ML20127D693
| ML20127D693 | |
| Person / Time | |
|---|---|
| Issue date: | 06/30/1984 |
| From: | Black K NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| Shared Package | |
| ML19283F001 | List: |
| References | |
| TASK-AE, TASK-N501 AEOD-N501, NUDOCS 8505090502 | |
| Download: ML20127D693 (17) | |
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AE0D/N501 A
SUMMARY
OF THE NONREACTOR EVENT REPORT DATABASE FOR THE PERIOD JANUARY - JUNE 1984 by the Nonreactor Assessment Staff Office for Analysis and Evaluation of Operational Data Prepared by: K. Black .
l Note:
This report characterizes the Nonreactor Event Report (NRER) database maintained by the Office for Analysis and Evaluation of Operational Data.
This report is intended to be descriptive only and not provide any analysis of events represented by NRER database records.
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SUMMARY
OF THE NONREACTOR EVENT REPORT DATABASE FOR THE PERIOD JANUARY - JUNE 1984 INTRODUCTION The AE0D Nonreactor Event Report (NRER) database contains information on licensed nuclear materials and fuel cycle operational events and on personnel radiation exposure events. The NRER database management system
- provides for input, storage, retrieval and computer-assisted analyses of operational event data and may be used in identifying trends in operational safety events which may signal a need for remedial actions by the NRC and/or licensees.
The NRER database includes 120 reports submitted by nonreactor licensees to the NRC Regional Offices during the first half of 1984 and extracted from 1 other sources, primarily inspection reports. It does not include information l from certain fuel cycle licensee reports, such as those related to routine I effluent releases, nor does it include information from reports of mis- ;
administrations.** The purpose of this report is to characterize operational l data included in the NRER database for the period January - June 1984.
Except when included in licensee reports to NRC Regional Offices, AE00 has not incorporated information on transportation events into the NRER database i because DOE funds a transportation incident file at Sandia. NUREG/CR-3611, Radioactive Material (RAM) Accident Incident Data Analysis Program, contains information about the data base, and summarizes data for the 10 year period 1971-1981.
DISCUSSION Information on the 120 records entered into the NRER database during the first half of 1984 includes information from various types of licensees.
Table I provides information on the types of licensees for which information was entered into the database.
An NRER database item may be associated with more than one type of event.
For example, a report from a radiography licensee concerning a personnel radiation exposure would be counted in the total number of radiation exposure.
events as well as in the total number of events involving radiography.
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The 120 nonreactor licensee reports were cataloged as 157 events in ten different areas. The details are included in Table II of Enclosure 1.
Note that, because some reports are associated with more than one event type, the total number of events exceeds the total number of reports.
The 120 nonreactor licensee reports were most frequently concerned with radiation exposures (25 times) and with lost, abandoned, and stolen material (45 times). The reports were associated less frequently with several areas.
- The NRER database utilizes the System 1022 database management system which operates on the Oak Ridge National Laboratory (0RNL) DEC System-10 computer.
- The results of AEOD studies of medical misadministrations are published elsewhere.
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- 1. Radiation Exposure Events The NRER database contains information from 25 reports received during the first half of 1984 from nonreactor licensees concerning events in which there was the potential for radiation overexposures. Of these events,18 involved real radiation overexposures. Information on the 25 overexposure reports is provided in Table III. The types of licensees associated with the overexposures reported during the first half of 1984 were as follows:
Number Total Number Licensee Event Overexposure Events Individuals Exposed Radiography 8 10*
Commercial /Inoustrial 4 2 Medical / Academic 13 8 Total 25 20
, *Includ,es two members of public.
- 2. Lost, Abandoned, and Stolen Material Forty-five (45) events reported during the first half of 1984 involved lost, abandoned, or stolen licensed material (LAS). Report documents of
, these even.ts are summarized in Table IV. Report documents consisted of 28 reports of lost material, and 17 reports of abandoned well logging sources. None of the 31 events resulted in a known radiation over-exposure About half the number of LAS reports (22) were received during the first half of 1983 as were received during the first half of 1984. Of the 1983.
number, ten (10) concerned lost material, five (5) stolen, and seven (7) abandoned material . The 1984 data show an increased number of events involving lost material .
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- 3. Leaking Sources Fourteen (14) events of leaking sources were identified during the first half of 1984. Information from the reports is included in Table V. None of these was associated with a radiation overexposure and none of the events appears to indicate a generic problem. Americium, cesium, iridium, nickel, and polonium sources were found to be leaking. The number (14) of events reported in the first half of 1984 was about the same number (10) l reported in the second half of 1983.
