ML20135E792
| ML20135E792 | |
| Person / Time | |
|---|---|
| Issue date: | 09/30/1996 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| References | |
| NUREG-1272, NUREG-1272-V09-N02, NUREG-1272-V9-N2, NUDOCS 9612120065 | |
| Download: ML20135E792 (184) | |
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AVAILABILITY NOTICE Availability of Reference Materials Cited in NRC Publications Most documents cited in NRC publications will be available from one of the following sources:
1.
The NRC Public Document Room, 2120 L Street, NW., Lower Level, Washington, DC 20555-0001 2.
The Superintendent of Documents, U.S. Government Printing Office, P. O. Box 37082, Washington, DC 20402-9328 3.
The National Technical Information Service, Springfield, VA 22161-0002 Although the listing that follows represents the majority of documents cited in NRC publica-tions, it is not intended to be exhaustive.
Referenced documents available for inspection and copying for a fee from the NRC Public Document Room include NRC correspondence and ' internal NRC memoranda; NRC bulletins, circulars, information notices, inspection and investigation notices; licensee event reports; vendor reports and correspondence; Commission papers; and applicant and licensee docu-ments and correspondence.
The following documents in the NUREG series are available for purchase from the Government Printing Office: formal NRC staff and contractor reports, NRC-sponsored conference pro-ceedings, international agreement reports, grantee reports, and NRC booklets and bro-chures. Also available are regulatory guides, NRC regulations in the Code of Federal Regula-tions, and Nuclear Regulatory Commission issuances.
Documents available from the National Technical information Service include NUREG-series reports and technical reports prepared by other Federal agencies and reports prepared by the
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Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission.
I Documents available from public and special technical libraries include all open literature I
items, such as books, journal articles, and transactions. Federal Register notices, Federal l
and State legislation, and congressional reports can usually be obtained from these libraries.
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Documents such as theses, dissertations, foreign reports and translations, and non-NRC con-ference proceedings are available for purchase from the organization sponsoring the publica-tion cited.
1 Single copies of NRC draft reports are available free, to the extent of supply, upon written request to the Office of Administration, Distribution and Mail Services Section, U.S. Nuclear Regulatory Commission, Washington DC 20555-0001.
Copies of industry codes and standards used in a substantive manner in the NRC regulatory process are maintained at the NRC Library, Two White Flint North,11545 Rockville Pike, Rock-ville, MD 20852-2738, for use by the public. Codes and standards are usually copyrighted
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and may be purchased from the originating organization or, if they are American National i
Standards, from the American National Standards institute,1430 Broadway, New York, NY
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S EPTEM B E R 1996 V j E E E E E E E E E E E E E E E
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Previous Reports in Series
'Ibe following semiannual or annual reports have been prepared by the Office for Analysis and Evaluation of Operational Data (AEOD).
Semiannual Report, January - June 1984, AEOD S/405, September 1984 e
Semiannual Report, July - December 1984, AEOD/S502, April 1985 e
Annual Report 1985, AEOD/S601, April 1986 e
Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational Data e
1986, NUREG-1272, AEOD/S701, May 1987 Report to the U.S. Nuclear Regulatory Comnusswn on Analysis and Evaluation of Operational Data e
1987, Power Reactors, NUREG-1272, AEOD/S804, Vol. 2, No.1, October 1988 Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of OperatwnalData e
1987, Nonreactors, NUREG-1272, AEOD/S804, Vol. 2, No. 2, October 1988 Office for Analysss and Evaluation of Operatwnal Data 1988 Annual Report, Power Reactors, e
NUREG-1272, Vol. 3, No. L June 1989 Office forAnalysis and Evaluation of Opemtional Data 1988 Annual Report, Nonreactors, e
NUREG-1272, Vol. 3, No. 2, June 1989 Office for Analysss and Evaluation of Operational Data 1989 Annual Report, NUREG-1272, Vol 4, 1
e No.1 July 1990 Officefor Analysss and Evaluation of Operatwnal Data 1989 Annual Report, NUREG-1272, Vol 4, e
No. 2, July 1990 Officefor Analysts and Evaluation of Operatwnal Data 1990 Annual Report, NUREG-1272, Vol 5, e
No.1, July 1991
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Office forAnalysis and Evaluation of Operatwnal Data 1990 Annual Report, NUREG-1272, Vol 5, e
No. 2, July 1991 OfficeforAnalysss and Evaluation of Operational Data 1991 Annual Report, NUREG-1272, Vol. 6, e
No.1, July 1992 Officefor Analysis and Evaluation of Operational Data 1991 Annual Report, NUREG-1272, Vol 6, e
No. 2, August 1992 Officefor Analysts and Evaluation of Operational Data 1992 Annual Report, NUREG-1272, Vol 7, e
No.1. July 1993 Officefor Analysss and Evaluation of Operational Data 1992 Annual Report, NUREG-1272, Vol 7, i
e No. 2, October 1993 i
Office for Analysus and Evaluation of Operational Data 1993 Annual Report, NUREG-1272, Vol. 8, e
No.1, November 1994 Officefor Analysts and Evaluation of Operational Data 1993 Annual Report, NUREG-1272, Vol 8, e
No. 2, May 1995 4
Officefor Analysis and Evaluation of Operational Data 1994-FY 95 Annual Report, NUREG-1272, e
Vol 9, No.1, July 1996 l
Abstract Tne United States (U.S.) Nuclear Regulatory calendar year 1994 (1994) and fiscal year 1995 (FY Commission's Office for Analysis and Evaluation
- 95) reports which describe activities conducted i
of Operational Data (AEOD) has published between January 1,1994, and September 30,1995.
reports of its activities since 1984. The first report Certain data which have historically been covered January through June of 1984, and the reported on a calendar year basis, however, are i
second report covered July through December of complete through calendar year 1995. Throughout 1984. Since those first two semiannual reports, this report, whenever information is presented for AEOD has published annual reports of its fiscal year 1995, it is designated as FY 95 data.
activities from 1985 through 1993. Beginning with Calendar year information is always designated by the report for 1986, AEOD Annual Reports have the four digits of the calendar year.
been published as NUREG-1272. Beginning with the report for 1987, NUREG-1272 has been NUREG-1272, Volume 9, No.1, covers power published in two volumes, No.1 covering power reactors and presents an overview of the operating reactors and No. 2 covering nonreactors (changed experience of the nuclear power industry from the to " nuclear materials" with the 1993 report). The NRC perspective. This report, NUREG-1272, 1993 AEOD Annual Report was NUREG-1272, Vol. 9, No. 2, covers nuclear materials and Volume 8.
presents a review of the events and concerns associated with the use of licensed material in AEOD has changed its annual report from a non-power reactor applications. A new part has calendar year to a fiscal year report to be been added, NUREG-1272, Volume 9, No. 3, consistent with the NRC Annual Report and to which covers technical training and presents the conserve staff resources. NUREG-1272, activities of the Technical Training Center in Volume 9, Nos.1 and 2, therefore, are combined support of the NRC's mission.
iii NUREG-1272
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Contents Page Abstract.................................................................................
iii A bb revi ations............................................................................
ix Executive Summary......................................................................
xi 1 Introd u cti on..........................................................................
1 2 ' Operating Experience Feedback.........................................................
3 l 2.1 Nuclear Material Events Database..................................................3 2.2 Medical Misadministrations.......................................................
4 23 Radiation Overexposures..........................................................
7 2.4 Loss of Control of Licensed Material...............................................
8 2.5 Leaking Sources................................................................,.
10 2.6 Rele ase of Material...............................................................
11
' 2.7 Transportation Events.............................................................
11 -
2.8 Equipment Problems..............................................................
12 2.9 Fuel Cycle Facility Problems.......................................................
12 2.10 Test, Research, and Training Reactors...............................................
14 2.11 Annual Radiation Exposure Data..................................................
14 3 Abnormal Occurrences................................................................
17 3.1 NRC Licens ees...................................................................
17 3.1.1 Medical Institutions........................................................
17 3.1.2 Research Facili ty..........................................................
17 3.13 Mili tary Base..............................................................
17 3.2 Agreement States.................................................................
17 3.2.1 ' Medical Institutions........................................................
17 3.2.2 Industrial Radiography.....................................................
17 3.23 Other Industrial Facilities..................................................
17 4 Other AEOD Activities................................................................
19 4.1 Agreement State Operational Experience Data.......................................
19 4.2 Abnormal Occurrence Reporting...................................................
19 43 Feedback of Nuclear Materials Experience..........................................
20 43.1 Taking Control-Safety Procedures for Industrial Radiographers................
20 43.2 Human Performance Evaluation of Industrial Radiography Overexposure Events.
20 433 Misadministrations and Other Medical Events Caused by Computer Errors......
21 5 Incident Investigation Program.........................................................
23 5.1 Incident Investigation Teams.......................................................
23 5.2 - Augmented Inspection Teams......................................................
23 v
I 3
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l Contents (cont.)
Page 6 Inci dent Response.....................................................................
25 6.1 Operations Center................................................................
25 i
6.2 Emergency Response..............................................................
25 6.3 Operations Center Data for 1994 and 1995..........................................
26 6.4 Emergency Exercises..............................................................
28 6.5 Gaseous Diffusion Process Activities...............................................
28 1
7 Committee to Review Generic Requirements.............................................
29 l
i i
)
Appendices A
Nuclear Materials Data by Event Type B
Summary of 1994 and FY 95 Abnormal Occurrences (Nuclear Materials)
C Reports and Videotapes Issued From 1981 Through 1993 (Nuclear Materials)
D Status of AEOD Recommendations (Nuclear Materials)
E Status of NRC Staff Actions for Events Investigated by Incident Investigations Teams (Nuclear Materials)
'Ihbles 2.1 Number of Reportable Events by Event 'Iype and Year for NRC and Agreement State Nuclear Materials Ucensees, January 1,1994 - September 30,1995.......................
4
- 2.2 Medical Misadministrations Reported by NRC and A January 1,1994 - September 30,1995...............greement State Ucensees 6
23 NRC Information Notices on Medical Misadministrhtions January 1,1994 - September 30,1995...................................................
7 2.4 Radiation Overexposures Reported by NRC and Agreement State Ucensees January 1,1994 - September 30, 1995...................................................
8 2.5 NRC Information Notices on Radiation Overerposures January 1,1994 - September 30,1995...................................................
9 2.6 Loss of Control of Ucensed Material Reported by NRC and A January 1,1994 - September 30,1995.......................greement State License 9
2.7 NRC Information Notices on Release of Material Events January 1,1994 - September 30, 1995...................................................
12 2.8 Equipment Problems Reported by NRC and Agreement State Licensees January 1,1994 - September 30, 1995...................................................
13 2.9 NRC Information Notices on Equipment Problems January 1,1994 - September 30,1995...................................................
13 2.10 Annual Exposure Data for NRC Industrial Radiography Ucensees, 1989-1994..............
15 NUREG-1272 vi
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I Tables (cont.)
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Pu e s
i 2.11 Annual Exposure Data for NRC Manufacturing and Distribution Licensees,1989-1994......
15 4
2.12 Annual Exposure Data for NRC Low. Level Waste Disposal Ucensees, 1989-1994...........
15 2.13 Annual Exposure Data for NRC Independent Spent Fuel Storage Ucensees,1989-1994......
16 2.14 Annual Exposure Data for NRC Fuel Fabrication and Processing Licensees,1989-1994......
16 6.1 Events Reported to the NRC Operations Center in 1994..................................
27 6.2 Events Reported to the NRC Operations Center in 1995..................................
27
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63 Alerts Reported at NRC-Licensed Nuclear Materials Facilities in 1994 and 1995............
27 1
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1 vii NUREG-1272
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4 4
Abbreviations i
i ACMUI Advisory Committee on Medical Uses HMO health maintenance organization
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ofIsotopes AEOD Analysis and Evaluation of I
iodine Operational Data (NRC Office for)
IIP Incident Investigation Program AFB Air Force base IIT Incident Investigation Team AO abnormal occurrence IMC inspection manual chapter ARG Accident Review Group IN (NRC)Information Notice ARM area radiation monitor IND investigational exemption of a new ASLB Atomic Safety and Ucensing Board drug AU authorized user IRC Indiana Regional Cancer (Center)
ISA integrated safety analysis 3
l Bq becquerel j
LDR low-dose-rate cGy centigray MBq megabecquerel
]
Ci curie mci millicuries Co-60 cobalt-60 MD Management Directive (NRC) dv dsim MOU memorandum of understanding CY calendar year mrem millirem i
DMC Deaconess Medical Center mSv millisievert DOE U.S. Department of Energy i
NaI sodium iodide DOT U.S. Department of'Iransportation NMED Nuclear Material Events Database -
NMSS Nuclear Material Safety and EDO Executive Director for Operations j
(NRC)
Safeguards (NRC Office ef)
NMT nuclear medicine technologist FC fuel cycle NRC U.S. Nuclear Regulatory Commission i
FCSS Fuel Cycle Safety and Safeguards NRCC Northern Rockies Cancer Center l
(NMSS Division of)
NRR Nuclear Reactor Regulation (NRC FDA U.S. Food and Drug Administration Office of) 2 FR FederalRegsster OCIMS Operations Center Information FY fiscal year Management System i
OGC Office of the General Counsel (NRC)
NE" OSC Oncology Services Corporation GE General Electric Corporation OSP Office of State Programs (NRC)
GI gastrointestinal 4
P&GD policy and guidance directive HDR high-dose-rate ix NUREG-1272
QA quality assurance SCBA self-contained breathing apparatus QC quality control SF&CG standard format and content guidance j
QMP quality management program SNM special nuclear material Sr-90 strontium-90 RCEP Radiological Contingency and SRP Standard Review Plan Emergency Plan REIRS Radiation Exposure Information he cent Hospital and Health Reporting System RES Nuclear Regulatory Research (NRC TR1R Test, Research, and Training Reactors l
Office of)
TS Technical Specifications RI Region I(NRC)
RII Region II(NRC)
USEC United States Enrichment Corporation RSC radiation safety committee RSO radiation safety officer YNHH Yale-New Haven Hospital i
I NUREG-1272 x
i 4-J EXECUTIVE
SUMMARY
t t
The U.S. Nuclear Regulatory Commission (NRC) report was NUREG-1272, Volume 8, which i
licenses the use of reactor-produced isotopes, the covered AEOD activities in 1993. NUREG-1272, milling of uranium, and the subsequent Volume 9, is a combined calendar year 1994 processing of both natural and enriched uranium, (1994) and fiscal year 1995 (FY 95) report. Certain as well as other special nuclear material (SNM).
data which have historically been reported on a He NRC directly regulates licensees in 21 States, calendar year basis, however, are complete i
the District of Columbia, and the U.S. territories.
through December 31,1995. Throughout this The remaining 29 states, known as Agreement report, whenever information is presented for States, have entered into agreements with the fiscal year 1995, it is designated as FY 95 data.
NRC under Section 274 of the Atomic Energy Calendar year information is always designated by i
Act, as amended, whereby the NRC relinquishes the four digits of the calendar year. NUREG-l and the States assume regulatory authority over 1272, Vol.9, No.1, covers power reactors and the use of byproduct materials, source materials, presents an overview of the operating experience l
and other SNM in quantities not capable of of the nuclear power industry from the NRC i
sustaining a chain reaction.
perspective, including the trends of some key l
performance measures. NUREG-1272, Vol.9, he NRC's Office for Analysis and Evaluation of No. 3, covers technical training and presents the Operational Data (AEOD) was created in 1979 to activities of the Technical Training Center in
. provide a strong, independent capability to support of the NRC's mission. Dis report, analyze operational data. AEOD implements this NUREG-1272, Vol.9, No. 2, covers nuclear role for nuclear materials applications by materials and presents a review of the events and analyzing and evaluating operating experience concerns with the use of licensed materials in data, publishing studies of operational experience non-power reactor applications in 1994 and and, as appropriate, recommending actions to FY 95.
reduce the probability or consequences of these events.
Operating Experience Feedback AEOD coordinates the overall NRC operational Nuclear materials licensees are required by Title data program, serves as the central point for 10 of the Code ofFedemlRegulations (10 CFR),
interaction with domestic and foreign organi-comparable Agreement State regulations, or zations performing similar work, and obtains license conditions, to submit reports of events industry feedback on these activities. The AEOD which meet established criteria. Reportable programs, taken as a whole, constitute the nuclear materials events include (1) medical essential independent review and assessment of misadministrations of radiation or radio-power reactor and nuclear materials safety pharmaceuticals to patients, (2) radiation performance, and complement the regional, the overexposures,(3) loss of control oflicensed Office of Nuclear Reactor Regulation, and the material, (4) problems with equipment that uses Office of Nuclear Material Safety and Safeguards licensed material or is otherwise associated with reviews of operating events. They perform a the use of licensed material (5) releases of quality verification function that provides material or contamination, (6) leaking radioactive assurance of feedback of important operational sources, (7) problems during the transportation of safety lessons. AEOD findings and recommen-licensed material, (8) problems in fuel cycle dations continue to be addressed through generic facilities, and (9) problems in non-power reactors.
correspondence, in the resolution of generic issues, and in initiatives taken by industry and AEOD collects, reviews, and codes nuclear licensees.
materials event information reported by NRC licensees and Agreement States. Approximately AEOD has changed iS annual report from a 7000 NRC li:ensees and 15,000 Agreement State calendar year to a fiscal year (FY) report to be licensees submit reports of events. NRC licensees consistent with the NRC Annual Report and to submit reports directly to the NRC regional or conserve staff resources. The last calendar year headquarters offices. Agreement State licensees xi NUREG-1272
(
AEOD Annual Report,1994-FY 95 submit reports to the States, which in turn reported by Agreement States involved industrial voluntarily transmit summary reports to the NRC radiography. It should be noted that Agreement under an informal information sharing agreement.
States have approximately three times as many industrial radiography licensees as does the NRC.
In 1993 AEOD developed a new database called The primary causes of medical / academic and the Nuclear Material Events Database (NMED),
research/ commercial overexposures included designed to allow multiple effects of a single event failure to ensure that adequate dosimetry was to be appropriately recorded. For example, an issued and monitored, failure to wear adequate event may involve a medical misadministration protective clothing in areas containing discrete and a loss of control of licensed material. In such radioactive particles, and failure to follow a case, the event would be included in each procedures. The primary causes of industrial applicable category. An interim version of the radiography overexposure were failure to conduct NMED (a stand-alone version) was distributed to the required radiation surveys, failure to set up or the Agreement States in October 1994. Installa-monitor posted radiation boundaries, failure to tion of the NMED within NRC headquarters follow established emergency procedures, and lack personal computers began in July 1995.
of adequate supervision of assistants.
In 1994 and FY 95 there were 1058 reports of There were 961 other nuclear materials events, events involving nuclear materials licensees and including loss of control of licensed material, non-power reactors that were required to be leakmg sou,rces, release of material, transportation reported to the NRC. Sixty-nine of these were events, equipment problems, fuel cycle facility i
medical misadministrations,26 of which were Problems, and problems at test, research, and l
reported to Congress as abnormal occurrences trammg reactors. Some of these events were (AOs). The primary factors contributing to these sigmficant and resulted m seven AOs reported to misadministrations included misunderstanding of C ngress, overexposure of 25 people, and the the referring physician's request, errors in issuaneg of 21 NRC Information Notices.,A major contammation event occurred when a cesium-137 calculation of the treatment plan, errors in operation of the equipment, and not following the source ruptured while bemg removed from the quality management plan. The NRC issued nine source holder. An improperly packaged shipment Information Notices on Medical Misadminis-f wire s urces from a foreign country resulted m trations during 1994 and FY 95.
the exposure of more than 60 members of the public; 24 people exceeded their annual exposure limit. And there were 15 events in which licensed There were 28 events that occurred in 1994 and material was released to the environment.
FY 95 that resulted in overexposures to 57 people.
Altogether there were 43 nuclear materials events Four of these events were reported to Congress as which were reported to congress as AOs.
AOs. Seventy-two percent (41/57) of the overexposures were whole body doses ranging Other AEOD Activities from 0.12 cSv (0.12 rem) to 2136 cSv (2136 rem),
with a median value of 0.52 cSv (0.52 rem). The In order to establish standards for collecting 2136 cSv whole body exposure resulted from material event data from Agreement States and to radiography conducted by a trainee without encourage voluntary reporting of material event supervision. Sixteen percent (9/57) of the data, AEOD began a trial program for Agree-overexposures were to the extremities and ranged ment State event reporting in April 1995, from 5137 cSv (5137 rem) to 1500 cSv (1500 rem),
Agreement States are encouraged to report with a median value of 94.40 cSv (94.40 rem). The significant events to the NRC Operations Center 1500 cSv (1500 rem) overexposure was a shallow-within one working day. Agreement States are dose equivalent to the fingers of a radiographer encouraged to report routine events using the who failed to follow proper emergency procedures NMED software and procedures provided to the to recover a disconnected source. 'Ihis resulted in Agreement States.
blistering of the fm' gers. Most of the overexposure events reported by NRC licensees involved AEOD has recommended that the Commission research and commercial uses of licensed revise the AO reporting criteria. The proposed material, whereas most of the overexposures policy describes the manner in which the NUREG-1272 xii
I.
Commission will carry out its responsibilities for NMED. The scope of the study included the identifying AOs and for making each such review and analysis of historical and recent 1
occurrence available to Congress and the public events, the categorization of the events in terms of l
in a timely manner. Included in the policy human actions and contributing factors, and the
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statement are revised AO criteria that the detailed modeling of a subset of events for more Commission will use in determining whether a thorough analysis. A major finding of the study 4
5 particular event is a reportable AO. In addition, was that the primary factors contributing to AEOD drafted a preliminary revision of NRC radiography overexposures are procedural errors Management Directive (MD) 8.1, " Abnormal (e.g., improper survey, survey not performed, 4
Occurrence Reporting Procedure." This revision camera not locked), equipment problems (e.g.,
will be finalized after the Commission approves
- equipment design issues, source connections /
the new AO reporting criteria.
disconnections), and external factors (e.g.,
supervision and area control).
In 1994 and FY 95 the AEOD nuclear materials assessment staff produced one videotape and two In the second special study, "Misadministrations i
special studies. The videotape, entitled "Taking and Other Medical Events Caused by Computer Control-Safety Procedures for Industrial Errors," AEOD staff analyzed events involving l
Radiographers," covers several types of common computer errors that resulted in medical l
errors reported to the NRC by licensees that led misadministrations. There were 22 such events to personnel radiation overexposures. The Office involving 172 patients that were reported by NRC i
of Nuclear Material Safety and Safeguards licensees and Agreement States, he analysis distributed this video to all radiography licensees.
addressed treatment planning and dose delivery ne video can be used to supplement radiation systems with emphasis on software, hardware, and j
safety training for radiographers and ancillary human-machine interface issues that could 3
personnel. The video uses re-enactments, based potentially affect the system's operational safety.
1 on real events, to illustrate to radiography licensee Among the significant findings were the following:
personnel the importance of good practices in (1) the number of computer-based misadminis-performing industrial radiography.
trations per year has been increasing, (2) events resulting in reported misadministrations to AEOD contracted with the Idaho National multiple patients occur more often in Engineering Laboratory (INEL) to perform a computer-based radiation therapy processes than special study, " Human Performance Evaluation of in manual therapy, and (3) nearly three-fourths of Industrial Radiography Exposure Events,"
the computer error-related medical misadminis-consisting of a human factors review of the trations are directly linked to human errors and radiography overexposure event data in the procedural deficiencies.
xiii NUREG-1272
f i
l l
1 Introduction ne U.S. Nuclear Regulatory Commission (NRC)
AEOD programs, taken as a whole, constitute the licenses the use of reactor-produced isotopes, the essential independent review and assessment of l
milling of uranium, and the subsequent power reactor and nuclear materials safety l
processing of both natural and enriched uranium, performance, and complement the regional, the l
as well as other special nuclear material (SNM).
Office of Nuclear Reactor Regulation (NRR), and I
ne NRC directly regulates licensees in 21 States, the Office of Nuclear Material Safety and l
the District of Columbia, and the U.S. territories.
Safeguards (NMSS) reviews of operating events.
The remaining 29 states, known as Agreement They perform a quality verification function that States, have entered into agreements with the provides assurance of feedback of important l
NRC under Section 274 of the Atomic Energy operational safety lessons. AEOD findings and l
Act, as amended, whereby the NRC relinquishes recommendations continue to be addressed and the States assume regulatory authority over through generic correspondence, in the resolution the use of byproduct materials, source materials, of generic issues, and in initiatives taken by and other SNM in quantities not capable of industry.
sustaining a chain reaction.
In 1994 AEOD was reorganized into three ne NRC's Office for Analysis and Evaluation of divisions: the Incident Response Division, which Operational Data (AEOD) was created in 1979 to includes the Emergency Response Branch and the l
provide a strong, independent capability to Diagnostic Evaluation and Incident Investigation analyze operational data. AEOD implements this Branch; the Safety Programs Division, which role for nuclear materials applications by includes the Reactor Analysis Branch and the analyzing and evaluating operating experience Reliability and Risk Assessment Branch; and the data, publishing studies of operational experience Technical Training Division, which includes the and, as appropriate, recommending actions to Reactor Technology Training Branch, the reduce the probability or consequences of these Specialized Technical Training Branch, and the events.
Technical Training Support Branch.
In May 1987 AEOD also became responsible for AEOD has changed its annual report from a the NRC's Diagnostic Evaluation, Incident calendar year to a fiscal year (FY) report to be Investigation, Incident Response, and Technical consistent with the NRC Annual Report and to Daining Programs. The Diagnostic Evaluation conserve staff resources. The last calendar year Program provides independent assessments of report was NUREG-1272, Volume 8, which selected facilities to supplement information from covered AEOD activities in 1993. NUREG-1272, other NRC programs. The Incident Investigation Volume 9, is a combined calendar year 1994 Program provides a structured NRC investigative (1994) and fiscal year 1995 (FY 95) report. Certain response to significant operational events data which have historically been reported on a according to their safety significance. The calendar year basis, however, are complete Incident Response Program provides a through December 31,1995. nroughout this i
coordinated NRC emergency response to ongoing report, whenever information is presented for i
events through the NRC Operations Center. The fiscal year 1995, it is designated as FY 95 data.
'Rchnical Daining Center provides initial and Calendar year information is always designated by l
continuing technical training for NRC staff and the four digits of the calendar year. NUREG-contractors. AEOD also provides administrative 1272, Vol.9, No.1, covers power reactors and and technical support to the NRC's Committee to presents an overview of the operating experience Review Generic Requirements of the nuclear power industry from the NRC perspective. including the trends of some key AEOD coordinates the overall NRC operational performance measures. NUREG-1272, Vol.9, data program, serves as the central pomt for No. 3, covers technical training and presents the interaction with domestic and foreign activities of the Technical Training Center in l
organizations performing similar work, and support of the NRC's mission. His report, obtains industry feedback on these activities. The NUREG-1272, Vol.9, No. 2, covers nuclear 1
NUREG-1272, Section 1
. - -. - _ ~..
AEOD Annual Report,1994-FY 95 materials and presents a review of the events and Appendix C lists nuclear materials reports concerns with the use oflicensed materials in and videotapes issued by AEOD from 1981 nonpower reactor applications in 1994 and FY 95.
through FY 95 He report also includes the following appendices:
Appendix D presents the Status of Appendix A summarizes the 1994 and FY 95 Recommendations included in AEOD nuclear materials events by event type nuclear materials stud,es i
Appendix E presents the status of staff i
Appendix B summarizes the 1994 and FY 95 actions resulting from the findings of NRC nuclear materials abnormal occurrences IITs for nuclear materials events i
J l
i i
i NUREG-1272, Section 1 2
I i
l l
l I
l 2 Operating Experience Feedback The primary concern with the use of radioactive and are therefore not included in this annual l
materials is the potential for overexposure, which report.) NRC licensees submit reports directly to can cause cancer or, in severe cases, death, the NRC regional or headquarters offices.
Extremity or localized skin exposures from Agreement State licensees submit reports to the radioactively hot particles are a lesser health States, which in turn voluntarily transmit concern but are still important to the NRC in summary reports to the NRC under an informal assessing the effectiveness of byproduct materials information sharing agreement. In addition, the control.
NRC obtains reports of events from other sources, such as NRC inspection reports, and occasionally One measure of the effectiveness of a licensee's from non-licensees, including members of the control of regulated materials is the collective public.
dose received by all employees who work with, or may be present in the vicinity of, nuclear From 1981 through 1992, nuclear materials event materials. Licensees are required to provide data were coded and maintained in two 1
appropriate monitoring equipment to, and to databases, one containing records of medical require the use of such equipment by, each misadmnustration events and the other contammg individual who is likely to receive a dose in any records of other reported nuclear materials calendar quarter in excess of 25 percent of the events. In 1993 AEOD developed a new database i
allowable limits specified in 10 CFR Part 20.
called the Nuclear Material Events Database l
Licensees are also required to monitor and (NMED), designed to allow multiple effects of a control activities that can lead to exposing their single event to be appropriately recorded. For employees or the general public to radiation.
example, an event may involve a medical misadministration and a loss of control of licensed material. In such a case, the event would i
2.1 Nuclear Material Events Database be included in each applicable category. In 1994 l
and FY 95, approximately four percent of the Nuclear materials licensees are required by Title reported events include multiple category entries.
10 of the Code of Federal Regulations (10 CFR),
In developing the data base structure, AEOD comparable Agreement State regulations, or solicited and received substantial input from the license conditions, to submit reports of events NRC Headquarters Offices of Nuclear Materials which meet established criteria. Reportable Safety and Safeguards, State Programs, and nuclear materials events include (1) medical Nuclear Regulatory Research; the regional offices; misadministrations of radiation or and the Agreement States. Most of this input was radiopharmaceuticals to patients, (2) radiation provided during AEOD-sponsored workshops in overexposures, (3) loss of control of h,eensed November 1993 and May 1994. An interim version material, (4) problems with equipment that uses of the NMED (a stand-alone version) was licensed material or is otherwise associated with distributed to the Agreement States in October the use of licensed material,(5) releases of 1994. Installation of the NMED within NRC material or contamination, (6) leaking radioactive headquarters personal computers began in July sources, (7) problems during the transportation of 1995.
licensed material, (8) problems in fuel cycle facilities, and (9) problems in non-power reactors.
'Ihe NMED contains about 12,480 detailed records of reported events, including voluntary AEOD collects, reviews, and codes nuclear reports, as well as information for identifying materials event information reported by NRC associated reports, such as inspection reports.
licensees and Agreement States. Approximately (Agreement State data are available only from 7000 NRC licensees and 15,000 Agreement State 1991 on.) The NMED contains records of material i
licensees submit reports of events. (Licensees also events for all categories of materials licensees, l
voluntarily submit reports of events that are not including non power reactors. Radiation i
required to be reported. Voluntary reports are not overexposure events for commercial power considered when evaluating operating experience reactors are also maintained in the NMED. A 3
NUREG-1272, Section 2
AEOD Annual Report,1994-FY 95 new NMED data entry, search, and report with the use of radioactive materials in medical program is expected to be fully operational during applications arise from either a licensee's failure the first quarter of 1996.
to effectively control a licensed material or from other human errors, such as dispensing a In 1994 and FY 95 there were 1058 reports of radiopharmaceutical that does not comp,1y with a events invoMng nuclear materials licensees and physician's prescription. This can result m a non-power reactors that were required to be patient receiving an unintended or excessive dose reported to the NRC. 'Ihble 2.1 shows the number or a dose to the wrong treatment site.
of reportable events by type for both NRC and Occasionally a radiopharmaceutical is Agreement State licensees. Because licensees administered to the wrong patient. Excessive submit revisions, late reports, or retractions, exposures to monitored employees and minor changes may occur in the data published uncontrolled exposures to the general public are from year to year, also a concern in the medical use of radioactive i
materials. However, such incidents are relatively rare considering that hundreds of thousands of 2.2 Medical Misadministrations procedures are performed each year.
i The NRC and Agreement States regulate certain
'Ihe misadministration rule, which became i
aspects of reactor-produced radionuclides used in effective on November 10,1980, required NRC nuclear medicine and therapeutic radiology medicallicensees to report medical pursuant to Part 35 of Title 10 of the Code of misadministration events to the NRC. This rule Federal Regulations (10 CFR Part 35), " Medical was revised in 1987 to require medical licensees in Use of Byproduct Material." The major concerns the Agreement Sates to report misadministration Table 2.1 Number of Reportable Events by Event 'Iype and Year for NRC and Agreement State Nuclear Materials licensees January 1,1994 - September 30,1995 NRC Agreenient States Total Type of Event 1994 1995 Total 1994 1995 Total 1994 1995 Total Misadministration 28 21 49 14 6
20 42 27 69 Overexposure 5
4 9
12 7
19 17 11 28 I.oss of Control of Material 114 85 199 151 62 213 265 147 412 leaking Sources 15 9
24 18 11 29 33 20 53 Release of Material 54 23 77 16 9
25 70 32 102 Transportation 47 16 63 33 18 51 80 34 114 Equipment Problems 77 62 139 58 29 87 135 91 226 Fuel Cycle Operations 28 17 45 28 17 45 i
Research and Training Reactors 5
4 9
5 4
9 Total 373 241 614 302 142 444 675 383 1058 NUREG-1272, Section 2 -
4
Nuclear Materials-Operating Experience Feedback events to the appropriate regulatory agency in The potential or actual effect of a therapeutic their state. Agreement State agencies then had 3 misadministration generally differs from that of a years to promulgate State rules compatible with diagnostic misadministration. Therapeutic those of the NRC. Therefore, Agreement State misadministrations are associated yvith licensees were required to report medical mis-procedures in which large doses of radiation are administration events by 1991. The Agreement administered to patients to achieve a therapeutic States have agreed to voluntarily submit effect, while diagnostic misadministrations are misadministration reports to the NRC.
associated with clinical or investigative proce-dures requiring comparatively small doses of radiation. However, some misadministrations The Quality Management Program and involving the use of NaI-125 or NaI-131 for Misadministrations Rule, which became effective diagnostic purposes may deliver unintended doses in 1992, requires a quality management program in the therapeutic range to the patient's thyroid, and contains revised definitions of and reporting Not all therapeutic overdoses result in significant requirements for medical misadministrations. As radiation-induced clinical effects to patients.
part of this rule, the misadministration definitions Some misadministrations occur because patients were changed to include the following six types of are administered a dose of radiation that is less procedures: (1) administration of diagnostic than that prescribed. In these cases, if the error is radiopharmaceuticals, including less than 1.11 found in time, the total prescribed dose can still megabecquerels (MBq)(30 microcuries [nCi])
be achieved.
sodium iodide-125 (Nal-125) or NaI-131, (2) diagnostic administrations of Nal-125 or The NRC regulates approximately 2000 licensees Nal-131 radiopharmaceuticals in quantities in 21 states, the District of Columbia, and the greater than 1.11 MBq (30 pCi), (3) administra-U.S. territories, that use radionuclides m tion of therapeutic radiopharmaceuticals (other.
radiation therapy and nuclear medicme than NaI-125 or Nal-131),(4) gamma stereotactic applications. These facilities submitted reports of 49 misadministrations that occurred in 1994 and radiosurgety, (5) teletherapy, and (
therapy. The criteria for misadmm, 6) brachy-FY 95. The 29 Agreement States regulate about istrations vary and include such things as treatment of the wrong 5000 medical institutions, including hospitals, organ or patient, use of the wrong radiopharma-clinics, and physicians in private practice.
ceutical, admuustration of a dose that differs Agreement States submitted reports of 20 misadministrations that occurred in 1994 and from the prescribed dose, or an incorrect admmistration route or treatment mode. The FY 95.These events are listed in Appendix A, Tables A-1.1 and A-2.1 for NRC licensees and specific definitions are located in 10 CFR Part 35.
Agreement State licensees respectively.
Of these 69 misadministrations,58 percent The term " diagnostic misadministration," as used occurred during brachytherapy treatments,22 in NRC regulations, refers to the misadminis-percent involved sodium iodide procedures using tration of radioisotopes in such nuclear medicine quantities greater than 1.11 MBq ( 30 Ci), and 17 studies as renal, bone, and liver scans.
percent occurred during teletherapy treatments.
" Therapeutic misadministration" refers to the Therapeutic radiopharmaceutical procedures and misadministration of radiation in the treatment of gamma stereotactic radiosurgery were each patients using cobalt-60 (Co-60)(the external use responsible for 1.5 percent of the reported of radiation from a single Co-60 source for misadministrations. No diagnostic therapeutic treatment), gamma stereotactic radiopharmaceutical misadministrations were radiosurgery (the external use of radiation from reported.
about 200 small Co-60 sources for therapeutic treatment), brachytherapy (the insertion or Misadministration events that demonstrate a implantation of sealed sources containing maior failure of the radiation safety program or radioactive material for therapeutic treatment), or result in adverse health effects to a patient are radiopharmaceutical therapy (the ingestion or reported to Congress as Abnormal Occurrences injection of radioactive materials for patient (AOs). There were 26 misadministrations that therapeutic treatment).
occurred in 1994 and FY 95 that were reported as 5
NUREG-1272, Section 2
AEOD Annual Report,1994-FY 95 AOs. They are described in Appendix B to this an equipment problem. Communication problems report. In addition, there were seven were primarily due te misunderstanding the j
misadministrations that occurred in 1992 and referring physician's iequest, not following the 1993 that were reported as AOs in 1994 and FY quality maragement plan, and not properly 95 that were not included in the 1993 AEOD documenting changes to the treatment plan.
4 Annual Report. These events are also listed in Human error problems included incorrect Appendix B.
calculation of the treatment plan, errors in the i
operation of treatment equipment, and incorrect 4
i Reported medical misadministrations are shown preparation, loading, and implantation of l
by type of procedure in Thble 2.2. For both NRC brachytherapy applicators and seeds. Equipment and Agreement State licensees, the majority of the problems were primarily the result of source misadministrations involved brachytherapy migration.
l treatment. Sodium iodide procedures resulted in i
the second highest number of misadministration by NRC bcensees. Misadnu,mstrations myolving Corrective actions reported by licensees included dose variance during brachytherapy and sodium creating a new procedure, implementing a new iodide treatments most often result m an overdose training program, modifying an existing
)
]
rather than an underdose. Teletherapy procedure, providing retraining, and writing a new misadmmistrations were exclusively overdoses as quality management plan. Licensees did not were gamma stereotactic surgety report corrective actions in 32 of the misadnunistrations.
misadministrations, The causes for the reported misadministrations As part of the response to medical were reviewed and separated into three categories:
misadministration events, the NRC has issued (1) misadministrations involving a communication nine Information Notices (ins) to alert licensees problem; (2) misadministrations involving a of events associated with their particular license i
human error; and (3) misadministrations involving type. These notices are listed in Table 23.
i 4
d Table 2.2 Medical Misadministrations Reported by NRC and Agreement State Licensees j
January 1,1994 - Set temher 30,1995 i
NRC Agreement States Total
}
Procedure 1994 1995 Total 1994 1995 Total 1994 1995 Total Diagnostic j
Radiopharmaceutical 1
0 1
0 0
0 1
0 1
Sodium Iodide Radiopharmaceutical 7
5 12 1
1 2
8 6
14 Brachytherapy 16 13 29 11 2
13 27 15 42 Teletherapy 6
1 7
3 2
5 9
3 12 i
Gamma Stereotactic i
Radiosurgery 0
0 0
0 1
1 0
1 1
)
Total 30 19 49 14 6
20 44 25 69 a
NUREG-1272, Section 2 6
Nuclear Macerials-Operating Experience Feedback Table 23 NRC Information Notices on Medical Misadministrations January 1,1994 - September 30,1995 No.
Title i
l 94-17 Strontium-90 Eye Applicators: Submission of Quality Management Plan (QNP),
Calibration, and Use 94-37 Misadministration Caused by a Bent Interstitial Needle During Brachytherapy Procedure 94-39 Identified Problems in Gamma Stereotactic Radiosurgery 94-65 Potential Errors in Manual Brachytherapy Dose Calculations Generated Using a Computerized Treatment Planning System 94-70 Issues Associated with Use of Strontium-89 and Other Beta Emitting Radiopharmaceuticals 94-74 Facility Management Responsibilities for Purchased or Contracted Services for Radiation Therapy Programs 95-25 Valve Failure During Patient Treatment with Gamma Stereotactic Radiosurgery Unit 95-39 Brachytherapy Incidents Involving Treatment Planning Errors 95-50 Safety Defect in GammaMed 12i Bronchial Catheter Clamping Adapters 2.3 Radiation Overexposures T bles A-1.2 and A-2.2, of Appendix A of this The occupational dose limits for radiation workers are defined in 10 CFR 20.1201, Seventy-two percent (4737) of the overexposures
" Occupational dose limits for adults," while 10 were whole body doses ranging from 0.12 cSv CFR 20.1301, " Dose limits for individual (0.12 rem) to 2136 cSv (2136 rem), with a median members of the public," establishes the dose value of 0.52 cSv (0.52 rem). The 2136 cSv whole limits for non-radiation workers (members of the body exposure resulted from radiography public). In addition, the dose limits for minors are conducted by a trainee without supervision.
contained in 10 CFR 20.1207, " Occupational dose Sixteen percent (9/57) of the overexposures were limits for minors."
to the extremities and ranged from 5137 cSv (5137 rem) to 1500 cSv (1500 rem), with a median Medical misadministrations resulting in doses to value of 94.40 cSv (94.40 rem). The 1500 cSv (1500 patients in excess of planned treatments are not rem) overexposure was a shallow-dose equivalent categorized as overexposures. Only doses to to the fingers of a radiographer who failed to patients not intended to be treated are included in follow proper emergency procedures to recover a this section.
disconnected source. This resulted in blistering of the fingers and was reported to Congress as an NRC licensees reported 9 events that occurred in AO (AS 94-3). Three other overexposures were 1994 and FY 95 that resulted in overexposures to reported as AOs (95-9, AS 95-3, and AS 95-5).
11 people and Agreement State licensees reported These events are described in Appendix B.
