ML20128H303

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Summary of Nonreactor Event Rept Data Base for Jul-Dec 1984
ML20128H303
Person / Time
Issue date: 12/31/1984
From: Black K
NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
Shared Package
ML20128H300 List:
References
TASK-AE, TASK-N502 AEOD-N502, NUDOCS 8507090478
Download: ML20128H303 (14)
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AE00/N502 A

SUMMARY

OF THE NONREACTOR EVENT REPORT DATABASE FOR THE PERIOD JULY - DECEMBER 1984 by the Nonreactor. Assessment Staff Office for Analysis and Evaluation of Operational Data Prepared by: K. Black 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.

B507090478 850628 PDR MISC 8507090476 PDR

A

SUMMARY

OF THE NONREACTOR EVENT REPORT DATABASE FOR THE PERIOD JULY - DECEMBER 1984 INTRODUCTION Tne AEOD 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 112 reports submitted Dy nonreactor licensees to the NRC Regional Offices during the second half of 1984 and extracted from other sources, primarily inspection reports. It does not include information from certain fuel cycle licensee reports, such as those related to routine effluent releases, nor does it include information from reports of mis-administrations.** The purpose of this report is to characterize operational data included in the NRER database for the period July - December 1984.

Except when included in licensee reports to NRC Regional Offices, AE00 has not incorporated information on transportation events into the NRER database 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 112 records entered into the NRER database during the second 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.

The 112 nonreactor licensee reports were cataloged as 153 events in nine different areas. The details are included in Table 11 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 112 nonreactor licensee reports were most frequently concerned with radiation exposures (21 times) and with lost, abandoned, and stolen material (31 times). The reports were associated less frequently with several areas.

  • The URER database utilizes the System 1022 database management system which operates on the Oak Ridge National Laboratory (ORNL) DEC System-10 computer.
    • The results of AE0D studies of medical misadministrations are published elsewhere.
1. Radiation Exposure Events The NRER database contains information from 21 reports received during the second half of 1984 from nonreactor licensees concerning events in which there was the potential for radiation overexposures. Of these events,12 involved real radiation overexposures. Infonnation on the 21 overexposure reports is provided in Table III. The types of licensees associated with the overexposures reported during the second half of 1984 were as follows:

Number Total Number Licensee Event Overexposure Events Individuals Exposed Medical / Academic 5 5 Radiography 3 4 (two members of public)

Fuel Cycle 3 3 Commercial / Industrial 1

_2 Total 12 14 One of the events, a significant exposure to I-125, was determined to be an abnormal occurrence. The individual received about 2000 rad to the thyroid at a medical licensee's facility.

2. Lost, Abandoned, and Stolen Material Thirty-one (31) events reported during the second half of 1984 involved lost, abandoned, or stolen licensed material (LAS). Report documents of these events are summarized in Table IV. Report documents consisted of 19 reports of lost or stolen material, and 12 reports of abandoned well-logging sources. None of the 31 events resulted in a known radiation overexposure.

About 50% more LAS reports (45) were received during the first half of 1984 as were received during the second half of 1984. Of the 19 lost or stolen sources, eight were recovered (found), one was disposed of with rad waste, and one was disposed of to sanitary landfill. The disposition of nine is unknown. One of these nine was a stolen exit sign containing tritium.

3. Leaking Sources Fifteen (15) events of leaking sources were identified during the second half of 1984. Information from the reports is included in Table V. None of these were associated with a radiation overexposure and none of the events appeared to indicate a generic problem. Americium, cobalt, cesium, iron, iridium, nickel, promethium, and tellurium sources were found to be leaking. The number (15) of events reported in the second half of 1984 was about the same number (14) reported in the first half of 1984.
4. Fuel Cycle Facility Event Reports
  • The NRER database contains information from eight fuel cycle licensee event reports received during the second half of 1984 as follows: two personnel exposures, a small UF6 release, and an unsolified radwaste shipment. One licensee reported four different events: a personnel contamination; ventilation system failure; uranium contamination level in scrubbers exceeding action levels; and detection of a significant accumulation of uranium in a ventilation duct.

