that beensed activities are latter part of 10M. augment the NitC policy statement condu;ted safely. Licensees are r equired to repor t certain exampics and are summarized in Table A-1 in Appen-incidents or events to the NitC. 'lhis ieporting helps to d_ix A. On January 27,1992, new medical nusadministra-identify deficiencies early and to ensme that corrective tion definitions becarne effectim,11herefore, revised actions are taken to prevent recurrence, guidelines for idemifying medical misadministrations as abnormal occurren: are currento being descloped. I or nuclear power plants, dedicated groups have been 'the revised guidelines will be published for comment in formed both by the NItC and by the nuclear power induo Ihe federal Regi3rcr. try for the detailed revicw of operating experience to help identify safety concerns early to improve dissemination In order to provide wide dissemination of information to of such information; and to leed back the experience into l the public, a Iedaal Regitrcr notice is issued on each heensing, regulations, and operation in addition, the abnormal occurrence. Copics ofIhe notice are distributed NltC and Ihe nuclear power indust ry have ongoing eIfor is to the NitC Public Document floom and all local puhhc to improve the operational data systems, which include Document itooms. At a mimmum, each notice must con-not only the type and goality of reporis icquired to be tain the dare and place of the occunence and describe its submitted, but also the methmis used to analpe the data. nature and probable consequences. In order to more cifectively collect, collate, store, re-trieve, and evaluate operational data, the information is 'lhe NitC has determined that only those events de-maintained in computer-based data files. l scribed in this report meet the criteria for abnormal oo cuuence reporting,'this report covers the period from 'lhree primary sources of operatioed data are Licensee April I through June 30,1992, Information reported on Event Iteports (1.lills), immediate notifications made cach event meludes date and place, nature and probable pursuant to 1001:1150 72 and medical misadministration consequences, cause or causes, and actions taken to pre, reputs made pursuant to 10 CFil 3533. vent recurrence. liscept for records exempt from pubhc disclosure by stat-ute a nd/or regulation, information concer ning r eportable Tlle llegtllillOry System oworrences at facihtic.s hcensed or otherwise regulated by the NitC is routinely disseminated by the NitC to the 'lhe system of licenung and regulation by which Nltf nuclear industry, the public, and other interested groups carries 'out its responuhditics is implemented through as these events occur. vis NUltlit i-0090, Vol.15, No. 2

Abnormal Occurrences,2nd Otr CY92 Dissemination includes special notifications to licensees programs must be comparable to and compatible with the and otner affected or interested groups, and public Commission's program for such material. announcements. In addition, information on reportable events is routinely sent to the NRC's more than 100 local Presently, information on reportable occurrences in publicdocument rooms throughout the United States and Agreement State licensed activities is publicly available at to the NRC Public Document Room in Washington, D.C. the State level. Certain information is also provided to the 'lhe Congress is routinely kept informed of reportable NRC under exchange of information provisions in the events occuning in licensed facilities. agreements. Another primary source of operational data is reports of in early 1977, the Commission determined that abnormal reliability data submitted by licensees under the Nuclear occurrences happening at facilities of Agreement State Plant Reliability Data System (NPRDS), the NPRDS is a licensees should be included in the quarterly reports to voluntary. industry-supported system operated by the In-Congress. 'the abnormal occurrence criteria included in stiti . Nuclear Power Operations (INPO), a nuclear Append (x A are applied uniformly to events at NltC and utility organizadon. Iloth engmeenng and failure data are Agreement State licensee facihties. Procedures hav: submitted by nuclear power plant licensees for specified been developed and implemented, and abnormal occur-plant comptments and systems. the Commission consiJ-rences reported by the Agreement States to the NRC are ers the NPRDS to be a vital adjunct to the 1,11R system for neluded in these quatterly reports to Congress. the collection, review, and,cedback of operational expe, rience; therefore, the Commission periodically rnonitors the NPRDS reporting activities' IforeigII Illforillatioll Agr0Cll100t StalCS 'lhe NRC participates in an exchange of information with various foreign governments that have nuclear facilities. Section 274 of the Atomic linergy Act, as amended, 'ihis foreign information is reviewed and considered in adthorizes the Commission to enter intoagreements with the NRC's assessment of operating experience and in its States whereby the Commission relinguishes and the res-arch and regulatory activities. Reference to foreign States assume regulatory authority over byprouuct, information may occasionally be rnade in these quarterly source, and special nuclear materials (in quantities not abnormal occurrence reports to Congress; however, only capable of sustaining a chain reaction). Agreement State domestic abnormal o(currences are reported. NURIiG-0090, Vol.15, No, 2 viii n

Abnormal Occurrences, 2nd Qtr CY92 ItEl'OltT TO CONGitESS ON AllNOltMAI,0CCUltitENCES Al'Itll-J UNE 1992 Nticlear l'ower l'imits '!he NI(C is reviewing events reported at the nuclear stances leading to the event, the event itself, the licen-power plants licensed to operate. For thi. report, the see's corrective actions, and the safety significance of the NitC has determined that the following event was an event. A meeting with the licensee to discuss the event abnormal ocem tence. and coller; adJitional information was held on August 20,

1942, 9M 1,oss of Iligli llead Safely injeelion

'the degraded piping and relief valves ate part of a subsys-Capobility at Shenron liarris Nuclear tem that provides protection against the possibility of opnaung the charging / safety injection pumps against a l'ower Plant reactor system pressurized atx>ve the pump discharge premne by pmviding a flow path via the relief valves to The following information pertaining to this event is also the refudmg water stomge tanM We sub@el)n is m being reported concurrently in the redend Register. Ap. ferrcJ to as the alternate mmmfum flow (Ahil system pendix A(see the second general entenon)of this tcport (see Figure 1). 'lha subytem is designed to pass flow notes that a major degradation of essentialsafety related onh when We pump discharge pressure is above the lift equipment can be considered an abnorrnal occurrence. In setpmnt of 2M 4 M39 gmg fonehef valves ICS-744 and addition, the third general eritcrion notes that major defi-1CS-755. Ihtended operation of the pumps with no net ciencies in management contmis can be considered an How can cause damage and thereby preclude achieving abnormal occurrence. the safety function flow rate at a later tune. Ihe Ahil-system was installed as part of the original facility prior to Date and Place-April 3,1991, Shearon ilarris Unit 1, a cee ving an operatmg beense.'Ihe design was deficient in Westinghouse designed pressurved water reactor,oper-that the physicallayout of the AMF piping permits air to ated by Carolina Power & I.ight Company and h>cated in be trapped upstream and downstream of the relief valves Wake County, North Cmohna. den the vMves are removed and reinstalled in the sys-tem. 'lhe upstream isolation valves ICS-746 and Nature and Probable Consequences-~While the reactor ICS-752 remain closed until a safety injection signal is was shutdown for refueling activities, the licensee ob. received. 'Ihis prevents water from refilling this piping. served a degradation of pipmg and relief valves used in Also, p ping upstream of the relief valves does not have the high head safety injection (1111S1) system (see Fig-high point vents for removing the trapped air. Water ure 1) 'this degradation was reported initially on Aptd 3* hammer events most likely Fve occurred as a result of a 1991, by the licensee as adversely impacting the perform