19 events that overexposed 46 people (see Table 2.4). Four events involved multiple overexposures, Table 2.4 shows that most of the overexposure two of which resulted in multiple overexposures to events reported by NRC licensees involved members of the public. These events are listed in research and commercial uses of licensed 7
NUREG-1272, Section 2
AEOD Annual Report,1994-FY 95 l
Table 2.4 Radiation Overexposures Reported by NRC and Agreement State Licensees January 1,1994 - September 30,1995 No. of Reports No. ofIndividuals
]
i Agreement Agreement Type of Licensee NRC State Total NRC State Total Medical / Academic 0
4 4
0 4
4 Research/ Commercial 6
3 9
8 29 37 I
4 Industrial Radiography 3
12 15 3
13 16 Total 9
19 28 11 46 57 i
material, whereas most of the overexposures events associate with their particular licensee reported by Agreement States involved industrial type. These notices are listed in Table 2.5 radiography. It should be noted that Agreement i
States have approximately three times as many industrial radiography licensees as does the NRC.
2.4 IAss of Control of Licensed Matenal less of control of licensed material events occur The primary causes of medical / academic and when licensed material is not under the direct research/ commercial overexposures included physical or administrative control of a nuclear failure to ensure that adequate dosimetry was materials licensee. These types of events are i
issued and monitored, failure to wear adequate caused by an actual or administrative loss, protective clothing in areas containing discrete unauthorized abandonment or disposal, or theft radioactive particles, and failure to follow procedures. The primary causes of industrial of licensed material. Discovery of licensed material in the public domain is also considered a radiography overexposure were failure to conduct loss of control event even if the licensee did not the required radiation surveys, failure to set up or monitor posted radiation boundaries, failure to recognize the loss. The primary safety concerns stem from the loss of control oflicensed material, follow established emergency procedures, and lack whether or not the material is later recovered.
of adequate supervision of assistants. These causes are consistent with causes identified in an The reporting requirements are listed in 10 CFR AEOD-sponsored study of industrial radiography Part 20 for all loss of control events except for overexposure events performed by the Idaho well logging sources that have been declared j
National Engineering Laboratory (INEL). The irretrievable. Well logging sources may be results of the study are documented in the report abandoned (left in place)in accordance with the entitled " Human Performance Evaluation of requirements of 10 CFR 39.77 and guidelines Industrial Radiography Exposure Events." This approved by the NRC and the Agreement States.
study is described in Section 4.2 of this report.
They are tracked in the Nuclear Material Events Corrective actions reported by licensees included Database as loss of control events so that the suspension of workers for not following associated risk can be more easily quantified.
procedures, writing new procedures, and retraining workers.
NRC licensees reported 199 loss of control events that occurred in 1994 and FY 95 and Agreement States reported 213. 'Ihese 412 events are listed in As a part of the response to overexposure events, Tables A-13 and A-2.3 of Appendix A and are the NRC has issued four ins to alert licensees of summarized in Table 2.6 below.
NUREG-1272, Section 2 8
Nuclear Materials-Operating Experience Feedback Table 2.5 NRC Information Notices on Radiation Overexposures January 1,1994 - September 30,1995 l
No.
Title 94-15 Radiation Exposures During an Event Involving a Fixed Nuclear Gauge 95-44 Ensuring Compatible Use of Drive Cables Incorporating Industrial Nuclear Company Ball-Type Male Connectors 95-51 Recent Incidents Involving Potential Loss of Control of Licensed Material Table 2.6 14ss of Control of Ucensed Material Reported by NRC and Agreement State Licensees January 1,1994 - September 30,1995 Agreement Type of14ss NRC States Total lost Material Recovered 30 46 76 Not Recovered 53 38 91 Total 83 84 167 Stolen Material Recovered 13 16 29 Not Recovered 10 31 41 Total 23 47 70 Abandoned Licensed Material Recovered 39 59 98 Not Recovered 19 20 39 Total 58 79 137 Abandoned Welllogging Sources 35 3
38 lbtal-Material Recovered 82 121 203 Tbtal-Material Not Recovered 82 89 171 lbtal - Abandoned Well logging Sources 35 3
38 Tbtal - Loss of Control Events Reported 199 213 412 l
i 9
NUREG-1272, Section 2
AEOD Annual Report,1994-FY 95 l
Reported events can be grouped into five general quarterly to every three years, depending upon the l
areas: (1) licensed material (mostly medical waste) source construction and the method of l
inadvertently sent to commercial land-fills; encapsulation. Test results that show 18.5 Bq (2) licensed material (usually contaminated metal (0.0005 Ci) or greater of removable beta or or industrial measuring gauges) inadvertently gamma emitters, or 185 Bq (.005 Ci) or greater shipped to metal scrap yards; (3) licensed material of removable alpha emitters, are required to be (most often in portable moisture density gauges) reported. Detecting leaking sources early is that was stolen:(4) licensed material (usually essential to preventing significant facility cesium-137 and americium-241) in well logging contamination, personnel contamination, and sources that are abandoned downhole; and personnel exposures. Sources that are ruptured 1
(5) miscellaneous losses from inventory of because of a physicalimpact or that are ground calibration sources and medical marker sources.
up in a recycling facility are not counted as leaking sources. Events of this nature are Radionuclide activities involved in the loss of captured in other event categories.
control events ranged from undetermined trace amounts of iodine-131 in municipal waste to a l
2.96x106 MBq (80 Ci) iridium-192 radiography There were 53 leaking source events reported that sealed source that was in a vehicle which was occurred in 1994 and FY 95-24 from NRC 1
stolen. One event resulted in a radiation licensees and 29 from Agreement State licensees.
overexposure, and two events were reported to These events are listed in Appendix A. Tables Congress as Abnormal Occurrences (95-9 and AS A-1.4 and A-2.4. Thirty percent of the events 94-4). These events are described in Appendix B.
involved nickel-63 in electron capture detectors contained in gas chromatographs. Another twenty The causes associated with the reported events percent of the reports involved leaking cesium-137 generally involved inadequate accounting sources used in various industrial gauges. The procedures, failure to follow procedures, and remainder of the reports involved industrial inadequate security measures Dadiation monitors gauges using sources other than cesium-137, installed at commercial landfills and scrap metal sources used for medical therapy, sealed sources yards can reduce the amount of licensed material for an irradiator and a sealed well logging source.
entering such facilities. Corrective actions that were reported included retraining of personnel on procedures for handling and oversight of licensed Nickel-63 sources may exceed leak test limits and material, new procedures for using devices not be leaking. One manufacturer of nickel-63 containing licensed material, and improving the suces has reported that under certain labeling and handling of licensed material.
conditions an oxide layer can build up on the source surface. When the source is wiped while The NRC issued the following two ins to alert conducting the leak test, this oxide layer can be licensees to events associated with their particular removed, giving leak test results higher than the bcensee type: (1) IN 94-09, " Release of Patients limit. If the leak test is done again after the oxide with Residual Radioactivity from Medical layer is rernoved, test results are normally below Treatment and Control of Areas Due to Presence the limit. An unknown number of the reported of Patients Containing Radioactivity Following nickel-63 leaking sources could have resulted from Implementation of Revised 10 CFR Part 20," and removing this oxide layer during cleaning or leak (2) IN 95-51, "Recent Incidents Involving testm, g. Based on tests on this oxide layer, the Potential Loss of Control of Licensed Material."
manufacturer has submitted a new leak test procedure to the NRC for approval. This 2.5 Leaking Sources Sealed sources are constructed of a licensed All licensees took prompt corrective action by radioactive material encapsulated within a sealing removing the leaking sources from service. Most material, such as metallic foil or a ceramic licensees returned the leaking sources to the material, or welded in a metal capsule. Leak tests equipment manufacturer for source replacement.
are required on a periodic basis, ranging from Severallicensees elected to dispose of the sources.
NUREG-1272, Section 2 10
Nuclear Materials-Operating Experience Feedback 2.6 Release of Material until the following day. This event was reported to Congress as an AO (AS 94-7) and is discussed in Release of licensed material events include spills Appendix B.
and gaseous or effluent releases where licensed material was released to the environment (air or Nearly half of the release of material events water) or resulted in personnel and/or facility occurred at either medical or fuel facilities. The contamination in excess of regulatory limits. The majority of the events at hospitals involved either release of licensed material events are reported to iodine-131 or technetium-99m, and were pri-the hRC or to the Agreement States as required marily due to spills. Six events involved by 10 CFR 20.2202 and 20.2203 or comparable technetium-99m vials that broke while being Agreement State regulations. Certain heated during preparation. Equipment failure was contamination events that occur at facilities are the primary cause of the events at fuel facilities, also included in this category and are reported to but the causes of the equipment failures were not the NRC and Agreement States as required by reported. Few of the reports indicated what 10 CFR 30.50,40.60,50.72,50.73 and 70.50 or corrective actions were taken to prevent future comparable Agreement State regulations.
events. Of the actions that were reported, the principal ones were additional training and There were 102 release of licensed material events Procedure revisions. One employee was reported that occurred in 1994 and FY 95. NRC terminated for his actions.
licensees reported 77 of them and Agreement States reported 25. These events are listed in As a part of its response to release of material Appendix A, Tables A-1.5 and A-2.5. Approxi.
events, the NRC issued six ins to alert licensees mately 54 percent of these events involved minor of events associated with their particular licensee contamination of facilities licensed to possess type, as shown in Table 2.7.
nuclear materials. Licensed material was released from a licensed facility to the general environment m 15 percent of the events. An additional 11 2.7 'IYansportation Events percent of the events involved either shipment of Transportation events involve shipments of licensed material that was released from its packages that have removable radioactive surface shipping container to the immediately surround-contamination or radiation levels that exceed ing environment or shipment of equipment that NRC limits. Licensed material shipments that are was found to be contaminated when it reached its involved in accidents or damaged during destination. Nuclear power plants reported 14 shipment are also captured as transportation percent of the events, including nine inadvertent events. Transportation events are reported to the releases of contaminated material and the NRC or to the Agreement States as required by transportation of four contaminated individuals to 10 CFR Part 71 and 10 CFR 20.1906 or area hospitals for treatment of injuries. The comparable Agreement State regulations.
remaining events involved releases or potential releases from building fires because sources were NRC licensees reported 63 transportation events stored inside, and discharges to sewers above the that occurred in 1994 and FY 95, and Agreement limits. There were two cases where cesium-137 States reported 51. These events are listed in gauges were smelted. One facility had extensive Appendix A, Table: A-1.6 and A-2.6. Forty-two contamination while the other had limited percent of the events were accidents involvidg contamination. No individuals were overexposed vehicles transporting licensed material that did at either facility.
not result in the loss of shielding or the release of material. There were three transportation A major contamination event occurred when a accidents, however, in which licensed material was cesium-137 source ruptured while being removed released. In each case, the material released had from the source holder. The source was stuck in very low activity and was decontaminated in a the holder after being used in a corrosive short period of time. Approximately 30 percent of environment, and the manufacturer tried remov-the events were packages that exceeded the ing it using a hammer and a steel rod. The sealed external radiation limits. An improperly packaged source was ruptured but this was not discovered shipment of wire sources from a foreign country 11 NUREG-1272, Section 2
AEOD Annual Report,1994-FY 95 l
Table 2.7 NRC Information Notices on Release of Material Events January 1,1994 - September 30,1995 No.
Title 94-07 Solubility Criteria for Liquid Effluent Releases to Sanitary huverage Under the Revised 10 CFR Part 20 94-09 Release of Patients with Residual Radioactivity from Medical Treatment and Control of Areas Due to Presence of Patients Containing Radioactivity Following Implementation of Revised 10 CFR Part 20 94-15 Radiation Exposures During an Event Invohing a Fixed Nuclear Gauge 94-16 Recent Incidents Resulting in Offsite Contamination 95-07 Radiopharmaceutical Vial Breakage During Preparation 95-55 Handling Uncontained Yellowcake Outside of a Facility Processing Circuit.
f resulted in the exposure of more than 60 members Three equipment problems were reported to of the public; 24 people exceeded their annual Congress as AOs (95-1, AS 94-3, and AS 94-7).
exposure limit. This event was reported to
'Ihese events are described in Appendix B.
Congress as an AO (AS 95-5) and is described in Appendix B. The other events involved removable radioactive surface contamination on packages As part ofits response to equipment problems, i
the NRC issued the Information Notices shown in shipped from one licensee to another or packages Table 2.9.
that were damaged during shipment.
2.8 Equipment Problems 2.9 Fuel Cycle Facility Problems NRC and Agreement State licensees reported 226 Fuel cycle facility problems include criticality, loss equipment problems that occurred in 1994 and of a control that is required to prevent criticality, FY 95. NRC licensees reponed 139 of them and or a release involvmg any of the nonradioactive Agreement States reported 87. These events are chemicals that are used in the fabrication of listed in Tables A-1.7 and A-2.7 of Appendix A uranium reactor fuel. The criteria for reponing and are summarized in Table 2.8. Twenty five fuel cycle facility problems are found in 10 CFR percent of the equipment problems involved Part 50,10 CFR Part 70, and NRC Bulletin 91-OL moisture density gauges, most of which sustained damage from an operating vehicle at a The NRC regulates all commercial fuel cycle construction site. Nineteen percent involved facilities involved in the processing of uranium i
industrial radiography equipment problems, most ore and the fabrication of reactor fuel. There are j
of them caused by a failed or defective part.
nine major facilities, comprised of one uranium Other significant equipment problems involved hexafluoride production facility and eight uranium gauges other than moisture density gauges which fuel fabrication facilities. In addition, two gaseous i
failed due to either defective parts, fire, or diffusion uranium enrichment plants, owned by mechanical impact, and exhaust hoods that failed the Department of Energy (DOE) but leased to primarily due to fan motor problems caused by and operated by the U.S. Enrichment power failure with no back-up power supply Corporation, will come under NRC regulatory available.
oversight in early 1997.
NUREG-1272, Section 2 12 i
Nuclear Materials-Operating Experience Feedback Table 2.8 Equipment Problems Reported by NRC and Agreement State Licensees January 1,1994 - September 30,1995 Agreement Type Of Equipment NRC State Total Industrial Gauges 35 52 87 Industrial Radiography Devices 23 18 41 Exhaust Hoods 24 0
24 Irradiators 15 2
17 Fuel Processing 8
0 8
Teletherapy Units 4
3 7
Electrical Problem 5
2 7
Radioluminescent Devices 3
3 6
HDR Units 5
0 5
Sealed Sources 2
1 3
LDR Units 0
1 1
Medical Equipment 0
1 1
Non-Power Reactors 1
0 1
Well Logging Tools 0
1 1
Other 14 3
17 Total 139 87 226 Table 2.9 NRC Information Notices on Equipment Problems January 1,1994 - September 30,1995 No.
'Utle 94-15 Radiation Exposures During an Event InvoMng a Fixed Nuclear Gauge 94-37 Misadministration Caused By a Bent Interstitial Needle During Brachytherapy Procedure 94-39 Identified Problems in Gamma Stereotactic Radiosurgery 94-65 Potential Errors in Manual Brachytherapy Dose Calculations Generated Using a Computerized 'Ileatment Planning System 94-89 Equipment Failures at Irradiator Facilities 95-07 Radiopharmaceutical Vial Breakage During Preparation 95-25 Valve Failure During Patient Treatment with Gamma Stereotactic Radiosurgery Unit 95-44 Ensuring Compatible Use of Drive Cables Incorporating Industrial Nuclear Comp --
BalllIppe Male Connectors 95-50 Safety Defect In GammaMed 12i Bronchial Catheter Clamping Adapters I
13 NUREG-1272, Section 2
AEOD Annual Report,1994-FY 95 Licensees reported 45 fuel cycle facility problems Nine TRTR events were reported in 1994 and FY that occurred in 1994 and FY 95. Of these 45 95, five of them caused by equipment failures and events,39 involved the loss or degradation of three by personnel error. These events caused no criticality controls and 6 involved the release of a radioactive material releases to the environment non-radioactive chemical. Equipment problems and no adverse effects on public health and were involved in 10 of the 45 events, including all safety. TRTR events are listed in Appendix A, of the chemical releases. The majority of the Table A-1.9.
I criticality control events involved exceeding the administrative limits of fissionable materialin a given area as defined by a licensee condition or 2.11 Annual Radiation Exposure Data criticality safety analysis. A listing of the fuel i
cycle events is provided in Appendix A, Table According to the National Council on Radiation A-1.8.
Protection and Measurements, the average total effective dose equivalent to a person in the United There were three fires in fuel cycle facilities, one States is approximately 0.36 centisieverts (cSv) of which caused six people to be exposed to (360 milh, rem [ mrem]) per year, mostly from airborne radioactive material. No radiation natural sources of radiation. The average person overexposure was reported in this event. Neither n the United States receives an effecuve dose of the other two fires resulted in radioactive egmvalent of about 0.05 cSv(50 mrem) per year contamination or personnel injmy. There were no from medical applications. The entire fuel cycle, fuel cycle facility problems that were repcrted to neludmg operation of reactors, contributes less Congress as Abnormal Occurrences.
than 0.001 cSv (1 mrem) per year. All other human-controlled sources of radiation combm, ed add up to an effective dose equivalent of As part ofits response to fuel cycle facHity approximately 0.006 cSv (6 mrem) per year.
problems, the NRC issued three ins: IN 93-60, 4
Supplement 1. " Reporting Fuel Cycle and Materials Events to the NRC Operauons Center,...
The NRC. re8"lates both reactor and nonreactor IN 94-73, " Clarification of Criticality Reporting applications of nuclear materials. All NRC Criteria;" and IN 95-55, " Handling Uncontained licensees are reguired to provide radiation Yellowcake Outside of a Facility Processing m mtormg equipment to each mdividual who has Circuit ~"
the potential to receive a dose m any calendar quarter in excess of 25 percent of the allowable limits specified in 10 CFR Part 20, " Standards for Protection Against Radiation." The performance 2.10 Test, Research, and ' Raining of power reactors is discussed in NUREG-1272, Reactors Vol. 9, No.l. That report also compares the performance of power reactors with the The NRC regulates all reactor facilities, including performance of nuclear materials licensees.
power reactors and test, research and training reactors (TRTR). NUREG-1272, Vol. 9, No.1, Personnel exposure data from 1989 through 1'994 covers power reactors and presents an overview of (the latest year for which data are available) are the operatmg experience of the nuclear power.
given in Tables 2.10 through 2.14 for the following industry from the NRC perspective. The operatmg five categories of materiallicenses:(1) industrial experience of TRTRs is described here. The NRC radiography, (2) m:mufacturing and distribution, regulates the T2TR facilities m accordance with 10 CFR, Part 50.
(3) low-level waste disposal, (4) independent spent fuel storage, and (5) fuel fabrication and processing. Exposure data for Agreement State There are 58 TRTR facilities currently licensed by licensees are not included in these tables because the NRC,45 with operating licenses,8 with the Agreement States are not required to supply possession-only licenses, and 5 with dismantling this information to the NRC. Because licensees orders. The TRTR facilities are owned and submit revisions, late reports, or retractions, data operated by universities, the Federal Government, are updated as appropriate. This may cause and commercial companies.
minor changes in the data published from year to NUREG-1272, Section 2 14
l Nuclear Materials-Operating Experience Feedback l
Table 2.10 Annual Exposure Data for NRC Industrial Radiography Licensees 1989-1994 No. of Average Workers Collective Average Measurable No. of with Dose Individual Dose per No. of Monitored Measurable person-cSv Dose-cSv Worker-Year Licensees Individuals dose (rem)
(rem) cSv (rem) 1989 276 6745 4352 2067 031 0.47 1990 258 6523 4458 2120 033 0.48 1991 248 6820 4649 2160 032 0.46 1992 246 6703 4265 1864 0.28 0.44 1993 176 4721 3007 15 %
034 0.53 1994 139 3230 2351 1415 0.44 0.60 Table 2.11 Annual Exposure Data for NRC Manufacturing and Distribution Licensees,1989-1994 No. of Average Workers Collective Average Measurable No.of with Dose Individual Dose per No. of Monitored Measurable person-cSv Dose-cSv Worker-Year Ucensees Individuals dose (rem)
(rem) cSv (rem) 1989 48 4554 2345 770 0.17 033 1990 58 4203 2279 693 0.16 030 1991 59 4930 1952 722 0.15 037 1992 67 5210 2250 784 0.15 035 1993 58 4913 2254 680 0.14 030 1994 44 2941 1251 580 0.20 0.46 i
Table 2.12 Annual Exposure Data for NRC Low-level Waste Disposal Licensees 1989-1994 No. of Average Workers CoIIective Average Measurable No. of with Dose Individual Dose per No.of Monitored Measurable person-cSv Dose-cSv Worker-Year Licensees Individuals dose (rem)
925 119 35 0.04 0.29 1990 2
784 115 26 0.03 0.23 i
1991 2
905 147 39 0.04 0.27 1992 2
467 82 37 0.08 0.45 i
1993 2
432 76 21 0.05 0.27 l
1994 2
202 83 22 0.11 0.27 I
15 NUREG-1272, Section 2
i AEOD Annual Report,1994-FY 95 Table 2.13 Annual Exposure Data for NRC Independent Spent Fuel Storage Ucensees,1989-1994 l
No. of Average l
Workers Collective Average Measurable No. of with Dose Individual Dose per l
No. of Monitored Measurable person-cSv Dose-cSv Worker-t l
Year Ucensees Individuals dose (rem)
190 102 33 0.17 032 1990 2
56 22 6
0.11 0.27 1991 2
41 24 4
0.10 0.17 1992 2
290 85 11 0.04 0.13 1993 2
135 52 14 0.10 0.26 1994 1
158 89 42 0.27 0.47 i
Table 2.14 Annual Exposure Data for NRC Fuel Fabrication and Processing Ucensees,1989-1994 No. of Average Workers Collective Average Measurable No. of with Dose Individual Dose per I
No.of Monitored Measurable person-cSv Dose-cSv Worker-Yrar Licensees Individuals dose (rem)
11,583 2992 243 0.02 0.08 1990 11 14,505 3871 422 0.03 0.11 1991 11 11,702 3929 378 0.03 0.10 1992 11 8439 5061 545 0.06 0.11 1993 8
9649 2611 339 0.04 0.13 1994 8
35 %
2847 1147 032 0.40 year. The data are taken from the Radiation There has been a decreasing trend since at least Exposure Information Reporting System (REIRS) 1992 in the number of individuals monitored and funded by the NRC's Office of Nuclear the number of individuals who received a Regulatory Research.
measurable dose among most categories of In 1994 NRC radiography licensees had the licensees. Over this same period the average highest collective dose and average measurable measurable dose per worker has increased for dose per worker. I.ow-level waste disposal most categories of licensees. In all cases, however, i
licensees and independent spent fuel storage the average measurable dose per worker is far licensees had relatively low collective doses, below the allowable limits of 10 CFR Part 20.
NUREG-1272, Section 2 16
3 Abnormal Occurrences Section 208 of the Energy Reorganization Act of five teletherapy misadministrations e
1974 PL 93-438) requires the NRC to report to Cong(ress each quarter any abnormal occurrences two radiopharmaceutical misadmm..istrations e
1 (AOs)invohing facilities and activities regulated by the NRC. (Public Law 104-66, which became three sodium iodide misadministrations e
effective on December 21,1995, changed this requirement to an annual report.) AEOD has the 3.1.2 Research Facility responsibility for preparing the NRC's " Report t one event involving ingestion of radioactive Congress on Abnormal Occurrences,,
e (NUREG-0090 senes). An AO is defined as an material by research workers unscheduled incident or event that the l
Commission determines to be significant from the 3.1.3 Military Base standpoint of public health or safety.
one event involving lost reference sources e
AEOD identifies AOs using criteria which were initially promulgated in an NRC policy statement that was published in the Federal Register on 3.2 Agreement States February 24,1977 (Vol. 42, No. 37, pages 10950-10952). This policy statement was published 3.2.1 Medical Institutions before medical heensees were required to report misadministrations to the NRC, and few of the six brachytherapy misadministrations e
examples in the policy statement are applicable t two teletherapy misadministrations medical misadnum,strations. Therefore, m 1984 e
the NRC adopted additional guidance for one radiopharmaceutical misadministration e
reporting of medical misadministrations. On January 27,1992, new medical misadministration e
one event involvm.g the overexposure of requirements became effective. The AEOD staff medical personnel involved in brachytherapy has developed a new, proposed policy statement treatment with revised criteria for reporting incidents and events to Congress. This is discussed in Section 4.2 of this report.
3.2.2 Industrial Radiography The seven AO reports covering 1994 and FY 95 (NUREG-0090, Vol.17, Nos.1 through 4, and Vol.18, Nos. I through 3) described 28 nuclear 3.2.3 Other Industrial Facilities materials events reported by NRC licensees and 15 nuclear materials events reported by one lost welllogging source Agreement States. These AOs are summarized in one loss of management and procedural e
Appendix B of this report.
control of a radioactive source one major contamination event due to a e
3.1 NRC Licensees breached source 3.1.1 Medical Institutions ne event involving personnel exposures due e
to importation of a package havmg excessive sixteen brachytherapy misadministrations external radiation o
17 NUREG-1272, Section 3
1 4
I 4 Other AEOD Activities 4.1 Agreement State Operational 4.2 Abnormal Occurrence Reporting Experience Data Section 208 of the Energy Reorganization Act of In order to establish standards for collecting 1974, as amended, provides that the Commission material event data from Agreement States and to shall submit to Congress each quarter a report of encourage voluntary reporting of material event any Abnormal Occurrences (AOs) at or assoc-data, a trial program for Agreement State event lated with any facility which is licensed or reporting began in April 1995. The scope of the otherwise regulated by the NRC. (Public Law trial program is defined in the draft " Handbook 104-66, which became effective on December 21, on Nuclear Material Event Reporting in the 1995, changed this requirement to an annual j
Agreement States, prepared by the NRC Office report.) Based on its experience in the preparation of State Programs (OSP). The handbook and issuance of AO reports, the Commission addresses the definition and guidelines for decided that its responsibilities under Section 208 prompt (within one working day) reporting of could be carried out better if the existing AO material events to the NRC, the definition and criteria were updated to reflect changes in the guidelines for reporting of routine events to the Commission's policy and changes to the j
NRC, and the guidelines for screening material regulations. Accordingly, AEOD revised the l
events for meeting abnormal occurrence criteria.
criteria and published for comment a revised The trial program was originally intended to last general statement of policy. The proposed policy for six months, at which time the results would be describes the manner in which the Commission presented to the Commission for a decision on will carry out its responsibilities for identifying whether to continue the program. The report of AOs and making each such occurrence available the trial program and its results is in preparation, to Congress and the public in a timely manner.
1 and the trial program has been extended until the Included in the policy statement are revised AO i
Commission has seen the report and has reached criteria that the Commission will use in i
a decision.
determining whether a particular event is a reportable AO. 'Ihe most significant change to the As part of the trial program, Agreement States reporting criteria was to define a medical are encouraged to report significant events to the misadministration as one which results in a 1 gray 1
NRC Operations Center within one working day.
(Gy)(100 rad) dose to a major portion of the bone Agreement States are encouraged to report marrow, lens of the eye, or gonads, or a 10 Gy routine events using the NMED software and (1000 rad) dose to all other organs. In addition, i
procedures provided to the Agreement States.
the dose must be 50 percent greater than Agreement States not using the NMED system Prescribed in a written directive, or either (1) the can send hard copies of reports to the deputy wrong pharmaceutical, (2) delivered by the wrong director of OSP. In either of the above cases, route, (3) delivered to the wrong treatment site, updated information such as inspection reports (4) delivered by the wrong treatment mode, or should be sent to the deputy director of OSP. At a (5) the source is leaking.
future date, Agreement States will be encouraged to send all hard copy documents to the NRC In keeping with the changes to the AO policy and Document Control Center.
criteria, AEOD drafted a preliminary revision of NRC Management Directive (MD) 8.1, " Abnormal Other important aspects of the program for Occurrence Reporting Procedure." This revision Agreement State event reporting include the will be finalized after the Commission approves following: (1) the NRC operations center will the new AO reporting criteria. The revised MD promptly notify the appropriate regional duty 8.1 will incorporate the new AO reporting criteria; officer, who will notify the regional state specify publishing the AO report on a fiscal-agreements program officer, and (2) all events year basis in compliance with the Federal Reports reported to the NRC Operations Center will be Elimination and Sunset Act, Public Law 104-66; entered into the NRC's Event Notification System.
and specify how AO identification and report
^
19 NUREG-1272. Section 4
AEOD Annual Report,1994-FY 95 preparation functions will be handled at the staff 43.2 Human Performance Evaluation of level.
Industrial Radiography Exposure Events INEI-95/0387 The data in the Nuclear Material Events 4.3 F'edback of Nuclear Materials Database (NMED) show that industrial Experience radiography overexposures account for a significant number of the overexposures reported to the NRC and for most of the acute over-In 1994 and FY 95 the AEOD nuclear materials exposures that have resulted in physical injury.
assessment staff produced one videotape and two The number of reported radiography licensee special studies. Appendix C lists the nuclear overexposures is especially significant considering materials reports and videotaps issued by that radiography licensees account for less than AEOD from 1981 through 1W5. Appendix D 10 percent of NRC and Agreement State licensees.
presents the status of all formal AEOD nuclear While the direct cause of most radiographer materials recommendations.
overexposures generally can be ascribed to the failure to use survey meters, underlying causes of radiographer overexposures are not always documented.
43.1 Taking Control-Safety Procedures for In order to develop better information on the Industrial Radiographers causes of radiography overexposures and methods to minimize their occurrence, AEOD contracted Although most radiography is performed safely, with the Idaho National Engineering Laboratory radiation overexposures to radiographers, and (INEL) to perform a human factors review of the occasionally to the general public, do occur.
radiography overexposure event data in the Errors that have been identified that lead to NMED. The scope of the study included the i
overexposures are equipment failures and failures review and analysis of historical and recent to follow proper safety procedures. The latter events, the categonzation of the events m terms of include, for example, failing to perform required human actions and contributing factors, and the radiation surveys, or allowing assistant detailed modeling of a subset of events for more radiographers to perform the radiography thorough analysis. The major findings from the themselves without the direct supervision of study are described below.
trained and skilled radiographers. Some of the (1) The primary factors contributing to failures of radiography hce,nsees to follow proper radiography overexposures are procedural procedures and NRC requirements have been errors, e.g. improper survey, survey not documented in NRC Information Notices.
performed, camera not locked; equipment problems (equipment design issues, source connections / disconnections); and external AEOD developed a short videotape on " Safety factors (supervision and area control).
Procedures for Industrial Radiography." The tape (2) Errors in performance ofindustrial covers several types of common errors reported t radiograp 2y can be characterized by the the NRC by beensees that led to personnel types of information processing involved in radiation overexposures. The Office of Nuclear the task. For example, errors were found to l
Material Safety and Safeguards distributed this commonly occur in the setting-up of i
video to all radiography hcensees. The video may equipment before the radiograph. 'Ihese be used to supplement radiation safety trainmg errors involved the diagnosis of system status, for radiographers and ancillary personnel. The the development of work strategies, and the video uses re-enactments, based on real events, to execution of procedures.
illustrate to radiography licensee personnel the importance of good practices in perforating (3) Available data describing radiography industrial radiog aphy.
overexposure events are sparse and lacked NUREG-1272, Section 4 20
i Nuclear Materials-Other AEOD Activities many of the details needed for rigorous in computer-based radiation therapy human factors evaluation.
processes than in manual therapy.
Although the available data are limited, the staff (4) Delays in the detection and reporting of believes the events modeled in detail were multiple misadministrations have been much representative of the population of events longer for computer-based radiation therapy reported to the NRC. Additionalinformal than for manual treatments because licensee information obtained from incident investigators personnel do not have the information on indicated that the events analyzed were consistent computer system errors readily available to with historical radiographer performance data.
detect them.
The findings of this study were fed back to the radiography community, including equipment (5) Nearly three-quarters of the computer manufacturers, through an article in the NMSS error-related medical misadministrations are newsletter.
directly linked to human errors and procedural deficiencies.
j 433 Misadministrations and Other (6) Nearly one-half of the events have involved i
Medical Events Caused by Computer user interface deficiencies.
Errors (7) In none of the events did the software or the The NRC has been collectm.g and reviewing events hardware limit the conse uences of a l
mvolymg computer errors that resulted m medical misadministration for followmg reasons:
nusadmimstrations. As part of this effort, and i
with the assistance of Lawrence Livermore (a) in the application of computerized,
NationalLaboratory, AEOD rformed an therapy, the task of detecting a analysis of the 22 events i ng 172 patients misadministration in progress is left to that were reported by NRC licensees and the computer-based system whose design Agreement States. The analysis addressed may not be adequate for the task; treatment planmng and dose delivery systems with emphasis on software, hardware, and human-(b) computer-based therapy permits rapid 4
machine interface issues that could potentially setup, high-dose rates and short affect the system's operational safety. The major treatment periods which provide fewer findings of the study are described below.
opportunities for detecting and limiting (1) The number of computer-based
^
misadministrations per year has been (c) in most cases a computer-based radiation increasing, based on the number of events therapy misadministration was not reported to the NRC from 1981 through 1993.
discovered until the therapy was completed.
(2) The number of reported misadministrations involving'the treatment planning process has
'Ihe analysis also identiSed the causes and been higher than that associated with the contributing factors of the compufer-based events dose delivery process, partly because multiple reported to the NRC. A frequent factor was the patients are more likely to be affected by lack of training oflicensee personnel in the use of treatment planning errors.
computers. In some cases, licensees such as small hospitals and private clinics used outside (3) Events resulting in reported misadminis-consultants to perform computer-based system trations to multiple patients occur more often operations because they lacked in-house expertise.
21 NUREG-1272, Section 4
l l
5 Incident Investigation Program l
The Incident Investigation Program (IIP) is a requiring medical intervention occurred at the formal program administered by AEOD to ensure William H. Bacchus Hospital in Norwich, CT.
that NRC investigations of significant operational One Hundred twelve radioactive seeds with events are timely, thorough, and systematic. The activities greater than 10 times that prescribed IIP includes investigations of events involving were surgically implanted in a patient. The reactors and nuclear materials licensed by the mistake was identified within one hour and a NRC. The program is structured so that the NRC decision was made to remove the seeds responds to an operational event according to its immediately. However, the surgeon was only able safety significance. For an event of potentially to remove 70 seeds. Additionally, during removal, major safety significance, the Executive Director one seed was punctured, contaminating some for Operations (EDO) establishes an Incident operating room personnel. The patient was Investigation Team (IIT) to investigate the event; subsequently transferred to a second hospital for an event of less safety significance, the where 15 additional seeds were removed. The cognizant NRC Regional Administrator may remaining seeds were determined by X-ray to be establish an Augmented Inspection Team (AIT) to scattered within the patient's prostate and did not investigate the event. Both IITs and AITs are pose an immediate life-threatening situation. The tasked to determine the circumstances and causes AIT determined that the root cause of this event of the event and to assess its safety significance so was personnel error.
that appropriate follow-up actions can be taken.
For events of extraordinary safety significance, the On June 29,1994, Babcock & Wilcox of Commission may establish an Accident Review Lynchburg, VA, determined that the 350 gram Group (ARG), led by an individual from outside U-235 safety limit for the low-level scrap the NRC and composed of experts from within dissolution operation for uranium recovely had and outside the NRC. The ARG reports directly been exceeded. The material had been previously to the Commission and is independent of NRC assayed to contain 121 grams of U-235. However, management.
following dissolution, the dissolved material was found to consist of 291 grams and the undissolved Administration of the NRC's incident material was found to consist of 358 grams of investigation activities is prescribed in U-235. Some criticality margin remained in that NUREG-1303, " Incident Investigation Manual."
an actual critical geometry could not result with As described in the NUREG, AEOD has less than 700 grams of U-235 total. The root responsibility for overall administration of the IIP, cause of the event was determined to be while NRR is responsible for maintaining the inadequate procedures for the original assay.
procedures for an AIT response.
On June 28,1995, a pregnant reseal @ employee at the NationalInstitutes of Health (NIH)in 5.1 Incident Investigation Teams Bethesda, MD, was found to be internally contaminated with phosphorous-32 (P-32) and Of the 1058 nuclear materials events reported in was sent to a local hospital for treatment. The 1994 and FY 95, none was judged to have a level NRC formed an AIT which included a medical of safety sigmficance sufficiently high to warrant consultant, to review the incident. The consultant an IIT investigation. Appendix E documents the determined, based on the licensee's initial report, status of staff actions that the EDO assigned to that there would not be any adverse health various NRC offices associated with previous IIT consequences to the researcher or to the fetus.
reports regardmg nuclear materials events.
The licensee subsequently found that 26 individuals in addition to the pregnant researcher 5.2 Augmented Inspection Teams were also contaminated. The F:deral Bureau of Investigation, the NRC's Office of Investigations, During 1994 and FY 95, three AITs were and the NIH Police Department are currently conducted in response to nuclear materials events.
investigating the event. Because of the ongoing On June 21,1994, a therapeutic misadministration investigation, the NRC has not reached a final 23 NUREG-1272, Section 5
=. _
_ - = -...
AEOD Annual Report,1994-FY 95 i
l l
conclusion as to the cause of the event. On Potential loss of Control of Licensed Material,"
i October 27,1995, the NRC issued Information to alert addressees to two recent incidents Notice 95-51, "Recent Incidents Involving resulting in internal contamination of individuals.
i 1
)
1 I
j NUREG-1272, Section 5 24
=
6 Incident Response AEOD maintains and implements the NRC's Although the Operations Center, with its Incident Response Program with the support of sophisticated OCIMS subsystems, utilizes other headquarters and regional offices. This state-of-the-art technology, it was also designed to program includes the receipt of data and reports accommodate future enhancements that will likely 4
for both emergency and non-emergency events be necessary as technology continues to ra sidly from licensees, followed by an appropriate NRC evolve. The NRC received the 1994 Federaf response. The response for the more serious Technology Leadership Award for outstanding 1
emergencies is through an incident response achievement in using the OCIMS to make organization that includes representatives from government more effective through the use of i
several headquarters offices and the affected information systems.
regional office. The NRC's response program also
{
includes coordination with other Federal agencies, 6.2 Emergency Response as well as State and local governments.
Production and utilization facilities (power and non-power reactors) are required to maintain 1
6.1 Operations Center emergency plans for responding to events which could impact the health and safety of the public.
The Operations Center provides the focal point Emergencies at these facilities are classified into for NRC communications with Commission one of the following four levels, in order of licensees, State agencies, and other Federal increasing severity: Unusual Event, Alert, Site agencies regarding the events that occur in the Area Emergency, or General Emergency. An commercial nuclear sector. The Operations Unusual Event denotes a condition that does not i
Center is continuously staffed by a Headquarters represent an immediate threat to public health Operations Officer who is a reactor systems and safety, while an Alert indicates substantial engineer trained to receive, evaluate, and respond actual or potential degradation of plant safety. A to all types of events.
Site Area Emergency or General Emergency indicates a major failure of one or more systems The NRC commenced operations from its new required for public safety or an event with the Potential for a major offsite radiological release.
Operuhns Center at Two White Flint North in Rockville, Maryland, on, May 31,1994. This NRC-certified gaseous diffusion plants are also milestor.e was the culmination of a multi-year required to maintain emergency plans. In effort that started with the development of addition, facilities or activities which are licensed functional specifications and the establishment of for the possession and utilization of byproduct a conceptual design. The new center feature,s a material, source material, or special nuclear state-of-the-art Operations Center Information material are required to maintain emergency Management System (OCIMS) which integrates plans if they possess quantities of nuclear voice, video, and data subsystems to provide materialin excess of the amounts specified in 10 timely and effective mformation flow durmg the CFR Parts 30,40, and 70. For these facilities there NRC's response to an m, eident.
are only two classes of emergencies, Alerts and Site Area Emergencies. In this case, an Alert Before transferring operations to the new center, indicates that events may occur, are in progress, the NRC conducted extensive acceptance testing or have occurred that could lead to a release of of the Operations Center with the OCIMS radioactive material that is not expected to contractor. This was followed by three require a response by offsite response
" shakedown" drills using a nuclear plant analyzer organizations. A Site Area Emergency indicates to familiarize NRC response personnel with the that events may occur, are in pregres',, or have new Operations Center systems and to identify occurred that could lead to a signiGcant release of any deficiencies in the design or implementation radioactive material that cou d require a response of the Operations Center that were not discovered by offsite organizations. Altheugh not required by during the acceptance testing period.
the Code of Federal Regulations, some nuclear 25 NUREG-1272, Section 6
AEOD Annual Report,1994-FY 95 materials licensees may also report events of communications with the media, State and lower safety significance as Unusual Events.
Federal officials, Congress, and the White House will also be coordinated from the Operations In the event of an emergency at an NRC-licensed Center.
facility (or associated with an NRC-licensed activity), the licensee places an emergency Once the NRC site team arrives on the scene and telephone call to the Operations Center is prepared to accept the authority and immediately after notifying appropriate State and responsibility for the Federal response, the NRC local agencies. For Alert and higher declarations enters the Expanded Activation Mode. The and for events where an NRC response may be Director of Site Operations, typically the Regional appropriate, the Regional Admimstrator and an Administrator, will report to the licensee's facility.
Executive Team member (typically the Director of The lead responsibility for performing reactor the Office of Nuclear Materials Safety and safety and protective measures assessments then Safeguards for nuclear materials events) will be shifts from headquarters to the NRC team at the tied in to the telephone call.
site. The headquarters Operations Center will then provide logistical and technical support to The NRC's response to an event may range from the NRC Site Team as necessary.
routine follow-up to a complete activation of the regional Incident Response Center and 6.3 Operations Center Data for 1994 headquarters Operations Center. The NRC and 1995 utih,zes the followmg formal modes for responding to events at its licensed facilities: Normal Mode, In addition to emergency event notifications, the Standby Mode, Initial Activation, and Expanded Operations Center receives many notifications for i
Activation, events that do not meet the threshold for emergency classification. Actions taken by the For the Normal Mode, the lowest level of NRC Headquarters Operations Officer in response, the NRC will not fully staff the head-response to such notifications range from quarters Operations Center or the regional computer and log entries followed by appropriate Incident Response Center, but it may take some notifications, to establishing emergency other action such as sendmg out a special conference calls among the licensee and senior inspection team or staffing the response centers NRC regional and headquarters representatives.
with a few select experts. The latter is referred to For very significant events, conference calls as the Monitoring Phase of the Normal Mode.
resulted in the activation of the agency's Incident Standby Mode is the next level of response.