The event in which a significant accumulation of uranium in a ventilation duct was an abnormal occurrence and was the subject of an IE information notice.

S. Radiography Eleven (11) licensee event reports received during the second half of 1984 involved radiography. Five of the events occurred at a fixed radiography site and six occurred at remote (field) radiography sites.

Information on the reported events is included in Table VI.

Three of the reports, all from remote sites, concerned overexposure or potential overexposure events. The number of radiography events (11) does not differ substantially from the number of events reported during prior six-month periods, 6-13 reports.

6. Manufacturing and Distribution (MAD)

Seven (7) events identified during the second half of 1984 involved the manufacturing and distribution of byproduct material. Information from the reports is included in Table VII. None of the events was significant as a MAD event.

7. Gauges / Measuring Systems Eleven (11) events during the second half of 1984 were related to licensed byproduct material in gauges / measuring systems. Information from the reports is included in Table VIII.
8. Medical and Teletherapy There were 13 events during the second half of 1984 at medical licensees.

Two of the events concerned distribution of technetium-99m that was contaminated with molybdenum-99. Two radiopharmacies had received technetium generators that had been incorrectly assembled by a New York licensee. Twenty-eight (28) patients received unnecessary exposures during diagnostic tests as a result of the distribution of these contaminated radiopharmaceuticals. These two events were detennined to De abnormal occurrences.

  • NRER database does not include information frun fuel cycle licensee reports of routine effluent releases.
9. Findings and Conclusions When reports in the NRER database for the second half of 1984 are compared witn those from the first half of 1984, the number and type of reports are generally similar.

ENCLOSURE 1 Table I Types of Licensees that Submitted Reports During the Second Half 1984 License Type Number of Reports Received

  • Academic 7 Medical 19 Commercial / Industrial Measuring Systems Well Logging 17 Other Measuring Systems 11 28 M.D. & S. 9 Other Commercial / Industrial 1 10 Radiography

' Single Location (in plant) 6 Multiple Locations (field) 7 13 R&D Licenses 5 Source Materials **

Mills --

UF6 2 Other 1 3

Special Nuclear Material (including plutonium) 10 Other*** 17 Total 112

  • 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).

Table II '

Frequency With Which Reports Were Associated With Particular Areas Area With Which' Report Was Associated Number of Reports Associated Personnel Radiation Exposures 21 Lost, Abandoned, and Stolen Material 31 Leaking Sources 15 Radiography 11 Fuel Cycle 8 Manufacturing and Distribution 7 Release of Material 3 Gauges / Measuring Systems 11 Medical and. Teletherapy 15 Otner 31 Total 153 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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1

Table III July-December 1984 Parsonnpl Radiation Exposure Licensee License No. Location Event Date No. Exposed Comment Advanced Medical Systems 341908901 Geneva, OH 11/1/84 2 Whole Body Allegheny Health, Education 370131702 Pittsburgh, PA 11/23/84 0- Badge-Allied Corporation Docket 40 Metropolis, IL 9/4/84 1 Internal American Airlines 351396401 Los Angeles, CA 8/25/84 0 Radiography Event Babcock & Wilcox Docket 70 Lynchburg, VA 11/12/84 1 Extremity Capital X-Ray 351111401 Tulsa, OK 9/25/84 0 Radiography Event -

Crane Midwest Fitting 240056302 St. Louis, MO 9/18/84 2 Two Members of Public Deaconess Hospital 240075201 St. Louis, MO 9/14/84 1 Extremi ty Indiana University Med Ctr 130275208 Indianapolis, IN 8/3/84 0 Teletherapy Intermountain Testing Co. 050787201 Englewood, CO 7/25/84 1 >1.25 rem w/b Nuclear Fuel Services Docket 70 Erwin, TN 10/15/84 1 Internal Nuclear Pharmacy, Inc. 121804401 Chicago, IL 8/15/84 1 Extremity St. Anthony Hospital 3S0142803 Oklahoma City, OK 11/1/84 1 >1.25 rem w/b St. Barnabas Med Ctr 290160803 Livingston, NJ 12/1/84 1 >5 rem w/b (1984)