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anee of the system during the previous operatmg cycle should it have been required to operate and deliver water 'Ihe licensee identified the following damage to the AM F: to the reactor coolant system. 'the flow rate of water required to be going into the reactor system to mitigate (1) llelief valve ICS-744 had a broken bellows and a design basis accidents assumed in the licensing analysis cracked spring, and was found to have a reduced re-would not have been attained because a significant lief setpoint of 1100 psig. amount of safety injection P aw would have been diverted by the piping failure and early rehef valve opening. Subsc-(2) lletief valve ICS-755 had a broken bellows. Valve quent to the initial assessment of the event, the es ent was seat leakage prevented determining itnetpoint with analyzed by the NitC's Accident Sequence Precursor the available equipment. Program and the conditional core damage probability was estimated to be 6 x IOS for a particular set of conditions. (3) 'the piping connection upstream of ICS-754 failed 'the estimate is based upon the unavailability of the 111151 as a result of a water hammer during engineered for a year prior to discovery 'this value is indicative of an safety feature (l.SF) testing. A smallleak had previ-event with safety significance. ously existed in this weld,and was scheduled for re-pair during the 1991 refueling outage, in 1992, after receiving preliminary notification of the cote damage probability, an NRC inspection team was Cause or Causes /lhe degradation of the AMF relief sent to the Sheaton liarris site to review the circum-valves and pipmg was the result of a design change that i NUlti!G-0090, Vol.15, No. 2

c 1 Abnormal Occunences, 2nd Otr CY92 1 .1 --{RHR NX 1 A-SAj S %C" %Qn1CS-182 (St AL WTR HXh....WayaSAQ..~aagag g%Q AtT. - 1CS-214

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~ NI* i CHG/SI ~ ii > nm .i.l_1.18-S8 I Damaged Valve s _ ( pgggx33,33l l ICS-753 ,5jp: IC -755 On i 10.... ... 4 : 752.f8 l l Weld Leak / 1 Pipe Rupture %'ST l ICS-754 l l i l 1CS-745 { { l l CS-744 f .....I...d Damaged Valve ICS-746 G1CS-756 ALTERNATE MINIMUM FLOW SYSTEM 1 l Figure 1 Shearon liarris Iligh IIcad Safety Injection System NUR110-0090. Vol.15. No. 2 2

Abnormal Occurrences. 2nd Qtt CY92 had implications that were not understood at the time of pumps pressurited the Ah1F system piping which con-installation. Subsequent inadequate root cause tained air, in addition, the following AMF system design deterrninations of recutient water hammer events are weaknesses at f,hearon Ilarris were identified: celieved to have primitted equipment to be degradedt damaged to the extent that the tilISI function would not (1) 'the potential for water hammer events upstream be fulfilled. and downstream of the relief valves had not been analy/ed. 1 Actions Taken to Present Iterurrence (2) 'the AMF system piping had not been analyzed for l.icensee 'the licensee has taken corrective actions by transient or water hammer loads. revWng plant procedurea to require the piping upstream of the relief valves to be refilled prior toinstallation of the (3) '!he potenual for relief valve chatter and setpoint relief valves and vented through the relief valves by hy-drift had not been analy/cd. draulic pressure to climinate the air. They have also re-paired the damage identified above. 'lhe licensee is em-Similar damage to AMF system wmponents has previ-rently ev;duating the potential for water hammer ously beer: identified at other facilities. Information No-downstream of the relief valves. Uce 92-61, "less of thgh llead Safety In eetion," was NitC-A special inspection team was sent to the Shearon llatris site to review the event.The team determined toat '!he event is still under staff review.The NitC will review several water hammer events could have occursed in the the inspection team's findings and will take actions, as AMF system over the past 6 years. They concluded that appropriate. the water hammer events hkely occurred during liSF testing and during !!SF system actuations when the I uture reports will be rnade as appropriate. Fuel Cycle Facilities (Other Tlian Nucicar Power Plants) 'lhe NilC is reviewing events reported by these licensees. events were abnormal occurrences. t For this report, the NitC has not determ.ned that any Olher NRC 1 icensees (industrial Radiograrhers, Medical Institutions, Industrial Users, etc.) There are eturently mer 8000 NltC nuckar material notes t hat a therape utle dase that is leu than 0.S tirnes the licenses in effect in the United States, principally for use prescribed dose can be considered an abnnrmal occur-of radioisotopet, in the medical, industrial, and academic rence. fields. Incidents were reported in this category from licen. secs such as radiographers, medical institutions, and Date und Place-August 'G,1990; lleth iscaci llespind; byproduct material users. 'lhe NitC is reviewing events Passaic, New hrsey. During a routine faspection con-reported by these licensees. I or this report, the NitC has ducted on May 241092,it was discovt red that the thera-determined that the following events were abnormal oc. peutie misadministration, as well as m overexposure to a cuirences using the criteria and guidelines given in Ap. rado -lon workcts' hand, had vt been reported to the pendix A. As noted in the Preface to this report, the NltC. - guidelines for identifying medical misadministrations as Nature and Pro;ule Consegarnces -On August 23, abnstmal occurrences are currently being revised. 1990, a plent was sel eduled ta ave an endobronchial implant procedure that required two ribbons contr.ininga mtal cf 35 iridium 192 sceos S.54 rai:lieuries) to be 92-5 Medical Therapy Misadministration implanted into the patient. One ribbon contained 20 at lieth Israel llosp.tlal in Passate, ridmm e.eeds and the othei contained 15 iridium seeds. New.lersey the medical physicist gave the uttending physician the-wrong end (portion that does not include radwaetive The following information pertaining to this event is also sources) of one of the two viblons and the physician being relvried concurrently in the redcral Register. Ar innrted the wrong end into the patient.The other ribbon pendix A (sec !! vent Type 5 in Tabte A-1)of this report etmtaming 20 iridium-142 seeds was inserted correctly. 3 NUlt!!G-0090, Vol.15 No. 2