Standby Mode is entered when an event is judged Tables 6.1 and 6.2 show the total number of events to be sufficiently uncertain or complex that the reported to the Operations Center in 1994 and situation needs to be continuously monitored 1995, respectively. These notifications were from the headquarters and regional response primarily received from nuclear power plant centers.
licensees. A small subset of these notifications involved events classified by licensees into one of If the event could threaten public health and the four emergency classifications.
safety, the NRC will enter the Initial Activation Mode. Upon entering this mode, the NRC will Table 63 lists the Alerts reported by promptly send a team from the regional office to NRC-licensed nuclear materials facilities in 1994 the site to lead the NRC response. Until the Site and 1995. The NRC entered the Monitoring Phase Team is in place, the NRC response will be led for the reported release of uranium hexafluoride from the headquarters Operations Center. Within at a Westinghouse fuel fabrication plant in the Operations Center, teams of specialists will January 1994. The NRC also entered the evaluate the status of critical safety functions and Monitoring Phase for a potentially uncontrolled will independently evaluate protective actions radioactive source in Cleveland, Ohio, in March recommended by the licensee for implementation 1994 and for Hurricanes Erin and Opalin July by State and local authorities. All and October 1995, respectively.
NUREG-1272, Section 6 26
j Nuclear Materials-Incident Response i
i l
Table 6.1 Events Reported to the NRC Operations Center in 1994 Event Power Fuel Non-Power Transport /
Type Reactor Facility Reactor Hospital Materials Other Total Non-Emergency 1312 20 2
63 72 77 1546 i
Unusual Event 92 2
0 0
0 0
94 i
Alert 3
1 0
0 0
0 4
I f
l Site Area Emergency 0
0 0
0 0
0 0
General Emergency 0
0 0
0 0
0 0
Total 1407 23 2
63 72 77 1644 i
{t i
Table 6.2 Events Reported to the NRC Operations Center in 1995 l
Event Power Fuel Non-Power Transport /
Type Reactor Facility Reactor Hospital Materials Other Total 4
i Non-Emergency 1260 13 1
66 68 101 1509 l
Unusual Event 62 1
2 0
1 0
66 1
1 Alert 6
2 0
0 0
0 8
I Site Area Emergency 0
0 0
0 0
0 0
{
General Emergency 0
0 0
0 0
0 0
T6tal 1328 16 3
66 69 101 1583 Table 6.3 Alerts Reported at NRC-Licensed Nuclear Materials Facilities in 1994 and 1995
]
Facility Event Name and Type Number Date Description Duration
Response
Westinghouse 26682 01/26/94 Uranium hexafluoride release 2 hrs 35 mins Monitoring 1
(Fuel Facility)
I Allied-Signal 28329 02/03/95 Leak of uranium hexaGuoride 50 mins N/A 1
(Fuel Facility) from a loose cylinder connection i
into the feed material building j
Babcock and 29087 07/20/95 Plant evacuation due to a nitric 3 hrs 5 mins N/A Wilcox acid spill (Fuel Facility)
I l
i
-l j
27 NUREG-1272, Section 6
l AEOD Annual Report,1994-FY 95 6.4 Emergency Exercises 1992. Among other things, the Act amended the Atomic Energy Act of 1954 to establish a new Emergency exercises are held periodically to t
ensure that NRC, licensee, local, State, and other government corporation, the United States I
Federal response organizations are proficient in Enrichment Corporation (USEC) for the purpose dealing with each type of emergency. The NRC's of managing and operating the uranium main role in these exercises is to assist the enrichment plants owned and previously operated by the Department of Energy (DOE). These licensee as requested, review the protective action enrichment plants are the Portsmouth Gaseous recommendations licensees make to State and Diffusion Plant located in Piketon, Ohio, and the local authorities, and facilitate communications Paducah Gaseous Diffusion Plant located in between licensees and these authorities.
Preparation for these exercises includes the Paducah, Kentucky. The Act further directed the development of a postulated accident scenario NRC to establish a certification process under that usually goes well beyond the facility's design which these two plants will be certified annually basis and that results in the release of some by the NRC for compliance with NRC standards, radioactivity outside the site boundary. NRC These standards, when implemented, will include r
those for emergency response to events at these experts follow the progression of the simulated plants.
event and provide recommendations to an NRC Executive Team in the Operations Center. The NRC, conducted a table-top emergency planning During FY 95, in preparation for the certification exercise with Siemens Power Corporation, a process for emergency response, AEOD uranium fuel fabrication facility, on October 25, participated in general gaseous diffusion process 1995.
training and a round-table discussion on potential events and emergency response at the gaseous diffusion facilities. Participants included 6.5 Gaseous Diffusion Process individuals from the Portsmouth and Paducah Activities Plants, the USEC, the DOE, and the NRC. 'Ihe NRC also began the process of installing the The President signed H.R. 776, the " Energy Policy Federal telecommunications system telephone Act of 1992" (the Act), into law on October 24, lines at these facilities.
l NUREG-1272, Section 6 28
7 Committee to Review Generic Requirements The Committee to Review Generic Requirements correspondence, and significant proposals with (CRGR) consists of senior managers from various highly expedited schedules. A June 15,1994, staff headquarters program offices and, on a rotational requirements memorandum (SRM) directed the basis, from one of the NRC regional offices. The staff not to reduce the scope of the CRGR AEOD Director serves as the CRGR Chairman, Charter but to consider, and to recommend a and the AEOD staff provides support for all of course of action for, enlarging the scope of CRGR the Committee's activities. The AEOD Director review to include proposed generic requirements also oversees plant-specific backfit activities of in the nuclear materials area. The SRM also the NRC staffin the headquarters program directed the staff to look at measures which would offices and the regional offices. The membership lessen the time spent on CRGR reviews by of the CRGR as of September 30,1995,is as individual CRGR members. The Committee follows:
evaluated this option and agreed to address, on a 1 year trial basis, selected nuclear materials issues Edward L Jordan, Director, AEOD (Chairman) identified by the NMSS Director or by the EDO.
Frank J. Miraglia, Deputy Director, NRR The Committee will assess whether or not the Malcolm Knapp, Deputy Director, NMSS nuclear materials issues that are presented by the Joseph Murphy, Executive Assistant to staff for CRGR review warrant CRGR attention Director, RES and, if so, whether the CRGR review adds Ellis Merschoff, Director, Division of significant value. Based on that assessment, the i
Reactor Projects, RII Committee will make appropriate Dennis Dambly, Assistant General Counsel recommendations to the EDO regarding i
for Materials, Antitrust and Special Proceedings, continuation of the CRGR review of nuclear OGC materials issues. This assessment will be included in the CRGR meeting minutes during the trial While performing the CRGR review function, a period, and it will also be reported to the EDO in CRGR member expresses an individual the CRGR Weekly Items of Interest to be professional opinion about each item considered, reported to the Commission. This aspect of the rather than representing the view of his or her expanded scope of CRGR review was included in respective office. The members of the CRGR the ongoing CRGR Charter revision process.
determine whether proposed new generic requirements have sufficient merit in terms of On February 9,1996, in SECY-96-032, the EDO safety and are justified in terms of cost (where requested Commission approval for this 1 year appropriate) before reaching a consensus trial program to include selected nuclear materials recommendation about each issue considered.
issues. The Commission was also informed that Each independent CRGR recommendation is the CRGR has considered and adopted measures given to the EDO for consideration.
to lessen the time spent by members on CRGR reviews. When appropriate, based on lack of The CRGR was established to review all generic controversy, low expected impact, or small requirements proposed by the NRC staff that potential for error related to the proposed generic involve one or more classes of power reactors. In actions, the CRGR Chairman may agree to one of 1994 a staff proposal was submitted to the three courses of action:(1) defer the CRGR's Commission to reduce the scope of the CRGR review pending public comment on the proposal; review and to evaluate various means of reducing or (2) agree to a negative consent approach which, the burden on CRGR members. On April 21, in essence, is an abbreviated review; or (3) forgo a 1994, the EDO transmitted to the Commission second CRGR review, thus reducing the number SECY-94-109 proposing to reduce the basic of dual reviews (i.e., review at both the proposed scope of CRGR review to include only "high and final stage). All other staff proposals will be impact" and " controversial" generic scheduled for regular CRGR review.
correspondence and rules before public comment, issues which the staff has difficulty resolving after On March 22,1996, the Commission approved public comment, emergency and urgent generic Revision 6 to the CRGR Charter, which expanded 29 NUREG-1272, Section 7
AEOD Annual Report,1994-FY 95 the scope of CRGR reviews, on a 1 year trial systems aspects of low-enriched uranium fuel basis, to include selected nuclear materials issues fabrication facilities could be helpful. It was also requested by the NMSS Director or the EDO.
suggested that, with regard to proposed new requirements that are risk-and/or Between January 1,1994, and September 30,1995, the CRGR held 24 meetings during which it performance-based, the Committee can provide a useful independent assessment of under-or discussed 45 issues, including 3 related to nuclear over-regulation in the nuclear materials area.
materials. The Committee, in its reviews of proposed new generic requirements, continued to place emphasis on less prescriptive, more The Committee agreed to review, on a 1 year trial basis, selected nuclear materials issues at the performance-based and risk-informed regulations.
The following nuclear materials issues were request of the NMSS Director or the EDO.
Specifically, the Committee will assess the value reviewed by the CRGR in 1994 and FY 95:
added by CRGR reviews, and based on that final rule to add the standardized NUHOMS assessment will make appropriate e
horizontal modular storage system to the list recommendations to the EDO regarding of approved spent fuel storage casks in 10 continuation of the review of nuclear materials issues.
CFR 72.214 briefing on proposed revision to 10 CFR The Committee recommended to the staff the e
following revisions: (1) place more emphasis on Part 70 experience accumulated with similar casks in use under facility-specific licenses; (2) provide The CRGR review of the planned revision of 10 additional flexibility to the licensees with respect CFR Part 70 was done at the Commission's to temperature monitoring during the initial direction. The Committee suggested that it m,ght i
period; and (3) evaluate the endorsement of be useful for the staff to concentrate on the " core" ACI-34-85 in lieu of ACI-34-80, which is sections of the proposed rule that are directed to currently approved by Regulatory Guide 3.60, to the large nuclear materials processmg facilities determine if that constitutes a backfit.
and address that portion of the rulemakm, g package on a priority basis.
discussion with NMSS Director on CRGR e
review of nuclear materials items The discussion at this meeting with the staff was especially useful to the CRGR in the light of the The CRGR discussed possible expansion of the forthcoming meeting with the licensee and the CRGR review scope to include proposed new tour of the Westinghouse Columbia Fuels facility requirements in the nuclear materials area. NMSS by the Committee members and the CRGR staff.
indicated that the Committee's perspective and Based upon the candid dialogue with the licensee advice on structural, electrical, and mechanical during the site visit, the Committee provided i
aspects of the regulation of spent fuel and waste valuable insights and feedback to NMSS storage / transportation operations, and on the management.
NUREG-1272, Section 7 30
Appendix A i
i Nuclear Materials Data by Event Type
\\
A-1 NRC Licensee Events i
i A-2 Agreement State Licensee Events 4
1 l
e i
j s
i i
1 Appendix A-1 r
NRC Licensee Events l
I I
i i
l I
h 9
l l
I l
r i
--n...,
Contents Page Appendix A-1 h bles A-1.1 Medical Misadministration Reported by NRC Licensees...............................
1 A-1.2 Overexposures Reported by NRC Licensees...........................................
4 i
A-13 Loss of Control of Material Events Reported by NRC Licensees........................
5
)
A-1.4 Leaking Sources Reported by NRC Licensees.........................................
16 A-1.5 Material Release Events Reported by NRC Licensees..................................
18 A-1.6 Transportation Events Reported by NRC Licensees....................................
23 A-1.7 Equipment Problems Reported by NRC Licensees.....................................
29 j
A-1.8 Fuel Cycle Events Reported by NRC Licensees........................................
37
)
A-1.9 Research and Training Reactor Events Reported by NRC Licensees.....................
39 l
Appendix A-2 h bles A-2.1 Medical Misadministrations Reported by Agreement States............................
43 A-2.2 Overexposures Reported by Agreement States.........................................
45 A-23 Loss of control of Material Events Reported by Agreement States.......................
47 A-2.4 Leaking Sources Reported by Agreement Ststes.......................................
59 A-2.5 Material Release Events Reported by Agreen:ent States................................
61 A-2.6 Transportation Events Reported by Agreement Sates..................................
63 A-2.7 Equipment Problems Reported by Agreement States...................................
68 ni NUREG-1272
Table A-1.1 Medical Misadministrations Reported by NRC Licensee, January 1994-September 1995 Item Ucense Event
'I)pe of No.
Licensee No.
City State Date Misadministration 941471 Air Force, 42-23539-01AF Brooks AFB TX 01/13/94 Brachytherapy Department of the 950644 Air Force, 42-23539-01AF Brooks AFB TX 04/25/95 Brachytherapy Department of the 941470 Alexandria 45-09358-02 Alexandria VA 01/27/94 Brachytherapy Hospital 950974 Arlington Hospital 45-01099-01 Arlington VA 07/17/95 Sodium Iodide 950755 Army, Department 46-02645-03 Fort Lewis WA 05/09/95 Brachytherapy of the, Madigan i
Army Medical Center 941581 Blodgett Memorial 21-01424-03 Grand Rapids MI 06/14/94 Brachytherapy Medical Center 950659 Butterworth 21-00243-06 Grand Rapids MI 05/17/95 Brachytherapy Hospital 951166 Central Plains 40-26865-01 Sioux Falls SD 09/18/95 Sodium Iodide Clinic 941090 Cincinnati, 34-06903-05 Cincinnati OH 01/07/94 Brachytherapy University of 950959 Cleveland Clinic 34-00466-01 Cleveland OH 07/12/95 Brachytherapy Foundation 951324 Community 49-23121-01
'Ibrrington WY 09/06/94 Sodium Iodide Hospital 1
951325 Community 49-23121-01 Torrington WY IUO7/94 Sodium Iodide Hospital 941356 Garden City 21-04072-01 Garden City MI 03/28/94 Brachytherapy Osteopathic Hospital 951003 Healtheast Saint 22-24441-01 Maplewood MN 05/17/95 Sodium Iodide John's Hospital 941080 Henry Ford 21-04109-16 Detroit MI 03/02/94 Sodium Iodide Hospital i
941844 Jewish Hospital 34-00855-07 Cincinnati OH 09/12/94 Brachytherapy 960096 Lee, Philip J.W.,
53-04935-01 Honolulu HI 05/06/95 Brachytherapy M.D.
941582 Lucy Lee Hospital 24-16652-02 Poplar Bluff MO 04/05/94 Teletherapy 1
NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 Table A-1.1 Medical Misadministrations Reported by NRC Ucensee, January 1994-September 1995 (cont.)
i Item Ucense Event Type of No.
Ucensee No.
City State Date Misadministration 4
]
950842 Marshfield Clinic 48-10966-03 Marshfield WI 06/06/95 Brachytherapy 950645 Massachusetts 20-03814-80 Boston MA 05/09/95 Sodium Iodide General Hospital 941712 Massachusetts, 20-13758-01 Worcester MA 07/29/94 Brachytherapy University of 941675 Medical Center 34-11852-02 Chillicothe OH 07/21/94 Teletherapy Hospital 941865 Memorial Hospital 13-18881-01 South Bend IN 09/13/94 Brachytherapy 951165 Miami Valley 34-00341-06 Dayton OH 09/21/95 Sodium Iodide Hospital 941043 Mount Sinai 34-00746-03 Cleveland OH 03/29/94 Teletherapy Medical Center
}
951137 Navy, Department 45-23645-01NA Washington DC 08/29/95 Brachytherapy of the 1
942047 Navy, Department 45-23645-01NA Washington DC 11/18/94 Brachytherapy of the 950642 New Jersey 29-02957-13 Newark NJ 05/11/95 Brachytherapy
{
University of I
Medicine & Dentistry i
941746 North Memorial 22-05792-01 Robbinsdale MN 08/03/94 Brachytherapy Medical Center 951007 Providence 21-02802-03 Southfield MI 07/25/95 Brachytherapy Hospital 941084 Queen's Medical 53-16533-02 Honolulu HI "V02/94 Brachytherapy Center 941062 Saint John's Mercy 24-00794-03 Saint Imuis MO 04/15/94 Brachytherapy Medical Center 941670 Saint Joseph 21-11651-01 Pontiac MI 07/26/94 Sodium Iodide Mercy Hospital 950754 Saint Luke's 48-01338-01 Milwaukee WI 06/01/95 Brachytherapy Medical Center 4
941093 Saint Rita's 34-12100-03 Uma OH 01/19/94 Sodium Iodide Medical Center NUREG-1272, Appendix A-1 2
Nuclear Materials-NRC Licensee Events 1
Table A-1.1 Medical Misadministrations Reported by NRC Licensee, January 1994-September 1995 (cont.)
Item License Event Type of No.
Licensee No.
City State Date Misadministration 4
9501 % Saint Vincent 48-03220-03 Green Bay WI 02/22/95 Brachytherapy Hospital 940717 Sinai Hospital of 21-00299-06 Detroit MI 07/28/94 Teletherapy Detroit 941727 Sinai Hospital of 21-00299-06 Detroit MI 08/03/94 Teletherapy i
Detroit 960051 Southwest Medical 35-13127-01 Oklahoma City OK 08/25/95 Brachytherapy Center of Oklahoma 941355 Stamford Hospital 06-06697-02 Stamford CT 05/16/94 Sodium Iodide 951167 Temple University 37-00697-02 Philadelphia PA 09/28/95 Teletherapy 951061 Thomas Jefferson 37-00148-06 Philadelphia PA 08/14/95 Brachytherapy University 941719 V.A. Medical 04-00689-07 Iong Beach CA 08/09/94 Radiophar-Center maceutical 951141 V.A. Medical 16-08896-04 Lexington KY 09/07/95 Brachytherapy Center 950291 \\irginia, 45-00034-26 Charlottesville VA 03/14/95 Brachytherapy University of 941038 Whshington 24-00063-10 Saint Louis MO 04/22/94 Teletherapy University Medical Center 941413 Welborn Cancer 13-01674-01 Evansville IN 03/09/94 Sodium Iodide Cer.ter 942059 Welborn Cancer 13-01674-02 Evansville IN 11/18/94 Brachytherapy Cetter 941575 William W. Backus 06-11734-02 Norwich CT 06/21/94 Brachytherapy Hospital 3
NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 Table A-1.2 Overexpecures Reported by NRC licensees, January 1994 - September 1995 Item License Event Type of No.
Dose No.
Licensee No.
City State Date Exposure Exposed (Rem) 950387 Amersham 20-12836-01 Burlington MA 03/24/95 Skin 1
230.00 Corp.
j 951150 Amersham 20-12836-01 Burlington MA 09/13/95 Skin 1
342.00 Corp.
950954 Amersham 20-12836-01 Burlington MA 10/19/94 Skin 1
180.00 Corp.
950875 Bethlehem 37-01861-05 Bethlehem PA 06/16/95 Whole Body 3
0.12 Stcel Corp.
0.12 1
0.12 941070 General 34-09037-01 Washingtonville OH 03/15/94 Whole Body 1
5.65 Testing &
Inspection Co.
950922 Health &
19-00296-10 Bethesda MD 06/28/95 Internal 1
231 Human Services, Department of 1
942016 Penn Inspection 35-21144-01 Chickasha OK 07/19/94 Whole Body 1
6.49 i
Co.
941720 Quad Cities, DPR-0029 Cordova IL 08/08/94 Skin 1
60.00 Unit 1 942146 T6chnical 42-25214-01 Pasadena TX 06/28/94 Whole Body 1
5.74 Welding Laboratory, Inc.
NR Indicates NOT REPORTED NUREG-1272, Appendix A-1 4
i Nuclear Materials-NRC Licensee Events Table A-1.3 IAss of Control of Material Events Reported by NRC Ucensees, January 1994 - September 1995 Item License Event Radio-No.
Ucensee No.
City State Date Nuclide 941725 Abbott Laboratories, GENERAL Alta Vista VA 07/26/94 Am-241 Ross Products Division 950951 Adventist Health 34-13857-01 Kettering OH 02/13/95 P-32 Sys-Eastern Middle 950091 Air Force, 42-23539-01AF Brooks AFB TX 02/05/95 Am-241 Department of the 941473 Air Force, 42-23539-01AF Brooks AFB TX 03/23/94 Am-241 Department of the U-Dep 950940 Air Force, 42-23539-01AF Brooks AFB TX 07/06/95 Po-210 Department of tbe 951064 Air Force, 42-23539-01AF Brooks AFB TX 08/17/95 Mn-54 Department of the Th-232 941859 Air Force, 42-23539-01AF Brooks AFB TX 09/20/94 Am-241 Depanment of the 950197 Air Products &
37-05105-07 Allentown PA 01/31/95 H-3 Chemicals, Inc.
942110 Allied-Signal.
29-28131-01 Teterboro NJ 11/01/94 NR Aerospace Co NR 941071 Alt & Witzig 13-18685-01 Indianapolis IN 03/01/94 Am-Be Engineering, Inc.
Cs-137 941769 Alt & Witzig 13-18685-01 Indianapolis IN 08/25/94 Am-Be Engineering, Inc.
Cs-137 941800 Alt & Witzig 13-18685-01 Indianapolis IN 09/06/94 Am-Be Engineering, Inc.
Cs-137 i
941104 Alteon, Inc.
29-28447-01 Northvale NJ 08/04/94 I-125 941935 Ambric Engineering.
37-20968-01 Philadelphia PA 10/12/94 Am-Be Inc.
Cs-137 941495 American Compress NON-LICENSEE Cincinnati OH 07/19/94 NR 950346 Amersham Corp.
20-12836-01 Burlington MA 02/17/94 Ir-192 951254 Amersham Corp.
20-12836-01 Burlington MA 09/13/95 Ir-192 950097 Amersham Corp.
20-12836-01 Burlington MA 12/28/94 Ir-192 941514
- Army, NR Highland NJ 01/25/94 ND Department of the 5
NUREG-1272, Appendix A-1
i AEOD Annual Report,1994-FY 95 l
Table A-1.3 14ss of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont)
Item LJcense Event Radio-No.
Licensee No.
City State Date Nuclide 941065
941578
- Army, 12-00722-06 Rock Island IL 05/26/94 H-3 Department of the RockIsland Arsenal 950780
- Army, 12-00722-06 RockIsland IL 08/04/94 H-3 Department of the RockIsland Arsenal 951174
- Army, 12-00722-13 Rock Island IL 08/30/95 Am-241 1
Department of the RockIsland Arsenal 951246
- Army, 12-00722-13 Rock Island IL 09/24/95 Am-241 l
l Department of the Th-232 RockIsland Arsenal 942064
- Army, 19-00294-19 Aberdeen MD 11/25/94 H-3 Deoartment of the Ab^erdeen Proving Ground 950679 Atlantic Richfield Co.
SNM-1993 Los Angeles CA 11/20/94 Pu-238 941074 Baker Hughes Oilfield 17-27437-01 Broussard LA 02/24/94 Am-Be Operations, Inc.
Cs-137 941438 Battelle Columbus SNM-7 Columbus OH 03/25/94 Am-241 Laboratories Cs-137 Pu-239 i
942038 Ben-Hur Ford NON-LICENSEE Sioux Falls SD 09/19/94 Po-210 Sales, Inc.
951034 Biosearch,Inc.
37-21118-01 Philadelphia PA 06/14/95 H-3 941713 Book Crafters, Inc.
GENERAL Fredericksburg VA 07/29/94 Po-210 950524 Boston University 20-00805-11 Boston MA 04/25/95 P-32 941552 Bowser-Morner, Inc.
34-17390-01 Dayton OH 06/02/94 Am-Be Cs-137 NUREG-1272, Appendix A-1 6
Nuclear Materials-NRC Licensee Events Table A-1.3 Loss of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 941925 BPB Instruments, Inc.
35-26895-01 Oklahoma City OK 08/15/94 Am-Be Cs-137 941744 Braidwood, Unit 2 NPF-0077 Braidwood IL 08/12/94 Ni-63 950194 Calumet Testing 13-16347-01 Highland IN 02/25/95 Ir-192 Services, Inc.
9418 %
Cammenga 21-26460-01 Holland MI 10/04/94 H-3 Associates, Inc.
941767 CBC Envirorimental 48-24625-02 Oak Creek WI 07/01/94 Ni-63 Laboratories Ni-63 950289 Center For Blood 20-04490-01 Boston MA 01/01/95 S-35 Research 9509 %
Champion International 34-15956-01 Hamilton OH 07/18/95 Kr-85 Corp.
951131 Champion International GENERAL Nonvay MI 07/31/95 Kr-85 Corp.
951039 Champion International 34-15956-01 Hamilton OH 08/09/95 Kr-85 Corp.
9511 %
Champion International 34-15956-01 Hamilton OH 12/31/94 Kr-85 Corp.
941455 Columbus & Southern 34-18994-01 Columbus OH 03/30/94 Ni-63 Power Co.
941954 Conestoga Landfill NON-LICENSEE Morgantown PA 10/18/94 I-131 941437 Connecticut Resource NON-LICENSEE Hartford C1' 05/18/94 I-131 Recovery Authority 941646 Cubist Pharmaceuticals, 20-30065-01 Cambridge MA 03/1U94 P-32 Inc.
950084 Cumberland Village GENERAL Nashville TN 03/16/94 Cs-137 Mining Group NR 950969 Delaware State 07-11871-06 Dover DE 09/30/94 Ni-63 University Ni-63 Ni-63 Ni-63 951056 Dresden, Unit 2 NR NR IL 06/01/94 Sr-90 7
NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 Table A-1.3 IAss of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 1
941878 Drexel University 37-04594-11 Philadelphia PA 07/27/94 Am-Be Co-60 Cs-137 951112 E-Systems, Inc.,
GENERAL Saint FL 02/27/95 Po-210 ECI Division Petersburg 950493 Eastern Iron & Metal NON-LICENSEE Detroit MI 04/26/95 ND i
950660 Eli Lilly & Co.
13-01133-02 Indianapolis IN 05/15/95 I-125 950961 Emery Worldwide NON-LICENSEE Dayton OH 07/10/95 Cd-109 Fe-55 950998 Eye & Ear Clinic NON-LICENSEE Charleston WV 06/07/95 Sr-90 941279 Fair Lawn Diagnostic 29-11187-01 Paterson NJ 01/04/94 Cs-137 Imaging Center 951251 Fairfax Hospital 45-17128-01 Falls Church VA 09/2&/95 I-125 941899 Federal Express NON-LICENSEE Manhattan NY 10/04/94 I-125 941926 Federal Express NON-LICENSEE Bloomington MN 10/04/94 I-125 951073 Fisons Instruments, Inc.
20-30142-01 Beverly MA 04/05/95 Ni-63 940945 Ford Motor Co.
GENERAL Dearborn MI 03/02/94 Po-210 950970 Geisinger Medical 37-01421-01 Danville PA 03/01/95 I-131 Center 950615 Geo-Test, Ltd.
21-25870-01 Saginaw MI 05/09/95 Am-Be Cs-137 951130 Georgetown University 08-01709-04 Washington DC 07/06/95 Pd-103 Medical Center 950446 Ginna DPR-0018 Ontario NY 04/24/95 U-235 960088 Globe X-Ray 35-15194-41 Tulsa OK 09/01/95 Ir-192 Service, Inc.
941834 Greater Southeast SNM-1379 Washington DC 04/20/94 Pu-238 Community Hospital 941790 Greater Southeast 08-11182-01 Washington DC 04/26/94 I-131 Community Hospital 950976 Halliburton Co.
42-01068-07 Houston TX 05/11/95 Cs-137 NUREG-1272, Appendix A-1 8
Nuclear Materials-NRC Licensee Events i
Table A-1.3 less of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont) l 1
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 951199 Halliburton Co.
42-01068-07 Houston TX 07/16/95 Am-Be Cs-137 s
1 951200 Halliburton Co.
42-01068-07 Houston TX 08/26/95 Cs-137 941857 Halliburton Co.
42-01068-07 Houston TX 09/21/94 Cs-137 950912 Halliburton Co.
42-01068-07 Houston TX 11/14/94 Am-Be Cs-137 942101 Harman Mining Corp.
GENERAL Harman VA 06/30/94 Cs-137 941047 Harrison Steel 13-02141-01 Attica IN 04/22/94 NR Castings Co.
I 1
942060 Harvard University 20-00297-59 Cambridge MA 06/23/94 S-35
)
950922 Health & Human 19-00296-10 Bethesda MD 06/28/95 P-32 i'
Services, Department of 941734 Health & Human 19-00296-10 Bethesda MD 07/12/94 I-125 Services, Department of I
951202 Hewlett-Packard Co.
07-28762-01 Wilmington DE 04/04/95 Ni-63 l
942117 Hewlett-Packard Co.
07-28762-01 Wilmington DE 08/22/94 Ni-63 950883 Indiana Department of 13-26344-01 Crawfordsville IN 06/20/95 Am-Be Transportation Cs-137 950921 Indiana Department of 13-26342-01 Seymour IN 06/30/95 Am-Be Transportation Cs-137 950464 Indiana University at 13-02752-03 Indianapolis IN 04/07/95 H-3 Indianapolis P-32 S-35 950920
- Interior, 30-15065-01 Albuquerque NM 06/11/95 Am-Be Department of the Cs-137 941663 Italian Body Shop GENERAL Columbus OH 02/21/94 Po-210 941721 Jaworski Geotech, Inc.
28-30018-41 Manchester NH 10/13/94 Am-Be Cs-137 950749 Jeff Zell Consultants 37-28531-01 Coraopolis PA 06/02/95 Am-Be Cs-137 950701 Kuakini Medical Center 53-17797-01 Honolulu HI 05/24/95 I-131 9
NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 l
Table A-1.3 14ss of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont) l Item License Event Radio-No.
Licensee No.
City State Date Nuclide 951045 - Liposome Co., Inc.
29-19918-01 l'rinceton NJ 05/10/95 C-14 i
1 H-3
{
942130 Ludlum Measurements, 42-21454-01E Sweetwater TX 04/01/94 Am-241 Inc.
\\
941094 Mallinckrodt Medical, 24-04206-01 Maryland MO 04/24/94 I-131 j
Inc.
Heights 1
951154 Mallinckrodt Medical, 24-0420641MD Saint Louis MO 09/18/95 Mo-99 Inc.
Tb-99m q
942083 McCormick,'Ihylor &
37-28496-01 Philadelphia PA 09/07/94 Am-Be Associates, Inc.
?
942035 Medical Arts Center 21-26523-01 West Branch MI 06/30/94 Tc-99m 950235 Medical Center of 20-02452-01 Worcester MA 03/05/95 Mo-99 Central Massachusetts 950606 Metorex, Inc.
37-28461-01 Langhorne PA 04/20/95 Fe-55 950463 Michigan State 21-00021-29 East Lansing MI 03/31/95 P-32 University l
941776 Michigan, University of 21-00215-04 Ann Arbor MI 07/01/94 C-14 H-3 941973 Miller Engineering &
28-23457-01 Manchester NH 10/24/94' Am-Be Testing, Inc.
Cs-137 950336 Millstone, Unit 3 NPF-49 Waterford CT 02/09/95 Am-241 -
950191 Milton S. Hershey 37-13831-01 Hershey PA 02/06/95 P-32 Medical Center 950494 Minnesota Mining &
22-00057-34G Saint Paul MN 02/21/94 H-3 Manufacturing Co.
941955 Missouri, University of 24-005LM0 Rolla MO 09/23/94 U-Nat
'951058 Mitotix, Inc.
20-30002-01 Westford MA 07/24/95 P-32 951096 Monmouth Medical 29-08113-03 long Branch NJ 08/23/95 I-131 Center 960071 Mullinix Packages, Inc.
GENERAL Fort Wayne IN 08/23/95 Kr-85 951279 National Aeronautics GENERAL Kennedy Space FL 08/21/95 H-3 l
& Space Administration Center NUREG-1272, Appendix A 10
I i
Nuclear Materials-NRC Licensee Events L
i i
Table A-1.3 less of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont) l Item Ucense Event Radio-No.
Ucensee No.
City State Date Nuclide j
i 950249 Navy, Department of the 45-23645-01NA Washington DC 01/28/95 Am-241 1
941819 Navy, Department of the 45-23645-01NA Washington DC 03/16/94 H-3 950136 Navy, Department of the 45-23645-01NA Washington DC 07/15/94 Kr-85 941706 New England Medical 20-03857-06 Boston MA 06/30/94 P-32 Center Hospitals 941078 New England Power Co.
20-07227-02 Somerset MA 03/17/94 Sr-90 950788 New Jersey Institute of 29-19517-03 Newark NJ 04/10/95 Ni-63 Technology 941773 Northern Indiana Public 13-14984-01 Hammond IN 08/22/94 Cs-137 Service Co.
950941 NRD, Inc.
31-28397-01G Grand Island NY 05/31/95 Po-210 942151 Nucor Steel Corp.
NON-UCENSEE Darlington SC 01/03/95 ND 941494 Nucor Steel Corp.
13-25975-01 Crawfordsville IN 02/15/94 ND 941553 Nucor Steel Corp.
13-25975-01 Crawfordsville IN 06/04/94 ND 950303 Ogden-Martin Systems, NON-UCENSEE Indianapolis IN 03/16/95 I-131 Inc.
951062 Perry NPF-0058 Perry OH 07/01/95 Cs-137 Sr-90 941838 Pfizer, Inc.
06-05869-01 Groton CT 09/09/94 Cf-252 950454 Pilgrim DPR-0035 Plymouth MA 03/29/95 U-235 940389 Pneumo Abex Corp.
NON-UCENSEE Cleveland OH 05/12/94 Th-Nat 950822 Porcello Engineering, Inc. 29-19155-01 Fairfield NJ 06/06/95 Am-Be Cs-137 941726 Premier Radiopharmacy NR Indianapolis IN 07/28/94 I-131 940442 Primex Plastics Corp.
GENERAL Richmond IN 01/08/94 Po-210 950219 Princeton University 29-05185-24 Princeton NJ 02/24/95 I-125 950388 Private Individual NON-UCENSEE NR VA 03/17/95 Sr-90 941751 Private Individual NON-UCENSEE Okarche OK 07/28/94 H-3 941995 Private Individual NON-UCENSEE Cleveland 1U08/94 U-Oth a
4 11 NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 i
1 Table A-1.3 14ss of Control of Material Events. Reported by NRC Licensees, 1
January 1994 - September 1995 (cont) 3 Item Ucense Event Radio-No.
Licensee No.
City State Date Nuclide 950610 Process Technology, Inc.
21-25900 4 1 Calumet MI 05/04/95 Am-Be Cs-B7 950523 Prolerized Schiabo NON-LICENSEE Jersey City NJ 05/01/95 ND l
Neu Co.
941662 R&R International 34-20292-02 Akron OH 07/07/94 Am-Be j
Cs-137 i
950225 Rensselaer Polytechnic CX-22 Schenectady NY 07/12/94 Ni-63 i
Institute 941798 Rhode Island Nuclear R-95 Narragansett RI 05/17/94 Co-40 Science Center 941923 Ross Products Division GENERAL Altavista VA 08/05/94 Am-241 950299 S.D. Myers, Inc.
34-17546-01 Tallmadge OH 02/14/95 Ni-43 9510B Saint Joseph's Hospital 48-00537-03 Milwaukee WI 04/B/95 Ir-192 950488 Scandia Plastics GENERAL Sheboygan WI 04/20/95 Po-210 941439 Schlumberger 42-00090-03 Houston TX 01/21/94 Am-Be i
Technology Corp.
950067 Schlumberger 42-00090-03 Houston TX 01/27/95 Am-Be Technology Corp.
941278 Schlumberger 42-00090-03 Houston TX 02/08/94 Am-Be Technology Corp.
941490 Schlumberger 42-00090-03 Houston TX 02/21/94 Am-Be Technology Corp.
Cs-B7 941275 Schlumberger 42-00090-03 Houston TX 02/26/94 Am-Be Technology Corp.
Cs-B7 950476 Schlumberger 42-00090-03 Houston TX 03/07/95 Am-Be Technology Corp.
950719 Schlumberger 42-00090-03 Houston TX 03/31/95 Am-Be Technology Corp.
Cs-137 941603 Schlumberger 42-00090-03 Houston TX 05/07/94 Am-Be Technology Corp.
950845 Schlumberger 42-00090-03 Houston TX 05/28/95 Am-Be Technology Corp.
NUREG-1272, Appendix A-1 12
~
Nuclear Materials-NRC Licensee Events 1
Table A-1.3 Loss of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont) a l
item License Event Radio-No.
Licensee No.
City State Date Nuclide 941816 Schlumberger 42-00090-03 Houston TX 07/03/94 Am-Be Technolog Corp.
951035 Schlumberger 42-00090-03 Houston TX 07/19/95 Am-241 Technology Corp.
1 941817 Schlumberger 42-00090-03 Houston TX 09/08/94 Am-Be Technology Corp.
Cs-137 s
942030 Schlumberger 42-00090-03 Houston TX 09/26/94 Cs-137 Technology Corp.
1 942119 Schlumberger 42-00090-03 Houston TX 10/11/94 Am-Be TechnologyCorp.
950781 Scott Brass, Inc.
GENERAL Mishawaka IN 03/15/95 Pm-147 950077 Scott Paper Co.
GENERAL Philadelphia PA 11/20/94 Kr-85 941491 Stater Steel Co.
NON-LICENSEE Fort Wayne IN 01/12/94 ND 941492 Slater Steel Co.
NON-LICENSEE Fort Wayne IN 04/13/94 h3 951164 Smithkline Beecham 37-00282-04 King of Prussia PA 09/01/95 P-32 Pharmaceutical 941055 Soil & Materials 21-17158-02 Plymouth MI 04/06/94 Am-Be Engineers, Inc.
Cs-137 941472 Southwestern 42-26828-01 Houston TX 02/19/94 Am-Be Laboratory, Inc.
Cs-137 950482 Sperry-Sun Drilling 42-26844-01 Houston TX 04/19/95 Am-Be Services, Inc.
Cs-137 941323 Sperry-Sun Drilling 42-26844-01 Houston TX 05/06/94 Am-Be Services, Inc.
Cs-137 951044 Sperry-Sun Drilling 42-26844-01 Houston TX 06/18/95 Am-Be Services, Inc.
Cs-137 941811 Sperry-Sun Drilling 42-26844-01 Houston TX 07/25/94 Am-Be Services, Inc.
Cs-137 951095 Sperry-Sun Drilling 42-26844-01 Houston TX 08/22/95 Am-Be Services, Inc.
Cs-137 942034 Sperry-Sun Drilling 42-26844-01 Houston TX 09/01/94 Am-Be Services, Inc.
Cs-137 13 NUREG-1272, Appendix A-I
AEOD Annual Report,1994-FY 95 I
Table A-1.3 14ss of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont)
Item License Event Radio-No.
Ucensee No.
City State Date Nuclide 942029 Sperry-Sun Drilling 42-26844 4 1 Houston TX 09/13/94 Am-Be Services, Inc.
Cs-137 950034 Sperry-Sun Drilling 42-26844-01 Houston TX 11/27/94 Am-Be Services, Inc.
Cs-137 950393 Syncor International 34-19007-01MD Miamisburg OH 03/17/95 I-131 Corp.
942041 Syncor International 24-16617-01MD Kansas City MO 11/10/94 I-131 i
Corp.
941510 Tennessee Department NR -
Knonille TN 02/25/94 ND of Environment &
Conservation 941633 Texas A&M University 42-09082-09 College Station TX 01/13/94 Ir.192 950981 Thiokol GENERAL Cape Kennedy FL 07/19/95 H-3 941574 Trash Contractor NON-LICENSEE Checotah OK 06/16/94 Ir-192 941966 Uniformed Services 19-23344-01 Bethesda MD 07/06/94 P-32 University of Health Sciences 941316 Uretek, Inc.
GENERAL New Haven CT 02/04/94 Pm-147 950282 Urps Iron & Metal Co.
NON-LICENSEE Davy WV 03/13/95 Cs-137 941060 V.A. Medical Center 04-00689 4 7 Iong Beach CA 02/24/94 I-125 950472
'V.A. Medical Center SNM-1305 Buffalo NY 04/10/95 Pu-238 941792 V.A. Medical Center 06-11222-01 Newington CT 04/19/94 1-131 960078 V.A. Medical Center 42-10739-03 Temple TX 09/21/95 I-131 950087.
V.A. Medical Center 06-00092 4 5 West Haven CF 10/06/94 Ca-45 950784 Virginia Commonwealth 45-00048-17 Richmond VA 06/21/94 Ni43 University j
941777 Washington University 24 4 0167-11 Saint Imuis MO 07/21/94 Am-241 Medical School 951147 Weavexx Corp.
32-18405-02 Wake Forest NC 09/11/95 Am-241 941597 West Virginia 47-23035-01 Morgantown WV 04/27/94 S-35 University NUREG-1272, Appendix A-1 14
1 Nuclear Materials-NRC I.icensce Events I
Table A. I.3 Imss of Control of Material Events Reported by NRC Licensees, January 1994 - September 1995 (cont)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 4
950381 Western Atlas 42-02964-01 Houston TX 03/04/95 H-3 i
International, Inc.
941656 Western Atlas 42-02964-01 Houston TX 05/05/94 Am-Be International, Inc.
Cs-137 951142 Western Atlas 42-02964-01 Houston TX 09/06/95 Am-Be International, Inc.