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- 4. Fuel Cycle Facility Event Reports The NRER database contains information from six fuel cycle licensee event reports received during the first half of 1984 as follows: two from uranium recovery facilities and four from fuel fabrication plants. The I
NRER database does not include information from fuel cycle licensee reports of routine effluent releases.
The two uranium mill reports concerned leaks from a pipe split during cleanout and a split plastic liner in a tailing pond. Each of the leaks occurred at a different mill.
The four fuel cycle events concerned two facilities, and are of statistical value only. Two of the reports concerned waste shipments that were not strong, tight packages; one report concerned a total loss of off-site power; and one concerned airborne releases that exceeded allowable limits.
- 5. Radiography Twelve (12) licensee event reports received during the first half of 1984 involved radiography. Two of the events occurred at a fixed radiography site and ten (10) occurred at remote (field) radiography sites. Information on the reported events is included in Table VI.
Six of the reports, all from remote sites, concerned overexposures.
In one of these (an Agreement State licensee), it is estimated that an assistant radiographer received 63 rem to the whole body and 5348 rem to the hand, and a radiographer received 9 rem to the whole body and 3013 rad to the hand. This event was an abnormal occurrence.
In another event, two members of the public received small exposures.
The number of radiography events (12) does not differ substantially from the number of events reported during prior six-month periods, 6-13 reports.
- 6. Manufacturing and Distribution (MAD)
Twelve (12) events identified during the first half of 1984 involved l
the manufacturing and distribution of byproduct material . Information from the reports is included in Table VII. None of the events was l significant as a MAD event.
- 7. Gauges / Measuring Systems Twenty two (22) events during the first half of 1984 were related to l licensed byproduct material in gauges / measuring systems. Infomation l
from the reports is included in Table VIII. The reports generally concerned leaking sources, a lost device, or other events of statistical significance only. One report concerned the release of 33 Ci of Kr85 resulting from damage to an Isovac Radiflo device damaged during shipment.
Repairs made to the device were incomplete and damage remaining after the repair resulted in the loss of Kr85 when the device was put into service. -
- 8. Medical and Teletherapy There were 22 reports submitted during the first half of 1984 concerning events at medical licensees. One concerned radiopharmaceutical doses of Tc99 that were contaminated with Mo; another concerned a malfunction of two Medtronic pacemakers. Two other events concerned the unknowing transfer of sources between hospitals; a member of the public was exposed as a result of the transfer. The remaining events were of statistical information only and concerned exposures, lost sources, transportation, or release of materials.
- 9. Findings and Conclusions When reports in the NRER database for the first half of 1984 are compared with those from the second half of 1984, the number and type of reports do not differ substantially from one another.
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Enclosure 1 Table I Types of Licensees that Submitted Reports During the First Half 1984 License Type Number of Reports Received
- Academic 6 Medical 15 Commercial / Industrial Measuring Systems Well Logging 22 Other Measuring Systems 22 44 M.D. & S. 14 Other Commercial / Industrial --
14 Radiography Single Location (in plant) 2 Multiple Locations (field) 13 15 Irradiator Licenses --
R&D Licenses 4 Source Materials **
Mills 2 UF6 --
Other 1 3
Special Nuclear Material (including polonium) 10 Other*** 9 Total 120
- Medical misadministration reports are not included.
- Routine environmental effluent release reports, e.g., reports required by 40.65 and 70.59 were not included in the totals for source and special nuclear materials licensees.
- Number of Reports Received includes reports received from non-licensees (no program code).
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Table II Frequency With Which Reports Were Associated With Particular Areas Area With Which Report Was Associated Number of Reports Associated Personnel-Radiation Exposures - 25 Lost, Abandoned, and Stolen Material 45
. Leaking Sources 14 Radiography- 12 Fuel Cycle 6 Manufacturing and Distribution 12 Releases of Material , 4 Gauges / Measuring Systems 22 Medical and Teletherapy 5 Other 12 Total 157 t
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l- Note: . An NRER database item may be associated with more than one type of event. For example, a report from a radiography licensee concerning a personnel radiation exposure would be counted in the total number of radiation exposure events as well as in the total number of events involving radiography.