- ~ - ~ - - - - - - - ~ ~ ~ ~ - Abnormal Occmrence% 2od OLr CY92 i 'lhe ternainmg estra lengths of these ribimos were cut of f NltC-Ni(C ltcrion 1 inspectors continued the mspec-by the phystesan and given to the inedic;d phpient ne tion of the circumstances surrounding thn inividnh medical phpient, assuming that these picees of oblxms nisuation on June 2,1992 (itel. 2) Numerous appment l contained no radauctive raatetial. coded them and held Wolations were identified, A Confirmatory Action I riter them in her hand. One of these pieces contained 15 irid. was inued on June $.1992 (Itef, 3). An linforcement ium 192 seeds (29.37 indlieuries). Conference was held with the heer.sce in llegion I on i J une 25,1992, to discuss the s iolations and t he cor r ective 'lhe medical pl3 :ist, fonowing the completion of the actions proposed and implemented by the licensee (llef. i proecdure, discarded these pieces of sihbons into a waste 4). basket hicated in a wailmg soom acrow fr om the patient % toorn thus ercalmg a tadiation dose rate of up to approsi-A Notice of Vmlation and Pmposed Imposition of Civil mately 63 millit ems per hout in an unr est ucted area. 'lhis Penaltis s m the amount of $13,500 was sent to the licen. dose atewasyellalae1heiUmlMoryI;rnit of 2 rndhrein see ori August 7,1992(Itef.5).The violationsinclude: the in any one hant for unrestricled areas. 'ihe implant was overesposuie of the h.md of the medical physicist; the i perforrned at 2:30 p m and the patit nt was Rheduled to fadure to per form a survey which directly contributed to have a dot e of 1500 redsJihe physician decided to rernove the iniNid:ninistration and the overexjn,ure; the failure l the nbhons from the patient catlier t han planned because to repott the tmsadtninistration and overcrimsure to the the dose tale was higher than what he nottually aummi. NI(C, av weh as the fadure to report the misadministra-steis. The rib!xnn wuc semoved at &30 ' gun, on tion to the patient's tefes ting physician:!md a breakdown August 23, MO. Neither the rnedical physteist nor the in control of licensed activities of the facihty. 'the viola. hospitars Itadtation Safety Olheer (1150) was present tions awociated with the overexposure and the failure to dunng the removal procedum, perform a sutvey were classified in the appregate an a Severity I.csel 11 problem (on a scale in which Severity 'Ihe followmg morning at apprmirnately N30 a.m. the I evels I through V are the most and least significant, nmdbd physicist invento: icd ti,e sourtes removed from respectively), and awessed a uvil penalty of $6.000. *lhe the pa' ant and fonnd that one of the nbhons contained violations of telvrting requh ements w ere clawified in the no seeds She immediately mformed the ItSO, who con-aggregate as a Seventy 1.evel ill problem and awessed a ducted a redtch forIhe missing radioactive matenal and at civd p"nalty of $3,750.The violations associated with the-approxmiately 11.00 a.in. f ound Ihe Iwo pieces of obhon brcaldown in cont of oflicensed activities were clasufied in_ the waste brket. 'the beensee determined that the in the apperate as a Seventy I.evel til problem and dosc 'o the hand of the medical rhysicist was apprmi. awessed a civd penalty of $3,7bO. mately 272 rads awnnnnp'n herhamt for about 5 minutes. U"IcSS Oc", significant inft.nnation becomes avadable, that she held the nbbon con. tainmg iriJmm-142 st eds i 'the physician stated that D e patient receised a dose or dus irem m conudered closed for the purposes of this J approsimately 400 rads (whi; h was only about 50 percent repm (4 the inten Sd dose), No make up oose was given to the patient Neither the herapeutic rntsadministration nor 92-(i Medical'lherapy Misadntinistration the overcspusute to the phy9eist% hand was reported to at llogital WroplitaW in 1(lo the NI(L. l'a,rdras. Puerto l(,c0 1 Came or Causes Neithea tSe medical physicist _aor the The following information pertaining to t his event n also physician performed a suncy of the ablxms before ik heing icponed concunentiv in thc lh/cm/ Registcr. Ap-phnling into the patient. Tbc heensee did not mventoO penda A (see Fvent Type 3 in Table A-1) of this report the mures promptly af ter renwal fr,m the patient. notes that a therapeutic exposure to a part of the tmdy not Also, the hcensee f,uled to lohow estabhshed proceducs dedulN to re eive radiation can be considued an ab-c l mvolving the temoval of tempaary implants m that the ng,md ocemenen - 1(SO or his desynce was not pmsent duong the removal of temporary imp'ams f rom the patients. ' Date and place -Ma rch 24 25, 1092: llospital L Metropohtano; liso ISedras. Puerto Ilico. Artions *Iaken to Prevent Hum temc Nature and probahic C<msequeracy On Aptd 8,1992, I icensec 'the beensec% conecive actions include the beensee informed the NitC that on March 24-25. w m :ndatory requirement that the itSO or hn designee 1992, a br achytherapy miudminisa ation occun ed involv-mua be present during all implant and iemmal of radio' ing a patient recenmg a iherapeutie dose to the wrong vt.ve matenak The management of the licensee is now piirt of the lnly. more deeph involved in the radiological safety alfans. 'Ihe beensee is conduchng an audit of its radiation safety The misadnumstration occun ed when meoncer, program by an independent person. no longet in use, cesioit 137 soutecs were placed in a NURl!O4090. Voh 15, No. 2 4 i ~. -. -.. - - - -... - ~ ~. - - - - - - - - ~ - - - ~ ~ ~ ~ - - - - - ~ ~ ~ ~ - - - - ~ ~ ~ ~ - ~ ~ - ~ ~