Cs-137 l
960077 Western Atlas 42-02964-01 Houston TX 09/06/95 Am-Be International, Inc.
Cs-137 950003 Western Atlas 42-02964-01 Houston TX 09/30/94 Am-Be International, Inc.
Cs-137 950234 Western Atlas 42-02964-01 Houston TX 12/16/94 H-3 International, Inc.
i 941088 Westinghouse Electric 37-28556-01 Forest Hills PA 01/31/94 Cs-137 Corp.
941580 Wisconsin, University of, 48-09843-18 Madison WI 06/08/94 P-32 941087 Wyeth-Ayerst 29-28210-02 Princeton NJ 01/13/94 I-125 Research, Inc.
951177 Wyoming Medical 49-00152-02 Casper WY 09/15/95 Pd-103 Center 941717 Yale-New Haven 06-00819-03 New Haven CT 07/28/94 I-125 Hospital NR Indicates NOT REPORTED ND Indicates NOT DETERMINED 15 NUREG-1272, Appendix A-1
AEOD Annaal Report,1994-FY 95 i
Table A-1.4 leaking Sources Reported by NRC Licensees, January 1994 - September 1995 Item License Event Radio-No.
Licensee No.
City State Date Nuclide 950295 ABB Process 34-00255-03 Columbus OH 01/07/95 Pm-147 Automation, Inc.
951146 ABB Process 34-00255-03 Columbus OH 07/17/95 Pm-147 Automation, Inc.
950872
- Army, 12-00722-06 Rock Island IL 05/12/95 H-3 Department of the Rock Island Arsenal 941728
- Army, 30-02405-10 White Sands NM 06/21/94 Co-60 Department of the 950380
- Army, 42-01368-04 Fort Sam TX 12/29/94 Cd-109 Department of the Houston 960081 Battelle Columbus SNM-7 Columbus OH 09/29/95 Ni-63 i
Laboratories 950967 Dow Chemical Co.
21-00265-06 Midland MI 05/22/95 Ni-63 l
942116 E.I. Du Pont 07-00455-02 Wilmington DE 09/29/94 Am-241 i
Experimental Station 950294 Eastern Well 34-12927-01 Wooster OH 12/26/94 Am-Be Suiveys, Inc.
3 950231 Environmental 34-12736-02 Cincinnati OH 01/27/95 Ni-63 Protection Agency 941 % 9 Environmental 19-14125-01 Annapolis MD 03/10/94 Ni-63 i
Protection Agency 940592 Hazelton 48-11805-02 Madison WI 05/27/94 Ni-63 950106 Hazelton 48-11805-02 Madison WI 12/05/94 Ni-63 941073 Health & Human 04-09763-01 Los Angeles CA 01/10/94 Ni-63 Services, Department of 950681 Health & Human 08-00482-03 Washington DC 03/30/95 Ni-63 Services, Department of 942122 Michigan State 21-00021-29 East Lansing MI 12/15/94 Ni-63 University 941063 Minnesota Department 22-09861-01 Saint Paul MN 05/03/94 Ni-63 of Agriculture 950680 Pennsylvania State 37-00185-04 University Park PA 03/10/95 Ni-63 University NUREG-1272, Appendix A-1 16
Nuclear Materials-NRC Licensee Events Table A-1.4 12sking Sources Reported by NRC Ucensees, January 1994 - September 1995 (cont.)
Item Ucense Event Radio-No.
Ucensee No.
City State Date Nuclide 940113 Princeton.
29-12783-01 Princeton NJ 03/17/94 Fe-55 Gamma-Tech, Inc 941797 Smithkline Beecham 37-00282-04 King of Prussia PA 05/10/94 Ni-63 Pharmaceutical 951309 Smithsonian 08-05938-13 Washington DC 08/30/95 Cm-244 Institution 950237 TRS, Inc.
GENERAL Amesbury
'MA 11/16/94 71-204 Pm-147 942044 Wright State 34-11912-03 Dayton OH 10/11/94 Ni-63 University 941968 Zeneca 07-03990-01 Wilmington DE 06/19/94 Cs-137 Pharmaceutica 1s Group 17 NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 Table A-1.5 Material Release Events Reported by NRC Licensees, January 1994 - September 1995 Item IJcensee Event Type of Radio-No.
Licensee No.
City State Date Release Nuclide 941915 Advanced Medical 34-19089-01 Cleveland OH 07/07/94 Surface NR
.i Systems, Inc.
941884 Air Force, 42-23539-01AF Brooks AFB TX 09/27/94 Surface ND Department of the j
950079 Allied-Signal, Inc.
SUB-526 Metropolis IL 02/03/95 Air UF6 941082 Allied-Signal, Inc.
SUB-526 Metropolis IL 04/27/94 Surface NR 941947 Allied-Signal, Inc.
SUB-526 Metropolis IL 10/16/94 Surface UF6 950643 American 24-21362-01 Saint Louis MO 05/11/95 Surface C-14 Radiolabeled Chemicals 950284 Arkansas, Unit 1 DPR-0051 Russellville AR 03/14/95 Water H-3 Fe-55 Cs-134 Cs-137 941653
- Army, 29-01022-14 Fort NJ 01/16/94 Air Kr-85 Department of the Monmouth 950182
- Army, 12-00722-06 Rock Island IL 02/21/95 Surface H-3 i
Department of the l
RockIsland Arsenal 950250
- Army, 12-00722-06 Rock Island IL 03/07/95 Air H-3 Department of the RockIsland Arsenal 941064
- Army, 12-00722-06 Rock Island IL 03/13/94 Air H-3 Department of the i
RockIsland Arsenal 941067
- Army, 12-00722-06 Rock Island IL 03/15/94 Air H-3 Department of the Rock Island Arsenal 950753
- Army, 12-00722-06 Rock Island IL 04/07/95 Air H-3 Department of the RockIsland Arsenal 950872
- Army, 12-00722-06 Rock Island IL 05/12/95 Surface H-3 Department of the Rock Island Arsenal j
940927
- Army, 12-00722-06 Rock Island IL 07/20/94 Air H-3 Department of the Rock Island Arsenal NUREG-1272, Appendix A-1 18
i Nuclear Materials-NRC Licensee Events i
Table A-1.5 Material Release Events Reported by NRC Licensees, January 1994 - September 1995 (cont.)
4 Item Licensee Event Type of Radio-No.
Licensee No.
City State Date Release Nuclide 941890
- Army, 12-00722-06 Rock Island IL 08/22/94 Surface H-3 i
j Department of the l
Rock Island Arsenal i
941843
- Army, 12-00722-06 Rock Island IL 09/07/94 Air H-3 i
Department of the Rock Island Arsenal
[
942064
Department of the Aberdeen Proving Ground l
940925 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 01/20/94 Surface U-235 941666 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 07/07/94 Air U-Oth i
941682 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 07/26/94 Surface U-Aq f
i 941593 Becton-Dickinson 19-14977-01E Sparks MD 06/22/94 Surface C-14 Diagnostic Instrument Systems 941521 Braidwood, Unit 1 NPF-0072 Braidwood IL 04/10/94 Surface NR 941516 Brooks & Perkins STB-362 Livonia MI 02/01/94 Surface Mn-Th i
Corp.
9418 %
Cammenga 21-26460-01 Holland MI 10/04/94 Surface H-3 j
Associates, Inc.
950147 Catawba, Unit 1 NPF-0035 York SC 02/15/95 Surface NR 941069 Caylor-Nickel 13-01629-03 Bluffton IN 01/13/94 Air Xe-133 Hospital, lac.
941110 Center For Molecular 29-28554-01 Newark NJ 05/02/94 Surface I-131 4
Medicine &
Immunology 950371 Cleveland Clinic 34-00466-01 Cleveland OH 05/02/94 Surface I-131 Foundation d
951028 Dresden, Unit 2 DPR-0019 Morris IL 08/04/95 Surface NR 941899 Federal Express NON-Manhattan NY 10/04/94 Surface I-125 LICENSEE 951127 Heuer Time &
29-23795-01 Springfiel3 NJ 06/28/95 Surface H-3 Electronics Corp.
19 NUREG-1272, Appendix A-1
.-==-
1 l
AEOD Annual Report,1994-FY 95 l
l
\\
Table A-1.5 Material Release Events Reported by NRC Ucensees, January 1994 - Septernber 1995 (cont.)
Item IJcensee Event Type of Radio-
)
No.
Licensee No, City State Date Release Nuclide 950453 Hope Creek NPF-0057 Hancocks NJ 04/05/95 Air NR Bridge l
i 941520 Hope Creek NPF-0057 Hancocks NJ 04/09/94 Surface NR Bridge 941444 Indian Point, Unit 2 DPR-0026 Buchanan NY 05/23/94 Surface NR 941916
- Interior, 27 4 3106-03 Reno NV 08/18/94 Surface H-3 Department of the j
940731 Mallinckrodt 24-04206-01MD Saint Iouis MO 04/07/94 Air I-131 l
Medical, Inc.
941981 Mallinckrodt 24-17450-03 Saint louis MO 11/06/94 Surface
'Ib-99m Medical, Inc.
941867 Medi+ Physics 48-26240-01MD Milwaukee WI 02/09/94 Water Tc-99m Pharmacy Services, Inc.
941085 Metpath, Inc.
29-15797-01 Teterboro NJ 04/12/94 Surface I-125 950118
- Michigan, 21-00215-04 Ann Arbor MI 04/20/95 Surface P-32 University of 950837 Oconee, Unit 3 DPR-0066 Seneca SC 06/12/95 Surface NR 951145 Ohio State University 34-00293-02 Columbus OH 09/12/95 Surface I-131 941879 Osram Sylvania, Inc.
STB-281
'Ibwanda PA-04/05/94 Surface Th-232 941752 Palisades DPR-0020 Covert MI 08/09/94 Surface NR 950748 Palo Verde, Unit 1 NPF-0041 Wintersburg AZ 05/04/95 Water Co-60 941704 Pittsburgh, 37-00245-02 Pittsburgh PA 07/20/94 Surface Sn-113 University of 941964 Pneumo Abex Corp.
NON-Cleveland OH 06/13/94 Surface Th-232 IlCENSEE
-j 942013 Prairie Island, Unit 1 DPR-0042 Redwing MN 10/25/94 Air NR 950459 Program Resources, 19-21091-01 Frederick MD 01/11/95 Surface P-32 Inc.
950480 Protechniques 42-26926-01 Houston TX 04/18/95 Surface Ir-192 International, Inc.
941733 River Bend NPF-0047 Saint LA 08/03/94 Surface NR Francisville NUREG-1272, Appendix A-1 20 i
Nuclear Materials-NRC Licensee Events j
l Table A-1.5 Material Release Events Reported by NRC Licensees, January 1994 - September 1995 (cont.)
i Item Licensee Event Type of Radio-No.
Licensee No.
City State Date Release Nuclide J
4 950905 Roadway Express NON-Akron OH 06/27/95 Surface Cd-109 LICENSEE I
941283 Shell Chemical Co.
34-13012-01 Belpre OH 05/27/94 Air Cs-D7 l
l 941443 Shieldalloy Corp.
SMB-1507 Newfield NJ 04/11/94 Surface Th-Nat i
U-Nat 941810 Siemens Nuclear SNM-1227 Richland WA 06/24/94 Water U-Oth Power Corp.
941849 Siemens Nuclear SNM-1227 Richland WA 09/18/94 Surface U-235 Power Corp.
960051 Southwest Medical 35-13127-01 Oklahoma OK 08/25/95 Surface I-125 Center of Oklahoma City 941354 Syncor International 24-16617-01MDKansas City MO 05/18/94 Surface Tc-99m Corp.
941096 Syncor International 24-19360-01MD Saint Louis MO 06/07/94 Air I-131 Corp.
Xe-D3 942090 Syncor International 21-19219-01MDGrand Rapids MI 12/06/94 Air Tc-99m Corp.
941689-Total Minerals Corp.
SUA-1341 Casper WY 07/14/94 Surface U-Oth 941710 Total Minerals Corp.
SUA-1341 Casper WY 08/01/94 Surface U-Oth 940987 U.S. Enrichment Corp. USEC-K Paducah KY 02/17/94 Air UF6
.951001 U.S. Enrichment Corp. USEC-O Piketon OH 05/24/95 Air '
UF6 942109 U.S. Enrichment Corp. USEC-K Paducah KY 12/13/94 Air UF6 951060 Unicare-Edgewood NON-Youngstown PA 08/07/95 Surface I-131 Nursing Center LICENSEE 950745 V.A. Medical Center 20-00671-02 Boston MA 06/29/94 Surface Sr-89 951306 V.A. Medical Center 48-02130-02 Milwaukee WI 08/22/94 Surface NR 950479 Virginia, University of 45-00034-26 Charlottes-VA 04'18/95 Surface I-131 ville 950957 Washington Nuclear, NPF-21 NR WA 07/12/95 Water Co-60 Unit 2 l
941322 West Hudson Hospital 29-08532-01 Kearny NJ 01/06/94 Surface I-131 21 NUREG-1272, Appendix A-1
. -. =.
i AEOD Annual Report,1994-FY 95 Table A-1.5 Material Release Events Reported by NRC Licensees, January 1994 - September 1995 (cont.)
hype of Item Licensee Event Radio-No.
Licensee No.
City State Date Release Nuclide 940784 Westinghouse Electric SNM-1107 Pittsburgh PA 01/26/94 Air UF6 Corp.
940986 Westinghouse Electric 37-00497-15 Pittsburgh PA 02/07/94 Surface U-235 Corp.
941946 Westinghouse Electric 37-05809-01 Pittsbur;;h PA 09/13/94 Surface Cs-137 Corp.
Co-60 Cs-134 941152 Yale University 06-00183-03 New Haven CT 04/29/94 Surface I-125 941522 Zion, Unit 1 DPR-0039 Zion IL 03/15/94 Surface Co-60 NR Indicates NOT REPORTED ND Indicates NOT DETERMINED
)
NUREG-1272, Appendix A-1 22
Nuclear Materials-NRC Licensee Events Table A-1.6 Transportation Events Reported by NRC Licensees, January 1994 - September 1995 Item Licensee Event Type of No.
Licensee No.
City State Date Transportation Event 942063 Alaron Corp.
37-20826-01 Wampum PA 11/23/94 Radiation Levels Exceed Limits For Package 950248 Allied-Signal 29-28131-01 Teterboro NJ 12/16/94 Improperly Aerospace Co.
Packaged Material 941 % 2 Allied-Signal, Inc.
SUB-526 Metropolis IL 05/19/94 Surface Contami-nation Levels Exceed Limits For Package 941 % 1 Allied-Signal, Inc.
SUB-526 Metropolis IL 06/10/94 Surface Contami-nation Levels Exceed 1
Limits For Package 941079 Amersham Corp.
20-12836-01 Burlington MA 02/24/94 Improperly Packaged Material Radiation Levels Exceed Limits For Package 941836 Amersham Corp.
12-12836-02E Arlington IL 09/12/94 Radiation Levels Heights Exceed Limits For Package 960079 Anvil Corp.
46-23236-03 Bellingham WA 01/01/95 Failed To Meet Reguirements OF NRCB 95-01 941994
- Army, SNM-1998 Redstone AL 11/04/94 Improperly Packaged Department of the Arsenal Material 950189 Baptist Regional 35-16233-01 Miami OK 07/25/94 Surface Contami-Health Center nation Levels Exceed Limits For Package 950424 Calvert Cliffs, NR NR NR 05/26/94 Radiation Levels Unit 1 Exceed Limits For Package 941274 Century Inspection, 42-08456-02 Dallas TX 03/07/94 Transporting Vehicle Inc.
Involved In One-Vehicle Accident 951043
- Missouri, 24-00513-32 Columbia MO 06/20/95 Improperly Packaged University of Material 23 NUREG-1272, Appendix A-1
l AEOD Annual Report,1994-FY 95 Table A-1.6 Transportation Events Reported by NRC IJcensees, January 1994 - September 1995 (cont.)
Item Licensee Event Type of.
No.
Licensee No.
City State Date
'Iransportation Event 941497 Del Med Corp.
NON-South NJ 03/06/94 Transporting Vehicle LICENSEE Plainfield Involved In One-Vehicle Accident 941886 DOE-Fernald DOE Fernald OH 10/01/94 Transporting Vehicle Involved In One-Vehicle Accident
% 0074 Dresden, Unit 2 DPR-0019 Morris IL 08/1U95 Radiation Levels Exceed Limits For Package 941103 Duane Arnold DPR-0049 Palo IA -
05/04/94 Transporting Vehicle Involved In One-Vehicle Accident 941956 E.I. Du Pont De 20-00320-21 Bosto:t MA 10/13/94 Improperly Packaged Nemours & Co., Inc.
Material 941092 E.I. Du Pont Merck 20-28598-01 North MA 02/03/94 Radiation Levels Pharmaceutical Co.
Billerica Exceed Limits For Package Improperly Packaged Material 951140 E.I. Du Pont Merck NR NR NR 09/06/95 Radiation Levels Pharmaceutical Co.
Exceed Limits For Package Damaged Packaging 950238 Federal Express NON-NR CA 01/24/95 Improperly Packaged LICENSEE Material 941724 Federal Express NON-NR MA 08/05/94 Transporting Vehicle LICENSEE Involved In One-Vehicle Accident 941899 Federal Express NON-Manhattan NY 10/04/94 Improperly Packaged LICENSEE Material 941850 Fermi, Unit 2 NPF-0043 Newport MI 09/16/94 Radiation Levels Exceed Limits For Package i
940929 Fort Saint Vrain NR Platteville CO 01/19/94 Transporting Vehicle Involved In One-Vehicle Accident NUREO-1272, Appendix A-1 24 l
Nuclear Materials-NRC Licensee Events Table A-1.6 Transportation Events Reported by NRC Licensees, January 1994 - September 1995 (cont.)
Item Licensee Event Type of No.
Licensee No.
City State Date hansportation Event 950584 General Electric Co. SNM-960 Pleasanton CA 01/13/94 Radiation Levels Exceed Limits For Package 950661 Healtheast Saint 22-24441-01 Maplewood MN 05/20/95 Surface Contami-John's Hospital nation Levels Exceed Limits For Package 950175 Indian Point, Unit 2 DPR-0026 Buchanan NY 03/28/95 Radiation Levels Exceed Limits For Package 941324 Indian Point, Unit 2 DPR-0026 Buchanan NY 05/13/94 Surface Contami-nation Levels Exceed Limits For Package 941664 Interstate Nuclear 37-23341-01 Royersford PA 03/24/94 Transporting Vehicle Services Involved In One-Vehicle Accident 950466 IRT Corp.
SNM-1405 San Diego CA 11/04/94 Radiation Levels Exceed Limits For Package 942113 Kindrick Trucking NON-NR IL 12/10/94 Radiation Levels Co.
LICENSEE Exceed Limits For Package 950751 Mallinckrodt 24-04206-04MA Maryland MO 03/29/95 Surface Contami-Medical, Inc.
Heights nation Levels Exceed Limits For Package 950860 Mallinckrodt 24-04206-16MD Saint Louis MO 06/10/95 Radiation Levels Medical, Inc.
Exceed Limits For Package 941786 Mallinckrodt 20-15215-02MD Saint Louis MO 07/05/94 Surface Contami-Medical, Inc.
nation Levds Exceed Limits For h'ckage 941900 Mallinckrodt 34-16272-01 Cleveland OH 09/28/94 Surface Contand-Medical, Inc.
nation levels Exceed Limits For Package 941981 Mallinckrodt 24-17450-03 Saint louis MO 11/06/94 Failure To Brace Medical, Inc.
And Block Shipment 25 NUREG-1272, Appendix A-1 l
1
AEOD Annual Report,1994-FY 95 l
l Table A-1.6 Transportation Events Reported by NRC Licensees, January 1994 - September 1995 (cont.)
\\
Item Licensee Event Type of
{
No.
Licensee No.
City State Date Transportation Event l
941982 Medi + Physics 48-26240-01MD Milwaukee WI 10/26/94 Surface Contami-Pharmacy Services, nation Levels Exceed Inc.
Limits For Package 940928 Millstone, Unit 1 NR Waterford CT 01/12/94 Radiation Levels Exceed Limits For Package 950036 Missouri, University R-103 Columbia MO 05/05/94 Radiation Levels of, at Columbia Exceed Limits For Package a
942042 New England Nuclear NR Billerica MA 11/15/94 Improperly Packaged Matenal 1
941700 _ Oklahoma, 35-03176-04MD Oklahoma City OK 07/25/94 Surface Contami-University of nation Levels Exceed Limits For Package 941774 Pittsburgh NON-Pittsburgh PA 08/23/94 Improperly Packaged 4
International LICENSEE Material Airport 950480 Protechniques 42-26926-01 Houston TX 04/18/95 Transporting Vehicle International. Inc.
Involved In One-Vehicle Accident 941658 Radiopharmacy, Inc. 13-26246-01MD Evansville IN 04/16/94 Transporting Vehicle Involved In One-Vehicle Accident j
941515 Raytech Express,Inc. NR NR IA 04/24/94 Transporting Vehicle Involved In Multi-Vehicle Accident 950905 Roadway Express NON-Akron OH 06/27/95 Improperly Packaged LICENSEE Material 950776 Saint John Medical 35-00376-02 Tulsa OK 03/01/95 Surface Contami-i Center nation Levels Exceed Limits For Package 941044 Sequoyah Fuels SUB-1010 Gore OK 04/19/94 Improperly Packaged Corp.
Material 950039 Siemens Nuclear SNM-1227 Richland WA 08/04/94 Improperly Packaged s
Power Corp.
Material NUREG-1272, Appendix A-1 26 l
Nuclear Matcrials-NRC Licensee Events Table A-1.6 Transportation Events Reported by NRC Licensees, January 1994 - September 1995 (cont.)
Item Licensee Event Type of No.
Licensee No.
City State Date Transportation Event 941091 Syncor International 29-1%08-01MD Fairfield NJ 02/08/94 Transporting Vehicle Corp.
Involved In One-Vehicle Accident 950192 Syncer International 35-19583-01MD Tulsa OK 02/25/95 Radiation Levels Corp.
Exceed Limits For Package 941008 Syncor International 37-18467-01MD Pittsburgh PA 03/07/94 Surface Contami-Corp.
nation Levels Exceed Limits For Package i
950999 Syncor International 34-19007-01MD Miamisburg OH 05/01/95 Surface Contami-Corp.
nation Levels Exceed Limits For Package 951000 Syncor International 34-19007-01MD Miamisburg OH 05/21/95 Transporting Vehicle Corp.
Involved In One-1 Vehicle Accident 950858 Syncor International 34-16405-01MD Cleveland OH 06/15/95 Transporting Vehicle Corp.
Involved In One-Vehicle Accident 942023 Syncor International 13-26457-01MD Fort Wayne IN 11/14/94 Transporting Vehicle Corp.
Involved In One-Vehicle Accident 950233 Syncor International 37-18461-01MD Sharon Hill PA 12/23/94 Surface Contami-Corp.
nation Levels Exceed Limits For Package 942126 Technical Welding 42-25214-01 Pasadena TX 05/31/94 Radiation Levels Laboratory, Inc.
Exceed Limits For Package 941572 Testwell Craig 06-19720-01 Danbury CT 06/15/94 Transporting Vehicle Laboratories of Involved In Multi-i Connecticut. Inc.
Vehicle Accident 950470 V.A. Medical 04-17862-01 Imma Linda CA 03/01/94 Surface Contami-Center nation Levels Exceed Limits For Package 941802 V.A. Medical 04-17862-01 Loma Linda CA 07/13/94 Surface Contami-Center nation Levels Exceed Limits For Package 27 NUREG-1272, Appendix A-1
)
AEOD Annual Report,1994-FY 95 l
l Table A-1.6 Transportation Events Reported by NRC Licensees, January 1994 - September 1995 (cont.)
Item Licensee Event Type of No.
Licensee No.
City State Date Transportation Event 950188 V.A. Medical 05-01401-02 Denver CO 12/19/94 Surface Contami-Center nation Levels Exceed Limits For Package
)
l 942058 Western Atlas 42-02964-01 Houston TX 11/21/94 Transporting Vehicle International, Inc.
Involved In One-Vehicle Accident Accident t
NR Indicates NOT REPORTED I
l l
4 i
l i
i NUREG-1272, Appendix A-1 28
_._______.m.-._
Nuclear Materials-NRC Licensee Events r-I Table A-1.7 Equipment Problems Reported by NRC Licensees, January 1994 - September 1995 Item Licensee Event i
No.
Ucensee No.
City State Date Equipment 941489 Abbott Health 52-24994-01 Vega Alta PR 04/15/94 Irradiator Products, Inc.
950614 Abbott Health 52-24994-01 Vega Alta PR 04/16/95 Detector, Radiation Products, Inc.
941254 Abbott Health 52-24994-01 Vega Alta PR 05/12/94 Irradiator, Panoramic Products, Inc.
941971 Adams Construction 45-17887-01 Roanoke VA 10/27/94 Gauge, Moisture /
Co.
Density 941468 Air Force, 42-23539-01AF Brooks AFB TX 03/03/94 Mobile Neutron l
Department of the Radiography System Unit 950335 Air Force, 42-23539-01AF Brooks AFB TX 03/21/95 Irradiator l
Department of the 950086 Air Force, 42-23539-01AF Brooks AFB TX 12/17/94 Motor Department of the 951231 Alliant Techsystems, 22-26604-01 New Brighton MN 06/26/95 Gauge Inc.
950079 Allied-Signal, Inc.
SUB-526 Metropolis IL 02/03/95 Valve, Pigtail 941947 Allied-Signal, Inc.
SUB-526 Metropolis IL 10/16/94 Calciner 960107 Amersham Corp.
20-12836-01 Burlington MA 07/01/94 Camera, Radiography 942068 Amersham Corp.
20-12836-01 Burlington MA 09/07/94 Camera, Radiography 941778 Apac-Virginia, Inc.
45-21343-02 Manassas VA 10 11/94 Gauge, Moisture /
Density 950377 Apgee Corp.
37-28697-01 Aliquippa PA 01/17/95 Gauge i
941215 Arkansas, Unit 1 DPR-0051 RusselMile AR 05/09/94 Pin Connector 941880
- Army, 19-1725N)5 Adelphi MD 02/02/94 Valve, Elevator
- Department of the Control 950250
- Army, 12-00722-06 Rock Island IL 03/07/95 Sensor, Muzzle Department of the Reference l
941067
- Army, 12-00722-06 Rock Island IL 03/15/94 Vehicle, Tank Sensor, j
Department of the Muzzle Reference 950753
- Army, 12-00722-06 Rock Island IL 04/07/95 Collimator Department of the l
29 NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 Table A-1.7 Equipment Problems Reported by NRC Licensees, January 1994 - September 1995 (cont.)
Item Licensee Event No.
Licensee No.
City State Date Equipment 941754 ATEC Associates, 34-18893-01 Cincinnati OH 08/13/94 Gauge, Moisture /
Inc.
Density 940925 Babcock & Wilcox SNM-42 Lynchburg VA 01/20/94 Line, Waste Drain Co.
940780 Babcock & Wilcox SNM-42 Lynchburg VA 02/11/94 Drain Co.
941504 Babcock & Wilcox SNM-42 Lynchburg VA 02/21/94 Tray Co.
942045 Babcock & Wilcox SNM-42 Lynchburg VA 11/17/94 Alarm, Stack Exhaust Co.
Fan Alarm, Evacuation 950462 Barmet Aluminum 34-26204-01 Uhrichsville OH 08/01/94 Gauge Corp.
942106 Bechtel/ Parsons 20-28645-01 Boston MA 12/10/94 Gauge, Moisture /
Brinckerhoff Density 942105 Berthold Systems, 37-21226-01 Aliquippa PA 12/09/94 Shield, Source Inc.
941885 Board of Municipal 24-18952-01 Sikeston MO 09/29/94 Support System Utilities 950038 Braun Intertec Corp. 22-16537-01 Minneapolis MN 01/09/95 Gauge, Moisture /
Density 941155 Braun Intertec Corp. 22-16537-01 Minneapolis MN 05/05/94 Gauge, Moisture /
Density 950477 Brucker Earth 24-26550-01 Saint Iouis MO 03/19/94 Gauge, Moisture /
Engineering &
Density Testing, Inc.
950474 Carlisle Hospital 37-02385-01 Carlisle PA 03/29/95 'Ibletherapy Unit 960085 Carondelet Foundry 24-26136-01 Saint Iouis MO 09/09/95 Camera, Co.
Radiography 940263 Central Soya Co.,
13-18876-01 Indianapolis IN 06/28/94 Gauge, I2 vel Inc.
950007 Consolidated NDE, 29-21452-01 Woodbridge NJ 10/26/94 Camera, Inc.
Radiography NUREG-1272, Appendix A-1 30
__--_.m___.__
i Nuclear Materials-NRC Licensee Events j
Table A-1.7 Equipment Problems Reported by NRC Ucensees,
{
January 1994 - September 1995 (cont.)
Item Licensee Event i
No.
Licensee No.
City State Date Equipment 941674 Construction 37-18456-02 Pittsburgh PA '
07/14/94 Gauge, Moisture /
Engineering Density l
Consuldnts, Inc.
i 950839 Const'oction Testing 21-18680-01 Flint MI 06/14/95 ' Gauge, Density Engineers l
.950859 CTI & Associates, 21-17007-01 Farmington MI 06/14/95 Gauge, Moisture /
Inc.
Hills Density 942043 CTI, Inc.
50-19202-01 Anchorage AK 11/11/94 Camera, Radiography 951143 Dayton X-Ray 34-06943-01 Dayton OH 08/08/95 Camera, Radiography l
951031 Defense Nuclear 19-08330-02 Bethesda MD 06/2U95 Calibrator Agency l
.951152 Defense Nuclear 19-08330-02 Bethesda MD 06/21/95 Irradiator, Cabinet Agency i
960089' Defense Nuclear 19-08330-03 Bethesda MD 06/21/95 Irradiator Agency
?
951120 Diamond H Testing 11-27316-01 Chubbuck ID 08/27/95 Drive Cable Co.
Connector 950288 Florida, University R-56 Gainesville FL 03/09/95 Reactor, Research 1
of j
950975 Frank Barker 29-28783-01 Pequannock NJ 07/13/95 HDR Unit Associates, Inc.
j 950789 Frochling &
45-08890-02 Richmond VA 06/08/95 Gauge, Moisture /
Robertson, Inc.
Density 940073 Geisinger Medical 37-01421-04 Danville PA 04/27/94 Teletherapy Unit Center 951158 General Dynamics 06-01781-08 Groton CT 08/04/95 Camera, Radiography.
Corp.
941576 General Electric Co. SNM-1097 Wilmington NC 06/13/94 Furnace 951097' General Electric Co. SNM-1097 Wilmington NC 08/20/95 Digital Control System 941056 Georgia Institute of R-97 Atlanta GA 02/15/94 Reactor, Research Technology 950006 Glitsch Field 34-14071-01 North Canton OH 11/21/94 Drive Cable Services /NDE, Inc.
31 NUREG-1272, Appendix A-1
)
i AEOD Annual Repolt,1994-FY 95 l
Table A-L7 Equipment Problems Reported by NRC Ucensees, January 1994 - September 1995 (cont.)
Item Licensee Event No.
Licensee No.
City State Date Equipment 951162 GRD Steel Mill 37-30147-01 Monongahela PA 09/22/95 Gauge, Level 950611 H&G Inspection 42-26838-01 Houston TX 03/27/95 Camera, l
Co., Inc.
Radiography
)
950339 H&G Inspection 42-26838-01 Houston TX 04/13/94 Lock Mechanism Co., Inc.
950962 H&G Inspection 42-26838-01 Houston TX 05/15/95 Camera, Co., Inc.
Radiography l
95 % 52 Harrison Steel 13-02141-01 Attica IN 03/23/95 Camera, Castings Co.
Radiography 941075 Health & Human 19-00296-17 Bethesda MD 01/04/94 Irradiator
- Services, Department of 941076 Health & Human 19-00296-17 Bethesda MD 01/21/94 Irradiator
- Services, i
Department of l
941791 High Steel 37-17534-01 Lancaster PA 05/26/94 Camera, Structures, Inc.
Radiography J
950032 Honolulu Resource 53-23291-01 Ewa Beach HI 01/06/95 Gauge, Level Recovery Venture 950300 Honolulu Resource 53-23291-01 Ewa Beach HI 03/17/95 Gauge, Level Recovery Venture 942118 Hospital Center at 29-03038-02 Orange NJ 08/31/94 Teletherapy Unit Orange 941883 Hull & Associates, 34-24957-01 Toledo OH 09/28/94 Gauge, Moisture /
Density Inc.
940823
- Illinois, NR Urbana IL 01/03/94 Pump, Primary University of Coolant i
941897 Joseph Ciccone &
37-18431-01 Bath PA 10/03/94 Gauge, Moisture /
Sons,Inc.
Density i
942028 Lahey Clinic 20-05766-02 Burlington MA 11/16/94 HDR Unit Foundation 941499 Limitorque Corp.
GENERAL Lynchburg VA 03/23/94 Switch, Drque NUREG-1272, Appendix A-1 32
m.
Nuclear Materials-NRC Licensee Events 1^
l Table A-1.7 Equipment Problems Reported by NRC Ucensees, January 1994 - September 1995 (cont.)
Item Licensee Event No.
Ucensee No.
City State Date Equipment 951149 Lippincott 29-19503-4)1 Ruverside NJ 09/14/95 Gauge, Moisture /
Engineering Delisity t
Associates 951228 Massachusetts 07-01173-03 New Castle DE 10/31/94 Camera, Materials Research Radiography 950966 Measurex Corp.
04-24564-01 Cupertino CA 03/23/95 Gauge, Thickness 950481 Measurex Corp.
GENERAL Cupertino CA 11/18/94 Gauge, Thickness 941159 Mercy Medical Center 34-00852-03 Springfield OH 07/2U94 Teletherapy Unit 942122 Michigan State 21-00021-29 East Lansing MI 12/15/94 Electron Capture University Detector 950267 MOS Inspection,Inc. 12-00622-07 Elk Grove IL 04/27/94 Source Assembly, Village Radiography i
951230 MOS Inspection, Inc. 12-00622-07 Elk Grove IL 08/26/95 Camera, -
Village Radiography 941889 MOS Inspection, Inc. 12-00622-07 Elk Grove IL 10/03/94 Camera, Village Radiography 940703
- Navy, 45-23645-01NA Washington DC 04/20/94 Camera, Department of the Radiography 941469
- Navy, 45-23645-01NA Washington DC 04/22/94 Irradiator Department of the 951136 North Star Steel 34-20328-01 Youngstown OH 08/27/95 Gauge, Level Ohio 950941 NRD, Inc.
31-28397-01G Grand Island NY 05/31/95 Static Eliminator 940619 Nuclear Fuel SNM-124 Erwin TN 07/02/94 Alarm, Criticality Services, Inc.
941711 Palisades DPR-0020 Covert MI 08/01/94 Storage Cask 941752 Palisades DPR-0020 Covert MI 08/09/94 Tank, Storage 950986 Parkview Memorial 13-01284-02 Fort Wayne IN 04/24/95 Applicator, Tandem, Hospital Plastic 950277 Pittsburgh, 37-00134-06 Pittsburgh PA 01/05/95 Irradiator University of 940442 Primex Plastics GENERAL Richmond IN 01/08/94 Static Eliminator Corp.
33 NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 i
Table A-1.7 Equipment Problems Reported by NRC Licensees, January 1994 - September 1995 (cont.)
Item Licensee Event No.
Licensee No.
City State Date Equipment 950844 Professional 37-28744-01 ChambersburgPA 06/13/95 Gauge, Moisture /
)
Inspection & Testing Density Services 950647 PSI Energy Co.
13-15544-01 Plainfield IN 07/01/94 Gauge, Moisture /
i Density l
950005 OSL Inspection, Inc. 37-28085-01 Huntingdon PA 04/20/94 Drive Cable Valley 940941 Rensselaer Poly-CX-22 Schenectady NY 01/21/94 Line, Automatic Fill J
technic Institute 941057 RIO Algom Mining SUA-1119 Moab UT 03/28/94 Pond, Evaporation Corp.
951036 RTI, Inc.
29-13613-02 Rockaway NJ 08/01/95 Irradiator l
941055 Soil & Materials 21-17158-02 Plymouth MI 04/06/94 Gauge, Moisture /
l Engineers, Inc.
Density 950608 Soil & Materials 21-17158-02 Plymouth MI 05/08/95 Gauge, Moisture /
Engineers, Inc.
Density 950757 South Jersey Process 29-20900-01 Rockaway NJ 04/05/95 Irradiator, Module Technology, Inc.
942082 South Jersey Process 29-20900-01 Rockaway NJ 12/02/94 Rack, Source Technology, Inc.
960051 Southwest Medical 35-13127-01 Oklahoma OK 08/25/95 Implantation Needle Center of Oklahoma City Needle Stylet 941912 Southwestern 42-26828-01 Houston TX 02/18/94 Camera, Laboratory, Inc.
Radiography 950008 Spec Consultants, 37-27891-01 Trafford PA 11/18/94 Camera, Inc.
Radiography 950043 Syncor International 07-30158-01MD Seaford DE 01/18/95 Hood, Exhaust Corp.
950046 Syncor International 21-19219-01MD Grand Rapids MI 01/19/95 Hood, Exhaust Corp.
i 950N9 Syncor International 21-17189-01MD Southfield MI 01/25/95 Hood, Exhaust Corp.
950103 Syncor International 22-19174-01MD Saint Paul MN 01/25/95 Hood, Exhaust Corp.
NUREG-1272, Appendix A-1 34
~ _ _ _ ~.
Nuclear Materials-NRC Licensee Events Table A-1.7 Equipment Problems Reported by NRC Licensees, January 1994 - September 1995 (cont.)
Item Licensee Event Ne.
Licensee No.
City State Date Equipment 950100 Syncor International 07-30158-01MD Seaford DE 02/08/95 Hood, Exhaust l
l Corp.
950262 Syncor International 45-18378-01MD Virginia VA 02/22/95 Hood, Exhaust Corp.
Beach 950190 Syncor International 06-28229-01MD Stamford CT 02/27/95 Hood, Exhaust Cog.
950321 Syncor International 21-21141-01MD Swartz Creek MI 03/19/95 Hood, Exhaust Corp.
950457 Syncor International 06-28229-01MD Stamford CT 04/10/95 Hood, Exhaust Corp.
950713 Syncor International 07-30158-01MD Seaford DE 05/26/95 Hood, Exhaust Corp.
941644 Syncor International 35-19583-01MD Tulsa OK 06/06/94 Hood, Exhaust Corp.
941096 Syncor International 24-19360-01MD Saint Louis MO 06/07/94 Hood, Exhaust Corp.
950840 Syncor International 45-18378-01MD Virginia VA 06/13/95 Hood, Exhaust Corp.
Beach 950854 Syncor International 35-23359-01MD Oklahoma OK 06/13/95 Hood, Exhaust Corp.
City 950855 Syncor International 37-18461-01MD Sharon Hill PA 06/14/95 Hood, Exhaust Corp.
950685 Syncor International 37-18461-01MD Sharon Hill PA 06/20/95 Hood, Exhaust Corp.
950904 Syncor International 37-30106-01MD Duncansville PA 06/25/95 Hood, Exhaust Corp.
941671 Syncor International 45-18378-01MD Virginia VA 07/06/94 Hood, Exhaust Corp.
Beach 950960 Syncor International 24-16617-01MD Kansas City MO 07/12/95 Hood, Exhaust Corp.
950968 Syncor International 21-17189-01MD Southfield MI 07/16/95 Hood, Exhaust Corp.
940833 Syncor International 47-25248-01 Huntington WV 07/25/94 Hood, Exhaust Corp.
35 NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 I
i
\\
Table A-1.7 Equipment Problems Reported by NRC Ucensees, l
January 1994 - September 1995 (cont.)
i Item Licensee Event No.
Licensee No.
City State Date Equipment 951011 Syncor International NR NR PA 07/28/95 Hood, Exhaust Corp.
950012 Syncor International 35-19583-01MD Tblsa OK 12/26/94 Hood, Exhaust Corp.
950914 Technical Welding 42-25214-01 Pasadena TX 11/16/94 Camera, i
Laboratory, Inc.
Radiography 950085 TEI Analytical 37-28004-01 Washington PA 10/25/94 Drive Cable Services, Inc.
Connector I
941689 Total Minerals Corp. SUA-1341 Casper WY 07/14/94 Well Head Fitting 941710 Total Minerals Corp. SUA-1341 Casper WY 08/01/94 Container, Storage 940987 U.S. Enrichment USEC-K Paducah KY 02/17/94 Cylinder, UF6 4
Product Corp.
951243 V.A. Medical Center 42-00084-06 Houston TX 04/25/95 Hood, Exhaust
)
942059 Welborn Cancer 13-01674-02 Evansville IN 11/18/94 HDR Unit Center 940784 Westinghouse SNM-1107 Pittsburgh PA 01/26/94 Line, Ammonium Electric Corp.
UO2 950444 Westinghouse SNM-1107 Pittsburgh PA 09/01/95 Fitzmill Electric Corp.
Chute, Feed Container, Polypack 950379 Westinghouse SNM-1107 Pittsburgh PA 09/08/94 Fuel Pellet Press /
Slugger Electric Corp.
Die 950378 Westinghouse SNM-1107 Pittsburgh PA 10/29/94 Housing, Elevator Electric Corp.
960080 Wisconsin, State of 48-07436-01 Madison WI 08/24/95 Scaled Source (4) 951144 Wisconsin, 48-09843-18 Madison WI 09/12/95 Irradiator i University of 950278 Wisconsin, 48-09843-18 Madison WI 11/30/94 HDR Unit University of 942037 XRI Testing NR Cincinnati OH 10/06/94 Camera, Radiography NR Indicates NOT REPORTED NUREG-1272, Appendix A-1 36
=
. = -.
Nuclear Materials-NRC Licensee Events Table A-1.8 Fuel Cycle Events Reported by NRC Ucensees, January 1994 - September 1995 Item Ucensee Event Type of Fuel No.