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Table III .~
January - June 1984 Personnel Radiation Overexposure Reports Nonreactor Licensee Li ce.t se No. Location Event Date No. Exposed -Exposure Alaska Welding Center 501920201 Prudhoe Bay, AK 3/7/84 1 Extremity Bethesda Hospital 341092103 Cincinnati, OH --
0 See University of Cincinnati (1/3/84)
Combustion Engineering 60415401 Windsor, CT 10/4/83 0 Source Recovery ,
Combustion Engineering 60021706 Windsor, CT 6/13/84 1 Extremity Greater Community Hospital 14133ul01 Crestun,'IA 2/1/82 1 Whole Body Industrial NDT AS Charleston, SC 2/2/84 2 Whole Body, Extremity Inspection & Testing, Inc. 111992101 Vernal, UT 1/29/84 1 Whole Body Kessler Memorial Hospital 291198201 Hammonton, NJ 2/4/84 1 Extremity Magnaflux 120062202 --
6/16/84 2 Member of Public ,
Massachusetts Bay Trans. Co. 201828101 Dorchester, MA 3/3/84 0 Badge Nuclear Metals, Inc. Dkt 400672 Concord, MA 5/1/84 1 Extremity Rohm & Haas Company 370166501 Philadelphia, PA 12/6/83 0 Contamination St. Elizabeth Hospital 290433301 Elizabeth, NJ 6/1/84 1 Whole Body l Suisman Titanium Corporation 61765301 Hartford, CT --
0 Badge l Superior Production Logging 421958201 Snyder, TX 5/1/81 1 Whole Body Trans-Eastern Insp. 371485501 Mazie, OK 4/1/84 2 Whole Body Trans-Eastern Insp. 371485501 Mazie, OK 6/28/84 2 Whole Body 2
Table III (Continued)
January - June 1984 Personnel Radiation Overexposure Reports
- Nonreactor Licensee License No. Location. Event Date No. Exposed Exposure i United States Testing Co. 290247709 Plymouth, MA 3/1/84 1 Extremity
! Univ. of Cincinnati Hosp. 340690305 Cincinnati, OH 1/3/84 1 Whole Body Univ. of Cincinnati Hosp. 340690305 Cincinnati, OH -- 1 Extremity 4
Univ. of Pennsylvania 370011807 Philadelphia, PA 1/13/84 1 ' Thyroid Burden 4
Univ. of Hawaii 530001723 Honolulu, HI 10/15/81 0 Badge i
Veterans Administratio'n 40018104 Los Angeles, CA 5/1/84 1 Whole Body i
Ventrex Lab Inc. 181730301 Portland, ME O MPC Hour Yale-New Haven Hosp. 060081903 New Haven, CT 11/1/83 1 Fluoroscopy e
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Table IV ,
.Part I January - June 1984 Reports on Lost, Abandoned, and Stolen Sources ,
Isotope Location Licensee License No. Event Date Disposition Am241 Greenbelt, MD Goddard Space Flight Ctr 190574802 5/7/84 Unknown Am241 Newton, IL International Wireline 122029701 --
Found Am241 Stanton, KY Mid-States Logging & Perforating 121998501 --
Found Cel44 Rochester, NY New England Nuclear 200032013 2/14/84 Unknown Cs137 Kremlin, OK Champlin Petroleum Co. 350674302 12/6/83 Found Cs137 Cincinnati, OH Cincinnati Gas and Electric 340725103 4/16/84 Unknown Cs137 Kalamazoo, MI General Licensee Gen 2/23/84 Found Cs137 Arlington, IL Kay Ray Inc. 121118402 5/1/84 Unknown Cs137 Arlington, IL Kay Ray Inc. 121118401 8/16/83 Unknown Cs137 Saddlebrook, NJ Langan Engineering Associates 291578601 4/3/84 Found ,
H3 Elyria, OH Bendix Corporation 210193104 3/9/84 Unknown H3 Warren, MI General Dynamics Corp. 212106801 6/16/84 Unknown 1131 Fairfax, VA North Virginia Endocrinologists 452112101 6/27/84 Commercial Maste Disp.
1131 Toledo, OH Syncor Inernational 341665401 1/30/84 Found Ir192 Cincinnati, OH Univ. of Cincinnati Hosp. 340690305 1/3/84 Found Kr85 Ft Wainwright, AK Dept. of Army. 290102211 1/16/84 Unknown
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Table IV Part I (Continued) '
January - June 1984 Reports on Lost, Abandoned . and Stolen Sources Isotope Location Licensee License No. Event Date' Disposition N163 Avondale, PA Hewlett Packard 370700203 --
Unknown N163 Monroeville, PA Koppers Company 371084501 -- Commercial Waste Disp.