Abnorrnal Occurrences,2nd Ott CY92 i i brxhy therapy apphcatorand administeled to the pitient, ar e the most sigmficant imd least significant. s espectively. Deenc athne sources e ct e snudier in diameter than t he !!ach violation was aasessed a promised civu penalty of intended sources,ihey >Jipped from the prescribed pwi- $ 1,250. Sis other siolatum..(mduthng the fadute to notify tion any irradiated normal tissue nN ntende>l to be ura-the NitC within 24 hours after discovcey of a therapy diated.1hc apphcator w3 Luded b,, technologist who misadministration) were also cited at enhet Seventy has never perimmed the pnwedtue. lhe technologtst 1.evel IV w V and involved the beenscei rad:ation ufety was sepelvised by a technoiogiu r ho had not per formed program. the pedre bi cight Scan, wkn the incorrect souters were in active use.'lhe incorrect unuets wre doemered Unlen new,Jgmficomt information becemes available, at the mid;6sv of the treatment by the hcemee's medW.d the itern i, ainsideied closed for the purposes of this i phpictr_ duriny, an ur.limned tr#ning sewion for a new rep)r t. ~ physicist. The mcottM saa'res were promptly emoved fiorn the pitient and the treatnj nt restarted and com-p gg p; ggg ggggg, nitted as duetted by the authorved uscr. ilott at llaystate Metthal Center, The licensee estimated the dose to normal tissue was IllC"I'lWI'HINI.IIIb8FilllIl0!(IeYilMU* l appnnimately 4(Wh5(Ni radt 'lhe IPtensee adsed the ch,lsrHN NitC that no adverse clicc ts to t he patient are antidpat cJ s as a ter uit al the snisadminutration. The following infonnation pettaining te this event isalso being repotted concuraently m the Tc cul Reghter. Ap-Cause or Cames-The causes ate attributed to the licen-pens A See !! vent 'lipe 4 in Table A-1) of Ihis teport see' ire to: (1) properly tram individuals handhng notes that mhuinistenng a diagnostie dosc of a radiophar. braca,..crapy sources,(2) adequately implement a Qual-maceutical that is g cater than five times the presciihed h can be conWered an abnonnat occurrence. ity Management Pmgrain (QM P),(3) develop and imple, ment adequate QMP procedures, and (.1) properly label the storage vault for the brachytherapy sources. Udif""d MdC'~ Mdf 19' I992;llaystate Medicall. enter, incorponted (llaystate); S.pringfield, Massachusetts. An tions Takt'st to Picsent llecutiente Natme and Probable ComequentewOn May 20,1992, the licenspe noufied the NRC by telephone that a medi-1.irensee-The licensee 3 cortective actions included te^ cal misathnimstration involving hidinc.131 (1 131) radio-vision of the OMP policia and procedures, training all phannateuticals had occuo rd at t hc licensee's faality the supervked mdividuals on b achytherapy pmcedures and ps cv ous day. A diagnostic dose was intended; however, a m the revised QMP, arr anpng safe storage for the sour ces therapearic dose was administered. The details of the no longer in use, posting a map of the source storage uult event ate described below, mdicating tne type of source at each storate point, and i enhancing source accountabdity pmetices-A nurse from the referring enthierine chnic called Hap state to make an appointinent for a patient for a thyroid NHC-Itegion 11 reviewed the cireurnstances associated scan and I-131 uptake study. llaystate's departmental with the misadministration and the li:ensee's immediate pmeedure for a thyroid som and l-131 uptake is to per- ~ corrective actions during a reachve inspection on form the study using lh inicrocuries of i-131 and 10 mil-April 10,1992, and a It4!ow-up impection on Apn122 and lieuries of technetium.99m. A whole body scan acquires 23,1992, w hich inc!" led N RC consultants m the areas of that approximately 4 millicut_ies of I-131 be given to the medictd physics, oncology, and tisk assessment (itef, b) panent, ^.ppuently, the order was entered in the pt,- NRC Region 11 ccnducted an linforcement Conference tient's scheduling chart as a whole imdy scan rather than with the licensu on May 20,1912. to discuss the event the thyroid ran omd 1-131 uptake study which wm in. (itef. 71 A notice of Wolation and Proposed Imposition tended. Questions were raised on several occasions by of Civil Penalty in the amount of $2,500 was issued on licensee pen.onnel because the patient was diagnosed June 25,1992 (Rel. 8). with an enlarged thyroid and snerally an 1-131 whole - body seam is not indicated for this diagnosis. Also, an This action was based on two violations that cont ributed authorized user was not consuhed to review the study and to the brachytherapy miadmimstratiom (1) failure of the prepare a written directive prior to the administration of OMP to include written poPeies and procedures to venfy gicater than 30 microcuries of I-131 m required by 10 the use of corteet brachytherapy sources and identify any CFR 35.32. A nudear inedicine technologist admini-unintended deviations, and (2) failure to instruct super-sicred 4.1 millieuries of I-131 for a wiiole body sean with-vised indmduals in the prinoples of radiation safety und out following the department's procedures for admini-the OMP. liach violation was categoriecd at Severity stration of I-125 or 1-131. The licenice evaluated the i.evel til on a scale in w hich Sescrity 1.eveh I through V dose to the patient's thyroid to be q,proxi.nately 14.300 5 NUR!!O -0090, Vol.15, No. 2 a.-.-..-.-- ...=-a-._-,-.,.--,---.--.

Abnormal Occurrences, 2nd Qtr CY92 l rads based on an uptake of 66 percent end the dose to thi 92 8 Medical Therapy Misadministration whole lody to be approximately h25 radt at Tlle Christ llospital in Cincinnati, Ohio Cause or Causes-It was determined that one of the causes of the misadministration was a rniscommumcation 'lhe fo!!owing information pertaining to this event as also between staff at both the referrmg endocrine chnic and being reported concurrently in the Federal Register. Ap-llaystate. Other causes were failure of the staff at llay-pendix A (see !! vent Type 5 in Table A-1)of this report state to follow regulatory procedures involvmg notes that a therapeutic dose that isless then 0.5 times the raAoiodine doses greater than 30 microcuries which re-prescribed dose can be considered an abnormal occur. quae that an authorved user prepare a written directive rence. In addition, some tissue received considerably pic to ihe admmistration. Nuclear Niedieme Depart-more radiation than it would have had the treatment been i meeta, proceduces idsoiequire that when an order for a as prescribed. r equested study is unuca; nr Diegible, the eferring physi-cian be contacted pnor to the performance of the study. Ilate and Plac-hiay.!9,1992;The Christ ilospital: Cin- ) einnati, Ohio. 1 Attlons Tahen to Present Ittcurante Nature and Probable Consequences-On hiay 29,1992, the hcensee performed an implant of radiation seeds for lirensee-The beensee's corrective actions included: treatment of a patient's prostate cancer.The patient had (1) instruction of nuclear medicine staff in the depart-previously received radiation treatment to the prostate ment procedures and regulatory requirements for usmp a hnear accelerator. 'lhe implant treatment plan radioiodine studies (2) preparation, prior to the admini-cidled for placement of SS seeds, each containing 0.31 e rtration. of a wntten direchve by the Directut of Endo-millieuries of iodine-125. 'lhe seeds were to be implanted erme (an authorized user), or a designated authorized in the prostate using needles guided by an ultrasound user before any todme study using greater than 30 imape. 'the implanted seeds were to deliver a dose of mierocuries is performed;(3) prompt transmittal of writ-12,000 rads to the prostate. ten requests for nuclear medieme studies f rom the climes to the llaystate Medical Center, Nuclear h*cdieme Dim 'ihe 58 seeds were implanted, but a subseque".t comput-sion, in order to compare the request to the computer erved tomographic sean showed that 21 serds wete im. l entry prior to the admmistration; and (4) review of this planted la tissue surmunding the prostate other than the patient's progress once every six w ecks for three months. mtended sites. Two seeds were climinated with the patient's urine. 'the licensee calculated that the NitC-An NitC l{egion I inspector conducted an mspec. mispositicaing of the seeds resulted in the patient receiv-tion on May 27 and 28,1992, to determine the etreum-ing a 5,000 rad dose to the prostate ratber than the m-stances associated with the misadmimstrati m(llef.9). An tended 12,000 rad dose. NitC medical consultant worked with the licensee to pro-vide a elinical assessment of the misadministration. Al. The principal consequence of this misadministration is though the medical eonsultant c;deulated the thyroid dose the potential effects of the underdosage to the prostate. i i to be considerably less than the bcensee's estimate, his in addition, tissue surrounding the prostate received a evaluation of the cient and consequences to the patient greater radiation dose than mtended. the prescribing ~ were similar to the hcensee's evaluation. 'lhey were in physteian concluded that the delivered dose from the agreement that because the patient was diagnosed as implanted seeds and from the previous linear accelerator treatment was sulheient An NltC mediud conseltant. having Graves' disease, the ultimate therapy would be [ treatment with about 10 millicuries of iodine-131 (com, retained to evaluate the circumstances and response to j pared to about 4 millicunes that wcre mistakenly admini. the nusadmm, istration, noted: "'I umor recurrence is ne stered). Therefore, the patient did not suffer adverse greatest rd and it will be monitored closely. The con. >= health effects from the rnisadministration worse than sultant dm concluded thr. there was not a high probabil-l those normally aoociated with treatment of Graves' dis. ity of radiation damage to the rectum, which would be the i area of principal concern. ey Cause or Causes-The misadministration resulted from l The NitC inspection identified two apparent violations of the difficulties in the ultrasound placement technique. I rillC requirements:(1)fmiure of authorued user to pre' 'the ultrasound image is difficult to interpret in guiding ..re a written directive, and (2) failure to follow proce-the placement of the seeds with the implanting needles. dures. An enforcement conference was held on June 23, 'the prescribing physician, who is the Authorized User in 1992. Enforcement action is pendmf-the NitC license, had been trained and ecrtified in the ultrasound guided implant technique. but had not netu-Future icports will be made as appropriate. ally performed the procedure. NUltEG-0090. Vol,15, No. 2 6 -. _ _, _ _ _ _ _ _ ~ _. _. _. _ _ _ _ _ _ _ _ _.