Ucensee No.
City State Dan Cycle Event 950079 Allied-Signal, Inc.
SUB-526 Metropolis IL 02/03/95 Other i
940778 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 02/02/94 Potential Criticality 940923 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 02/02/94 Potential Criticality 940924 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 02/02/94 Potential Criticality 940780 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 02/11/94 Potential Criticality Equipment Malfunction 940834 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 02/18/94 Potential Criticality 950333 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 03/19/95 Potential Criticality 941456 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 03/22/94 Potential Criticality 950973 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 05/11/95 Other 951314 Babcock & Wilcox Co.
SNM-1168 Lynchburg VA 06/14/95 Other 940950 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 06/28/94 Potential Criticality 941666 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 07/07/94 Other 960082 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 07/19/95 Potential Criticality 950982 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 07/20/95 Equipment Failure 941681 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 07/26/94 Potential Criticality 951139 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 08/29/95 Potential Criticality 941963 Babcock & Wilcox Co.
SNM-1168 Lynchburg VA 09/08/94 ' Potential Criticality l
l 942045 Babcock & Wilcox Co.
SNM-42 Lynchburg VA 11/17/94 Equipment Malfunction 941672 Combustion Engineering, SNM-33 Hematite MO 06/29/94 Potential Criticality Inc.
942015 Combustion Engineering, SNM-33 Hematite MO 11/09/94 Potential Criticality Inc.
941519 General Electric Co.
SNM-1097 Wilmington NC 01/24/94 Potential Criticality 950068 General Electric Co.
SNM-1097 Wilmington NC 01/30/95 Potential Criticality 950726 Gene al Electric Co.
SNM-1097 Wilmington NC 04/08/95 Potential Criticality 6
i 941576 General Electric Co.
SNM-1097 Wilmington NC 06/13/94 Potential Criticality l
951012 General Electric Co.
SNM-1097 Wilmington NC 07/30/95 Potential Criticality l
37 NUREG-1272, Appendix A-1
AEOD Annual Report,1994-FY 95 Table A-lJ Fuel Cycle Events Reported by NRC Ucensees, January 1994 - September 1995 (cont.)
{
Item Ucensee Event Type of Fuel No.
Ucensee No.
City State Date Cycle Event 951038 General Electric Co.
SNM-1097 Wilmington NC 08/09/95 Other 951063 General Electric Co.
SNM-1097 Wilmington NC 08/20/95 Other 951097 General Electric Co.
SNM-1097 Wilmington NC 08/20/95 Potential Criticality 941770 General Electric Co.
SNM-1097 Wilmington NC 08/25/94 Other 941508 General Electric Co.
SNM-1097.Wilmington NC 09/02/94 Potential Criticality 941518 Nuclear Fuel Services, Inc. SNM-124 Erwin TN 01/20/94 Other l
940619 Nuclear Fuel Services, Inc. SNM-124 Envin TN 07/02/94 Equipment Malfunction 941881 Nuclear Fuel Services, Inc. SNM-124 Erwin TN 09/27/94 Other 941517 Siemens Nuclear Power SNM-1227 Richland WA 03/07/94 Potential Criticality Corp.
941506 Siemens Nuclear Power SNM-1227 Richland WA 03/22/94 Other Corp.
941849 Siemens Nuclear Power SNM-1227 Richland WA 09/18/94 Equipment Malfunction l
Corp.
951153 - Siemens Power Corp.
SNM-1227 Richland WA 09/19/95 Other 951071 U.S. Enrichment Corp.
USEC-K Paducah KY 05/04/95 Other 951001 U.S. Enrichment Corp.
USEC-O Piketon OH 05/24/95 Other 951037 U.S. Enrichment Corp.
USEC-O Piketon OH 08/06/95 Other 950035 U.S. Enrichment Corp.
USEC-O Piketon OH 12/29/94 Other 950379 Westinghouse Electric SNM-1107 Pittsburgh PA 09/08/94 Equipment Failure Corp.
950378 Westinghouse Electric SNM-1107 Pittsburgh PA 10/29/94 Equipment Failure Corp.
950376 Westinghouse Electric SNM-1107 Pittsburgh PA 11/21/94 Potential Criticality Corp.
4 950279 Westinghouse Electric SNM-1107 Pittsburgh PA 12/22/94 Potential Criticality Corp.
NUREG-1272, Appendix A-1 38 i
Nuclear Materials-NRC Licensee Events
(
l Table A-1.9 Research and 'kaining Reactor Events Reported by NRC Ucensees, 1
January 1994 - September 1995 Item Ucensee Event No.
Ucensee No.
City State Date Type of Reactor Event 950288 Florida, R-56 Gainesville FL 03/09/95 Equipment Problem l
University of l
950843 Florida, R-56 Gainesville FL 06/12/95 Equipment Problem University of 941056 Georgia Institute R-97 Atlanta GA 02/15/94 Personnel Error of Technology 940823 Illinois, NR Urbana IL 01/03/94 Equipment Problem University of 950995 Massachusetts R-37 Cambridge MA 07/19/95 Personnel Error Institute of Technology 941667 Missouri, R-103 Columbia MO 04/26/94 Equipment Problem l
University of, at Columbia 960083 Pennsylvania R-2 University Park PA 07/05/94 Inadequate Documentation State University Personnel Error 940941 Rensselaer CX-22 Schenectady NY 01/21/94 Equipment Problem Polytechnic Institute 950712 Saxton Nuclear DPR-4 Saxton PA 05/25/95 Inaccurate Documentation Experimental Personnel Error Facility NR Indicates NOT REPORTED l
l l
39 NUREG-1272 Appendix A-1
Appendix A-2 Agreement State Licensee Events i
1
\\
l
I i
l Table A-2.1 Medical Misadministrations Reported by Agreement States, January 1994 - September 1995 Item License Event Type of No.
Licensee No.
City State Date Misadministration l
941371 Cedars Medical L 2420-01 Miami FL 05/08/94 Brachytherapy i
Center 951082 H. Ixe Moffitt L 1739-1 Tampa FL 02/16/95 Brachytherapy Cancer & Research Center 941479 Harrisburg Cancer Ib01632-01 Harrisburg IL 03/28/94 Teletherapy Center 951266 Healthsouth L 2301-2 Coral Gables FL 09/22/95 Gamma Knife Doctor's Hospital, Inc.
941480 Johnson City TN-R-90005-K9 Johnson City TN 03/30/94 Brachytherapy Medical Center 951160 Louisville, KY-20-2055-31 Louisville KY 05/18/95 Teletherapy University of 940066 Medical Center at KY-20-2124-25 Bowling Green KY G4/29/94 Brachytherapy Bowling Green 951008 Medical Center, GA-0239-1 NR GA 05/05/95 Teletherapy Inc.
950290 Mobile Technology, CA-5919-70 Los Angeles CA 03/14/95 Brachytherapy Inc.
950871 Mother Frances NR Tjler TX 05/02/95 Sodium Iodide Hospital 950919 NR NR NR NY 05/17/94 Brachytherapy 950537 NR NR NR NY 07/25/94 Brachytherapy 950538 NR NR NR NY 07/27/94 Sodium Iodide 950534 NR NR NR NY 09/22/94 Teletherapy 950539 NR NR NR NY 10/20/94 Brachytherapy 950535 NR NR NR NY 11/09/94 Brachytherapy l
940980 Orlando Cancer L 2137-01 Orlando FL 04/01/94 Brachytherapy l
Center Radiation l
Oncology I
941957 Saint Joseph's CA-0379-30 Orange CA 10/17/94 Brachytherapy r
l Hospital 43 NUREG-1272, Appendix A-2
AEOD Annual Report,1994-FY 95 Table A-2.1 Medical Misadministrations Reported by Agreement States, January 1994 - September 1995 (cont.)
)
Item Ucense Event Type of No.
Licensee No.
City State Date Misadministration 950065 Southwest Texas NR San Antonio TX 07/28/94 Brachytherapy Methodist Hospital 941095 Utah, University UT-18000-01 Salt Lake City UT 03/28/94 Brachytherapy of NR Indicates NOT REPORTED 1
NUREG-1272, Appendix A-2 44
Nuclear Materials-Agreement State Ucensee Events Table A-2.2 Overexposures Reported by Agreement States, January 1994 - September 1995 Item License Event Type of No.
Dose No.
IJcensee No.
City State Date Exposure Exposed (Rem) 941440 BIX'Ibsting NR Baytown TX 03/23/94 Whole Body 1
21.36 bboratories 941441 Blazer Inspections NR Texas City TX 02/23/94 Extremity 1
1500.00 950268 Cogema Mining, NR Bruni TX 09/14/94 Internal 1
NR Inc.
950292 Coors Brewery CO-476-01 Golden CO 03/08/95 Whole Body 1
14.51 950915 Corpus Christi NR Corpus Christi TX 11/0164 Whole Body 1
7.86 i
Inspection &
Engineering 950200 Dakota Clinic, ND-33-02604 Fargo ND 12/31/94 Whole Body 1
5.47 12d.
-01 950928 Goolsby Testing NR Humble TX 12/01/94 Whole Body 2
5.52 Laboratories 5.06 950451 Gwinnett Medical GA-0677-01 Lawrenceville GA 04/06/95 Extremity 1
1256.00 Center 941949 ICN Biomedicals, CA-1828 Irvine CA 10/17/94 Extremity 1
51.37 Inc.
960008 Isotope Products CA-1509-70 Burbank CA 07/21/95 Organ 1
70.00 Laboratories j
9415 % Keith & Schnars, 1 0 -1385-01 Pompano FL 04/27/94 Whole Body 1
17.60 RA., Geotechnical Beach Division j
951316 Longview OR-0621-01 Portland OR 08/07/95 Extremity 1
71.00 i
Inspection Co., Inc.
j 950949 Iongview NR Houston TX 02/24/95 Whole Body 1
5.41 Inspection Co., Inc.
951126 Longview-FL-2239-1 Orlando FL 06/28/95 Whole Body 1
8.80 Advanced
'Ibchnology, Inc.
i 45 NUREG-1272, Appendix A-2
AEOD Annual Repoa 1994-FY 95 Table A-2.2 Overexposures Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Type of No.
Dose No.
IJcensee No.
City State Date Exposure Exposed (Rem) 950033 Omnitron LA-6430-Il)1 Lake Charles LA 12/20/94 Whole Body 24 4.61 International, Inc.
0.75 0.56 0.56 0.52 0.52 0.52 0.52 0.52 0.52 0.52 0.52 0.52 0.52 0.42 0.42 0.37 032 j
0.26 O.24 0.22 0.22 0.12 0.12 942079 Professional FL-211M)1 Plantation FL 08/29/94 Whole Body 1
15.89 Engineering &
Inspection Co., Inc.
950792 SCITEC Corp.
WN-10282-1 Kennewick WA 03/01/94 Extremity 4
102.84 94.40 85.72 68.56 950997 Valley X-Ray CA-2285-30 NR CA 07/13/95 Whole Body 1
10.0 Services 950590 Zycon Corp.
CA-4362 Santa Clara CA 10/04/94 Extremity 1
10535 NR Indicates NOT REPORTED NUREG-1272, Appendix A-2 46
Nuclear Materials-Agreement State Licensee Events A-2.3 IAss of Control of Material Events Reported by Agreement States, January 1994 - September 1995 Item Ucense Event Radio-No.
Licensee No.
City State Date Nuclide 951103 A.S. Waste Handler NON-LICENSEE NR FL 04/03/95 I-131 951102 A.S. Waste Handler NON-LICENSEE NR FL 04/10/95 I-131 950126 Abbott Laboratories GENERAL Abbott Park IL 04/27/94 Cs-137 941958 Ace Supply & Iron Co.
NON-LICENSEE Joliet TL 10/19/94 Co-60 941903 AG Processing,Inc.
GENERAL Denison TX 02/28/94 H-3 950593 Ahsan & Associates CA-5476 San CA 07/19/94 NR Bernardino 950101 Alabama Department NR Albertville AL 02/05/95 Am-Be of Transportation Cs-137 951077 All State Engineering L 1113-1 Hialeah FL 02/23/95 Am-Be
& Testing Consultants Cs-137 951118 All-Metro Collision GENERAL Pompano FL 05/23/95 Po-210 Beach 950195 Allstate Engineers, L 1113-01 Miami FL 02/22/95 Am-Be Inc.
Cs-137 941736 American Steel GENERAL Chicago IL 08/03/94 U-Oth Foundries U-Oth 951105 American Testing &
L 1891-1 Miami FL 03/18/95 Am-Be Engineering Corp.
Cs-137 951275 Ameriscan, Ltd L 2405-1 Fort FL 09/01/95 Cs-137 Lauderdale 951108 Ameriscan-Titusville, L 2425-1
'Iitusville FL 03/16/95 Cs-137 Inc.
950520 Applied Radiological GA-0899-01 Kennesaw GA 12/13/94 Am-241 Control, Inc.
Sr-90 950154 Applied Soil 86-01473-01 Naperville IL 09/26/94 Am-Be Mechanics, Inc.
Cs-137 950907 Arco Exploration GENERAL Plano TX 11/07/94 Ni-63
& Production Technology, Co.
950325 Arkansas Testing ARK-718 Pine Bluff AR 08/16/94 Am-Be Laboratories Cs-137 47 NUREG-1272. Appendix A-2
AEOD Annual Report,1994-FY 95 A-2.3 Loss of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 941940 AT Laboratories, Inc.
NR Arlington TX 05/05/94 Am-Be Cs-137 951339 AT&T GENERAL Richmond VA 06/01/95 Ni-63 950518 Atlanta, City of GA-0486-05 Atlanta GA 03/28/94 Ni-63 941860 Atlantic Automotive Flc0566-GL Miami FL 08/26/94 Po-210 Paints j
940744 Austel Lemont NON-LICENSEE Lemont IL 03/12/94 Cs-137 i
950911 Austin Bridge NR Dallas TX 01/09/95 Am-Be
& Road Cs-137 950791 Avart, Inc.
FL-2262-1 Miami FL 06/05/95 Am-Be Cs-137 i
941528 Baptist Memorial R-79032-F97 Memphis TN 04/08/94 NR Hospital Medical Center 950338 Baptist Memorial NR San Antonio TX 09/20/94 NR Hospital System 950357 Baptist Memorial NR San Antonio TX 10/14/94 NR Hospital System 951041 Basin Resources GENERAL Westin CO 10/01/94 Cs-137 941465 Bhate Engineering AIA55 Birmingham AL 02/21/94 Am-Be Corp.
Cs-137 950158 Blackford Corp.
NR Chicago IL 10/20/94 Co-60 941910 Browning Ferris NON-LICENSEE Houston TX 03/16/94 NR Industries 941591 Browning Ferris NON-LICENSEE Memphis TN 03/01/94 ND Industries Landfill 950356 Browning Ferris NON-LICENSEE San Antonio TX 10/14/94 NR Industries Waste Systems 950532 Buffalo General Hospital NY-2914 Buffalo NY 01/12/94 P-32 941481 Buller Group CA-2436-70 Oakley CA 02/24/94 Am-Be Cs-137 NUREG-1272, Appendix A-2 48
Nuclear Materials-Agreement State Licensee Events A-2.3 Loss of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 950585 California Department NR Corona CA 01/17/94 NR of Transportation 950574 California, University CA-1338 hvine CA 04/25/94 H-3 of, at Irvine 950589 California, University CA-1725-90 Sa.t Francisco CA 01/31/94 I-125 of, at San Francisco 951078 Cardiovascular Medical FL-2547-1 biiami FL 02/22/95 Ba-133 Associates Cs-137 950571 Cedars Sinai Medical CA-0404 Los Angeles CA 06/03/94 I-125 Center 950344 Central Freight NR Port Neches TX 04/20/94 Ir-192 951023 CentralIron NON-LICENSEE Hamilton IL 06/28/95 NR 950536 Champlain Valley NY-1085 Plattsburgh NY 12/13/94 Cs-137 Physician's Hospital 950575 Chapman General CA-1946 Orange CA 04/18/94 I-125 Hospital 950183 Chem Syn NR Lenexa KS 02/16/95 C-14 950884 Children's Hospital CA-0282-70 Los Angeles CA 01/26/95 P-32 oflos Angeles S-35 950578 Children's Hospital CA-0282-70 Los Angeles CA 03/18/94 I-125 ofIos Angeles 950020 Commercial Metals Co.
NON-LICENSEE ElPaso TX 06/10/94 ND 950898 Construction Material CA-2952-70 Concord CA 03/09/95 Am-Be Testing Cs-137 941766 Cooper City High NON-LICENSEE Cooper City FL 05/26/94 Co-60 School Po-210 Sr-90 TI-204 951016 Corning Co.
GIA65-0542-Wilmington NC 08/0U95 Po-210 950895 Costco Store NR Santa Rosa CA 03/31/95 H-3 951022 D&K International IL-99-92228-37 Elkgrove IL 06/20/95 Kr-85 Village t
950598 Dames & Moore, Inc.
CA-4393 I.os Angeles CA 10/24/94 NR 49 NUREG-1272, Appendix A-2
~
AEOD Annual Report,1994-FY 95 A-2.3 I4ss of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
j Item License Event Radio.
No.
Licensee No.
City State Date Nuclide i
941461 David J. Joseph Scrap NON-LICENSEE Knoxville TN 02/01/94 NR Recycling Co.
941718 David J. Joseph Scrap NON-LICENSEE West Palm BeachFL 07/18/94 Am-Be Recycling Co.
950588 Dehbozorgi, Sabu NON-LICENSEE San Diego CA 01/31/94 Am-Be Cs-137 950605 Dellavalle Laboratory, CA-3194 NR CA 11/21/94 NR Inc.
i 941541 Delray Community FL-1535-1 Delray Beach FL 03/19/94 ND Hospital 950522 Drain Field Services, FL-2351-1 Naples FL 04/30/95 Am-Be Inc.
Cs-137 941841 E-Systems, Inc.,
GID93 Saint FL 08/04/94 Po-210 CM Division Petersburg i
950193 Eagle-Picher Industries NR Lenexa KS 02/14/95 C-14 941295 Earth Systems CA-0368 Van Nuys CA 05/13/94 Am-Be Consultants Cs-137 941691 Eaton Iron & Metal Co.
NON-LICENSEE Glasgow KY 07/12/94 NR 950572 El Centro Community CA-0485 El Centro CA 06/0U94 Cs-137 Hospital 942072 Etc Engineering,Inc.
TN-R-79243 Memphis TN 11/25/94 Am-Be Cs-137 940977 Everglades Recycling NON-LICENSEE Opalocka FL 01/27/94 Cs-137 Corp.
940093 Florida Community NR Jacksonville FL 01/05/94 Co-60 College Po-210 TI-204 941058 Florida Steel Co.
NON-LICENSEE Jackson TN 04/04/94 Cs-137 Cs-137 941637 G.E Plastics GENERAL Dallas TX 02/16/94 Am-241 950599 GemologicalInstitute CA-5383 Santa Monica CA 10/31/94 NR of America 951217 Genelabs Technologies CA-4512-41 Redwood City CA 08/31/95 S-35 NUREG-1272, Appendix A-2 50
Nuclear Materials-Agreement State Licensee Events i
l A-2.3 less of Control of Material Events Reported by Agreement States, l
January 1994 - September 1995 (cont.)
Item License Event Radio-Nr.
Licensee No.
City State Date Nuclide 941907 Geo-Test, Inc.
NR Houston TX 03/23/94 Am-Be Cs-137 950519 Georgia Power Co.
GA-0M0-01 NR GA 10/31/94 Cs-137 950576 Geosoils CA-4741 Van Nuys CA 04/11/94 NR 941083 Global X-Ray LA-0577-L01 Morgan City LA 05/01/94 Ir-192
& Testing Corp.
950556 Golden Nugget GENERAL Las Vegas NV 12/31/94 Po-210 941869 Good Samaritan FL-0493-1 NR FL 01/14/94 ND Hospital 950107 Greenview School Unit NR Greenview IL 01/04/94 H-3 950342 Guardian NDT NR Corpus Christi TX 07/15/94 Ir-192 Services, Inc.
950361 Guardian NDT NR Corpus Christi TX 11/04/94 Ir-192 Services, Inc.
941906 H&H X-Ray Services, NR Bryan TX 04/07/94 Ir-192 Inc.
941214 H&H X-Ray Services, KY-20-1342-05 London KY 05/09/94 Ir-192 Inc.
951113 Harbor Branch FL-1034-1 Fort Pierce FL 05/02/95 Ni-63 Oceanographic Institution, Inc.
951019 Harry W. Kuhn, Inc.
IL-01870-01 West Chicago IL 05/04/95 Am-Be Cs-137 950570 Harza Engineering CA-0295 Oakland CA 06/30/94 NR 941840 HCA Central Florida FIA854-1 Sanford FL 08/04/94 Tc-99m Regional Hospital 942084 Highlands Regional FIA985-1 Sebring FL 09/07/94 I-125 Medical Center 950228 Hilltop Geotechnical NR Highland CA 01/18/95 Am-Be Cs-137 950834 Hollywood Auto Supply GENERAL Albany OR 05/11/95 Po-210 951297 Hollywood Auto Supply GENERAL Albany OR 05/11/95 Po-210 51 NUREG-1272, Appendix A-2
AEOD Annual Report,1994-FY 95
)
i A-2.3 less of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Radio-i No.
IJcensee No.
City State Date Nuclide 941764 Holy Cross Hospital FL-0308-3 Fort Lauderdale FL 05/27/94 I-13 1 950173 Honeywell, Inc.
99-92109-31 Freeport IL 12/21/94 Po-210 951116 Ibrahim, George W.,
L 1862-1 Lake Placid FL 06/08/95 Cs-137 M.D.
940975 ICF Kaiser Engineers, L 2306-1 Miami FL 01/24/94 Am-Be Inc.
Cs-137 i
950721 Illinois, University of II 01271-01 Urbana IL 02/17/95 U-Nat 951017 Illinois, University of, 11- 01883-01 Chicago IL 04/06/95 NR at Chicago 941545 IMC Fertilizer, Inc.,
L 1336-4 Mulberry FL 03/09/94 ND Uranium Operations 950226 Independent 'Ibsting NR NR NY 10/24/94 NR Laboratones, Inc.
i 941482 Industrial Rt.diography AI 754 Mobile AL 02/17/94 Ir-192 NDT Co., Inc.
941783 Iowa, University of IA-037-1-52-AAB Iowa City IA 08/23/94 Au-198 941927 Isolite Corp.
GENERAL Dallas TX 04/14/94 H-3 942081 J&R Roofm' g NON-UCENSEE Jessup MD 09/02/94 Am-Be 940017 Jefferson Smurfit fir 0577-1 Femandina FL 02/23/94 Cs-137 Corp) Container Beach Corp of America 941868 Jupiter Hospital L 1330-1 Jupiter FL 02/15/94
'Ib-99m 941117 Kajima Engineering &
AZ-07-359 Chandler AZ 05/03/94 Am-Be
{
Constuction Cs-137 950102 Kooney X-Ray, Inc.
NR Barker TX 02/08/95
- Ir-192 960075 Korean Air'ines NON-UCENSEE Los Angeles CA 05/03/95 Ir-192
-950587 Lakewood Sheriff NON-UCENSEE Lakewood CA 01/18/94 I-131 Station 941742 Lantana Transfer NON-UCENSEE West FL 06/10/94 I-131 Station Palm Beach 941875 Law Engincering SC-271 Charleston SC 07/16/94 Am-Be Cs-137 NUREG-1272, Appendix A-2 52
Nuclear Materials-Agreement State Licensee Events A-2.3 Iess of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Radio-No.
Ucensee No.
City State Date Nuclide 941980 Law /Crandall, Inc.
A7.A)7-326 Phoenix AZ 10/24/94 Am-Be Cs-137 951193 Leighton & Associates CA-3109-30 Irvine CA 06/15/95 Am-Be Cs-137 951225 Litton Industries GENERAL Grants Pass OR 08/10/95 Po-210 950591 Long Beach Memorial CA-0165-70 Long Beach CA 09/30/94 I-125 Medical Center 950601 Los Angeles County CA-0508 Downey CA 07/15/94 I-131 Rancho Los Amigos 950221 Imuisiana State LA-0001-L01 New Orleans LA 05/16/94 I-125 University 950013 McAllen Medical NR McAllen TX 07/23/94 I-131 Center 950384 McDowell Recycling NON-LICENSEE Marion NC 03/28/95 ND 950130 Medi+ Physics IL-01109-01 Arlington IL 05/18/94 I-125 Pharmacy Services, Inc.
Heights 942149 Medi+ Physics NR Dallas TX 07/12/94 I-125 Pharmacy Services, Inc.
950133 Medi+ Physics IIA)1109-01 Arlington IL 07/12/94 I-125 Pharmacy Services, Inc.
Heights 950159 Medi+ Physics IL-01109-01 Arlington IL 10/25/94 I-125 Pharmacy Services, Inc.
Heights 950170 Medi+ Physics IIA)1109-01 Arlington IL 12/14/94 I-125 Pharmacy Services, Inc.
Heights 951191 Medi-Nuclear CA-2816-70 Baldwin Park CA 07/08/95 Xe-133 951018 Memorial Hospital of IL-01054-01 Carbondale IL 05/02/95 NR Carbondale 951088 Metro-Dade Solid NON-LICENSEE Miami Springs FL 01/27/95 I-131 Waste Management l
951087 Metro-Dade Solid NON-LICENSEE Miami Springs FL 01/31/95 I-131 l
Waste Management 951086 Metro-Dade Solid NON-LICENSEE Miami Springs FL 02/02/95 I-131 Waste Management l
53 NUREG-1272, Appendix A-2
l AEOD Annual Report,1994-FY 95 l
i i
A-2.3 IAss of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 950604 MGEN, Inc.
CA-2952 Thousand Oaks CA 12/07/94 H-3 951115 Miami Heart Research FIA195-3 Miami Beach FL 06/20/95 C-14 l
Institute, Inc.
H-3 P-32 951195 Midway Hospital NR Los Angeles CA 03/29/95 NR Medical Center 950297 Mindis Metals NON-LICENSEE Birmingham AL 02/02/94 Th-232 Recycling 951274 Mississippi Steel NON-LICENSEE Jackson MS 09/01/95 Co-60 950602 Montana Testing CA-3714 Anaheim CA 12/16/94 Am-Be
& GE Cs-137 950609 Moses Cone Hospital NR Greensboro NC 05/06/95 I-131 1
950527 Mount Sinai Medical NR Huntington NY 05/13/94 I-125 Center 950553 Nashua Corp.
GENERAL Omaha NE 05/06/94 Po-210 941749 New Mexico Tech NR Socorro NM 08/03/94 ND 950487 New Mexico, NM-BM-233 Albuquerque NM 02/22/95 C-14 University of H-3 950483 New Mexico, NM-BM-233 Albuquerque NM 03/05/95 C-14 University of H-3 S-35 950053 New Mexico, NM-BM-233 Albuquerque NM 08/17/94 H-3 University of 950051 New Mexico, NM-BM-233 Albuqueique NM 09/08/94 Ni-63 University of 941862 Newnan Hospital GA-0135-2 NR GA 05/18/94 Cs-137 942124 North Star Steel NON-LICENSEE Beaumont TX 05/29/94 NR 941148 NR NON-LICENSEE Tampa FL 01/07/94 Co-60 951227 NR NR NR OR 06/30/95 Sr-89 950535 NR NR NR NY 11/09/94 Ir-192 942128 Nucor Steel Corp.
NON-LICENSEE Jewett TX 06/06/94 Am-241 NUREG-1272, Appendix A-2 54
Nuclear Materials-Agreement State licensee Events
(
A-2.3 Iess of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 942147 Nucor Steel Corp.
NON-LICENSEE Jewitt TX 07/06/94 Cs-137 941782 Oregon Health NR Portland OR 03/15/94 NR Division 9504 %
Oregon, University of OR-90220-01 NR OR 01/03/94 H-3 942153 Otis-Oakley Iron &
NON-LICENSEE Chicago IL 12/29/94 Cs-137 Supply Co.
950255 Palm Beach County NON-LICENSEE Palm Beach FL 12/03/94 I-125 Landfill i
951085 Palm Beach County NON-LICENSEE Delray Beach FL 02/11/95 I-131 Solid Waste Disposal 941781 Palm Springs General FL-0951-01 Hialeah FL 05/05/94 NR Hospital j
941788 Parrish Medical Center FL-0395-01 Titusville FL 05/04/94 I-131 951286 Polk County Landfill NON-LICENSEE Polk County FL 08/18/95
'Ib-99m 951282 Polk County Landfill NON-LICENSEE Polk County FL 08/29/95 I-131 941882 Precision Plastics, Inc.
IL-99-92076-48 Wheeling IL 09/26/94 Kr-85 950204 Product Development & NR Scotia NY 05/18/94 NR Technical Services, Inc.
950579 Professional Services CA-5650 los Angeles CA 03/14/94 NR Industries, Inc.
941459 R.Z. Agra OR-0370-1 Portland OR 03/14/94 Am-Be Cs-137 950030 Ranger Steel NON-LICENSEE Houston TX 01/03/95 Co-60 950202 Red RoofInn GENERAL Syracuse NY 03/08/94 H-3 950525 Red RoofInn GENERAL Utica NY 03/12/94 H-3 950275 RoofIxak Detection FL-1434-1 West FL 03/11/95 Am-Be Palm Beach 941780 Saint Mary's Hospital FIA)339-02 West FL 05/05/94 I-131 Palm Beach l
950203 Salwen NR NR NY 04/12/94 Sr-90 55 NUREG-1272, Appendix A-2
AEOD Annual Report,1994-FY 95 A-2.3 Loss of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
i Item License Event Radio-No.
Ucensee No.
City State Date Nuclide 941634 San Antonio Regional NR San Antonio TX 01/12/94 I-125 Hospital 950514 Savannah Steel NON-LICENSEE Savannah GA 01/13/94 ND
& Metal Co.
950366 Schlumberger NR Sugar Land TX 11/09/94 Am-Be Technology Corp.
Cs-137 1
950918 Schh:mberger NR Sugar Land TX 01/05/95 Am-Be Technology Corp.
Cs-137 950429 Science Application R-01069-F98 Oak Ridge TN 08/19/94 NR International Corp.
950565 Scripps Research CA-2670 La Jola CA 07/14/94 P-32 Institute 942078 Seminole Kraft Paper FL-1236-02 Jacksonville FL 08/21/94 Cs-137 Corp.
941483 SHB Agra,Inc.
AZ-07-095 NR AZ 01/31/94 Am-Be Cs-137 3
950052 SHB-Agra Earth NM-DM-201 Farmington NM 10/03/94 Am-Be
& Environment Cs-137 950910 Siemens Medical NR Grand Prairie TX 12/17/94 Am-241 Systems 950513 Sonic Surveys,Inc.
TX-LO2622 Mont Belieu TX 06/07/94 Co-60
^
950389 Speedie & Assoicates NR Phoenix AZ 03/30/95 Am-Be Cs-137 951194 Stanford University CA-0676-43 Palo Alto CA 05/01/95 P-32 950552 Stockyard Movie GENERAL Omaha NE 09/09/94 H-3
& theater 950355 Structural Metals, Inc.
NON-LICENSEE Sequin TX 11/21/94 NR 951040 STS Aquisition Co.
IIe01562-01 Deerfield IL 08/07/95 Am-Be Cs-137 950146 Summit Engineering NR Reno NV 02/09/95 Am-Be Cs-137 941737 Sun ChevroleUGeo GENERAL Miami FL 04/01/94 Po-210 NUREG-1272, Appendix A-2 56
l i
Nuclear Materials-l Agreement State Licensee Events l
l A-2.3 Loss of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 941476 Syncor International NR Bronx NY 03/21/94 I-131 Corp.
950208 Syncor International NR Bronx NY 08/04/94 NR Corp.
950442 Syncor International TN-R-19149-A98 Nashville TN 09/19/94 I-131 Corp.
941550 Tampa Bay Metals NON-LICENSEE Tampa FL 03/01/94 ND 950406 Tennessee, University of TN-R-47005-197 Knoxville TN 12/16/94 P-32 941618 Terra-Mar, Inc.
NR Fort Worth TX 01/01/94 Am-Be Cs-D7 950144 Testing Service Corp.
IL-01178-01 Carol Stream IL 08/11/94 Am-Be Cs-B7 942129 Texas Instruments, Inc.
GENERAL Dallas TX 05/20/94 Pm-147
'I1-204 941930 Texas, University of, NR Galveston TX 03/29/94 NR Medical Branch 950938 Texoma Medical Center NR Denison TX 11/08/94 Au-198 950612 Transportation, Arizona AZ-07-031 Phoenix AZ 03/20/95 Am-Be Department of Cs-137 i
950530 Troxler Electronics MD-27-040-01 NR MD 05/19/95 Cs-137 Laboratories, Inc.
950367 Tucker Wireline NR Victoria TX 10/28/94 Cs-137 Services, Inc.
941442 Tucker Wireline NR Corpus TX 04/19/94 Am-Be Services, Inc.
Christi 941761 U.S. Pipe & Foundry NON-LICENSEE Union City CA 08/19/94 Cs-137 Co.
950517 United Testing Group GENERAL Atlanta GA 05/22/94 Fe-55 941873 University Hospital FL-2075-1 Tamarac FL 04/26/94 Tc-99m 950548 Utah Valley Regional UT-25001-24 Salt Lake City UT 06/06/94 I-131 l
Medical Center 950580 Wallace Kuhl &
CA-4385 W. Sacramento CA 03/02/94 NR Assocates l
57 NUREG-1272, Appendix A-2
AEOD Annual Report,1994-FY 95
)
A-2.3 Loss of Control of Material Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item License Event Radio-No.
Licensee No.
City State Date Nuclide 941536 Walt Disney World FL-1273-1 Lake Buena FL 03/31/94 H-3 Corp., Industrial Vista Hygiene 941891 Wang Engineering, IL-01575-01 West Chicago IL 09/30/94 Am-Be Inc.
Cs-137 941738 West Boca Medical FL-1755-1 Boca Raton FL 06/17/94 I-131 Center 951084 West Palm Beach NON-LICENSEE West Palm FL 02/14/95 I-131 County Solid Waste Beach Authority 951083 Wheelabrator NON-LICENSEE Broward FL 02/14/95 I-131 Incinerator County 941475 X.W. Cole NR Bangor ME 03/03/94 Am-Be Cs-137 NR Indicates NOT REPORTED ND Indicates NOT DETERMINED
]
4 NUREG-1272, Appendix A-2 58
Nuclear Materials-Agreement State Licensee Events i
Table A-2.4 Leaking Sources Reported by Agreement States, January 1994 - September 1995 Item License Event Radio-No.
Licensee No.
City State Date Nuclide 1
951308 Acuson Corp.
GENERAL Mountain View CA 09/26/94 Pm-147 950725 Amersham Corp.
12-12836-011L Arlington IL 01/10/95 Cs-137 Heights
)
950113 Amersham Corp.
12-12836-01IL Arlington IL 03/03/94 Po-210 Heights 950114 Amersham Corp.
12-12836-011L Arlington IL 03/03/94 Pm-147 Heights 950127 Amersham Corp.
12-12836-011L Arlington IL 04/27/94 Fe-55 Heights 951025 Amersham Corp.
12-12836-01IL Arlington IL 05/04/95 NR Heights 951024 Amersham Corp.
12-12836-01IL Arlington IL 05/17/95 NR i
Heights 950546 Boeing Co.
WN-10005-1 Seattle WA 02/22/94 Cs-137 950893 California, University CA-1337-44 Santa Cruz CA 01/30/95 Cs-137 of, at Santa Cruz 941874 Chemical Waste LA-4187-L01 Sulphur LA 06/06/94 Ni-63 Management Inc.
941801 Chemical Waste LA-4187-L01 Sulphur LA 04/15/94 Ni-63 Management, Inc.
950531 Cold Spring Harbor NY-574 Cold Spring NY 05/17/94 Cf-252 Laboratory Harbor 950943 Computalog NR Fort Worth TX 02/0U95 Am-Be 950894 Dameron Hospital CA-1812-39 Stockton CA 01/26/95 Sr-90 Associates 942091 Florida State University FI,-0032-10 Tallahassee FL 10/11/94 Ru-106 950896 Generao Nucleonics, CA-1288-70 Pomona CA 03/07/95 Sr-90 Inc.
950515 Georgia Institute of GA-0147-1 Atlanta GA 01/18/94 Ni-63 Technology i
950923 Houston Northwest NR Houston TX 01/18/95 Sr-90 i
Medical Center i
59 NUREG-1272, Appendix A-2
AEOD Annual Report,1994-FY 95 Table A-2.4 leaking Sources Reported by Agreement States, i
January 1994 - September 1995 (cont.)
i Item Ucense Event Radio-No.
Licensee No.
City State Date Nuclide 950573 J.L Shepherd &
CA-1777 San Fernando CA 05/02/94 Cs-137 Associates 950597 J.L Shepherd &
CA-1777 San Francisco CA 1U21/94 NR Associates j
950720 Kay-Ray /Sensall, Inc.
IL-01010-03 Mount IL 04/11/95 Cs-137 Prospect
)
950041
Oregon, University of OR-90220-01 NR OR 01/03/94 H-3 951284 Orlando Laboratories, FIA492-1 Orlando FL 07/31/95 Ni-63 Inc.
950023 Team Consultants, Inc.
NR Dallas TX 08/06/94 Cs-137 941938 TN Technologies, Inc.
NR Round Pak TX 03/21/94 Fe-55 1
Cd-109 Am-241 941939 TN Technologies, Inc.
NR Round Rock TX 03/22/94 Cs-137 950132 Trade Waste IIA 1358-01 Sauget IL 06/07/94 Ni-63 Incineration 941478 Troxler Electronics NC-032-0182-1 Research NC 04/05/94 Cs-137 Laboratories, Inc.
NR Indicates NOT REPORTED i
NUREG-1272, Appendix A-2 60
Nuclear Materials-Agreement State Licensee Events Table A-2.5 Material Release Events Reported by Agreement States, January 1994 - September 1995 Item Licensee Event Type of Radio-No.
Licensee No.
City State Date Release Nuclide 950521 Amersham Corp.
NR Miami FL 04/27/95 Surface Tc-99m 950893 California, University CA-1337-44 Santa Cruz CA 01/30/95 Surface Cs-137 of,at Santa Cruz 941058 Florida Steel Co.
NON-Jackson TN 04/04/94 Surface Cs-137 i
IJCENSEE 951009 Human Genome NR Rockville MD 07/24/95 Surface P-32 Science S-35 950721 Illinois, University of IL-01271-01 Urbana IL 02/17/95 Surface U-Nat 941240 Iowa, University of IA037-1-52 Iowa City IA 08/03/94 Surface I-131
-AAB 950405 Jackson-Madison R-57002-C98 Jackson TN 12/22/94 Surface I-131 County General 950592 Kaiser Permanente CA-0372 Los Angeles CA 07/18/94 Surface I-131 942062 Kay-Ray /Sensall, Inc.
IIe01010-03 Mount IL 04/2U94 Surface Cs-137 Prospect 942089 Keys Hospital FL-1312-01 Tavernier FL 10/05/94 Surface Tc-99m Foundation, Inc.
951155 Little Bit Wireline Co.
NR Beaumont TX 08/24/95 Surface Am-241 950900 Long Beach CA-1486-70 Long Beach CA 02/24/95 NR P-32 Community Hospital 950042 Mallinckrodt Medical, MD-33-088-01 Greenbelt MD 01/10/95 Surface Tc-99m Inc.
951072 Medi+ Physics FL-2134-1 Miami FL G4/28/95 Surface Tc-99m Pharmacy Services, Inc.
941463 Methodist Hospital R-01029-G97 Oak Ridge TN 01/10/94 Surface I-131 of Oak Ridge 951267 NMA Hospitals,Inc.
FL-1295-1 Crystal River FL 09/21/95 Surface I-131 940976 Paracelsus Peninsula fir 0801-02 Ormond FL 01/24/94 Surface Xe-133 Medical Center, Inc.
Beach 941772 Ramp Industries, Inc.
NR Denver CO 08/24/94 Water Cs-137 Co-60 l
61 NUREG-1272, Appendix A-2
AEOD Annual Report,1994-FY 95 Table A-2.5 Material Release Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item Ucensee Event Type of Radio-No.
L!rensee No.
City State Date Release Nuclide 941464 Scientific Ecology R-73016 Oak Ridge TN 02/25/94 Air U-Dep Group, Inc.
942004 Syncor International NR Des Moines IA 11/08/94 Surface Tc-99m Corp.
950369 Syncor International NR Dallas TX 11/16/94 Surface Tc-99m Corp.
950163 Syncor International 86-01721-02 Chicago IL 11/25/94 Air Tc-99m Corp.
942071 Syncor International 86-01721-02 Chicago IL 11/29/94 Air Tc-99m Corp.
950365 Texas A&M University NR College TX 10/12/94 Surface Tc-99m Station 941761 U.S. Pipe & Foundry NON-Union City CA 08/19/94 Surface Cs-137 Co.
LICENSEE NR Indicates NOT REPORTED NUREG-1272, Appendix A-2 62
Nuclear Materials-Agreement State Licensee Events 1
Table A-2.6 Transportation Events Reported by Agreement States, January 1994 - September 1995 Item Licensee Event Type of No.
Licensee No.
City State Date Transportation Event 950418 A-C Co.
NR NewIberia LA 06/07/94 Radiation Levels Exceed Limits For Package 941250 Abbott Laboratories NR NR KY 04/14/94 Transport Vehicle Involved In One-Vehicle Accident 950112 Amersham Corp.
12-12836-01IL Arlington IL 02/24/94 Radiation Levels Heights Exceed Limits For Package 950521 Amersham Corp.
NR Miami FL 04/27/95 Surface Contami-nation Levels Exceed Limits For Package 950409 B&W Engineering TN-R-79222 Memphis TN 05/31/94 Failure Tb Brace
-L95 And Block Shipment Transporting Vehicle Involved In One-Vehicle Accident 941839 Basin Industrial NR Corpus TX 09/06/94 Radiation Levels X-Ray, Inc.