N163 Morris, IL Northern Petrochemical Co. 121397201 2/1/84 Unknown N163 Skokie, IL Searle R&D Co. 120070102 11/1/82 Commercial Waste Disp.
Po32 Alexandria, VA Amersham Corporation 121283606 2/6/84 Found St90 Lafayette, NJ James River Corp. Gen 4/1/84 Commercial Waste Disp.
Ta182 Pt. Magu, CA Dept. of Navy 41691301 1/19/84 Unknown l
Tc99 Long Beach, CA Veterans Administration MC 40068901 2/9/84 Commercial Waste Disp. -
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Tc99m Red Bank, NJ Riverview Hospital 290970101 1/31/83 Found Waste Blue Creek, OH Syncor International 34'1830901 2/16/84 Found
-- Cincinnati, OH Univ. of Cincinnati Hospital 340690305 -- Commercial Waste Disp.
-- Washington, DC Veterans Administration MC 80094205 3/11/83 Commercial Waste Disp.
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Table IV ,
Part II January - June 1984 Abandoned Well Logging Sources. ,
Isotope Location Licensee License No. Event Date .
Am241 -- Conoco, Inc. 420296401 4/11/84 Am241 -- Dresser Atlas 420296401 4/12/84 Am241 LA Dresser Atlas 420296401 12/23/84 .
Cs137 LA Dresser Atlas 420296401 2/10/84 Cs137 Dewey City, OK Dresser Atlas 420296401 4/24/84 H3 TX Dresser Atlas 420296401 --
-- -- Dresser Atlas 420296401 3/30/84 l
! Am241 Gulf of Mexico Gearhart Industries 420645803 4/17/84 Am241 Gulf of Mexico Gearhart Industries 420645803 3/27/84 ,
-- -- Gearhart Industries 420645803 2/20/84
-- -- Gearhart Industries 420645803 5/14/84 Am241 Gillette, WY NL McCullough 421389801 1/3/84 Am241 Federal Waters Schlumberger Well Services 420009003 4/4/84 Am241 North Slope, AK Schlumberger Well Se.rvices 420009003 4/30/84 Am241 Federal Waters Schlumberger Well Services 420009003 5/21/84 Am241 Fed Waters, LA Schlumberger Well Services 420009003 8/12/83
' Am241 Fed Waters, LA Schlumberger Well Services 420009003 8/12/83 a
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Table V January - June 1984 Reports of Leaking Sources ,
9 Isotope Location. Licensee License No. Event Date Manufacturer /Model No. .
Am241 McConnell, KS Dept. of Air Force 151381201 -- --
Am241 McConnell, KS Dept of Air Force 151381201 4/14/83 --
Am241 Little Rock, AR Dept. of Air Force 31375401 --
Amersham Billionaire
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Cs137 --
FEMA 80129701 Cs137 Wichita, KA Great Guns 152133201 5/11/84 --
Ir192 Groton, C.T General Dynamics 60178108 1/26/84 Tech Ops A-424-9, S/N 4850 Ir192 E. Essex, Ct. Brand Examination Serv. 61715601 -- --
N163 Columbus, OH Stilson Laboratories 341698801 5/28/84 Perkin Elmer Sigma 1 N163 Madison, WI Univ. of Wisconsin 480984318 1/26/84 --
2 Ni63 Madison, WI Madison Metropol Sewerage 481660401 10/31/83 --
Po210 Midland, MI 3M Minnesota Mining Manu. 220005732 --
Minnesota Mining Manu.
Po210 Midland, MI 3M Minnesota Mining Manu. 220005732 5/7/84 Minnesota Mining Manu.