Abnormal Occui.--nces 2nd Qtr CY92 Actions Taken to l'scient iteturience June 17-18.1992, to review the circumstances of the misadministration and to evaluate the licensee's follow-Licensee 'the physicians recommended several im-up activities. No violations of NltC requirennents associ-provcments in the implanting technique, including more ated with the misadministration were identified. 'the detailed pretreatment planning, steps to improve the NitC also retained a medical consultant to review the quahty of the ultrasound image, and enhancernents to the case. seed positioning technique. 'this item is considered closed for the purposes of this NitC-N!!C Jtegion 111 conducted a special inspecticn report. Agrectuelit State Licesisces i l'rocedures have been developed for the Agreement events to the NilC for inclusion in these quarterly reports States to screen unscheduled incidents or events using the to Congress. l'or this period, the Agreement States re-same criteria as the NitC(see Appendix A)and report the ported no events as abnormal occurrences, 1 7 Null 11G-0090, Vol.15, No. 2. s ..... ~., _... _. . ~

. _ _ - _. ~ _ Abnormal Occurrences,2nd Qtr CY92 i IEFElmNCES 1. U.S. Nuclear llegulatory Commission, NI(C Infor. 6. I etter from J. Phihp Stohr, Ducctor, Division of mation Notice 92-61, *1 ass of I'igh Ilead Safety 1(adiation Safety and Safeguards, NI(C l(erl * ;II, injection," August 20,1992.* to M.Maldonado,lixecutive Administrator,Ihopi-tal Metropolitano, forwarding NI(C Inspection 2. I etter fr om l(ichard W. Cooper,11. Director, Divi. He;vrt No. 52-16033-01/92-01, l.icense No, sion of Itadiation Safety and Safeguards, NI(C 52"16033-01, Docket No. 030-11155, May 13, 1992.* llegion I, to Patrick J. Kelleher, Vice President, liet h Israel llospital, for war ding Inspection 1(eport 7' I #UCf froni J. Philip Stohr. Director, Division of No. 030412465/92-001, I.icense No. 29-03047-01, 1(adiah.on Safety and Safeguards, NI(C llegion 11, Docket No. 030 02465. June 17,1992.* to M. Maldonado, linecutive Adnunist rator, Ilospi-tal Metropohtano, forwarding linforcernent Con. 3. Confumatory Action letter No. 1-92-009 frorn ference Sumtnary, IJcense No. 52-16033-41, itkhard W. Cooper,11 Director, Division of 1(adia. Docket No. 030-11155, May 28,1992.' tion Safety and Safeguards, NltC l(egion I, to Patrick J. Kelleher, Vice President, lieth Israel 8.

l. citer from Stewart D. libneter,1(egional Admin-1lospital, l.icense No. 29-03047-01, Docket No.

istrator, NI(C llegion 11, to M. Maktonado, !!xecu-030412465, June 5,1992.* tive Administrator, llospital Metropolitano, for-warding a Notice of Violation and Proposed 4. lxtter from Mohamed M. Shanbaky, Chief, Medi. Imposition of Civil Penaltics-$2,500,1Jcense No. calinspection Section, Division of iladiation Safety 52-16033-01, Docket No. 030-11155, June 26, and Safeguards, N!(C llegion I, to Patrick J. Kel. 1992

  • tcher, Vice PresiJent, lieth Israel llospital, fm warding I!ntorcement Conference 1(eport No.

9-1 etter from Richard W. Cooper,11, Director Divi. 030-02465/92-002, l.icense No. 29-03047-01, sion of Radiation Safety and Safeguards, NI(C Docket No. 030 02465, July 2. lu92

  • lterion I, to Joseph 'l)e, Acting lixecutive Vice Prendent Chicf OperatingOf ficer,llaystate Medi-cal Ccater, Inc., forwarding inspection Iteport No.

5. I xtter from.lhomas.I. Martin,1(egional Admn..us-030--09946/92--001, 1Jcense. No. 20 01412-05, trator, NRC 1(egion I, to Patrick J Kelleher, \\, ice DocM Na 030-099E June 17,1992' Prcsident, lleth Isract llospital, ferwarding a No-tice of Violatiore and Proposed imposition of Civil a l Pcnaltics-513,500, I.icense No. 29-03047-01 DJ$'},';ld fj@,@fllyl,'L'.7'i /jh"Q!7,,iy,[ij'y Docket No. 030-02465, August 7,1992.'

osss.