Chnsti Exceed Limits For Package Improperly Packaged Matenal 950866 Carlson Testing OR-0401-1 NR OR 09/15/94 Transport Vehicle i
Involved In One-Vehicle Accident and Caught Fire 950567 Cedars Sinai CA-0404 Los CA 07/13/94 Radiation Levels Medical Center Angeles Exceed Limits For Package 950555 Converse 00-11-0094-01 Las Vegas NV 12/31/94 Failure To Brace Consultants And Block Shipment Southwest, Inc.
950224 Empire Soils NY-2081-2168 NR NY 12/07/94 Transporting Vehicle Investigations,Inc.
Involved In One-l Vehicle Accident 63 NUREG-1272. Appendix A-2
]
l AEOD Annual Report,1994-FY 95 Table A-2.6 Transportation Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item Licensee Event Type of No.
IJcensee No.
City State Date Transportation Event 941466 Federal Express NON-Baton LA 03/18/94 Transporting Vehicle LICENSEE Rouge Involved In One-Vehicle Accident 942087 Federal Express NON-NR FL 09/27/94 TransportingVehicle LICENSEE Involved In One-Vehicle Accident i
941763 Florida Department FL-0109-1 Gainsville FL 06/03/94 Transporting Vehicle of Transportation Involved In One-Vehicle Accident 941785 Florida Depanment FIA)109-1 Gainesville FL 07/06/94 Hansporting Vehicle of Transportation Involved In One-Vehicle Accident i
951276 Florida Department FI 0109-1 Gainesville FL 08/31/95 Transporting Vehicle of Transportation Involved In One-Vehicle Accident 951269 Florida Department FIA)109-1 Gainesville FL 09/08/95 Transporting Vehicle of Transponation Involved In Multi-Vehicle Accident 942085 Florida Department FI 0109-1 Gainesville FL 09/19/94 Transporting Vehicle of Transportation Involved In One-Vehicle Accident 942094 Florida Department FI 0109-1 Gainsville FL 10/18/94 Transporting Vehicle of Transportation Involved In One-Vehicle Accident 950258 Florida Department FI 0109-1 Gainesville FL 11/15/94 Transporting Vehicle of Dansportation Involved In One-Vehicle Accident 950724 Frank W. Hake, NR Memphis TN 05/31/95 Radiation levels Associates Exceed Limits For Package 941906 H&H X-Ray NR Bryan TX 04/07/94 Failure To Brace Services, Inc.
And Block Shipment 941154 IEC Corp.
NR Three TX 04/30/94 Transporting Vehicle Rivers Involved In One-Vehicle Accident 950167 Indiana Habor Bett NON-Riverdale IL 12/04/94 Failure Tb Brace Railroad LICENSEE And Block Shipment NUREG-1272, Appendix A-2 64
Nuclear Materials-Agreement State Licensee Events Table A-2.6 Transportation Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item Ucensee Event Type of No.
Ucensee No.
City State Date Transportation Event 950688 Industrial X-Ray IR-062-05 Las Vegas NV 12/31/94 Transporting Vehicle Involved In One-Vehicle Accident 950925 Isotag NR Midland
'lX 01/31/95 Radiation Levels Exceed Limits For Package 950099 J.L Shepherd &
CA-17/7 San CA 01/11/95 Failure To Brace Associates Fernando And Block Shipment 950042 Mallinckrodt MD-33-088-01 Greenbelt MD 01/10/95 Surface Contami-Medical, Inc.
nation Levels Exceed umits For Package 951101 Mallinckrodt F1 -1932-2 Ft.
FL 04/21/95 Transporting Vehicle Medical, Inc.
Lauderdale Involved In One-Vehicle Accident 950109 Medi+ Physics 11 01109-01 Arlington IL 01/28/94 Radiation Levels Pharmacy Services, Heights Exceed Limits Inc.
For Package i
950302 Medi+ Physics NR Silver MD 03/16/95 Surface Contami-Pharmacy Services, Spring nation Levels Exceed Inc.
Umits For Package 941749 New Mexico Tech NR Socorro NM 08/03/94 Radiation Levels Exceed Limits For Package 950164 O' hare International NON-Chicago IL 12/01/94 Failure To Brace 4
Airport LICENSEE And Block Shipment i
950033 Omnitron LA-6430-IA1 Lake LA 12/20/94 Radiation Levels International, Inc.
Charles Exceed Limits For Package Improperly Packaged Material 940976 Paracelsus Peninsula fir 0801-02 Ormond FL 01/24/94 Radiation Levels Medical Center, Inc.
Beach Exceed Limits For Package 941831 Scientific Ecology TN-R-73006 Oak Ridge TN 09/09/94 Radiation Levels Group, Inc.
-G94 Exceed Limits For Package 65 NUREG-1272, Appendix A-2
AEOD Annual Report,1994-FY 95 Table A-2.6 'Iransportation Events Reported by Agreement States, January 1994 - September 1995 (cont.)
Item Ucensee Event Type of I
No.
Licensee No.
City State Date Transportation Event 950031 Sunbelt Courier NR Jackson MS 01/05/95 Transporting Vehicle Involved In One-Vehicle Accident 951094 Syncor International FL-1264-01 Gainesville FL 01/07/95 Transporting Vehicle Corp.
Involved In One-Vehicle Accident 950187 Syncor International NR NR NY 01/27/94 Transporting Vehicle Corp.
Involved In One-Vehicle Accident 950185 Syncor International NR NR NY 02/03/94 Transporting Vehicle Corp.
Involved In One-Vehicle Accident 950209 Syncor International NR NR NY 07/12/94 Surface Contami-Corp.
nation Levels Exceed Limits For Package 950566 Syncor International CA-5218 Colton CA 07/14/94 Surface Contami-Corp.
nation Levels Exceed Limits For Package 950851 Syncor International NR NR OR 08/22/94 Surface Contami-Corp.
nation Levels Exceed Limits For Package 950229 Syncor International NR NR NY 09/23/94 Transporting Vehicle Corp.
Involved In One-Vehicle Accident 951093 Transportation, FIA)109-1 Gainesville FL 01/09/95 Transporting Vehicle Florida Department Involved In Multi-of Vehicle Accident 951081 Transportation, 1 0 0109-1 Gainesville FL 02/20/95 Transporting Vehicle Florida Department Involved In One-of Vehicle Accident 951106
'Iransportation, FL-0109-1 Gainesville FL 03/17/95 Transporting Vehicle Florida Department Involved In One-of Vehicle Accident 951104 Transportation, FL-0909-1 Gainesville FL 03/30/95 Transporting Vehicle Florida Department Involved In One-of Vehicle Accident NUREG-1272, Appendix A-2 66
Nuclear Materials-Agreement State Licensee Events Table A-2.6 Transportation Events Reported by Agreement States, 1
4 January 1994 - September 1995 (cont.)
1 Item Licensee Event Type of No.
Licensee No.
City State Date Transportation Event 951098 Transportation, FL-0109-1 Gainesville FL 05/23/95 Transporting Vehicle j
Florida Department Involved In One-1 of Vehicle Accident 951133 Transportation, FIA)109-1 Gainesville FL 07/27/95 Transporting Vehicle i
Florida Department Involved In One-of Vehicle Accident 950993 U.S. Ecology, Inc.
WN-10019-2 Richland WA 02/09/95 Radiation Levels 4
Exceed Limits For Package 950343 X-Cel Group, Inc.
NR Corpus TX 06/14/94 Radiation Levels
)
Christi Exceed Limits For Package NR Indicates NOT REPORTED i
l i
67 NUREG-1272, Appendix A-2
i AEOD Annual Report,1994-FY 95 l
Table A-2.7 Equipment Problems Reported by Agreement States, January 1994 - September 1995 Item IJcensee Event i
No.
Licensee No.
City State Date Equipment i
950126 Abbott Laboratories GENERAL Abbott Park IL 04/27/94 Gauge 941870 Albert Whitted FL-1985-1 Saint FL 04/08/94 Radioluminescent Airport Petersburg Exit Sign 951263 Albert Whitted FL-1985-1 Saint FL 09/29/95 Radioluminescent Airport Petersburg Exit Sign 941760 Apac-Carolina, Inc.
SC-344 Darlington SC 06/16/94 Gauge, Moisture /
Density 950529 Atec Associates, MD-31-189-01 Rockville MD 08/31/94 Gauge, Moisture /
1 inc.
Density 941441 Blazer Inspections NR Teras City TX 02/23/94 Camera, Radiography 950512 BSC Steel, Inc.
MS-612-01 Jackson MS 11/03/94 Gauge, Level 950511 Bush Construction MS-508-01 Laurel MS 04/22/94 Gauge, Moisture /
4 Density 9505 %
California CA-0531 NR CA 09/15/94 Gauge Department of Transportation 951298 California Medical CA-0385-70 Los Angeles CA 06/28/95 LDR Unit Center 1
950516 Cobb Place 8 GENERAL Kennesaw GA 05/18/94 Radioluminescent Theater Exit Sign 941827 Cooper Industries LA-7095-IA1 Ville Platte LA 01/13/94 Camera, Radiography 941828 Cooper Industries LA-7095-IAI Ville Platte LA 01/20/94 Camera, Radiography 941826 Cooper Industries LA-7095-IA1 Ville Platte LA 03/09/94 Camera, Radiography 950510 Dames & Moore, OR-0405-1 NR OR 03/23/94 Gauge, Moisture /
Inc.
Density 950569 Earth Systems CA-0368 Ventura CA 07/01/94 Gauge, Moisture /
Consultants Density 941638 Ebasco Services, NR Houston TX 02/10/94 Camera, Inc.
Radiography 951283 Florida Department FI 0109-1 Gainesville FL 08/25/95 Gauge, Moisture /
ofTransportation Density NUREG-1272, Appendix A-2 68
Nuclear Materials-Agreement State Licensee Events Table A-2.7 Equipment Problems Reported by Agreement States, January 1994 - September 1995 (cont.)
Item Licensee Event No.
Licensee No.
City State Date
. Equipment 942085 Florida Department FL-0109-1 Gainesville FL 09/19/94 Gauge, Moisture /
of Transportation Density 941543 Florida Power Corp. FL-1157-2 Saint FL 02/26/94 Camera, Petersburg Radiography 950431 Florida Steel Co.
R-57015-K97 Jackson TN 08/16/94 Gauge 950090 Geo-Sciences GA-1211-01 NR GA 02/06/95 Gauge, Moisture /
Density 950577 Geocon, Inc.
CA-3924 San Diego CA 03/21/94 Gauge, Moisture /
Density 941876 Georgetown Steel SC-212 Georgetown SC 07/29/94 Gauge Corp.
950515 Georgia Institute of GA-0147-1 Atlanta GA 01/18/94 Electron Capture Technology Detector 950603 Geosoils CA-4741 Van Nuys CA 12/14/94 Gauge, Moisture /
Density 941829 Global X-Ray &
LA-0577-L01 Morgan City LA 03/21/94 Drive Cable Testing Corp.
950595 Golden West CA-5988 Livermore CA 08/24/94 Gauge, Density Environmental System 950484 H&G Inspection Co., IR-268 Bloomfield NM 01/22/95 Camera, Radiography Inc.
950054 H&H X-Ray Services,IR-267 Aztec NM 11/25/94 Camera, Radiography Inc.
951082 H. Lee Moffitt FL-1739-1 Tampa FL 02/16/95 Catheter, Seed Cancer & Research Ribbon Center 950360 Hoechst Celanese HR Bishop TX 09/16/94 Gauge Insertion Tube Corp.
950547 Hungingdon UT-18001-91 Salt Lake UT 10/26/94 Gauge, Moisture /
Engineering City Density 951099 ICF Kaiser FL-2306-1 Miami FL 05/09/95 Gauge, Moisture /
Engineers, Inc.
Density 950594 Industrial Nuclear CA-2229-60 San Ixandro CA 08/16/94 Drive Cable Corp.
69 NUREG-1272, Appendix A-2
l AEOD Annual Report,1994-FY 95 i
Table A-2.7 Equipment Problems Reported by Agreement States, January 1994 - September 1995 (cont.)
Item Licensee Event No.
Licensee No.
City State Date Equipment 950308 International Paper ARK-029 Camden AR 06/25/94 Gauge, Moisture /
Co.
Density 950104 Interstate Nuclear IA-172-1-20 Osceola IA 02/09/95 Ventilation System Services
-NL Air Sampling System 951033 Isomedix Operations, SC-267 Spartanburg SC 05/05/95 Irradiator Inc.
950099 J.L. Shepherd &
CA-1777 San CA 01/11/95 Camera, Radiography Associates Fernando 950017 K.G. Taylor Co.
NR Odessa TX 06/09/94 Sealed Source, Neutron 942062 Kay-Ray /Sensall, IL-01010-03 Mount IL 04/21/94 Gauge Inc.
Prospect 951117 KCI Technologies, 0718001 Baltimore MD 05/24/95 Gauge, Moisture /
Inc.
Density 951091 Keith & Schnars, FL-1385-1 Pompano FL G1/19/95 Gauge, Moisture /
P.A., Geotechnical Beach Density Division 951155 Little Bit Wireline NR Beaumont TX 08/24/95 Well Logging Tool f
Co.
Sealed Source 951126 Longview-Advanced FL-2239-1 Orlando FL-06/28/95 Camera, Radiography Technology, Inc.
950399 Manufacturing NR Oak Ridge TN 01/23/94 Ventilation System Science Corp.
950340 Midland Inspection NR Midland TX 09/08/94 Drive Cable
& Engineering, Inc.
950908 Midland Inspection NR Midland TX 12/02/94 Camera, Radiography
& Engineering, Inc.
950075 Milliken Co.
GENERAL La Grange GA 02/01/95 Gauge 941665 Mississippi MS-582-01 Friars MS 03/10/94 Gauge, Moisture /
Limestone Corp.
Density 950935 MQS Inspection,Inc. NR Houston TX 01/16/95 Camera, Radiography 950656 MOS Inspection,Inc. ARK-344 Memphis TN 02/27/95 Camera, Radiography 950206 MQS Inspection,Inc. NR NR NY 09/01/94 Camera, Radiography NUREG-1272, Appendix A-2 70
i Nuclear Materials-Agreement State Licensee Events Table A-2.7 Equipment Problems Reported by Agreement States, January 1994 - September 1995 (cont.)
Item Licensee Event No.
Licensee No.
City State Date Equipment 951020 O'Brien &
IL-01609-01 Arlington IL 05/11/95 Gauge, Moisture /
Associates Heights Density 950116 Olin Corp., Brass IL-01069-01 East Alton IL 03/20/94 Gauge Division f
941863 Presbyterian NR Dallas TX 06/16/94 Gamma Knife Unit Hospital of Dallas 941486 Proctor & Gamble R-79120-093 Memphis TN 02/17/94 Meter, Static Cellulose Corp.
951138 Professional GA-629-1 Martinez GA 07/12/95 Gauge, Moisture /
Services Industries, Density Inc.
950139 Quantum Chemical-IL-01737-01 Morris IL 07/21/94 Detector, Area USI Division Radiation 951029 Ratrie, Robbins, &
NR Towson MD 07/31/95 Gauge, Moisture /
Shwiezer, Inc.
Density 950137 Rust Environment & IIA 1307-01 Sheboygan IL 07/20/94 Gauge, Moisture /
Infrastructure Density 950439 S&ME TN-R-47124 Knoxville TN 10/05/94 Gauge, Moisture /
-H95 Density 950332 S.T Bunn Co.,Inc.
NR Tuscalosa AL 03/19/95 Gauge, Moisture /
Density 950528 Schnabel Engineer.
MD-07-141-01 Severn MD 11/03/94 Gauge, Moisture /
ing Associates Density 951163 SDI Consultants IL-01945-01 Oak Brook IL 09/23/95 Gauge, Moisture /
Density 950902_ Stoney Miller CA-5200-30 Irvine CA 02/02/95 Gauge, Moisture /
Consultants Density 941911 Structural Metals, NON-Sequin TX 03/04/94 Gauge, Level Inc.
LICENSEE 950582 SW Testing &
CA-5927 Santa Fe CA 02/28/94 Gauge, Moisture /
Inspection Springs Density 950369 Syncor International NR Dallas TX 11/16/94 Vial Corp.
71 NUREG-1272, Appendix A-2
{
AEOD Annual Report,1994-FY 95 i
l Table A-2.7 Equipment Problems Reported by Agreement States, January 1994 - September 1995 (cont.)
i l
S Item Ucensee Event No.
Ucensee No.
City State Date Equipment l
950163 Syncor International IL-01721-02 Chicago IL 11/25/94 Vial 1
Corp.
941630 Terra-Mar, Inc.
NR Dallas TX 02/16/94 Gauge, Moisture /
Density 941735 Terracon IA-126-1-57 Davenport IA 08/02/94 Gauge, Moisture /
a l
Consultants, Inc.
Density 941898 Terracon IL-01402-01 Naperville IL 09/29/94 Gauge, Moisture /
Consultants, Inc.
Density 950533
'Iherapy Services, MD-21-009-01 Frederick MD 01/19/94 Teletherapy Unit Inc.
950612 Transportation, AZ-07-031 Phoenix AZ 03/20/95 Gauge, Moisture /
Arizona Department Density of 951109 Transportation, FL-0109-1 Gainesville FL 03/10/95 Gauge, Moisture /
Florida Department Density of 951132 Transportation, FIA109-1 Gainesville FL 07/28/95 Gauge, Moisture /
Florida Department Density of 950450 Transportation, TN-R-19017 Nashville TN 08/30/94 Gauge, Moisture /
-J%
Density Department of 950913 Transportation, NR Austin TX 10/13/94 Gauge, Moisture /
Texas Department of Density 941053 Union Foundry AL-903 Anniston AL 08/05/94 Gauge 950723 Universal IIA 1132-22 Highland IL 02/10/95 Gauge, Moisture /
Construction Testing Park Density 942070 University Hospital CA-5592-70 Los Angeles CA 10/25/94 Gamma Knife Unit of California 950997 Valley X-Ray CA-2285-30 NR CA 07/13/95 Camera, Radiography Services 950554 Westec, Inc.
NV-00-11 Carlin NV 12/31/94 Gauge, Moisture /
-0197-01 Density NUREG-1272, Appendix A-2 72
Nuclear Materials-Agreement State Licensee Eve ':
Table A-2.7 Equipment Problems Reported by Agreement States, January 1994 - September 1995 (cont.)
Item Ucensee Event No.
Ucensee No.
City State Date Equipment 950059 Western Technologies NM-IR-244 Albuquerque NM 10/20/94 Gauge, Moisture /
Density 950826 Wildish Land Co.
OR-0473-1 Eugene OR 04/12/95 Gauge, Moisture /
Density 950347 X-Cel Group, Inc.
NR Corpus TX 08/23/94 Camera, Radiography Christi NR Indicates NOT REPORTED i
73 NUREG-1272, Appendix A-2
Appendix B i
Summary of 1994 and FY 95 Abnormal Occurrences j
(Nuclear Materials) i I
B-1 NRC Licensees d
i l
B-2 Agreement State Licensees i
l i
)
1 i
1 1
}
)
i 1
,I 4
4 I
i a
j i
I
I L
i Contents Page Appendix B-1
-l t
NRC Licensees r
NUREG-0090, Volume 17, No.1 i
I
%2 Medical Brachytherapy Misadministration at Hospital Metropolitano
. in Rio Piedras, Puerto Rico......................................................
1 43 ~ Teletherapy Misadministration at Triangle Radiation Oncology Associates in Pittsburgh, Pennsylvania.......................................................
1 94-4 Iest Reference Sources at Brooks Air Force Base in San Antonio, Texas...............
2
%S Medical Brachytherapy Misadministration at the University of Cincinnati in Cincinnati, Ohio..............................................................
2 94-6 Medical Brachytherapy Misadministration at Keesler Medical Center at Keesler Air Force Base in Biloxi, Mississippi......................................
3
%7 Medical Brachytherapy Misadministration at Alexandria Hospital in Alexandria, Virginia............................................................
4' NUREG-4090, Volume 17, No. 2 94-8 Multiple Medical Brachytherapy Misadministrations at Deaconess Medical Center in Billings, Montana..............................................................
5 49 Medical Brachytherapy Misadministration at Memorial Hospital in South Bend, Indiana...........................................................
5 l
%10 'Ibletherapy Misadministration at Jewish Hospital, Washington University Medical Center, in St. Louis, Missouri..............................................
6
%11 Medical Brachytherapy Misadministration at The Queen's Medical Center in Honolulu, Hawaii..............................................................
6
)
%12 Medical Sodium Iodide Misadministration at Stamford Hospital in Stamford, Connecticut............................................................
7
%13 Medical Brachytherapy Misadministration at Blodgett Memorial Hospital in East Grand Rapids, Michigan...................................................
7 W14 Medical Brachytherapy Misadministration at The William W. Backus Hospital in Norwich, Connecticut..................................................
8 NUREG-4090, Volume 17, No. 3 415 Sodium Iodide Event at Welborn Memorial Baptist Hospital in Evansville, Indiana.............................................................
9
%16 'Ibletherapy Misadministration at Medical Center Hospital in Chillicothe, Ohio...............................................................
9 iii NUREG-1272
I l
Contents (cont.)
Page NUREG-0090, Volume 17, No. 3 (cont.)
j l
l 94-17 Sodium Iodide Misadministration at St. Joseph Mercy Hospital in Pontiac, Michigan..............................................................
10 94-18 Multiple Teletherapy Misadministrations at Sinai Hospital in Detroit, Michigan '.........
10 94-19 Brachytherapy Misadministration Involving the Use of a Strontium-90 Eye Applicator j
- at the University of Massachusetts Medical Center in Worcester, Massachusetts........
11 NUREG-0090, Volume 17, No. 4 94-21 Recurring Incidents of Administering Higher Doses than Procedurally Allowed for Diagnostic Imaging at Ball Memorial Hospital in Muncie, Indiana.....................
12 94-22 Medical'Iherapy Misadministration at Veterans Affairs Medical Center-in Ix>ng Beach, California.........................................................
12 94-23 Medical Brachytherapy Misadministration at North Memorial Medical Center in Robbinsdale, Minnesota........................................................
13 NUREG-0090, Volume 18, No.1 95-1 Medical Brachytherapy Misadministration at Welborn Memorial Baptist Hospital in Evansville, In diana.............................................................
14 NUREG-0090, Volume 18, No. 2 95-4 Medical Brachytherapy Misadministration at the University of Virginia, in Charlottesville, Virginia...........................................................
15 95-5 Medical Therapeutic Radiopharmaceutical Misadministration of Iodine-131 at Massachusetts General Hospital in Boston, Massachusetts.........................
15 95-6 Multiple Medical Brachytherapy Misadministrations at Madigan Army Medical Center in Fort Lewis, Washington..................................................
15 NUREG-0090, Volume 18, No. 3 95-7 Medical Brachytherapy Misadministration at Marshfield Clinic in Marshfield, Wisconsin.......................................................................
17 95-8 Medical Brachythera Michigan..........py Misadministration at Providence Hospital in Southfiel 17 95-9 Ingestion of Radioactive Material by Research Workers at the National Institutes of Health in Bethesda, Maryland.....................................................
17 -
NUREG-1272 iv
l l
t l
l Contents (cont.)
l l
l Page t
1 i
l Appendix B-2 Agreement State Licensees NUREG-0090, Volume 17, No.1 AS 94-1 Therapeutic Radiopharmaceutical Misadministration at North Carolina -
Baptist Hospital in Winston Salem, North Carolina..............................
21 NUREG-0090, Volume 17, No. 2 AS 94-2 Medical Brachytherapy Misadministration at Memorial Medical Center in Lufkin, Texas..............................................................
22 AS 94-3 Radiation Burn of an Industrial Radiographer at Blazer Inspection in Texas City, Texas.............................................................
22 AS 94-4 Lost Well Logging Source at 'Ibcker Wireline Service of Corpus Christi, Texas......
23 AS 94-5 Multiple Brachytherapy Misadministrations at Cedars Medical Center i n Miami, Flori da............................................................
23 NUREG-0090, Volume 17, No. 3 AS 94-6 Loss of Management and Procedural Control of a Radioactive Source Licensed by the State of Illinois to KayRay, Inc., at a Georgia-Pacific Corporation Paper Mill in Palatka, Florida.................................................
25 NUREG-0090, Volume 17, No. 4 i
AS 94-7 Major Contamination Event Due to a Breached Source at KayRay/Sensall, Inc.,
in Mt. Prospect, Illinois.......................................................
26 AS 94-8 Medical Brachytherapy Misadministration at St. Joseph's Hospital in Orange, California...........................................................
26 AS 94-9 Brachytherapy Misadministration at the University of California's Long Hospital in San Francisco, California....................................
27 i
1 AS 94-10 Medical Teletherapy Misadministration by an " Unspecified Licensee" at an " Unspecified Location" in New York........................................
28 NUREG-0090, Volume 18, No. 2 AS 95-1 Medical Teletherapy Misadministration at an " Unspecified Licensee" in New York, New York.......................................................
29 AS 95-2 Medical Brachytherapy Misadministration by Mobile Technology, Inc.,
at Irvine Medical Center in Irvine, California....................................
29 y
I Contents (cont.)
Page NUREG-0090, Volume 18, No. 2 (cont.)
AS 95-3 Overexposure of Personnel at Gwinnett Medical Center in 3
Lawrenceville, Georgia........................................................
29.
I AS 95-4 Medical Brachytherapy Misadministration at Southwest Texas Methodist Hospital in San Antonio, 'Ibxas................................................
30 NUREG-0090, Volume 18, No. 3 AS 95-5 Importation of a Package Having Excessive External Radiation into the United States from the Republic of Korea...................................
31 i
i l
I NUREG-1272 vi
Appendix B-1 NRC Licensees
)
l i
1
Nuclear Materials-Abnormal Occurrences NUREG-0090, Volume 17, No.1 Report No. 94-2 Medical Brachytherapy Misadministration at Hospital Metropolitano in Rio Piedras, Puerto Rico On December 9,1993, a patient began a gynecological low-dose-rate brachytherapy treatment. The patient was prescribed a treatment of 3000 centigray (cGy)(3000 rad) by a 48-hour exposure to a? proximately 23 gigabecquerel (613 millicurie [ mci]) of cesium-137 (Cs-137). On December 11,1993, about 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> before the end of the prescribed treatment, the patient intervened with the procedure by removing the implant containing three Cs-137 sources of approximately 730 megabecquerel (20.4 mci) each, and placed it next to her thigh. The patient informed the floor nurse of her action, and the floor nurse consequently informed her supervisor. However, the supervisor took no corrective action because of unfamiliarity with radiation safety procedures caused by the infrequent handling of patients undergoing therapy with licensed rnaterials. Approximately 2-1/2 hours after the estimated time of soyrce removal, the attending physician discovered that the source had been removed and placed next to'the patient's thigh. As a consequence of the patient's intervention, the actual dose delivered to the intended treatment site was calculated to be 2270 cGy (2270 rad). 'Ihe written directive was revised to reflect the lower dose delivered. The licensee's evaluation of the incident indicated that assuming the implant remained in the same location for three hours, the maximum dose to the skin of the patient's thigh (the wrong treatment J
site) was 572 cGy (572 rad). The licensee reported that no adverse effects to the patient are expected. The l
patient was notified verbally at the time the misadministration was discovered and then notified in writing on January 13,1994.
To prevent recurrence, the licensee decided to dedicate one floor of the hospital for all therapies invohing NRC-licensed materials. This will provide additional controls to allow the licensee to better ensure that nurses assigned to the floor are kept current and familiar with operating and emergency procedures. The licensee is also evaluating the need to increase patient awareness regarding non-intervention of procedures.
Report No. 94-3 Teletherapy Misadministration at Triangle Radiation Oncology Associates in Pittsburgh, Pennsylvania On December 20,1993, Triangle Radiation Oncology Associates in Beaver, Pennsylvania, notified NRC of two potential teletherapy misadministrations that occurred between December 13 and 17,1993, at the licensee's Pittsburgh, Pennsylvania, facility. The potential misadministrations were identified during a review of patient records on December 17,1993, when the licensee observed calculation errors involving the depth of the dose given to each of the two patients. Both cases involved breast treatments where the i
original treatment plan prescribed 28 treatments of 180 centigray (cGy) (180 rad) each from a cobalt-60 l
teletherapy source (using 2 parallel opposed fields) for a total absorbed dose of 5040 cGy (5040 rad).
Normally, such a treatment plan would have been calculated by the teletherapy technologist at the Pittsburgh facility and communicated by telephone to the teletherapy physicist at the Beaver facility to be checked. However, this procedure was changed when the computer at the Pittsburgh facility was taken out of service. On December 9,1993, the teletherapy technologist hand wrote a paraphrased request of the written directive for the two breast-treatment patients needing scar booster dose calculations. Rather than writing dmax, the technologist stated the tumor dose at a depth of 5 cm (2 inch)instead of the 1
NUREG-1272, Appendix B
AEOD Annual Report,1994-FY 95 i
i intended 0.5 cm (0.2 inch) and sent the request via facsimile transmission to the teletherapy phy the Beaver facility. Hand calculations were performed for 200 cGy (200 rad) treatments at a 5 c depth, checked by a certified physicist, and sent back to the technologist via facsimile transmission on D ecember 9,1993. The patients were treated from December 13 to 17,1993, and received doses of 1300 and 1320 cGy (1300 and 1320 rad) respectively, rather than the 1000 cGy (1000 rad) intended. This resulted in misadministrations of 30 and 32 percent greater than the intended dose. He licensee's physician stated that no adverse clinical effects are expected as a result of the overexposures.
Tb correct the problem, the licensee implemented a requirement for a stamp to be placed on all written directives that prompts a clear documentation of key treatment parameters such as site, method dose, fractions, total dose, depth of calculation, spinal blocks, other blocks, and date.
I Report No. 94-4 i
Lost Reference Sources at Brooks Air Force Base in San Antonio, Texas As prescribed by the licensee's Compliance Accountability and Control Procedures, the licensee performed an audit of all licensed sources at Armstrong Laboratory in 1993. During this audit, the licensee identified four missing strontium-90 (Sr-90) reference sources of approximately 14.8 megabecquerel (400 microcurie) each. The licensee conducted an extensive physical search for the sources and reviewed all radioactive material permits issued to other organizatiev, at Brooks Air Force Base (AFB). When the disposition of the four Sr-90 sealed sources could not be determined, the licensee reported the loss to NRC by telephone on September 22,1993. The licensee suspected that the sources l
had been inadvertently discarded and transported to a sanitary landfill. The sources were apparently during 1991 when a number of individuals were responsible for the radiation safety program at Brooks l
AFB. These individuals were temporary or part-time Radiation Safety Officers, and had extensive, j
temporary duties at other sites.
To prevent recurrence, Armstrong Laboratory was placed under a new Air Force Command in 1991. The Command committed to increased management oversight of the radiation safety programs. Additiona physical inventory procedures were revised.
L Report No. 94-5 Medical Brachytherapy Misadministration at the University of Cincinnati in Cincinnati, Ohio On January 7,1994,16 Iodine-125 (1-125) seeds, with each having an activity ranging from 370 to 1110 megabecquerel (10 to 30 millicurie [ mci]), were implanted in the brain of a 30-year-old male patient.
Following the explant procedure on January 14,1994, the licensee found radioactive contamination in the l
surgical room and bathroom used by the patient. Personnel from the licensee's radiation safety office i
identified the contamination to be 1-125 and confirmed that at least one seed was leaking. Further analysis determined that the seed was damaged during the implant procedure by a surgical staple. The seed originally contained 758 megabecquerel (20.5 mci) of I-125 and, based on an assay of the explanted source, the licensee estimated that the loss was approximately 74 megabecquerel (2.0 mci). Thyroid monitoring of the patient's visitors and hospital employees involved in the patient's care was performed by the licensee. One of the licensee's employees was determined to have received a committed dose equivalent to the thyroid of 50 microsievert ( Sv)(5 millirem [ mrem]). In addition, a visitor was determined to have received a committed dose equivalent to the thyroid of 540 Sv (54 mrem), or a total effective dose equivalent of 160 Sv (1.6 mrem), which is less than the annual limit for members of the general public of 1000 Sv (100 mrem). Through patient monitoring, the licensee estimated that NUREG-1272, Appendix B 2
~. -
Nuclear Materials-Abnormal Occurrences approximately five percent of the free I-125 was taken up in the patient's thyroid. (In a normally functioning, unblocked thyroid, approximately 25 percent of the free iodine would be taken up in an individual's thyroid.) The licensee estimates that the uptake would result in a radiation dose to the thyroid of approximately 300 centigray (300 rad). The licensee does not expect any adverse medical effects to the patient as a result of the misadministration. An NRC medical consultant concluded that the non-radioactive iodinated contrast agent used during an imaging procedure performed on the patient prior to the implant blocked the absorption of the I-125. He also concluded that exposure to the 4
radiation levels described increased the probability of developing thyroid tumor (s)in the future. The licensee notified the referring physician, the patient, and the patient's family of the misadministration.
The cause of the event was that the seed leaked after being inadvertently crushed by a surgical staple used to secure the catheters during the implant procedure. To prevent re:urrence, the licensee plans to ensure that in the future implanted seeds are located further down the catheter in order to reduce the likelihood of seed damage from surgical staples. The licensee also plans to examine each I-125 seed for leakage following each explant procedure.
4 Report No. 94-6 Medical Brachytherapy Misadministration at Keesler Medical Center at Keesler Air Force Base in Biloxi, Mississippi On January 13,1994, at Keesler Medical Center of Keesler Air Force Base in Biloxi, Mississippi, a patient l
was prescribed a lung brachytherapy treatment delivered by an Omnitron 2000 high-dose-rate (HDR) remote afterloader system. The prescribed tumor treatment plan included 1000 centigray (cGy)(1000 rad) j absorbed doses at 5 treatment positions using a 144.3 gigabecquerel(3.9 curie) iridium-192 source within a special needle. At the end of fifth and final treatment, the source wire retracted 0.5 centimeter (cm)(0.2 inch) and stopped. Alarms immediately alerted Keester staff that the source remained inside the patient's a
body. Licensee personnel followed emergency procedures by entering the therapy room and removing the needle from the patient. Once outside the patient's body, the radioactive source retracted to the stored position. The licensee determined that the source remained stuck at 0.5 cm (0.2 inches) above the fifth l
position for approximately 2-1/2 minutes. The treatment plan called for the delivery of 1000 centigray (cGy)(1000 rad) at 1 cm from each of the 5 treatment positions. As a result of the additional 2-1/2 minutes exposure, the last treatment position received 1732 cGy (1732 rad) absorbed dose, or 73.2 percent over the prescribed dose. The treatment plan also predicted an 800 cGy (800 rad) absorbed dose at 0.5 cm (0.2 inch) from each of the 5 treatment positions. The point 0.5 cm (0.2 inch) above the last treatment position, where the movement of the source stopped, received approximately 1400 cGy (1400 rad), or 75 percent greater than the absorbed dose stipulated in the prescribed treatment plan. The failure of the source to retract resulted in a single overexposure, causing an overall absorbed dose of 75 percent greater than that prescribed, for all the tissue surrounding the position 0.5 cm (0.2 inch) above the last treatment site. The licensee reported that no adverse health effects to the patient are expected. The patient was immediately notified of the misadministration.
4 The event was caused when the patient had made a sudden move near the end of the treatment, which 1
bent the special needle at the point where it extended beyond the biopsy needle. The bend prevented the J
radioactive source from retracting to the stored position, thereby causing the misadministration. To prevent recurrence, the licensee immediately stopped the use of the HDR device pending a complete check of the system by the manufacturer. The licensee also evaluated the practice of extending special needles beyond biopsy needles and the probability of patient movement causing damage, and decided to discontinue the practice.
3 NUREG-1272, Appendix B 4
AEOD Annual Report,1994-FY 95 Report No. 94-7 Medical Brachytherapy Misadministration at Alexandria Hospitalin Alexandria, Virginia l
On January 27,1994, a patient was scheduled to receive a 500 centigray (cGy)(500 rad) brachytherapy a
treatment to the trachea using a Nucletron high-dose-rate (HDR) remote afterloader system. A single catheter was used for this endobronchial treatment and the licensee performed a routine simulated treatment. During this simulation, the oncologist established a 3 centimeter (cm) (1.2 inch) tumor r
treatment site and added a 1 cm (0.4 inch) margin on both ends of the tumor site. At this point the medical physicist and the dosimetrist normally plot distances, measured in centimeters along the length of the catheter shown in the simulation film, in order to program the HDR for precise treatment at the prescribed treatment site. This step was not performed and the procedure was initiated without the HDR being properly programmed. The unprogrammed source was allowed to travel beyond the treatment site into the left lung area where the catheter ended. The treatment resulted in the prescribed 500 cGy (500 rad) effective dose equivalent being delivered to the left lung instead of the trachea target site. Prior to 1
administering the dose, the treatment plan and treatment console printout were reviewed by the dosimetrist, the medical physicist, and the oncologist. All three individuals failed to identify the failure to i
plot the treatment site. Immediately following the treatment, the licensee's medical physicist realized that the plotting and programming of the treatment site were not performed. After discovery of the treatment error, the oncologist determined that the patient should be treated again using the correct treatment parameters. The licensee has advised NRC that no adverse effects to the patient are anticipated as a result of this misadministration. The licensee has informed the patient of the misadministration.
i The event was caused by the licensee's radiation therapy staff failing to follow the licensee's normal protocol for treatment with the HDR remote afterloader. To prevent recurrence, the licensee's corrective -
actions included immediate retraining of all personnel involved in brachytherapy treatments and the addition of a checklist for each step in the treatment process. The licensee also added steps to its Quality l
Management program for HDR brachytherapy. These steps now require the use of the treatment planning computer with manual verification of the input parameter and the use of the treatment parameter card generated by the planning computer to program the HDR rather than programming the HDR treatment parameters manually.
i l
NUREG-1272, Appendix B 4
- - -.. ~ -
. - - - - - - ~ -. -
l' Nuclear Materials-Abnormal Occurrences NUREG-0090, Volume 17, No. 2 Report No. 94-8 Multiple Medical Brachytherapy Misadministrations at Deaconess Medical Center in Billings, Montana Representatives from Northern Rockies Cancer Center (NRCC), Deaconess Medical Center (DMC), and St. Vincent Hospital and Health Center (SVHHC) notified NRC of a misadministration involving a brachytherapy treatment performed at DMC on September 24,1993, an additional brachytherapy misadministration at DMC, and nine other incidents due to the same error which resulted in administered doses greater than prescribed (one at DMC and eight at SVHHC). The misadministrations reported by DMC involved administration of radiation such that the doses received by the patients exceeded the prescribed doses by 21 and 24 percent. In each case, the patient had received radiation by external beam as well as " boost" doses administered via brachytherapy. The overdoses noted above pertain only to the brachytherapy component of each treatment. The patients involved in the misadministrations were notified both crally and in writing.
The root cause of the misadministrations was a failure to conduct independent (manual) verification checks of treatment plans that were adequate to determine the accuracy of computer-generated dose j
tables generated by a Theratronics Theraplan L treatment planning system. Several factors involving j
clarity of instructions provided in the Heraplan user's manual, and in prompts and data presented to treatment planning system users in printed format and at the system console, were identified as contributing factors to the inadvertent entry of and failure to detect the erroneous data entered in program software for linear cesium-137 sources. 'Ib prevent recurrence, DMC voluntarily suspended its brachytherapy program until certain corrective measures could be implemented.
Report No. 94-9 Medical Brachytherapy Misadministration at Memorial Hospital in South Bend, Indiana On April 13,1992, the first of two brachytherapy treatments was begun. Each of the treatments was to i
deliver 15 gray (Gy)(1500 rad) to the patient's cervix. For the first treatment, five cesium-137 (Cs-137) sources were to be loaded into a treatment device, known as a Fletcher-suit applicator, which was placed in the patient's vagina. The sources were placed into afterloaders by a dosimetrist in preparation for placement in the applicator. He afterloaders were then placed in the applicator by the treating physician.
About eight hours later, the patient's care provider discovered a Cs-137 source on the floor near the foot of the patient's bed. He source was found after the care provider had changed the patient's bed linen.
The care provider recovered the source with long-handled forceps and placed it in a shielded container.
The treating physician and the licensee's Radiation Safety Officer were notified. Hey determined that one afterloader in the applicator was empty and that the Cs-137 source had not been placed in the applicator. He source was then placed in the afterloader and loaded into the applicator to continue the patient's treatment. He first treatment was then completed, giving the patient a dose to the treatment site of 13.83 Gy (1383 rad), which was 8 percent less than the intended dose. The second treatment was then performed on April 27 and 28,1992, without incident.
He incident apparently was the result of the source falling out of the afterloader as it was being placed in the applicator. The physician reported some difficulty in placing the sources and apparently did not observe the source when it fell. Tb prevent recurrence, the licensee revised its procedures for placing the radiation sources, including use of a pillow under a patient's pelvis in difficult situations.
5 NUREG-1272, Appendix B
AEOD Annual Report,1994-FY 95 i
Report No. 94-10 Teletherapy Misadministration at Jewish Hospital, Washington University Medical Center, in St. Louis, Missouri i
1 On April 22,1994, a patient was being treated for cancer of the brain. The written prescription dire that a 3000 centigray (cGy)(3000 rad) total absorbed dose be delivered in a series of 10 treatments) cGy (300 rad) each. Each treatment was to consist of 150 cGy (150 rad) from the left side,i (150 rad) from the right side. The eyes were to be shielded during the treatments. He patient's first treatment on April 21,1994, was delivered without incident in accordance with the prescription.
he licensee informed the NRC that after administering the first treatment to the patient, the ph decided to include the patient's right eye orbit into the whole brain treatment field for subsequent treatment fractions. The radiation therapist was verbally instructed of the change, but the written directive was not changed. The first portion of the second treatment was properly delivered us; modified treatment plan. However, the radiation therapist erroneously changed the treatment an the second portion of the treatment. The error meant that the left eye orbit received the radiation dose instead of the right eye orbit. Consequently, the left eye orbit erroneously received a dose of approximately 150 cGy (150 rad) and the right eye orbit received 150 cGy (150 rad) less than intended.