Suisman Titanium Corp. 061765301 Hartford, CT Unknown 0 Badge Tulsa Inspection Services 352336201 Tulsa, OK 9/15/84 1 >3 rem w/b University of Chicago 120050903 ' Chicago, IL 10/1/84 0 Badge University of Wisconsin 480984318 Madison, WI 12/15/84 0 Badge Veterans Administration 140082201 Iowa Ci ty, IA 8/1/84 0 Badge Veterans Administration MC* 310063607 Bronx, NY 8/8/84 1 Internal Wheeling-Pittsburgh Steel 471687502 Wheeling, WV 10/24/84 0 Open Gauge

  • Abnormal Occurrence

Table IV .

Lost or Stolen Sources, July-December 1984 Part I Isotope Licensee License No. Location Event Date Disposition Am241 BPB Instruments Inc. 131743201 Henderson, KY 10/2/84 Found Am241 Harshaw/Filtrol Part. Solon, OH 9/19/84 Unknown Ca45 Iowa State University 140001906 Ames, IA 9/20/84 Other Cs137 Doctors Hospital North 310548801 Columbus, OH 12/7/84 Found Cs137 Halliburton Co. 420106801 Duncan, OK 12/1/84 Hadwaste Cs137 Metropolitan Hospital 521603302 San Juan, PR 11/11/84 Found Cs137 Radiology Inc. 342046501 Columbus, OH 12/12/84 Unknown Cs137 3M Co. Minn. Mining & Manu. 220005703 Cottage Grove, MN 7/14/84 Unknown H3 City of Waukesha, WI GEN Wakesha, WI 8/7/84 Unknown H3 Univ. of Massachusetts 200088207 Amherst, MA 10/1/84 Unknown Ir192 Muskogee General Hospital 351315701 Muskogee, OK 8/29/84 Unknown Ir192 Tech / Ops 200027703 Barberton, OH 10/23/84 Found I125 Univ of Illinois at Chicago 120050903 Chicago, IL 11/21/84 Unknown Mo99 Mallinckrodt Inc. 240420601 New York, NY 9/18/84 Found N163 Dept. of Navy 41349502 San Diego, CA 12/26/84 Unknown Hi63 Koppers Company 371084501 Monroeville, PA Found F32 Carnegie Mellon Univ. 370060203 Pittsburgh, PA 7/9/84 Sanitary Landfill P32 Yale University 060018303 New Haven, CT 10/16/84 Found UNK Schlumberger Technology Corp. 420009003 Uinta, WY 11/20/84 Found

Table IV 'I July-December 1984 Abandoned Well Logging Sources Part II Isotope Licensee License No. Location Event Date Am241 Dresser Industries 420296401 Canadian City, OK 10/13/84 Am241 Gearhart Owen Industries, Inc 420645803 Payne City, OK 8/1/84 Am241 Gearhart Owen Industries, Inc 420645803 Tulsa City, OK 8/20/84

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Am241 Schlumberger Well Services 420009003 Offshore, LA 9/10/84 Am241 Schlumberger Well Services 420009003 Fed Waters, LA 12/13/84 Am241 Schlumberger Well Services 420009003 Offshore, LA 11/S/84 Am241 Schlumberger Well Services 420009003 Offshore, LA 11/5/84 Csl37 Allegheny Nuclear Survey Inc 471197601 Athens City, OH 11/9/84 Cs137 Dresser Industries 420296401 7/27/84 Csl37 Dresser Industries 420296401 7/26/84 Csl37 Gearhart Owen Industries, Inc 420645803 Pottnwattomie, OK 8/5/84 Csl37 Gearhart Owen Industries, Inc 420645803 Venango City, PA 12/21/84

Table V  ?.