9 NUltlE0090, Vol.15, No. 2 i

Abnormal Occurrences, 2nd Qtr CY92 Al'I'ENI)lX A AllNOllM AL OCCUltitENCE CitlTEltl A 'Ihe following criteria for this report's abnormal occur-5. Any loss of licensed material in such quantities and rence (AO) dete:minations were set forth in an NltC under such circumstances that substantial hazard policy statement published in theledera/Reghte on 1 ob-rnay result to persons in unrestricted areas. ruary 24,1977 (Vol. 42, No. 37. pages 10950-10952) An event will be considered an AO if it involves a rnajor diversion oflicensed materialor sabotage of a facil-6. A substantiated case of actual or attempted theft or reduction in the degree of protection of the public health ity. or safety. Such an event would involve a moderate or 7. Any substantiated low of special nuclear material or more severe impact on the public health or safety and any substantiated inventory discrepancy that is j could include but need not be limited to: judged to be sigmficant relative to normally ex-pected performance and that is judged to be caused 1. Moderate exposure to, or release of, radioactive ma-by thelt or diversion or by substantial breakdown of terial licensed by or other wise regulat ed by the Cem-the accountability system. mission; 8. Any substantial breakdown of physical sceurity or 2. Major degradatian of essential safety related equip-rnaterial control (i.e., access control, containment, ment; or or accountability systems) that sigmficantly weak-ened the protection against the t, diversion, or salw r 3. Major deficiencies in design, const ruction, use of, or

iage, management cont rols for licensed facilities or mate-rial.

9 An accidental uiticality [10 CI lt 70.52(a)].

10. A major deficiency in desigo construction. or opera-lixamples of the types of ever.ts that are evaluated in detail using these enteria are:

tion having safety implications cquiring immediate rt.nedial action. l'or All 1,icennes

11. Serious deficiency in rnanagemerit or procedural controls in major areas.

1. lixposure of the whole body of any individual to 25 rem or mote of radiation: exposure of the skin of the

12. Series of events (where individual events are not of whole body of any individual to 150 rern or more of major importance), recorting incidents, and inci-radiation; or exposure of the feet, ankles, hands or dents with impheations for similar facilities (generie forearms of any individual to 375 rem or more of incidents) that create major safety concern.

radiation [10 CI:lt 20 403(a)(1)], or equivalent exlw sures from internal sources. l'or Commercial Nuclear Power Plams 1. lixceedirig a safety limit of license technical specifi-2. An exposure to an individual in an unrestNied area such tt:at the whole body dose ieceived exce ds 0.5 cations [10 CFit 50.36(c)]. rem in one calendar year [10 Cl il 20.105(ajj. 2. MWor degmdation of fuelintegrity, primary coolant 3 The release of radi. active material to an unre-Wure Nunhy, or primary containment bound- '"I' stricted area in concentrations which, if averaged over a period of 24 hours, exceef 500 times the 3. loss of plant capability to perform e.ssential safety regulatory limit of Appendix 11, Table it 10 CIP functionssuch that a potential release of radioactiv-Part 20 [Cl 1120.403(b)(24 ity in excess of 10 CFil Part 100 guidelines could result from a postulated (nmsient or accident (e.g., 4. Itadiation or contamination levels in excess of design loss of emergency core cooling system, loss of con-values on packages, or lo.w of confinernent of radio-trol rod system), active material such as (a) a radiation dose rate of 1000 rnrem per hour three het from the turf ace of a 4. Discovery of a makr condition not specifically con-package containing the radioactive material, or sidered m the safety analysis report (S Alt) or techni. (b) release of radioactive material from a package in cal specifications that requires immediate :emedial amounts greater than the regulatory limit. action. 1I NUltliG-0090, Vol.15, No. 2

Abnormal Occurrentes, 2nd Ott CY92 5. Personnel error or proccdural deficiencies that re-exceeded and a plant shutdown is requitsd i10 Cl~lt sult in loss of plant capabihty to perform essential 50.3b(c)]. safety functions such that a potential release of ra-dioactivity in escess of 10 Cl Il Part 100 puidelines 2. A major condition not specifically considered in the could result from a lostulated transient or accident ufety analysn repot t or technical spectfications that (e.g., loss of emerrency core cooling system, loss of requires immediate iemeriial action. control roJ system). 3. An event that seriously compromised the ability of a l'or l'uti Cple 1.icensees cor fir.ement system to perform its designated fune-1. A safety hmit of license technical specifications is tion. Medical Misadtninistrations As discussed in the Preface to this report, the N1(C policy the NitC policy staternent. statement on AOs was published before liccusets were required to report rnedical inisadinit:istrations to the NitC.' therefor e, d ur ing 1984, t he NitC dcveloped guide-As noted in the Preface, revised guidelines are currently lines for selecting such esents for AO reporting. 'ihese being developed bceause new rnedical rnisadministration guidelines, which ate summariicd inTable A-1, augment defirntions became offcctive on January 27,1992. N Ulti!G-0090, Vol.15, No. 2 12

- - - - - - - ~ - Abnorntal Occurrences. 2nd Qtt CY92 Table A 1 NitC Cuidelines for Selecting Medical Misadminktration l'sents for Almormal Occur ener (AO)lleporting AO itepor ting Thicshold thent Type Diagnostic thposure _ 'Iherapeutic thposure (1) Administering a radiopharina-If the improper administration If the imptoper administration ecutical or radiation from a results in any part of the txdy results in any part of the body scaled source other tLa the receivmg unscheduled radiation, receiving unscheduled radiation, one intended. an AO report should be pro-an AO report should be posed if: proposed for any such event. (a) the actual dose to 'hc wrong if the parts of the body i tuly part is great:9 than five receiving radiation improperly - i times the upperlinut of the would have received radiation norrnal range of exposures anyway, had the proper i prescribed for diagnostic pro-administration been used, an cedures involving that body AO tcport should be proposed part, or if: (b) there are clinical indications (a) the actual dose is greater of miy adverse health effects than 4.5 times that to the wrong Nx!y part. intended to the above described lxxly parts, or, if the parts of the ludy receiving ladiation improperly would have (b) the actual dose is less than received radiation anyway, had the 0.5 times that intended to - proper administration been used, - the above described lxxly an AO report should be proposed if: parts, or, (a) the actual dose is greater than (c) the above described body live times that intended to the jurts show signs of adverse above devribed luly parts, or, health effects greater than - expected had the proper-(b) the above desenbed body parts adrninistration been used, show signr of adverse health or cifects greater than expected had the proper administration (d) the event (regardless of been used. any health c!fects) alfects two or more patients at the sarre facility, (2) Administering a radiophat ma. An AO report should be proposed - An AO report should be ceutical or radiation to thc if: proposed for any such event. . wrong patient. (a) the actual dose to the wrong - patient exceeds hve times the prescribed dose for the intended patient, or (b) the event results in wry adverse health effects. 13 N Ultin(WWu, Vol.15, No. 2 ., a. _,._n__-..._.___,_._.____.,,,,;._..,_.2___..- ..__,...-,,._,2