The licensee stated that the patient received an explanation of the event and that the error did not affect the treatment. The entire treatment was completed on May 6,1994, without further incident. Thei subsequently died as a result of the cancer. The NRC consultant determined that the misadministration
)
had no impact on the patient's death.
The event was caused by failure of the authorized physician to prepare a change in the written directiv and failure to effectively supervise the administration of the treatment. T6 prevent recurrence, the licensee's corrective actions included the following: (1) making policy changes to clarify the radiation i
therapists' responsibility when treatment plan changes are made;(2) retraining staff on quality i
management program (QMP) procedures; (3) requiring that on the first day of treatment the setup is supervised by a physician; (4) modifying the written directive form used for documenting written directives and subsequent revisions; and (5) reviewing and revising the current QMP and submitting th}
changes to NRC for review.
Report No. 94-11 Medical Brachytherapy Misadministration at The Queen's Medical Center in Honolulu, Hawaii i
1 A patient was prescribed to receive two treatments of 1000 centigray (cGy)(1000 rad) to the right eye using a strontium-90 (Sr-90) eye applicator. The treatment plan called for the two treatments to be i
scheduled one week apart. The first treatment was properly delivered on April 25,1994, by keeping the I
source in contact with the patient's right eye for 18 seconds. On May 2,1994, when the patient returned for the second treatment, the same physician treated the patient, but a different oncology nurse assisted.
The physician did not refer to the written directive or to the dose-rate information available with the eye applicator, although he had used other applicators in the past. He also did not discuss the procedure with j
the oncology nurse prior to the second treatment. At the end of the desired 18-second period, the nurse raised her voice and paused at the count of "18" (as she had been trained) without saying "stop" as the physician expected. As a result, the treatment continued until 32 seconds had passed, when the physician realized that the desired time must have elapsed. As a result, the patient received 1778 cGy (17/8 rad) to the right eye during the second treatment, rather than the prescribed 1000 cGy (1000 rad). The patient was notified of the event during follow-up examinations by the referring physician. No clinical damage NUREG-1272, Appendix B 6
a 4
Nuclear Materials-Abnormal Occurrences i
4 4
was observed by the referring physician, and none is expected. The patient will be examined during 4
subsequent follow-up visits to the medical center.
3 j
To prevent recurrence, the licensee revised the procedure.
l Report No. 94-12 Medical Sodium Iodide Misadministration at Stamford Hospital in Stamford, Connecticut On May 17,1994, A patient was scheduled by a referring to have a "whole blood red cell mass" test, correctly known as a " red blood cell volume" test. This test involves withdrawing an amount of blood from the patient, and labeling the patient's red blood cells in vitro with the radionuclide chromium-51 having a nominal activity of 1.02 to 3.7 megabecquerel(MBq)(30-100 microcurie [ Ci]). His is followed by reinjection of the labeled red blood cells into the patient, and measurement of radioactivity
' Mod samples withdrawn from the patient 10 to 30 minutes later. The referring physician contacted the patient's Health Maintenance Organization (HMO), since the HMO requires that it place the order with
}
Stamford Hospital. The HMO wrongly contacted the central booking area for Nuclear Medicine at Stamford Hospital, rather than the Clinical Laboratory which performs this test as authorized in Part 35.100 of Title 10 of the Code of Federal Regulations. The central booking secretary, and the HMO secretary, in an attempt to fit the procedure into one of those listed under Nuclear Medicine, converted 1
the prescribed "Whole Blood Red Cell Mass" test into "Whole Body I-131 Scan," a scan that uses 37 i
l MBq (1 mci) of I-131. The central booking secretary then printed the name of the referring physician at i
the bottom of the form for " Consultation for Nuclear Medicine," and sent it to the Nuclear Medicine Department where it was received on May 13,1994. A nuclear medicine technologist (NMT) looked at the form and saw that it was for " total red cell mass," but since the NMT knew the referring physician, the NMT assumed that this was a new test using I-131 to determine " total red cell mass." The NMT ordered the requested 37 MBq (1 mci) I-131 capsule, which was administered on May 16,1994. The patient was scanned on May 17,1994, and May 18,1994, the authorized user (AU), who is also the Radiation Safety Officer (RSO), read the films. The AU immediately noticed the error and notified the referring physician, i
who notified the patient. The licensee estimated that the patient received a whole body dose equivalent of 4.7 millisievert (mSv)(470 millirem) and a thyroid absorbed dose of 800 centigray [cGy) (800 rad).
I
'Ihe event occurred because the licensee had failed to establish a quality management program (QMP) for administering quantities of I-131 and iodine-125 (I-125) greater than 1.11 MBq (30 Ci) which would require written directives and failed to instruct supervised individuals in NRC requirements of a QMP. To i
prevent recurrence, the licensee now requires the following actions: (1) all requests for diagnostic or therapeutic procedures be in writing and sent via facsimile transmission from the referring physician's office; (2) all administrations above 1.11 MBq (30 Ci) of I-131 be done only by written order from the AU/RSO or other AU's authorized to do so; (3) all diagnostic and therapy requisitions will be reviewed by a radiologist, and designated as approved or not approved; (4) all technologists will be trained in regard to the clinical diagnosis for which each test is applicable;(5) the central booking staff will meet I
with the RSO and will be informed that the clinical diagnosis must match the test being recuested, and that any deviation from the match or any diagnosis that they don't understand must be chalenged and brought to the attention of the radiologist; and (6) the RSO and physicist will review the QMP annually and discuss it at the Radiation Safety Committee meeting and with the entire nuclear medicine staff.
Report No. 94-13 j
Medical Brachytherapy Misadministration at Blodgett Memorial Hospital in East Grand Rapids, Michigan i
A misadministration occurred on June 14,1994, during the second of a series of three treatments to an eye surface lesion using a strontium-90 (Sr-90) eye applicator. The misadministration resulted in the 7
NUREG-1272, Appendix B
~.
AEOD Annual Report,1994-FY 95 l
1 patient receiving a total dose that was 53.6 percent above the intended total dose. The patient was to receive 25.5 gray (Gy)(2550 rad) in a series of three equal treatments. The intended treatment time for each of the three treatments was 19.1 seconds. The first treatment was performed as intended. However, during the second treatment, the treatment time of was misread and the patient received treatment for 1 minute and 9 seconds. The second treatment dose was 30.68 Gy (3068 rad)instead of the intended 8.5 Gy l
(850 rad). The third treatment was not administered. Therefore, the patient's eye received a total dose of 39.18 Gy (3918 rad). The patient and referring physician were notified of the incident by the licensee. The i
I licensee and the referring physician do not anticipate any serious health consequences to the patient and have conducted follow-up medical examinations.
The root cause of the event m that the treatment time of 19.1 seconds was erroneously recorded on the medical chart as 1.91 seconds. When it came time for the second treatment fraction to be administered, 1
the therapist made the assumption that the treatment time was 1 minute 9 seconds. To prevent recurrence, the brachytherapy quality management program (QMP) will be strictly adhered to when performing eye applications and a physics check will be done before each treatment fraction. In addition, a source activity decay chart for Sr-90 will be provided to the physicians for immediate reference.
Report No. 94-14 i
Medical Brachytherapy Misadministration at The William W Backus Hospital in Norwich, Connecticut On June 21,1994, a therapeutic misadministration occurred which involved a patient receiving a prostrate implant of 112 iodine-125 (I-125) seeds, with each having a radionuclide activity of 166 megabecquerel (MBq)(4.49 mci), rather than the prescribed 112 I-125 seeds with each having an activity of between 15.9 and 17.0 MBq (0.43 and 0.46 millicurie [ mci]). The licensee was able to explant 69 of the 112 seeds that were implanted, leaving 43 seeds still remaining inside the patient's body. During the explanting procedure, one of the I-125 seeds was ruptured. The patient was administered prophylactic potassium iodide to block the possible uptake of I-125 by the patient's thyroid. The licensee also collected the fluids and the tissue that may have been contaminated. Approximately 5 liters (5.28 quarts) of fluid were collected and appeared to be contaminated with approximately 1.85 MBq (0.050 mci) of I-125. The personnel who were present in the operating room during the surgery were also monitored for possible uptake, and the results indicated no internal contamination of these personnel.
The patient was transferred to Yale-New Haven Hospital (YNHH)in order that a more precise localization of the remaining seeds could be made by the use of equipment available at that facility. At YNHH three-dimensional scans were taken, and on June 27,1994, the patient was again operated on and an additional 15 seeds were explanted. This left 28 seeds still remaining which appeared to be scattered in the lower pelvic region, and the licensee decided that further mitigating surgery at this time was not warranted. The patient appeared to be in stable condition. Preliminary dose calculations by the licensee indicated that the remaining seeds would caun the body tissue to receive a radiation dose of the same order of magnitude as would have been rece r. by the surrounding organs and tissue if the originally planned seeds were permanently implante.. T e patient was discharged from YNHH on July 4,1994.
NUREG-1272, Appendix B 8
Nuclear Materials-Abnormal Occurrences '
1 NUREG--0090, Volume 17, No. 3 I
Report No. 94-15 Sodium Iodide Event at Welborn Memorial Baptist Hospital in Evansville, Indiana A pregnant patient was administered 185 megabecquerel(5 millicurie [ mci]) of sodium iodide-131(I-131) on March 9,1994, as prescribed in the written directive for the treatment of Graves' disease (hyperthyroidism). The licensee did not know that the patient was pregnant at the time of the l
administration. On May 10,1994, the licensee was informed by a private practice physician that the patient was 22-weeks pregnant at the time of treatment. As a result, the patient's fetus received an unintended radiation dose. Oak Ridge Institute for Science and Education calculated the fetal whole body j
and thyroid doses at NRC request. The fetal dose to the thyroid was calculated as 7,000-12,000 centigray (cGy)(7,000-12,000 rad), and the fetal whole body dose was calculated as 0.55 cGy (0.55 rad). Based on the calculated fetal dose there are a range of possible consequences, the most likely being no significant harm to the fetus. At NRC request, the Radiation Emergency Assistance Center / Training Site in Oak Ridge, Tennessee, contacted the licensee to discuss the dose assessment and potential fetal effects. On l
May 10,1994, a physician specializing in maternal fetal medicine, not affiliated with the licensee, discussed the incident with the licensee. The patient was informed of the exposure and possible consequences to the fetus by the maternal fetal specialist.
The principal cause for the event was licensee reliance on the patient's assurance of nonpregnancy.
Licensee procedures do not require determination of pregnancy status through serum testing, or other appropriately ~ documented means, for all female patients of child bearing age. The patient was apparently unaware of her pregnancy at the time of the I-131 administration on March 9,1994. To prevent recurrence, the licensee is developing internal policies which will address options for pregnancy i
determination, including serum pregnancy testing or suitable written proof, such as evidence of a hysterectomy.
Report No. 94-16 Teletherapy Misadministration at Medical Center Hospital in Chillicothe, Ohic On July 21 and 22,1994, a patient received a radiation dose of approximately 300 centigray (cGy)(300
)
rad) to an unintended treatment site using a cobalt-60 teletherapy unit. A patient was scheduled to receive 1400 cGy (1400 rad) in a series of seven treatments for cancer of the esophagus. Each of the treatments was to consist of two radiation exposures'of 100 cGy (100 rad) each delivered from different i
angles. The first treatment was performed on July 21. Following the first of the two exposures during the second treatment on July 22, the technologist found inconsistencies in the angles of treatment documented in the written directive and in the patient simulation sheet. Upon further review, the licensee 1
- determined that the wrong treatment angles had been used during the first treatment and part of the second treatment.As a result of the incorrect angles of exposure, the treatment site received only part of the prescribed dose and adjacent tissue received a higher dose than intended. The licensee estimates a dose of 300 cGy (300 rad) to the unintended site. Under normal conditions, the unintended site would have received approximately 20-50 cGy (20-50 rad). The treatment angles were corrected on the patient's chart, and the radiation dose was modified to compensate for the reduced dosage delivered in the initial treatments. The patient was informed and no adverse medical effects are expected.
l The error occurred because the simulated gantry angles had not been converted to the treatment unit gantry angles, and gantry angle conversion factors were not included in the licensee's treatment chart 9
NUREG-1272, Appendix B
AEOD Annual Report,1994-FY 95 checks conducted by the technologists. To prevent recurrence, the licensee's corrective actions included the following: (1) revising the simulation data form to include a specific location to document the converted gantry angles; (2) initialing all angle conversions by the person performing the conversion, and having a second individualindependently verify the conversions prior to treatment;(3) instructing the technologists to review all treatment information and to resolve any discrepancy prior to continuing treatment; (4) performing all future gantry angle conversions by the licensee rather than by the licensee's simulation contractor; and (5) conducting a review of past treatment plans back to 1988, with emphasis on those which did not identify any additional errors.
Report No. 94-17 Sodium Iodide Misadministration at St. Joseph Mercy Hospital in Pontiac, Michigan On July 26,1994, a misadministration occurred involving a patient receiving the wrong radiopharmaceutical for a diagnostic procedure. The patient's referring physician requested a thyroid scan which involves administration of a standard prescription at St. Joseph Mercy Hospital of a 9.25 megabecquerel (MBq) (0.25 millicurie [ mci]) sodium iodide-123 (I-123) capsule. However, the licensee administered a 92.5 MBq (2.5 mci) I-131 capsule. The amount of activity that was administered is normally used following removal of the thyroid to examine a patient for the spread of cancer from the thyroid through the body. An NRC medical consultant concluded that the resultant unnecessary dose to the patient's thyroid would result in a low, but finite, proba'oility of hypothyroidism developing in the future. Also, there is a lifetime probability of developing radiation-induced thyroid cancer of 10 percent, including a risk of fatal thyroid carcinoma of approximately 1 percent. The licensee has arranged for the patient to be seen by a endocrinologist, and for repeat thyroid imaging with I-123 to be performed several months after the misadministration. The patient was notified in person by the Radiation Safety Officer on July 27,1994. Subsequently, the patient was also given a written report that was dated August 5,1994.
The root cause of the misadministration was the lack of the treating physician's involvement in the patient's examination prior to the I-131 administration. The administrative staff and technologists failed to have the examination clarified by a treating physician with the referring physician prior to administration of the I-131. Other factors contributing to the event included the following:(1) failure of licensee management to ensure implementation of the licensee's written Quality Management Program; (2) deficiencies in training; and (3) failure to follow through on matters. To prevent recurrence, the licensee took the following corrective actions: (1) held a training session which included the Radiation Safety Officer, treating physicians and technologists; (2) instituted a limit on the number of individuals who will be involved in the use of I-131; and (3) required a written directive to be filled out and signed by a treating physician.
Report No. 94-18 Multiple Teletherapy Misadministrations at Sinai Hospital in Detroit, Michigan On July 28,1994, and August 3,1994, n-isadministrations occurred on two separate patients when the licensee's therapists failed to verify correct teletherapy machine parameters prior to treatment. Beginning on July 19,1994, a patient was to receive 4500 centigray (cGy)(4500 rad)in a series of 25 treatments to the left neck area. The first seven treatments were completed without incident. However, on the eighth treatment on July 28, one fraction was set up using the wrong treatment angle. This resulted in a radiation dose of 90 cGy (90 rad) being received by the right shoulder and neck area instead of the left neck area. Beginning July 5,1994, another patient was to receive 5000 cGy (5000 rad) in a series of 25 treatments to the right shoulder area. The first 20 treatments were completed without incident. However, NUREG-1272, Appendix B 10
Nuclear Materials-Abnormal Occurrences on the 21st treatment on August 3, the teletherapy unit was pos This resulted in a radiation dose of 100 cGy (100 rad) being rec,itioned using the wrong eived by the right lung area instead of the right shoulder area. An NRC medical consultant reviewed both cases and concluded that no significant adverse side effects or tissue injmy are expected.
The cause of both misadministrations was human errors by several of the licensee's therapists. The therapists failed to verify the collimator angle, the wedge setting, and the treatment site before l
administering the teletherapy dose to the patients. The licensee's corrective actions included l
(1) suspending all teletherapy treatments pending an internal investigation, and identification of i
appropriate corrective actions prior to re-start of the teletherapy treatments;(2) developing procedures l
which require independent verification of proper treatment parameters during patient set-up; and (3) installing a record-and-verify system on the teletherapy unit to ensure that all major treatment parameters are checked prior to a treatment.
Report No. 94-19 Crachytherapy Misadministration Involving the Use of a Strontium-90 Eye Applicator at the i
University of Massachusetts Medical Center in Worcester, Massachusetts j
1 On July 29,1994, a physician performed an ophthalmic treatment on a patient using a Sr-90 eye cpplicator without first removing the stainless steel mask from the source. Because of this oversight, the licensee estimated that the treatment site received 107 centigray (cGy)(107 rad) of radiation, rather than i
the 1250 to 2000 cGy (1250 to 2000 rad) that was intended. In addition, whereas the beta radiation from the eye applicator source only affects the surface of the eye, the bremsstrahlung radiation resulting from the interaction of the beta particles on the stainless steel mask is more penetrating. The patient returned on August 2,1994, for the completion of the therapy to bring the total dose delivered within the originally prescribed range. The licensee expects that the clinical outcome of the misadministration will be mconsequential for the patient.
The misadministration was caused by the following factors: (1) infrequent use of the ophthalmic epplicator and the fact that its appearance with the mask is similar to its appearance with the mask removed;(2) the event occurred on a Friday afternoon and the stress of the week's work affected the alertness of the individuals involved; and (3) the most experienced physicists were not available, and a relatively inexperienced physicist prepared the source and was unaware that the source was equipped with a stainless steel mask. To prevent recurrence, the licensee is reviewing the feasibility of modifying the mask in some manner to make it more easily distinguished from the unmasked source. In addition, the i
licensee has employed two new radiation oncology physicians and a new chief physicist.
l l
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11 NUREG-1272, Appendix B
AEOD Annual Report,1994-FY 95 NUREG-0090, Volume 17, No. 4 Report No. 94-21 Recurring Incidents of Administering Higher Doses than Procedurally Allowed for Diagnostic Imaging at Ball Memorial Hospital in Muncie, Indiana From October 1988 through June 1993, nuclear medicine technologists employed by the licensee had increased the dosages of radiopharmaceuticals used in diagnostic studies by as much as 40 percent. (The technologists had also falsified the required records of the dosages administered.) The doses were increased for imaging studies of the lung, liver, bone, and gastrointestinal tract using technetium-99m and xenon-133. The NRC did not identify any mdical misadministrations, as defined in 10 CFR 35.2, as a result of this practice of administering higher than approved doses for diagnostic imaging.
One technologist told licensee officials that the dosages were increased to minimize patient discomfort, to reduce imaging time for critically ill patients, and to enhance the clarity of images for studies performed on obese patients.
1 l
To prevent recurrence, the licensee conducted an internal review and consequently suspended two nuclear medicine technologists from all NRC-licensed activities. In addition, the licensee terminated one of the two individuals and the other was allowed to continue to perform duties that do not involve NRC-licensed i
activities. The licensee also committed to a number of corrective actions which include assigning a pharmacist or a radiologist to verify all radioisotope dosages, implementing a unit dose system, obtaining the services of an assistant radiation safety officer, and conducting monthly and quarterly audits of the Nuclear Medicine Section for at least one year, Report No. 94-22 Medical Therapy Misadministration at Veterans Affairs Medical Center in Long Beach, California On August 9,1994, a patient scheduled to receive 185 megabecquerel(MBq)(5 millicurie (mci]) of thallium-201 (a radiopharmaceutical not regulated by NRC) for a myocardial perfusion study was mistakenly administered 148 MBq (4 mci) of strontium-89 (Sr-89). Based on the misadministration of the Sr-89, the licensee estimated that the patient received 250 centigray (250 rads) to the surface of the bone.
The licensee reported that no action was taken to mitigate the consequences of the dose (i.e.,
administration of calcium as a blocking agent) because the patient had a preexisting heart condition which could have been exacerbated by administering calcium. The licensee also stated that medical experts were contacted to assist in an assessment of potential health effects to the patient. In addition, the licensee reported that with the exception of emergency procedures, it had voluntarily suspended all nuclear medicine procedures invoMng the intravenous administration of radiopharmaceuticals and had initiated an internal review of the misadministration.
l The cause of the misadministration was attributed to the administering technologist's failure to verify the dosage (by reading the label on the syringe) prior to injection. Corrective actions proposed by the licensee included the following: (1) physically separating diagnostic unit dosages from therapeutic radiopharmaceutical dosages in the licensee's hot lab; (2) packaging unit dosages received from a local radiopharmacy in different containers, according to isotopes; and (3) retraining technologists in requirements for identifying radiopharmaceuticals prior to injection.
NUREG-1272, Appendix B 12
i Nuclear Materials-Abnormal Occurrences i
i 1
4 Report No. 94-23 j
Medical Brachytherapy Misadministration at North Memorial Medical Center in Robbinsdale, Minnesota i
~
On August 3,1994, a catheter was inserted into the patient's bronchus and a ribbon containing 20 seeds of iridium-192 having a total activity of 673.4 megabecquerel (18.2 mci) was then inserted into the i
catheter and moved to the proper treatment location. The treatment plan was intended to deliver a prescribed dose of 2000 cGy (2000 rad) to the intended target. During the treatment, a nurse informed the l
physician that the visible portion of the catheter appeared to be protruding approximately 25.4 to 30.5 j
i centimeters (10 to 12 inches) frem the patient's nose. This was a significantly greater protrusion than previously observed, indicating that the catheter had moved from its initial placement. The nurse secured the catheter in place with additional tape. The physician stated that, based on the information available at that time, he determined that the catheter and ribbon had moved; but that the tumor was receiving some radiation dose and therefore he continued the treatment. ' Die iridium-192 seeds were removed on i
August 4 as planned. On August 4,1994, a staff radiologist read the portable x-ray film taken on August 3,1994, and indicated that the iridium implant was not seen. Due to catheter displacement, the tumor dose was significantly reduced and estimated to be 620 cGy (620 rads) or 31 percent of the intended dose. The remaining dose of 1380 cGy (1380 rads) was delivered to an unintended site. The patient was notified of the event by the treating physician on August 4,1994, and again by another i
physician on August 17,1994. The referring physician was informed by the treating physician on i
August 4,1994. An NRC medical consultant was retained to perform a clinical assessment of this misadministration. The medical consultant concluded that it is improbable that the patient will j
experience any long term consequences as a result of the exposure to the unintended treatment site.
The licensee has determined that the catheter movement caused a misadministration of the intended 4
dose. Two possible explanations for the catheter movement could be the following: (1) failure to properly secure the catheter in place with tape; or (2) nasal discharge decreasing the adhesive capability of the tape. The licensee's corrective actions include the following: (1) amending the nursing staff procedure so l
that the attending physician will be contacted if there are further questions; (2) directing nurses to follow the standing protocol for obtaining an administrative consult; (3) providing additional inservice training; (4) documenting the final length of the catheter in the patient chart; and (5) documenting the catheter position on each visit to the patient's room.
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e 1
j 13 NUREG.1272, Appendix B
AEOD Annual Report,1994-FY 95 NUREG-0090, Volume 18, No.1 Report No. 95-1 Medical Brachytherapy Misadministration at Welborn Memorial Baptist Hospital in Evansville, 1
Indiana l
On November 18,1994, a patient was prescribed a dose of 600 centigray (cGy)(600 rad) at the vaginal cavity using a high-dose-rate (HDR) afterloading device. However, because of a treatment error the patient received a 1250 cGy (1250 rad) dose instead. The misadministration occurred because of human error in entering a correction for treatment time, and because of read-only-memory (ROM) integrated circuits which contained a defective software program. The patient was notif:ed of the misadministration.
An NRC medical consultant concluded that long term effects such as fibrosis or loss of blood supply may occur because of the misadministration.
Corrective actions taken to prevent recurrence included revising the HDR operating procedure to require verification of all treatment data, and replacing the printed circuit board having the defective-software-program ROM with one having the correct-software-program ROM.
i I
NUREG-1272, Appendix B 14
Nuclear Materials-Abnormal Occurrences NUREG-0090, Volume 18, No. 2 Report No. 95-4 Medical Brachytherapy Misadministration at the University of Virginia, in Charlottesville, Virginia On March 14,1995, a patient was prescribed a gynecological treatment dose of 3000 centigray (cGy)(3000 rad). At the start of treatment, one of the sources fell onto the patient's bed and remained there for 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br />. As a consequence, the patient's foot received an unintended dose of about 13 cGy (13 rad). The patient was notified of the misadministration. The patient will not experience any adverse health effects j
as a result of the misadministration.
Corrective actions taken to prevent recurrence included informing the staff be more attentive during the source insertion process in order to account for all prescribed sources.
Report No. 95-5 i
Medical Therapeutic Radiopharmaceutical Misadministration ofIodine-131 at Massachusetts General Hospital in Boston, Massachusetts On May 9,1995, a padent was prescribed a 2% megabecquerel (MBq)(8 mci) dosage for hyperthyroidism. Because of human error, the administered dosage was 11063 MBq (29.9 mci). The patient was informed of the misadministration. The impact on the patient's health is expected to be negligible with no expected long-term disability. (The intent of the prescribed dose was to ablate the portion of the thyroid remaining after surgery, and then to support the patient with thyroid supplement for the remainder of life. This did not change with the administered dose.)
l Corrective actions taken to prevent recurrence included instituting procedures to ensure that correct doses are administered.
Report No. 95-6 Multiple Medical Brachytherapy Misadministrations at Madigan Army Medical Center in Fort Lewis, Washington During the period February 1994 through May 1995, four patients had brachytherapy treatments but received doses other than those prescribed because of the same computer input error. Patient A was prescribed a dose of 2800 centigray (cGy) (2800 rad) for a gynecological brachytherapy treatment, but received a dose of about 1680 cGy (1680 rad) instead. Patient B was prescribed a dose of 1600 cGy (1600 rad) for lung treatment, but received a dose of about 2128 cGy (2128 rad) instead. On another day Patient B was also prescribed a dose of 1500 cGy (1500 rad) for lung treatment, but received a dose of about 2350 cGy (2350 rad) instead. Patient C was prescribed a dose of 3000 cGy (3000 rad) for gynecological treatment, but received a dose of about 5142 cGy (5142 rad)instead. Patient D was prescribed a dose of 1500 cGy (1500 rad) for a biliary tract treatment, but received a dose of about 2050 cGy (2050 rad) instead. (The same computer input error could cause either underdoses or overdoses because the 15 NUREG-1272, Appendix B
AEOD Annual Report,1994-FY 95 algorithm used was dose dependent.) The patients were not expected to experience any adverse health effects as a result of the misadministrations.
Corrective actions taken to prevent recurrence included correcting the data entered into the computer treatment planning computer, recalculating the doses received by the patients, and ensuring that appropriate data will be used for future treatment plans.
NUREG-1272, Appendix B 16
l Nuclear Materials-Abnormal Occurrences NUREG-0090, Volume 18, No. 3 i
Report No. 95-7 Medical Brachytherapy Misadministration at Marshfield Clinic in Marshfield, Wisconsin i
On June 8,1995, a patient was prescribed a dose of 1640 centigray (cGy)(1640 rad) for a low dose rate brachytherapy treatment of the cervix using implanted sources. The sources were removed one day later than planned. Consequently the administered dose was 2440 cGy (2440 rad), or approximately 50 percent more than the prescribed dose. The patient was informed of the misadministration. The patient would have no adverse health affects.
Corrective actions taken to prevent recurrence included revising the requirements for documenting the actual implantation time, and the time for the prescribed and actual removal of sources.
Report No. 95-8 l
Medical Brachytherapy Misadministration at Providence Hospital in Southfield, Michigan
)
On July 25,1995, a patient was prescribed a dose of 1230 centigray (cGy)(1230 rad) for a palliative manual brachytherapy treatment of the brain using a seed. After implantation, confirmatory x-rays were taken but could not confirm the location of the seed and the treatment was terminated about 31 hours3.587963e-4 days <br />0.00861 hours <br />5.125661e-5 weeks <br />1.17955e-5 months <br /> after implantation. The licensee determined that the seed was implanted about 4 centimeters (1.57 inches) from the intended treatment site of the brain. Consequently, the wrong treatment site received an unintended radiation dose of about 739 cGy (739 rad) and the tumor received only about 72 cGy (72 rad).
'Ihe patient was notified of the misadministration. No adverse health effects would result from the misadministration.
Corrective actions taken to prevent recurrence included the future use of fluoroscopy to assme proper implantation of radioactive material.
Report No. 95-9 Ingestion of Radioactive Material by Research Workers at the National Institutes of Health in Bethesda, Maryland On June 28,1995, a pregnant research employee became internally contaminated with phosphorus-32 (P-32) and was sent to a local hospital for treatment. Subsequently,26 researchers (in addition to the pregnant researcher) were found to be contaminated. The cause of the event remains unknown.
Corrective actions taken to prevent recurrence included performing bioassay sampling to ensure that the scope of the contamination was known, developing an augmented radiological survey program to identify additional contaminations, and developing security plans for food storage.
17 NUREG-1272, Appendix B
r-I l
Appendix B-2
{
j Agreement State Licensees i
l 4
i 4
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.,.m.
Nuclear Materials-Abnormal Occurrences NUREG-0090, Volume 17, No.1 Report No. AS 94-1 Therapeutic Radiopharmaceutical Misadministration at North Carolina Baptist Hospital in Winston Salem, North Carolina 4
On June 17,1993, the nuclear medicine technologist had prepared dosages for two different patients and then prepared both patients for injection. The technologist was temporarily sidetracked and then returned to complete administration of the prepared dosages. The first patient received a 592 megabecquerel (MBq)(16 millicurie [ mci]) therapeutic dose of iodine-131 instead of the prescribed 37 MBq (1 mci) diagnostic dose of thallium-201 for a myocardial perfusion scan. Upon entering the next room to administer the dosage to the second patient, the technologist discovered the error. Immediate action taken by the licensee included notifying the referring physician and patient. An approved iodine contrast agent was mjected into the patient, hemodialysis was initiated, and daily doses of potassium iodine were started and continued for 2 weeks. The patient was also held overnight for observation. No thyroid uptake was performed. Without uptake data only rough estimates of the patient's exposure can be made.
According to the International Commission on Radiological Protection, publication 53, " Radiation Dose 4
to Patients from Radiopharmaceuticals," 100 percent blocking of the thyroid would result in all organ doses being less than 50 millisievert (mSv)(5 rem), and the effective dose equivalent would be i
approximately 43 mSv (4.3 rem). Assuming incomplete blockage, some parts of the gastrointestinal (GI) tract, the bladder wall, and the thyroid would have significantly higher doses. In addition, the Nelonal Council on Radiation Protection and Measurements Report No. 80, " Induction of Thyroid Cancer by Ionizind Radiation," states that a significantly increased risk of thyroid cancer has not been detected in several studies on humans at the dose level misadministered to the patient. However, due to the likelihood of incomplete thyroid blockage, the patient will need to be monitored for signs of hypothyroidism. The patient was contacted several times for follow-up observations; however, the patient
)
lives out of town and has not been willing to cooperate. Therefore, no additional actions are expected.
This misadministration occurred due to personnel error during a time of heavy workload. Tb prevent recurrence, the State licensee implemented a new policy to color-code prepared dosages to more clearly j
and easily distinguish between therapeutic and diagnostic dosages.
1 i
21 NUREG-1272. Appendix B
AEOD Annual Report,1994-FY 95 NUREG-0090, Volume 17, No. 2 Report No. AS 94-2 Medical Brachytherapy Misadministration at Memorial Medical Center in Lufkin, Texas On August 4,1993, brachytherapy treatment began on an obese 90-year-old patient using a Delclos vaginal cylinder implant. TWo cesium-137 implant sources of 25 milligram radium-equivalent strength (2323.6 megabecquerel [62.8 millicurie]) were loaded at 240 p.m. for a 20-hour treatment of 3000 ce (cGy)(3000 rad). The estimated dose to the abdomen due to the prescribed procedure would be 20 (20 rad). The implant was secured at the implant site with surgical tape. During the treatment period, the patient became distressed and was repositioned to ease her breathing, The implant placement was last verified at 6.00 a.m. on August 5,1993. At 10:30 a.m. that day, the doctor terminated the treatment. At the time he noted that one implant was positioned on the patient's abdomen. The doctor believes that the repositioning of the patient may have dislodged the implant and the tape pulled the implant onto the patient's abdomen. The doctor indicated that the tapens the only method used to secure the implant because of the, design and location. The hospital's raud n physicist calculated that the skin dose rate from the implant was 150 cGy (150 rad) per hour. If the implant was on the patient's abdomen for 4.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />, the unintended deses would have been 675 cGy (675 rad) to the abdomen and 2325 cGy (2325 to the tumor. This is a tis 5 cGy (655 rad) unintended to the abdomen and a 675 cGy (675 rad) underdose to the tumor. A review of personnel monitoring records for the doctor and nurses caring for the patient indicated there were no elevated radiation exposures. The patient was informed of the incident. On September 2,1993, the patient was examined by her doctor and no evidence of radiation damage to the abdomen was noted. The patient has since died.
The misadministration was caused by repositioning of the patient to relieve breathing distress was the probable cause of the implant relocation. To prevent recurrence, the hospital increased nursing in-service training with emphasis on source and implant apparatus identification, and the importance of verifying implant placement during each patient check. The doctors are also reviewing different means to secure these devices in patients.
Report No. AS 94-3 Radiation Burn of an Industrial Radiographer at Blazer Inspection in Texas City, Texas On February 23,1994, a radiography crew was radiographing welds on a 30.5-centimeter (cm)(12-inch) diameter pipe line in a 1.5 meter (5-feet) deep ditch at Amoco Pipeline, using a 3552 gigabecquerel (%
curie) iridium-192 source. They had experienced difficulty with the source exiting from and retracting into the camera earlier in the day. In trying to retract the source to the shielded position after a radiograph,it was apparent from the survey meter readings that the source was in an unshielded position. During subsequent activities, the radiographer disconnected the guide tube and the source fellinto the mud at the bottom of the ditch. While picking up the source from the mud with channel lock pliers the source slipped, the radiographer apparently touched the source. About 10 days later, the radiographer started experiencing discomfort in his left thumb and index finger and visited a doctor for treatment on March 9, 1994, and again on March 14, and April 1,1994. On April 11,1994, the radiography company's Radiation Safety Officer (RSO) and the radiographer visited the State agency office and reported the incident. ' Die State agency investigated the incident at this time, and found that the film badge reading was 213.6 millisievert (21.36 rem) whole body.
NUREG-1272, Appendix B 22
Nuclear Materials-Abnormal Occurrences The root cause of the event was the manufacturer's mistaken delivery of a pigtail model number, different than the one ordered, and the radiography company's assumption that the pigtails received were the models ordered, resulted in a pigtail being used in a camera for which it was not manufactured. Also, the radiographer knowing he was not authorized to do so, attempted to recover the disconnected source. He stated that due to the darkness and the mud in the ditch, he felt the circumstances warranted his attempt to recover the source. The radiographer was not trained in source recovery and had no previous experience with source disconnects. To prevent recurrence, the licensee and radiographer were cited for violations of the Texas Regulations for Control of Radiation and are being called in for an escalated Enforcement Conference.
Report No. AS 94-4 Lost Well Logging Source at Tucker Wireline Service of Corpus Christi, Texas On April 19,1994, a well logging crew with Tucker Wireline Services completed a job for Amoco Production Company at the Los Lomas Ranch, Peters Estate, Well Number 1, which is 16 miles south of Freer, Texas. They loaded all tools and equipment onto their truck along with a 111 gigabecquerel (3 curie) americium / beryllium-214 source and its shield, which were chained in a left rear compartment. The shield is a 36-centimeter (14-inch) diameter cylinder, which is painted purple and weighs 347 newtons (78 pounds). The well logging crew stopped in Freer to report to the office and noticed that the compartment was open. They checked the compartment and found that the source and shield were missing. On April 21,1994, the Texas Board of Health issued a press release about the missing source. That afternoon a ranch owner called and reported that he had found the source, and had placed it in his barn thinking it was a tool box. He agreed to meet the next morning and return the source to the licensee. On April 22, 1994, the State agency and licensee personnel met with the ranch owner who returned the source to the licensee. The ranch owner had found the source beside the road, and placed it in the back of his truck.
He drove it to his barn and kicked the source off the back of his truck. State agency calculations indicated the ranch owner received less than 50 microsievert (5 millirem) exposure during the handling of the source. The required labeling information was not on the shield.
The cause of the event was that the source and shield were not properly secured against accidentalloss from the truck. Although the well logging crew indicated they chained and locked the source and shield to the truck, circumstances do not support that contention. To prevent recurrence, the State agency cited the licensee for failure to secure the source against accidental loss and violations of labeling requirements.
The licensee was called in for an escalated Enforcement Conference.
Report No. AS 94-5 Multiple Brachytherapy Misadministrations at Cedars Medical Center in Miami, Florida On May 17,1994, an error was discovered in the treatment of seven patients with low dose rate cesium-137 (Cs-137) brachytherapy sources. One patient was treated with three Cs-137 sources during a gynecological implant procedure, during the period of May 4 through 8,1994. The patient received I
approximately 9130 centigray (9130 rad) to the treatment area, which was about 238 percent greater than prescribed. Further investigation of the incident revealed that the error involved six additional patients, with the patients each receiving doses ranging from 37 percent to 144 percent in excess of their intended doses. The licensee reported that the misadministrations for all seven patients were of similar naagnitude.
Possible consequences apply uniformly to the patients, and will be due to the dose received to organs near the implants. The licensee stated that all of the organs may have had similar complications even if there had been no overdose, and the risks for complications have increased even though the possibility 23 NUREG-1272, Appendix B
AEOD Annual Report,1994-FY 95 I
for cure has also increased. The referring physicians and patients have been notified, and patient follow-up has been implemented to include routine examinations.
The misadministrations were caused by a calculation error when the physicist entered the wrong gamma constant when he edited the computer program on March 29,1994. The physicist was attempting to convert from " milligram radium equivalent" to "millicurie" and entered 3.256 " radium" instead of j
"millicurie," resulting in an error ratio that was 2.5 times greater than expected. (The treatment planning i
system was developed by Computerized Medical System of St. Louis, Missouri.) To prevent recurrence, i
the licensee discussed the incident with the manufacturer of the treatment planning system. The licensee also instituted more thorough training and supervision of personnelin brachytherapy calculational methods, which includes independent hand calculations of at least one key point for confirmation of dose.
\\
1 NUREG-1272, Appendix B 24
l l
Nuclear Materials-Abnormal Occurrences NUREG-0090, Volume 17, No. 3 Report No. AS 94-6 Loss of Management and Procedural Control of a Radioactive Source Licensed by the State of Illinois to KayRay, Inc., at a Georgia-Pacific Corporation Paper Mill in Palatka, Florida l
On April 11993, the licensee notified the State of Florida that a presumably empty KayRay, Inc., Model 7063P fixed gauge was found to still contain its 7400 gigabecquerel (200 millicurie) cesium-137 sealed j
source. The licensee's radiation safety officer (RSO) reported that the gauge was one of 16 damaged devices removed from service between March 10 and 19,1993, for repair or replacement. Following the removal and reloading of their source holders into new housings by a manufacturer's factory service technician, four of the damaged gauges were stored on-site pending the disposal as scrap metal. The RSO reported that the cause of the incident was the failure of the KayRay service technician to successfully transfer the gauge's sealed source from its damaged source housing to a replacement housing. (The gauges operate as level indicators in the corrosive environment of a paper mill. Extensive corrosion of four of the 16 gauges that were removed from service had left their source holders as the only salvageable components.)
The primary cause of the incident was the failure of the manufacturer's service technician to transfer the source to its new housing and subsequent failure to follow procedures which would have identified the location of the source. A contributing factor was the failure of both plant personnel and the service technician to note the deteriorating condition of the gauges and take corrective measures. The State's licensee failed to perform annual physicalinventories as required, and the manufacturer's service technicians that were contracted to perform annual leak tests of the gauges had failed to inform their client of the safety hazard created by the corroded gauges. To prevent recurrence, the licensee hired a consultant to assist them in resolving the gauge incident, assessing the exposures received by their personnel, and evaluating and implementing revisions to their radiation protection program to ensure compliance. A meeting was held with the gauge manufacturer's management to ensure that all required safety precautions are taken when the manufacturer's service technicians are on-site. Additional radiation safety training was provided to all of the licensee's personnel.
25 NUREG-1272, Appendix B
AEOD Annual Report,1994-FY 95 1
NUREG-0090, Volume 17, No. 4 Report No. AS 94-7 Major Contamination Event Due to a Breached Source at KayRay/Sensall, Inc., in Mt.
Prospect, Illinois On April 21,1994, a sened source containing 74,000 megabecquerel (2 curies) of cesium-137 in a fixed gauge source housing was breached as the manufacturer of the Incasuring system removed the source from its housing. The source rupture was not detected by the licensee until the day after the breach occurred. During this time, personnel, facilities, homes, and vehicles, including the radiological consultant's (who was on-site when the breach occurred) vehicle, facility, and his employees' homes and vehicles became contaminated with unsealed radioactive material. A total of 102 vehicles and Illinois and Wisconsin were surveyed by the State ofIllinoh. All contamination found was reduced to background levels, or the items or areas were removed or excised for disposal. The highest off-site contamination level was found in a rental truck used by the consultant on the day of the breach. The vehicle was decontaminated and returned to its owner. The Staw spent approximately 100 person-days in April and May characterizing the extent of the contamination and monitoring the effectiveness of the decontamination. The licensee *s facility returned to full operation on April 26, with shoe covers required for production personnel. One individual was found, through in vivo and in vitro measurements, to have an intake of 44.4 kilobecquerel (1.2 microcurie) or 0.74 percent of the annual limit intake. This resulted in a commitment effective dose equivalent (CEDE) of 0.4 millisievert (mSv)(40 millirem (mrem]). Of the seven other individuals who submitted urine samples, CEDE was estimated at 0.01 mSv (1 mrem) for one individual and 0.002 mSv (0.20 mrem) for another. No intake was detected for the other five indiv Since the annual limit for occupational exposure is 50 mSv (5000 mrem), no long term health effect is expected for any individual involved in the incident.