July-December 1984 Reports of Leaking Sources Isotope Location Licensee License No. Event Date Manufacturer Dow Chemical GEN Am241 McConnell, KS Dept. of Air Force 151381201 Various Co60 Chicago, IL Ohmart Corporation 340063903 11/15/84 Gamma Industries Cs137 Wicnita, KS Great Guns Inc. 152133201 11/25/84 Gulf Nuclear Cs137 ,

Wooster, OH Schlumberger Technology Corp 420009003 7/20/84 GSR-J-5339 Cs137 Various Fed. Emerg. Man. Agency 80129706 Fe5S Madison, WI Univ. Wisconsin-Madison 480984318 7/14/84 ICN Ir192 NY (FPO), NY U.S.S. Emory Land 311904001 10/2/84 Gamma Industries Ir192 Burlington, MA Bestco 61715601 Gulf Nuclear RT-15 Ni63 Dugway, UT Dept. of Army 430131609 8/27/84 Hewlett Packard Pm147 Oklahoma City, OK Fife Corporation 351551101 9/4/84 T1204 Chicago, IL Magnaflux Corp. 120062207 8/13/84 T1204 Chicago, IL Magnaflux Corp. 120062207 8/27/84 T1204 Chicago, IL Magnaflux Corp. 120062207 11/2/84 T1204 Chicago, Il Magnaflux Corp. 120062207 12/17/84

Table VI '

July-December 1984 Radiography Events Licensee License No. Location Event Date Type of Event

  • Air Products and Chemicals 370510505 Richland, WA 12/13/84 WAS American Airlines 351396401 Los Angeles, CA 8/25/84 EXP**

Bestco 61715601 Burlington, MA Unknown LKS Capital X-Ray Services, Inc 351111401 Tulsa, OK 9/25/84 EXP _

Crane Midwest Fitting 240056302 St. Louis, MO 9/18/84 EXP tiamma Industries AS Newport News, VA 11/8/84 MSC Intermountain Testing Co. 50787201 Englewood, CO 7/25/84 EXP North American Inspection 372337001 Laurys Sta, PA 10/18/84 MSC Quaker Alloy Casting Co. 370367101 Myerstown, PA 7/12/84 MSC Quality Assurance Lab. 181907801 S. Portland, ME 10/5/84 MSC Westinghouse Electric Co. 370580902 Cheswick, PA Unknown MSC

  • Type of Event:

WAS waste LKS leaking source EXP exposure MSC miscellaneous

    • No exposures occurred

,.Ji y: o

-Table VII July-December 1984 Manufacturing and Distribution Event Reports-Licensee - License No. ' Location Event Date E. I. DuPont 200032013 Boston, MA 12/11/84 Gauna Industries AS Newport News, VA 11/8/84 Mallinckrodt Inc. 240420601 New York, NY 9/18/84 Ohmart Corp. 340063936 Crosset, AR 9/19/84 Chmart Corp. 340063936 Chicago, IL 11/15/84 Tech / Ops 200027703 Barbarton, OH 10/23/84 Victoreen Inc. 340048604 Cleveland, OH 10/18/84

q vi Table VIII

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July-December 1984 Gauges / Measuring Systems Event Reports Isotope Licensee License No. Location Event Date Am241 Bowser-Morner Testing Labs 341739001 Dayton, OH 10/14/84 Am241 Woodward Clyde Consultants - 151910901 Baldwin City, KS 8/21/84 Owens Steel Columbia, SC Cs137 AS 10/27/84 Cs137 3M Co. Minn. Mining & Manu. 220005703 Cottage Grove, MN 7/14/84 Cs137 Wheeling-Pittsburgh Steel 471687502 Wheeling, WV 10/24/84 Ir192 Newport News Shipbuilding - 450942802 Newport News, VA 11/14/84 Ir192 U.S.S. Emory Land 311904001 NY.(FPO) 10/2/84 Kr85 FAG Bearings Corporation 062063101 Stanford, CT 11/15/84 Ni63 Koppers Company 371084501 Monroeville, PA Unknown i

UNK STS Consultants 451831802 Fairfax, VA 11/28/84 UNK .Suisman Titanium Corp. 061765301 Hartford, CT Unknown

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