Abterrnal Occurrences, 2nd Qtt CY92 Table 41 (Continued) AO llepor ting T hr eshold 1: vent T)pe I)lagnostle 1:sposur e Therapeutic liposuie (3) Administering a radiophar-Same guidehnes as f or !! vent Same puiJelines as for livent maceuticid or radiation by a 'lype 1. 'Iype 1. route of administrction other than that intended by the prescribing physician. (4) Admirnstermg a diagnostic An AO report should be proposed Not upplkaSte. dose of a radiopharmaceutical if: diff cring 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 o he'Ith effects worse th.ai expe :ted for toe normal ranpc of exposures prescribed for the diagnostic procedure. (5) Administering a therapeutic Not apphcable. An AO repori should be dose of a radiopharmaceutical proposed if: differing from the prescribed dose by more than 10 percent; (a) the actual dose is greater or administering a therapeutic than 1.5 times the pre-radiation dose from a scaled scribed dose, or, source such that errors in the source cahbration, time of (b) the actual dose is less exposure, arid treatment than 0 5 times the geometry result in a calculated prescribed dose, or total treatment dose dif fering from the fmal prescribed total (c) the event results in adverse treatment dose by more than health effects worse than 10 percent. would be expected for the normal range of exposures pr escribed for the thera-peutic procedure, or. (d) the event (regardless of any health effects) affects two or more patients at the same facility. (6) itecurrmg or series of esents l'or either diagnostic or therapeutic exposures, an AO report should be (regardless of the number of proposed for recurring events or a serics 01 events (in which each individual patients or faellities involved). misaJministration is not of major importance) that create a significant public health or safety concern. (7) Generic events. l'or either diagnostic or therapeutic exposures, an AO report should be proposed for misadministrations with generie implications that create a significant public health or safety concern. NUltliG-0090, Vol.15, No. 2 14

Abrunrnal Onorrentes, 2nd ou cw2 Al'I'ENI)lX 15 Ul'l) ATE OF l'ItEVIOUSIN llEl'OllTEI) AllNOllM AI, OC' "" tit ENCES I)unne the Apul through June PN2 pern>J, NRC lucn-ude the untul and any subsequent updating infonnatnin secs Ayrtement States Arrectnent State licensecs, and on the abnormal occurrences discuwed. (the updating other nivohed paitics suth as reactor vendors and ar(hi-ptonded rencrally covcis oents that took plate donng tett enymeenng lums contmoed with the implementa-the t cpor t penal; some updatmr. howes er, may be ino:e tion of achons neccuary to present retuneme of presi-t un ent as mdicated by the awocuted cunt dates.) Open ously reixo ted abnonnal o. t urrences The eclerent ed items w di be discuwed m subsequent r eptu ts m the senes. ('onyn utonal abnonnal ouut tence tepiu ts below pro-Ollier NitC 1.ieciisees 91-S l(mliation Esposures ol' Menibers of' Nlte requuenants m the lass ef the radioactne sounc tiie l'uhlie f roin a 1 ost 1(tutioactise (llef Ibli Sou rce lhe liccusee tcplied to the NitC lettet in two letters T!n, abnonnal occunente was ontmauy reported m dated Januan 21, l'N2. ()ne letter adnutted the viola. NUlti-(i 0090, Vol.11, No. 3 *lteport Io ('onpreu on lions desenhed in the NOV. I he second letter a quested Abnonnal ()ccurrences: July-September PN)," it was imtigation of the proposed CP. Uplated in Vol.14, No.1 and Vol.15 No.l. The about. mal octurien,c n f urther updated as follows Alter conudenny the hcensce's responses the NRC stafI detcinuned that the wolations occurr ed as stated and that As pics iontly ruentioned.on Septeinber 3, PWl, Wester n the 510.000 CP shouhl be imposed. Consequently, on Atlas Int er national, an N RC bcensee, Icpor t( d Ihe low of J unc $, l'W2, NRC iuurd 1o t he hcensee a'.; Onler impov a 2 cane ccsium.137 scaled wc!! logging source frorn a mr ('iul Monetaty Penalty m thc amount of 510,000(Ret. s chicle en ioute kom the licensce's Yukon, Oklaborna, 1b 2 ).The notations assocuted with the civd penalty wet e fauhty to its llouston, Texas f acihty. As a result, two cellectively categoracJ as a Ses crity 1.crel I problem. on members of the pubhe recencd unneten.uy sadution a scale in which Ses enty I evels I through V are the most sigmhcant and least sirnificant, scspcctively. On June 11, exposur e. itN2. the hcensce p ud the (nd penahy in f ull. t )n Dcccmber 20, l'N1, the NRC iwurd to the hcensee a Noth e of Vio'.ation (NOV) and a Proposed impodtion of Tins item is conudered (losed for the Purposes of this (' int l'enahy (UP) m the amount of $10,000 f or untatmp r c por1 15 NURl 0 0000, Vol.15. No. 2

~ Abnormal Occurrences, 2nd Qtt CY92 APPENDIX C OTilER EVEN'1 J OF INTEREST The following item is described because it may possibly be the level of protection provided for public health or perceived by the public to be of public health or safety safetyt therefore, it is not reportable as an abnormal oc-significance.The item did not involve a aajor reduction in currence. Other NRC Licensees 1. Improper Movement of Fuel at the Uni. All equipment and instrumentation performed normally versity of Michigan Research Reactor during 'hv meident. The fuel handling crew reviewed the sequence of events and then completed the fuel move-On June 8,1992, while the licensee was moving fuel ments. Subsequently, a fifth fuel movement was com-elements in the reactor core in preparation fer several pleted before operations were terminated for the day. experiments, a fues element was removed from 'he core The reactor staff determined that the m.cident was not while the reactor was criticai. (When a reactor occomes critical, it is utilizing enough neutrons to cause additional reportable to the NRC. Ilowever, the hcensee's Safety Review committee determined on June 16,1992, that the fissioring of the fuel to maintain a chain reaction.) event was of sufficient interest that the NRC should be notified. On June 17, 1992, the licensee made both a ,Thc University o'f Michigan reactoris a 2 megawatt (ther-telephone and written report to the NRC Region 111 mal) open pool reactor with 35 to 45 fuel elements m the office. core. To move fuel elements, a reactor operator on a moveable bridge over the core uses a handling tool t The NRC dispatched an Augmented Inspection Team latch onto a fuel ele.nent, manually lift it, and then repo-(AIT) to the university to evaluate the circumstances sur-sition it in the core.The core is covered by 20 feet of water rounding the incident. The team was on site June 22-24, and the fuel elements remain underwater as they are 1992. De AIT reviewed its findings in a public exit meet-repositioned. - ing with the university on June 24,1992. The AIT report - A crew of three operators, all NRC-licensed senior reat-tor operators, was performmg the work. One operator The Air concluded that there were no "afety conse- ~ was in the control room, a second was actually mosing the quences as a result of the incident. Removing the fuel fuel, and the.aird was monitoring the fuel movements. In element caused the chain reaction to be terminated. Had the operation, a fuel element was repositioned and the the fuel element been reinserted, the power level would reactor was then taken to a critical condition at low power have been at or below the power level before the removal to measure the neutron production in the changed core of the fuel. Ilased on the Safety Analysis Repon for the alignment. Reactor power is regulated by the movement reactor, the team concluded that even if any additional of three shim rods and a control rod which can be moved fuel element were inserted in any vacant position avail-m and out of the core. able while the cure was critical, there would not have been Following the movement of three fuel elements, the fuel me ments were interiupted to place a research sample The incident was caused by a break down in communica-ho r in the reactor to determine its effect on neutron tions between the senior reactor operator, who was con-pri action.The reactor was critical for the neutron meas-trolling reactor activities, and the two operators perform-ui ents. The fuel handling crew then resumed fuel ing the fuel movements. In addition, there was no positive mu ments, lifting a fuel element from the core. Moving check on the status of the reactor before the fuel handlers the ici elemen, while the reactor was critical, was a began moving the fuel element. violaeon of the licensce's procedures and of the Techni-cal Specifications. The reactor operators involved were also very experi-enced and par nf the fulltime staff of the facility.Their Removmg the fuel c'ement caused the reactor to become experience appears to have led to the complacency re-suberitical, that is,6utdown with the chain reaction ter-garoing the routine fuct movements. They did not use minated. Another senior reactor operator. who was in their written procedures nor review them prior to the fuel i the area, then inserted the control md and the shim rods. movements. 17 N11RiiG-0090, Vol.15, No. 2 -4, .,., -., -. ~