Sb121 Danvers, MA GTE Products Co. 201546404 3/3/84 New England Nuclear Bill Miller 351904801 4/30/84 --
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Table VI January - June 1984 Radiography Event Reports ' .
t Isotope Location Licensee Event Date Other Category *
- Co60 Windsor, CT Combustion Engineering 10/4/83 EXP (0)
Ir192 Clinton, NJ Ebasco Services- 4/13/82 EXP (0)
Ir192 Groton, CT General Dynamics 1/26/84 LKS -
Ir192 Groton, CT General Dynamics 1/30/84 LKS Charleston, SC Industrial NDT (AS)** 2/20/84 EXP (2)
Vernal, UT Ir192 Inspection & Testing, Inc. 1/29/84 EXP (1)
-- Rockford, IL Kelsey-Hayes Co. 6/25/84 --
Magnaflux 6/16/84 EXP (2)***
) Ir192 Manville, NJ Non-Destructive Testing Corp. 3/9/84 -- .
i . -- Mazie, OK Trans-Eastern 4/1/84 EXP (2) 1
- i Ir192 Mazie, OK Trans-Eastern 6/28/84 EXP (2)
! Ir192 Plymouth, MA United States Testing Co., Inc. 3/1/84 EXP (1) i i
- EXP ( ) = Personnel Radiation Exposure (No. of Individuals Exposed); LKS = leaking Source l , ** Agreement State
- *** Members of Public i
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Table VII January - June 1984 Manufacturing and Distribution Event Reports ,
4 Isotope Location Licensee License No. Event Date Other Category * ,
Ce144 Rochester, NY New England Nuclear 200032013 2/14/84 LAS TRS Cs137 Arlington, IL Kay Ray Inc. 121118402 5/1/84 LAS Cs137 Arlington, IL Kay Ray Inc. 121118401 6/16/83 LAS H3 Warren, MI General Dynamics Corp. 212106801 6/16/84 LAS H3 Chapel Hill, NC Safety-Light Corp. 370003008 2/21/84 MSC I125 Portland, ME Ventrex Lab Inc. 181730301 --
EXP Kr85 Ft. Wainwright, AK Dept. of Army 290102211 1/16/84 LAS N163 Avondale, PA Hewlett Packard 370700203 --
LAS GAU Po210 Midland, MI 3M Minnesota Mining Manu 220005732 5/7/84 MSC LKS Po32 Alexandria, VA Amersham Corporation ~121283606 2/6/84 LAS Windsor, CT Combustion Engineering 60021706 6/13/84 EXP
-- Horsham, PA Micromedic Systems 371670701 6/14/84 TRS MSC
MSC = miscellaneous TRS = transporation
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Table VIII January - June 1984 Gauges / Measuring System Event Reports i
l Isotope Location Licensee License No. Event Date Other Category * ,
-- Martinsville, VA Prillaman & Pace Inc. 451849201 1/10/82 EXP(0)
-- McConnell, KS Dept. of Air Force 151381201 --
LKS Am241 Greenbelt, MD Goddard Space Flight Ctr 190574802 5/7/84 LAS Am241 McConnell, KS Dept. of Air Force 151381201 4/14/83 LKS j Am241 Gillette, WY NL McCullough 421389801 1/3/84 LAS i Am241 Little Rock, AR Dept. of Air Force 31375401 --
LKS Cs137 Kremlin, OK Champlin Petroleum Co 350674302 12/6/83 LAS Cs137 Cincinnati, OH Cincinnati Gas & Electric 340725103 4/16/83 LAS Cs137 --
Dept. of Navy 81794901 11/12/83 MSC i .
l Cs137 Kalamazoo, MI -General Licensee Gen 2/23/84 LAS
] Cs137 Saddleboro, NJ Langan Engineering Assoc 191578601 4/3/84 LAS Kr85 North Billerica, MA Geo Reliability Services 202135901 1/26/84 RLM Ni 63 Avondale, PA Hewlett Packard 370700203 --
LAS N163 Monroeville, PA Koppers Company 371084501 --
LAS N163 Morris, IL Northern Petrochemical 121397201 2/1/84 LAS N163 Columbus, OH Stilson Laboratories 341698801 5/28/84 LKS i
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Table VIII (Continued)
January - June 1984 Gauges / Measuring System Event Reports Isotope Location Licensee License No. -Event Date Other Category
- i N163 Madison, WI Univ of Wisconsin 480984318 1/26/84 LKS 1
N163 Madison, WI Madison Metropol Sewerage 481660401 10/31/83 LKS Sb121 Danvers, MA GTE Product Co 201546404- 3/3/84 .LKS-
-- Dorchester, MA Massachusetts Bay Transit 201828101 3/3/84 EXP (0)
- -- Richland, WA OH Materials 341859301 3/22/84 WAS
-- Hartford, CT Suisman Titanium Corp 61765301 --
EXP (0 f
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. *EXP ( ) = exposure (number exposed)
LAS = lost, abandoned, stolen source LKS =_ leaking source RLM = release radioactive material WAS = waste 1
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