~. _,. ~. - . ~ _. - -. ~ - ' Abnormal Occurrences, 2nd Otr CY92 Three violations of NRC requirements were identified most significant and least significant, respectively). 'Ihe - during the inspection. One was violating a Technical' third violation was classified as Severity lxvel IV. Specification for the reactor to be suberitical during fuel movements; the second was violating the procedure to The licensee has modified its procedures and will install have all rods fully inserted during fuel movements; and light indicators on the control rod drive housings located the third was the failure to report the event to the NRC on the bridge.The indicators will be lighted only when the - within 24 hours. A $ 1,250 civil penalty was prolw<ed (Ref. rods are fully inserted. These changes will require rnore C 2). The proposed civil penalty wa assessed for the first positive communication nmong the reactor staff and will two iolations which were classific(. as Severity Level 111 provide visual indication on the status of the control rod (on a scale in which Severity Levels I through V are the positions. I l l ' NUREG-0090, Vol.15 No. 2 jg

Abnormal Occurrences, 2nd Qtt CY92 ItEFEllENCES FOlt Al'l'ENDICES 111 lxtter from Itobert D, Martin, llegional Adminis-111, to Dr. Ilonald F. I'leming, Director, Michigan trator, NitC llegion IV, to Ilill Itose, Itadiation Memorial-Phoenix Project, University of Michi. Protection Officer, Western Atlas international, gan, forwarding NitC Augmented Inspection Team forwarding Notice of Violation and Proposed impo. Ileport No. $04102/92001, l.icense No,11-28, sition of Civil l'enalty-$ 10,000, I icense Dotket No. 504102, July 9,1992.* No. 42-02%4 -01, Docket No. 030-06402, Decem-ber 20,1991.* C-2 1xtter from A.llert Davis,llegional Administrator, NitC llegien 111, to Dr. llonald F.11 emir.g. Direc-11-2 1.etter from ilugh * ' thompson, Jr., NitC Deput) tor, Michigan Memorial-l'hoenix Project, Univer-I!xecutive Director for Nuclear Matenals Safety, sity of Michigan, forwarding Notice of Violation Safeguards, and Opera: ions Support, to Ilill Itose, and Proposed Imposition of Civil Penalty, l.icense Itadiation Protection Officer, Western Atlas Inter. No.11-28, Docket No. 50-002, August 21, 1992.' national, forwarding Order imposing Civil Mone-tary Penalty-$10,000, Licene No. 42-02964-01, Docket No. 030 06402, Junc 5,1992.* C-1 I etter from Charles I!. Norelius, Diicctor, Division ' ^ '"I7 """d * I"' i"f ch"" "' C"ly""8 "' " I'"n ur NIM'I'Alig 8 "'A""" of Itadiation Safety and Safeguards, NitC llegion $0['" """ 19 NUltiL -0090, Vol.15. No. 2

NRC FORM 335 U.S. NUCLE AR REGULATORY COMM$SION

1. HEPORT NUMBLR (2-89)

(Assigned tev NRC. Add Vol, NRCM 1102, Supp, Ret, and Addendum Num-320b 3N BIBLIOGRAPHIC DATA SHEET t=- l' *"v i (see instructx>ns on u. reven.) NUltlIG-0090 Vol.15, No. 2

2. mtc AND sue mtt

~ ' * " " " " ' " " Iteport to Congress on Abnormal Occu.rences: j April-June 1992 MONTH vcAn September 1992

4. f (J OR GRANT NUMBER
6. AU l tivh(W 6.1YPE OF HLPohi Quarterly L PtHioD cOVERr0 (inclusive Dates)

April - June 1992 0 PE HF OHMNG OHGAP42 alton - NAML AND ADDhtSS Uf NHC, pov.ca Oms +on, Othce or Hegion, U.S. Nuclear He;;ulatory Commission and malling add'ess; if Con 1? actor, prDvide name and maihng address = ) Office for Analysis and livaluation of Operational Data U.S. Nuclear Regulatory Commission "Iashington, DC 20555 9, bPONSORiNG OHGAre/ AllON - NAML AND ADDRE SS tit NRC. >e

  • Came as above~ ; if C(ntractor, proude NHC omsion, Othce or Heg;on.

O S. Nuclear Regulatory Comm4ssion and maihng address,) Same as 8., almve 10 buPt%.E MLNT AR Y NOI LS

11. ADSTRACT (200 wcrds or ness)

Section 20S of the linergy Reorganization Act of 1974 identifies an abnormal occurrence as an unscheduled incident or event that the Nuclear Regulatory Commission determines to be significant from the standpoint of public health and safety and requires a quarterly report of such events to be made to Congress. This report covers the period April through June 1992. 'lhree abnormal occurrences involving medical therapy misadministrations and one involv-ing a medical diagnostic misadministration at NRC-licensed facilities are discussed in this report. There was one ab-normal occurrence at a nuclear power plant, and none were reported by NRC's Agreement States. The report also contains information updating some previously reported abnormal occurrences.

13. AVAILAlltLITY STATEMENT
12. KEY WORDStDESCRPTORS (Ust words or phrases that will assist researchers 6n locatir>g the report )

Unlimited

14. SECURITY CLASStFICATION Medical Diagnostic Misadministration

( n a ra m MedicalTherapy Misadministrations Unclassified less of High-Head Safety injection Capability at Shearon Harris Nuclear Power Plant (1sm,,pa,o Unclassified 15 NUMBtH OF PAGLS

16. PHICE NRC FORM 335 (2-89)

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