The root cause of the event was the rupture of the source as State licensee used a steel hammer to remove it from its holder. (The source had apparently been used in a corrosive environment, causing it to become stuck in the holder.) However, the primary cause of the widespread contamination was failure of the licensee to perform adequate surveys and its failure to analyze the leak test sample until the day after it was collected. To prevent recurrence, the State licensee proposed that it would no longer unload source capsules from retumed source heads. Its customers would be directed to send returned source heads to a 1
third party for source removal. The licensee also proposed that hand and foot surveys would be required after handling a source head, whether at the licensee's facility, a customer site, or a third party licensed l'acility. Weekly surveys are to be performed on an interim basis in the production area of its plant. A complete shutdown of all plant operations and personnel movement in the production area would occur if any contamination was found.
Report No. AS 94-8 Medical Brachytherapy Misadministration at St. Joseph's Hospital in Orange, California i
On October 19,1994, a brachytherapy overexposure occurred at St. Joseph's Hospital in Orange, California, which involved a 1110 megabecquerel (30 millicurie) cesium-137 source. The intended dose to the patient was 1400 centigray (cGy)(1400 rad), of which 1268 cGy (1268 rad) was to be administered 0.25 centimeters (0.1 inches) below the surface. The source fell out of the applicator as the radiation oncologist was attempting to load the it into an intracavity applicator. This was not observed by the physician.
Approximately seven hours later the patient's nurse found the source on the bed while she was attending NUREG-1272, Appendix B 26
Nuclear Materials-Abnormal Occurrences to the patient. The nurse removed the source from the bed with long forceps and placed it in the lead pig provided in the room for source storage. When the radiation oncologist later checked with the nurse, she was informed of the incident and confirmed that the source was not in the applicator. After consulting with the radiation safety officer, the radiation oncologist proceeded to reinsert the source into the applicator. The treatment time was rechecked to give the full, originally prescribed dose and was completed without further complications. The patient and the referring physician were both notified. The source was present on the bed, next to the skin of the patient for seven hours. The legs, back, and pelvic area of the patient were immediately checked for acute radiation exposure of the skin. No effects were i
identified. The patient was also examined two and three weeks after the incident and remains symptom free. Using National Council on Radiation Protection and Measurements Commentary No. 40 and reenacting the event, the licensee calculated a dose of 7000 centigray (7000 rads) to the skin of this patient. The dose estimate was verified by the Radiological Emergency Assistance Center. No other consultants were contacted for this incident.
The misadministration occurred because the source fell out of its carrier during initial insertion because of the location and position of the applicator. Insertion required the carrier to be placed in an upward, tilting direction and this, coupled with the twisting of the carrier to position it in the applicator, caused the source to drop out. To prevent recurrence, the licensee will now visually check the source after the carrier has been placed in the applicator for each source loading.
1 Report No. AS 94-9 Brachytherapy Misadministration at the University of California's Long Hospital in San Francisco, California On December 7,1993, a female patient was prescribed to receive 3500 centigray (3500 rad) to treat a cervical tumor using a pulsed Selectron high-dose-rate (HDR) remote afterloader brachytherapy device.
(She was also treated with external beam therapy.) The HDR treatment plan was prepared via computer and consisted of the following: (1) 161 dwell positions of varying times, and an expected total treatment time of 535.5. conds per pulse; and (2) a total of 58 pulses for the treatment. The computer generated times and posnions were manually programmed into the HDR unit to initiate treatment. One of the dwell l
times was incorrectly entered as 52.9 seconds, instead of the computer-calculated 2.9 seconds. Six other positions required the same dwell-time, so the programming for the first dwell-time entry wr.s stored and recalled for the others. This resulted in seven positions being programmed for 52.9 seconds instead of the correct value of 2.9 seconds. The consequence of the seven dwell-time errors was a total treatment time of 885.5 seconds per pulse, or 1.65 times the correct total treatment time. The data entry error probably occurred because the physicist entering the data on the keyboard accidently hit the number-5 and number-2 keys at the same time, which resulted in a programmed time of 52.9 seconds. Further procedures required that the total radiation time be hand-calculated and entered on the treatment planning sheet prior to programming the HDR unit. The machine-printed tape displaying total radiation time programmed into the HDR must be compared with the hand-calculated value to verify agreement between the two values. This verification was not performed contributing to the misadministration. In June of 1994, the patient developed a recto-vaginal fistula which required admission to San Francisco General Hospital for a bypass colostomy. From a recalculation of the radiation doses received, the licensee determined that the combined doses from external beam therapy and the HDR misadministration could have caused a rectovaginal fistula.
The root cause of this incident was determined to be keyboard entry errors while programming the HDR unit. A contributing factor was the failure to verify the total time programmed with the manually calculated total time as required by licensee procedures. To prevent recurrence, the licensee changed its procedures to require that a physician review and sign the machine-printed tape that shows the plan details, in addition to signing the prescription in the chart. In addition, the machine programmer must 27 NUREG-1272, Appendix B I
AEOD Annual Report,1994-FY 95 write the " total radiation time" calculated by the machine on the planning sheet that contains the prior hand-calculation of this value. The two values must be checked by a second person, and both people must initial the sheet. The second person can be a physicist, dosimetrist, physician, or brachytherapy technologist. All of these actions must be completed prior to the initiation of treatment. The licensee is also discussing possible corrective actions with the manufacturer. One option being explored is the possibility of having the computer-calculated treatment plan written to a disk, which will then be used to program the afterloader. The manufacturer has also been asked to recommend other software changes to prevent this type of event from recurring.
l Report No. AS 94-10 Medical Teletherapy Misadministration by an " Unspecified Licensee" at an " Unspecified Location"in New York On May 10,1993, a patient, with a sarcoma on the palm of the hand, was prescribed a treatment of 100 centigray (100 rad) each to the anterior and posterior of the hand. The posterior port of a fractional treatment to the palm of the hand was administered using a larger field size (16 by 20 centimeters [cm]
[63 by 7.8 inches]) than prescribed (11 by 14 cm [43'by 5.5 inches]). The prescription called for 100 centigray (100 rad) each to the anterior and posterior of the hand. The field size had been increased for the second exposure of a port film, and the technologist failed to reduce it to the proper size prior to delivering the dose for the posterior treatment. Therefore radiation was delivered to a larger field than prescribed, resulting in normal tissue outside the treatment field being irradiated. The error was detected when the set-up was being prepared for the anterior field. The patient and the referring physician were notified of the error. The treatment course was not altered as a result of the error. The licensee indicated that no adverse effect to the patient is anticipated as a result of this error.
The misadministration occurred because the technologist failed to follow existing procedures which require that treatment parameters be checked prior to delivering the dose. To prevent recurrence, the licensee counseled the technologist and reviewed the existing procedures. The need to check parameters before treatment was emphasized. The licensee's Quality Assurance Committee also reviewed the incident and actions taken. The licensee has procedures in place which are designed to prevent such mistakes.
)
NUREG-1272, Appendix B 28
Nuclear Materials-Abnormal Occurrences NUREG-0090, Volume 18, No. 2 Report No. AS 95-1 Medical Teletherapy Misadministration at an " Unspecified Licensee" in New York, New York Please note that New York State law prohibits disclosure of the name of the licensee for this event.
During May 23-26,1993, a patient was prescribed a total dose to the right superclavicular area and spine of 2400 centigray (cGy)(2400 rad) using teletherapy equipment. However, because the technologist marked the wrong treatment area, the patient received a dose of 900 cGy (900 rad) to the left superclavicular area. The patient was not informed of the misadministration. 'Ihe patient will have no adverse health effects from the misadministration.
Corrective actions taken to prevent recurrence included issuing a notice that addressed the importance of accurately marking treatment areas, and revising the applicable procedures covering treatment prescriptions and markings.
i Report No. AS 95-2 Medical Brachytherapy Misadministration by Mobile Technology, Inc., at Irvine Medical Center in Irvine, Califorma j
On March 14,1995, a patient was prescribed a brachytherapy treatment to the left lung using a high-dose-rate (HDR) remote afterloading unit. However, because of an error the patient received 800 centigray (800 rad) to the right lung. The patient was informed of the misadministration. The patient is not expected to develop clinically noticeable complications, and no significant change in lung function could be measured. However, a dose of this type may eventually cause a drying out of the lung mucosal cells in that region, resulting in a " dry cough."
Corrective actions taken to prevent recurrence included using real-time fluoroscopy at the time of the bronchoscopy; using a guide wire within all bronchial catheters at the time of the bronchoscopy; having participating physicians obtain and review a chest x-ray immediately following the bronchoscopy and catheter insertion, and prior to patient transport to the brachytherapy unit; confirming the intended treatment site by reviewing the patient consent form and from verbal communication with the pulmonologist, radiation oncologist, patient, and unit staff members.
Report No. AS 95-3 Overexposure of Personnel at Gwinnett Medical Center in Lawrenceville, Georgia On April 6,1995, personnel involved in a brachytherapy treatment received exposures above the minimum allowed as a result of handling what they assumed was a dummy source. The personnel included physicists, physicians, technologists and nursing staff. One of the physicists was pregnant (estimated at 11 weeks), but did not receive any significant overexposure. The most significant case was an overexposure to Physicist A who received 8.83 millisievert (mSv)(883 millirem (mrem]) erfective dose equivalent and 12,560 mSv (1256 rem) to the hands. Exposures for other involved individuals were as follows: Physicist B,1.15 mSv (115 mrem) effective dose equivalent and 433 mSv (43.3 rem) to the hands; 29 NUREG-1272, Appendix B
AEOD Annual Report,1994-FY 95 Physician A,1.08 mSv (108 mrem) effective dose equivalent and 54 mSv (5.4 rem) to the hands; Physician B, 031 mSv (31 mrem) effective dose equivalent and 108 mSv (10.8 rem) to the hands; and a Technolog 1.55 mSv (155 mrem) effective dose equivalent. Physicist A has not shown any signs of erythema.
j Corrective actions taken to prevent recurrence included having a certified health physicist make exposur dose calculations, and modifying the personnel training and accreditation program.
Report No. AS 95-4 Medical Brachytherapy Misadministration at Southwest Texas Methodist Hospital in San j
Antonio, Texas On July 28,1994, two patients were prescribed prostate treatment using implanted brachytherapy sources.
One was prescribed a dose of 160 gray (Gy)(16,000 rad) from an iodine-125 source, and the other was prescribed a dose of 115 Gy (11,500 rad) from a palladium-103 source. However, the sources for the two patients were accidently switched. The patients were notified of the misadministration. The only effects expected as a consequence of the misadministration were those that would result if the prescribed doses were administered to the correct patients.
Corrective actions taken to prevent recurrence included implementing new procedures for ordering, 4
receiving, loading, sterilizing, and implanting prostate implants.
J l
i 1
1 l
NUREG-1272, Appendix B 30
Nuclear Materials-Abnormal Occurrences l
NUREG-0090, Volume 18, No. 3 l
Report No. AS 95-5 Importation of a Package Having Excessive External Radiation into the United States from the Republic of Korea On December 20,1994, Omnitron International in Edgerly, Louisiana, received a package having external radiation levels that were approximately 18 times higher than allowed by the U.S. Department of Transportation. The package was one of two received from a shipper in the Republic of Korea. The i
package was subsequently found to have high radiation levels because the radioactive material inside was l
not secured in a shielded position. The packages had arrived in the United States at Los Angeles International Airport, after which they were transported by truck to Omnitron via Houston, Texas, where there was an extended stopover. At least eight companies (two brokers, two trucking companies, one repackager, and three freight forwarders) had handled the packages in the United States before they left Houston. At least 32 people in the United States were probably exposed to the excessive radiation from the package. The estimated doses for the people who received maximum ex30sure are as follows: (1) Los Angeles International Airport to Houston, Texas, 5.82 mSv (582 mrem); (2) Houston, Texas, (freight companies, brokers and a repackager) 46.13 mSv (4613 mrem); and (3) Houston, Texas, to Edgerlyz, Louisiana,0.84 mSv (84 mrem). The maximum estimated dose was received by an employee of a Texas firm where the packages were stored near the employee's workbench for a day or more.
Corrective actions taken to prevent recurrence included a review of the radioactive material shipment procedures used by the Korean service company to see if they were in compliance with regulatory requirements for transportation in the United States.
I l
i 31 NUREG-1272, Appendix B
d i
Appendix C Reports and Videotapes Issued From 1981 Through 1995 l
(Nuclear Materials) 4 I.
i j
4 J
I Nuclear Materials-Reports [ssued j
i Reports and Videotapes Issued from 1981 Through 1995 f
D:te Title No.
Author Nuclear Materials Reports issued in 1995 I
Special Studies 08/95 Human Performance Evaluation of Industrial INEl 95/0387 S. Pettijohn l
Radiography Exposure Events I
07/95 Misadministrations and Other Medical Events Memorandum to H. Karagiannis Caused by Computer Errors D.A. Cool from l
C.E. Rossi Nuclear Materials Reports issued in 1994 i
Videotapes j
04/94 Taking Control-Safety Procedures for S.Pettijohn Industrial Radiographers
~
Nuclear Materials Reports issued in 1993 i
i 1
Videotapes 04/93 Good Practices in Cobalt-60 Teletherapy H. Karagiannis i
Nuclear Materials Reports issued in 1992 l
f Engineering Evaluations j
08/92 Report on 1991 Nonreactor Events NUREG-1272, K. Black Vol. 6, No.2, App.A
- i 08/92 Report on 1991 NRC Licensee NUREG-1272 H. Karagiannis Misadministrations Vol. 6, No. 2, App.B 08/92 Report on 1991 Agreement Statc NUREG-1272 H. Karagiannis Licensee Nonreactor Events and Vol. 6, Misadministrations No. 2, App.C 4
4 1
1 NUREG-1272, Appendix C
AEOD Annual Report,1994-FY 95 Reports and Videotapes Issued from 1981 Througl.1995 (cont.)
Date Title No.
Author Nuclear Materials Reports Issued in 1991 Engineering Evaluations 01/91 Brachytherapy Incidents Involving a N91-01 H. Karagiannis Handloading, Endobronchial Technique 07/91 Report on 1990 Nonreactor Events NUREG-1272 K. Black Vol.5, No. 2, App.A 07/91 Medical Misadministration Report-Medical NUREG-1272 H. Karagiannis Misadministrations Reported to NRC From Vol. 5, January 1990 Through December 1990 No. 2, App.B i
Videotapes 02/91 Good Practices in Preparing and H. Karagiannis Administering Radiopharmaceuticals Nuclear Materials Reports Issued in 1990 Engineering Evaluations 06/90 Report on 1989 Nonreactor Eveats NUREG-1272 K. Black Vol. 4, No. 2, App.A 06/90 Medical Misadministration Report-Medical NUREG-1272 H. Karagiannis Misadministrations reported to NRC From Vol. 4, January 1989 Through December 1989 No. 2, App.B Nuclear Materials Reports Issued in 1989 l
Engineering Evaluations 06/89 Use of Radioactive Iodine for Infrequent Medical N901 H. Karagiannis Studies and those Performed Under an FDA Investigational Exemption of a New Drug (IND) 06/89 Report on 1988 Nonreactor Events NUREG-1272 K. Black Vol. 3, No. 2, App.B NUREG-1272, Appendix C 2
Nuclear Materials-Reports Issued Reports and Videotapes Issued from 1981 Through 1995 (cont.)
Date Title No.
Author Nuclear Materials Reports Issued in 1989 (cont.)
Engineering Evaluations (cont.)
06/89 Medical Misadministration Report-Medical NUREG-1272 H. Karagiannis Misadministrations Reported to NRC From Vol. 3, January 1988 Through December 1988 No. 2, App.B 05/89 Review of Therapy Misadministrations
'1908 K. Black That Involved Multiple Patients and the Use of Computer Programs Nuclear Materials Reports issued in 1988 Engineering Evaluations 09/88 Review of Events at Large Pool 'Iype Irradiators S807 E. 'Irager (NUREG-1345, March 1989) 10/88 Report on 1987 Nonreactor Events N801 K. Black 10/88 Medical Misadministration Reported to NRC for N802 S. Pettijohn the Period January Through December 1987 Nuclear Materials Reports Issued in 1987 Special Reports 10/87 Radiography Overexposure Events Involving S703 S. Pettijohn Industrial Field Radiography Engineering Evaluations 01/87 Diagnostic Misadministrations Involving the N701 S. Pettijohn Administration of Millicurie Amounts ofIodine-131 03/87 Diagnostic Misadministrations Reported to NRC N702 S. Pettijohn for the Period January 1986 Through December 1986 03/87 Report on 1986 Nonreactor Events N703 K. Black I
3 NUREG-1272, Appendix C l
AEOD Annual Report,1994-FY 95 Reports and Videotapes Issued from 1981 Through 1995 (cont.)
Date Title No.
Author Nuclear Materials Reports Issued in 1987 (cont.)
Technical Review Reports 11/87 Review of Data on Teletherapy Misadministrations T711 S. Pettijohn Reported to the State of New York That Were the Tttle of PNO-1-87-74A 12/87 Distribution ofInformation Notices and Other T714 S. Pettijohn
" Mass Mailing" Information to Licensees That Have Users at Locations Remote From the j
Headquarters Locations Nuclear Materials Reports Issued in 1986 Case Studies 08/86 Rupture of an Iodine-125 Brachytherapy Source C601 S. Pettijohn at the University of Cincinnati Medical Center Engineering Evaluations 06/86 Report of 1985 Nonreactor Reported and Five-Year N601 K. Black Assessment for 1981-1985 Reports 06/86 Medical Misadministrations Reported for 1985 and N602 S. Pettijohn Five-Year Assessment of 1981-1985 Nuclear Materials Reports Issued in 1985 i
Case Studies 12/85 Therapy Misadministrations Reported to NRC C505 S. Pettijohn Pursuant to 10 CFR 35.42 05/85 Summary of the Nonreactor Event Report Data N501 K. Black Base for the Period January Through June 1984 l
Engineering Evaluations 06/85 Summary of the Nonreactor Event Data Base for N502 K. Black the Period July Through December 1984 NUREG-1272, Appendix C 4
Nuclear Materials-Reports Issued Reports and Videotapes Issued from 1981 Through 1995 (cont.)
Date Title No.
Author l
Nuclear Materials Reports issued in 1985 (cont.)
l Engineering Evaluations (cont.)
07/85 Report on Medical Misadministrations for N503 S. Pettijohn l
January Through December 1984 Nuclear Materials Reports issued in 1984 Case Studies 09/84 Breaching of the Encapsulation of Sealed C405 S. Pettijohn Well-Logging Sources 05/84 Report on Medical Misadministrations for N204D S. Pettijohn January Through June 1983 06/84 Nonreactor Event Report Database for the Period N401 K. Black July Through December 1983 06/84 Events Involving Undetected Unavailability of the N402 E. Trager Thrbine-Driven Auxiliary Feedwater *llain 07/84 Report on Medical Misadministrations for N403 S. Pettijohn July Through December 1983 Nuclear Materials Reports issued in 1983 Engineering Evaluations and Technical Reviews 01/83 Nonreactor Event Report Database for the N209A E. Trager Period January Through June 1982 03/83 1-125/I-131 Effluent Releases by Material Licensees N301 S. Pettijohn 06/83 Mound Laboratory Fabricated Pu-Be Sources N302 K. Black 06/83 Americium Contamination Resulting From N303 K. Black Rupture of Well-Logging Sources 06/83 Nonreactor Event Report Database From N209B K. Black l
July Through December 1982 07/83 Americium-241 Sources N304 5
NUREG-1272, Appendix C
4 AEOD Annual Report,1994-FY 95 Reports and Videotapes Issued from 1981 Through 1995 (cont.)
Date Title No.
Author i
Nuclear Materials Repcrts Issued in 1983 (cont.)
Engineering Evaluations and Technical Reviews (cont.)
07/83 Report on Medical Misadministrations for N204C S. Pettijohn January 1981 Through December 1982 12/83 Potentially Leaking Americium-241 Sources N306 S. Pettijohn Manufactured by Amersham Corporation i
12/83 Nonreactor Event Report Database for the N307 K. Black Period January Through June 1983 3
03/83 Internal Exposure to Am-241 NT301 K. Black 04/83 KayRay, Inc. Reports of Suspected Leaking NT302 S. Pettijohn Sealed Sources Manufactured by General Radioisotope Products 08/83 Possession of Unauthorized Sealed Source /
NT303 S. Pettijohn Exposure Device Combinations by MidCon Inspection Services, Inc.
Nuclear Materials Reports Issued in 1982 Engineering Evaluations 02/82 Report on Medical Misadministrations for the N201 S. Pettijohn Period November 10,1980-September 30,1981 01/82 Buildup of Uranium-Bearing Sludge in Waste Tanks N202 K. Black 02/82 Lost Plutonium-238 Source N203 K. Black 03/82 Report on Medical Misadministrations for CY 1981 N204 S. Pettijohn, (M/82 Preliminary AEOD Review of Iodine-125 Sealed N205 E. Trager Source Leakage Incidents j
05/82 Eberline Instrument Corporation Part 21 Report N206 K. Black 05/82 AEOD Review of Iodine-125 Sealed Source N207 E.'Rager Leakage Incidents 08/82 Potentially Leaking Plutonium-Beryllium N208 S. Pettijohn Neutron Sources i
NUREG-1272, Appendix C 6
Nuclear Materials-Reports Issued 4
j Reports and Videotapes Issued from 1981 Through 1995 (cont.)
Date Title No.
Author 4
Nuclear Materials Reports Issued in 1982 (cont.)
4 Engineering Evaluations (cont.)
08/82 A Summary of the Nonreactor Event Report N209 K. Black 4
Data Base for 1981 11/82 Leaking Hoses on Self-Contained Breathing N210 K. Black Apparatus (SCBA) Manufactured by MSA Nuclear Materials Reports Issued in 1981 Engineering Evaluations 03/81 Interim Report on Brown Boveri Betatron N101 E. Trager 4
Calibration Check Source i
03/81 Irradiator Incident at an Agreement State Facility N102 K. Black i
(Becton-Dickinson, Broken Bow, Nebraska) 1 04/81 Interim Report on the October 1980 Fire at the N103 E. Trager
]
Iicensee's Sweetwater Uranium Mill 04/81 Interim Report on the January 2,1981, Fire at N104 E. Trager the Atlas Uranium Mill 05/81 Interim Report on Tailings Impoundment Liner N105 E. Trager Failure at the Sweetwater Uranium Mill l
08/81 Review of Reports of Leaking Radioactive Sources N106 E. Trager 12/81 Engineering Evaluation of Fire Protection at N107 E. Trager Nonreactor Facilities 12/81 Notes on AEOD Review of Emissions From Tritium N108 E. Trager Manufacturing and Distribution Licensees
}
7 NUREG-1272, Appendix C
l i
Appendix D Status of AEOD Recommendations (Nuclear Materials) l l
l
l Status of AEOD Recommendations The Office for Analysis and Evaluation of issues involving AEOD recommendations Operational Data (AEOD) tracking system regarding nuclear materials activities are ensures that all formal AEOD recommendations unresolved that warrant the attention of the are tracked until resolution. At this time, no Executive Director for Operations.
7 f
1 t
1 I
i l
l l
1 NUREG-1272, Appendix D
Appendix E l
4 Status of NRC Staff Actions for Events Investigated by Incident Investigation Teams (Nuclear Materials) l i
I l
l
Status of NRC Staff Actions for Events Investigated by Incident Investigation 'Ibams (Nuclear Materials) l In accordance with NRC Management adequacy of the actions taken by the responsible Directive 8.3, "NRC Incident Investigation office (s), and documenting the resolution of all Program," dated August 12,1992, the Executive staff actions.
director for Operations (EDO) shall, upon receipt of an Incident Investigation Team (IIT) report, This appendix provides the status or disposition, l
identify and assign NRC office responsibilities for along with appropriate references, for each of the i
generic and plant-specific actions resulting from NRC staff action items that the EDO assigned to i
the investigation that are safety significant and the various NRC offices that were not carrant additional attention or action. Office documented as resolved in previous AEOD Directors designated by the EDO as having Annual Reports on Nuclear Materials. Included responsibility for the resolution of issues or are actions associated with the IIT reports on the concerns are responsible for providing written 1990 event at Amersham Corporation, the 1991 status reports on the disposition of assigned event at General Electric Nuclear Fuels actions. AEOD is responsible for monitoring the Component Manufacturing Facility, and the 1992 status of assigned staff actions, evaluating the event at the Indiana Regional Cancer Center.
Action Source:
IIT Report on " Inadvertent Shipment of a Radiographic Source from Korea to Amersham Corporation, Burlington, Massachusetts," NUREG-1405, dated May 1990 (Reference 1).
Item 6:
Adequacy of Reporting Requirements Action:
Evaluate whether NRC and U.S. Department of Energy (DOT) regulations should be amended to include requirement to report the receipt of shipments of radioactive materials that were improperly prepared, labeled, identified, or classified, or had improper contents. (Responsible Office: NMSS)
Disposition:
Resolved On August 13,1990, the NRC requested that the DOT provide comments on the need for a requirement for consignees to report improperly labeled or prepared packages upon receipt. The staff evaluated NRC and DOT reporting requirements (Reference 2) and concluded that requiring licensees to report all mislabeled or misidentified packages would require both the licensees and the NRC staff to expend significant resources for problems that are of little or no safety concern. However, the staff also concluded that the NRC should be informed and should respond to any situation similar to the Amersham incident. The NRC staff determined that because the new 10 CFR Part 20 requirements will only apply to labeled or damaged packages, the previous situation in which Amersham received a cropped source in a package thought to be empty may not be covered. The NMSS staff originally j
recommended to RES that Section 20.906 of 10 CFR Part 20 be amended to require l
a licensee to notify the NRC when the licensee received an unlabeled package l
containing radioactive materials that should have been labeled in accordance with DOT requirements (Reference 3). However, upon further review of the original recommendation, the NMSS staff determined that incident reporting requirements in 10 CFR 20.2202 were sufficient to address the concerns.
1 NUREG-1272, Appendix E
AEOD Annual Report,1994-FY 95 1
s i-Item 9:
Adequacy of Shipper Instructions 3
i i
Action:(a)
Meet with the DOT and determine (1) the purpose and expectations of actions by forwarding agents at the place of United States entry for shipments of radioactive 1
i materials, (2) whether such agents are informed of the pertinent DOT requirements, i
and (3) whether such requirements are realistic and important to the handling of radioactive material shipments and should be enforced. (Responsible Office: NMSS)
Disposition:
Resolved i;
l On August 13,1990, the NRC requested that the DOT provide comments on this issue. The DOT completed their mvestigation on July 30,1991 and issued a Probable Notice of Violation of 49 CFR 171.12(a)(Reference 5), to Amersham on July 31,1991.
i However, based on their review of the Notice of Violation, DOT Investigation Report, and Amersham's Corrective Action Response dated November 1,1991, DOT l
dismissed the violation, by order dated April 5,1993 (Reference 6) and determined
)
that no corrective action was required by Amersham regarding this issue.
l Based on their review of the above, the NMSS staff also determined that no corrective action was required by Amersham. However, the NMSS staffissued NRC Information Notice 90-56 (Reference 4), to inform their licensees of the need to comply with DOT import and export requirements. The responsible office considers i
this item resolved. AEOD performed an independent review of this issue and also considers the item resolved.
1 l
Action:(b)
Pending the results of Action Item 9(a), initiate action to ensure that Amersham has'.
taken appropriate corrective measures and to ensure the completeness and accuracy t
of information provided to forwarding agents. (Responsible Office: RI)
]
Disposition:
Resolved i
j Based on their review of the above issue, NMSS and RI concluded no corrective action was required. The responsible office considers this item resolved. AEOD j
performed an independent review of this issue and also considers the item resolved.
i l
References:
1.
NUREG-1405, " Inadvertent Shipment of a Radiographic Source from Korea to
{
j Amersham Corporation, Burlington, Massachusetts," dated May 1990.
4 p
2.
- Memorandum for J. Glenn to J. Hickey, " Evaluation of NRC and DOT Reporting Requirements: NMSS Follow-up to Inadvertent Shipment of a 3
Radiographic Source from Korea to Amersham Corporation"(NUREG-1405),
dated October 31,1990.
3.
Memorandum from R. Bernero to E. Beckjord, " Request for Rulemaking-Amendment to 10 CFR 20.906, Procedures for Receiving and Opening Packages," dated February 5,1991.
4.
NRC Information Notice 90-56, " Inadvertent Shipment of a Radioactive Source in a Container Thought to be Empty," dated September 4,1990.
5.
U.S. Department of Transportation Notice of Probable Violation, dated July 31, 1991.
6.
U.S. Department of Transportation Order, date issued, April 5,1993.
NUREG-1272, Appendix E 2
Nuclear Materials-Staff Actions 4
Action Source:
IIT Report on the " Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991," NUREG-1450, dated August 1991 (Reference 1).
Item 1:
Adequacy of Criticality Safety Reviews Action:(a)
Evaluate existing regulatory requirements, guidance, and review standards for criticality safety analyses of fuel facility licensees to modify processes, procedures, and facilities and develop new regulatory guidance, requirements, and review standards. (Responsible Office: NMSS/RES)
Disposition:
Ongoing The NMSS Division of Fuel Cycle Safety and Safeguards (FCSS) developed an action J
plan (SECY-93-128) that presented an integrated approach to revamping the regulations and guidance for fuel facility licensing and developing a Standard Review Plan (SRP) for license reviews. As stated in SECY-93-128, FCSS is taking a fresh look at the fuel cycle regulatory, licensing, and inspection programs, emphasizing activities that will offer the greatest and/or near-term safety benefit without placing undue burden on the licensees. Among the principal products of the effort will be a major revision of 10 CFR Part 70 and its supporting regulatory guidance, and issuance of review standard in the form of an SRP. The review will require, performance of an Integrated Safety Analysis (ISA) for the initial application and, as appropriate, reanalysis to support amendment of the application or a 10 CFR 50.59-type process. Criticality safety would be one part of an ISA. 'Ibe activities, described above, supersede the recommendation to consider separate action on criticality safety; Presently, Part 70 is going through a review process with licensees in an effort to develop a better understanding with licensees and interested parties concerning the objectives of new Part 70 rulemaking (Reference 23). This item is scheduled to be completed by March 30,1997.
Action:(b)
Evaluate the use of safety operating specifications for radiation and nuclear safety instruments and controls. (Respomible Office: NMSS)
Disposition:
Ongoing The staff has evaluated the need for a requirement for licensees to include in their applications technical specifications for nuclear safety instrumentation and controls and concluded that it is not warranted. Instead, the staff intends to address radiation and nuclear safety instrumentation and controls in the same manner as other safety-related structures, systems, and components.
Revision to 10 CFR Part 70 and accompanying Standard Format and Content Guidance (SF&CG) for fuel cycle facility license applications will reflect this intent.
It is expected that the planned revision to Part 70 will require licensees to perform ISAs. These ISAs will allow determination of defects or failures which could lead to ac-idents. Once the ISAs are in place, licensees will have NRC-approved analyses that identify equipment, personnel, and procedures needed to assure safety. The licensing project manager and the inspection staff will ensure that a licensee does not significantly change its ISA process without NRC approval, and that the ISA is used on an ongoing bas to evaluate any changes to the operations. The rule will make 3
NUREG-1272, Appendix E
AEOD Annual Report,1994-FY 95 clear that the licensee can make changes to the facility, including the plant operations and equipment, without prior Commission approval, only under certain limited conditions that involve no additional risk. This rulemaking and associate guidance will address management control and oversight of safety-related equipment and procedures, including assurance of reliability and availability, human factors aspects, and training regarding safety significance and deviations from the licensee's safety basis standard (Reference 23). This staff action has been included in the action plan in SECY-93-128. This item is scheduled to be completed by December 30,1996.
Action: (c)
Evaluate the need to change the licensing practice ofincorporating a license condition by reference in fuel facility licenses. Ensure that the resultant licensing practice is mutually understood by all involved in the process. (Responsible Office:
NMSS)
Disposition:
Ongoing The staff has been working with the fuel facility licensees during the amendment and renewal processes to include greater specificity in the commitments on their applications. This addresses the deficiency of having vague commitments that are ne; possible to inspect or enforce. The revamping of the regulations and guidance for fuel facility licensing, discussed in action (a) above, will provide a better regulatory base for obtaining adequate commitments.
Presently, NMSS is going through a review process with licensees in an effort to develop a better understanding with licensees concerning the objectives of the new Par : 70 (Reference 23). 'Ihis item is scheduled to be completed by December 30, 1996.
Action: (d)
Evaluate the existing NRC programs and develop new guidance for the inspection of changes to criticality safety controls at fuel fabrication facilities. (Responsible Office:
NMSS)
Disposition:
Ongoing The staff determined that completion of this item was dependent on issuance of the new Part 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content of ISA documents. These will provide an improved basis fc inspection guidance in this area. NMSS is presently going through a review process with licensees in an effort to develop a better understanding with licensees concerning the objectives of the new Part 70.
Even though the new Part 70 has not been issued in final form, FCSS staff has initiated actions to upgrade Manual Chapter 2600 and associated inspection procedures (the due date is March 30,1996). Once the revised Part 70 is issued in its final form, any additional required changes to the manual chapter or inspection procedures will be initiated (Reference 23). This item is scheduled to be completed by December 30,1996.
Action:(e)
Evaluate the adequacy of NRC training and qualification programs to effectively support criticality safety inspections at fuel facilities, and develop enhancements to the training program. (Responsible Office: NMSS/AEOD)
Disposition:
Resolved A crnicalty safety training program for NRC inspectors has been developed under contract and made part of the curriculum of the NRC's Technical Training Center.
NUREG-1272, Appendix E 4
l
Nuclear Materials-Staff Actions The program was given for the first time in June 1993. AEOD has performed an independent review of this issue and also considers the item resolved.
Action: (f)
Evaluate General Electric's (GE) response to the IIT report with respect to the site-specific corrective actions. Include in this evaluation, the adequacy of (1) the current license, (2) the Facility Change Request process and its implementation, and (3) the criticality safety margins. (Responsible Office: NMSS/RII)
Disposition:
Resolved The staff evaluated GE's response to the IIT report with respect to the site-specific corrective actions. This evaluation included the adequacy of the current license, the facility change request process and its implementation, and criticality safety margins.
NRC conducted inspections to verify that adequate corrective actions. AEOD has performed an independent review of this issue and considers the item resolved.
Item 2:
Adequacy of Facility Operational Safety Action: (a)
Upgrade existing inspection guidance related to management controls and oversight, including audits, personnel training, and procedure adequacy and compliance for major materials hcensees. (Responsible Office: NMSS/RES)
Dispositiom Ongoing The staff determined that completion of this item was dependedt on issuance of the revised Part 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content of ISA documents. These will provide a more specific basis for improved inspection guidance. NMSS is presently going through a review process with licensees in an effort to develop a better understanding with licensees concerning the objectives o' 'he new Part '0.
FCSS staff has initiated actions to upgrade Manual Chapter 2600 and associated inspection procedures even though new Part 70 has not been issued in final form the due date is march 30,1996). Once revised Part 70 is issued in its final form, any additional required changes to the manual chapter or inspection procedures will be initiated (Reference 23). This item is scheduled to be completed by December 30, 1996.
Action: (b)
Determine the need for regulatory requirements, guidance, and standard review plans regarding management controls and oversight, including audits, personnel training, and procedural adequacy and compliance for major materials licensees. Conduct reviews or inspections at selected hcensees to collect additional information on management controls and practices. If necessary, on the basis of these assessments, develop new guidance, requirements, and standards as appropriate. (Responsible Office: NMSS/RES/NRR)
Disposition:
Ongoing In February 1992, the NMSS Materials Regulatory Task Force issued NUREG-1324,
" Proposed Method for Regulating Major Materials Licensees," which set forth recommendations concerning deficiencies and needed improvements in licensing and regulation of major materials licensees. NUREG 1324 placed considerable emphasis on improving licensees' management controls because past incidents can be traced directy to breakdowns in these controls. As part of item 5.1.5, the staff was to analyze the costs and benefits of performing safety analyses and preparing safety 5
NUREG-1272, Appendix E
1 AEOD Annual Report,1994-FY 95 evaluation reports for initial materials licensing, renewals, and major amendment actions for the large materials plants.
De planned revision to 10 CFR Part 70, discussed in Action (a) above, will include requirements for management controls and oversight which are being addressed in detailin the SRP for review of applications for fuel cycle facility licenses, both in general and in chapters on specific topics, such as nuclear criticality safety. The SFACG, derived directly from the SRP, will convey the details to the licensees.
Policy and Guidance Directive (P&GD) FC 85-7, Revision 1; " Standard Review Plan for Applications for Type A Ijcenses of Broad Scope," was issued June 20,1994. This document stresses the necessity of strong management controls and oversight to ensure that licensed activities in an extensive radioactive materials program are conducted properly. The document also includes specific guidance on the duties and responsibilities of the Radiation Safety Committee (RSC) and Radiation Safety Officer (RSO), to include immediate termination of any activity that is a threat to public heahh and safety. As part of the licensing process, licensees are requested to provide certification that the RSO understands and accepts all the responsibilities of the position. In addition, NUREG-1516, " Management of Radioactive Material Safety Programs at Medical Facilities," was published in January 1995. This NUREG introduces the concept of the " management triangle" to emphasize that three parties (executive management, the RSC, and the RSO) are responsible for providing effective oversight of the radiation safety program.
With respect to item 5.1.5, the staff expects that review of this issue will be conducted as part of the overall Business Process Reengineering effort which will examine the licensing process. In the meantime, the revised licensing guidance, in addition to the revised inspection guidance contained in Manual Chapter 2800, is adequate to identify safety concerns for large materials licensees (Reference 23). However, because of recent incidents at the National Institutes of Health and Massachusetts Institute of Technology, the responsible office will keep this item open until a review and any needed revisions of existing regulations and guidance are completed.
Action:(c)
Examine the overall inspection process for monitoring and collecting fuel facility safety performance information. Include in the evaluation the merits of (1) a resident ins (3)pector program; (2) more frequent inspections, including use of team inspections; establishment of a systematic performance appraisal and feedback program analogous to the Systems Assessment of Licensee Performance for 10 CFR Part 50 licensees. (Responsible Office: NMSS/NRR)
Disposition:
Ongoing The staff determined that completion of this item was dependent on issuance of the revised Part 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content of ISA documents.
Part 70 is presently going through a review process with l'censees in an effort to develop a better understanding with licensees concerning the objectives of new Part 70. Even though new Part 70 has not been issued in final form, FCSS staff has initiated actions to upgrade Manual Chapter 2600, Manual Chapter 2604, and their associated inspection procedures (Reference 23). Once revised Part 70 is issued in its final form, any additional required changes to the manisal chapters or inspection procedures will be initiated. 'Ihis item is scheduled to be completed by December 30, 1996.
NUREG-1272, Appendix E 6
Action: (d)
Evaluate the adequacy of the NRC training and qualification programs to effectively support fuel cycle facility inspections and to develop enhancements to the training program. (Responsible Office: NMSS/AEOD)
Disposition:
Resolved A training course, title " Fuel Cycle Tedmv.ogy (H-107)" was presented in FY 1992.
This 5-day course provided an overview dlthe nuclear fuel cycle. Course topics included uranium mining and milling, uranium conversion including dry and wet processes, uranium enrichment including gaseous diffusion, gas centrifuge and atomic vapor laser isotope separation, and uranium fuel fabrication and scrap recovery. The course was developed by the NRC's Technical Training Center through a contract with technical assistance from NMSS. The course has been revised to incorporate feedback from the pilot course.
Additionally, a Fuel Cycle and Materials Training Advisory Group has been formed.
This advisory group will continue to evaluate the hdequacy of NRC training programs to effectively support criticality safety and fuel cycle facility inspections.
AEOD performed an independent assessment of this issue and also considers the item resolved.
Item 3:
Adequacy of Emergency Preparedness Action:(b)
Reevaluate the adequacy of the GE fuels facility Radiological Contingency and Emergency Plan (RCEP), assure as implementing procedures for emergency planning and event classification and notifications. Ensure that the RCEP and implementing procedures are revised as necessary. (Responsible Office: NMSS/RII)
Disposition:
Resolved By letter dated January 17,1992, GE submitted an amended application, dated December 28,1991, to update its RCEP. From January to September 1992, GE submitted several draft applications, and several meetings and telephone conference calls were held between GE, Region II, and the NMSS staff. On October 2,1992, GE resubmitted the amendment application to incorporate all changes agreed to by GE, Region II, and NMSS staff. This amendment application replaced the submittal of January 17,1992 in its entirety. It was later supplemented by a submittal on October 26,1992. On October 29,1992, the Committee submitted License Amendment No. 27 authorized GE to implement the RCEP changes.
A routine inspection in October 1992 included evaluation of the annual emergency response exercise and detailed review of the RCEP implementing procedures. No exercise weakness or program deficiencies were identified. AEOD performed an independent review of this issue and also considers the item resolved.
ItGm 4:
Adequacy of Operating Experience Reviews Actiom (a)
Reevaluate regulatory requirements and guidance for event reporting for fuel facilities as related to potential criticalities and failed contingencies (barriers).
Develop additional gmdance and requirements as appropriate. (Responsible Office:
NMSS/RES/AEOD)
Disposition:
Resolved
'Ihe staff is continuing to revaluate the regulatory requirements and guidance for event reporting for fuel facilities es related to potential criticalities and failed 7
NUREG-1272, Appendix E
AEOD Annual Report,1994-FY 95 contingencies (barriers) On October 18,1991, the staffissued NRC Bulletin 91-01,
" Reporting Loss of Criticality Safety Controls." The bulletin requested that licensees (1) evaluate their criticality safety criteria and procedures; (2) modify the criteria as appropriate to ensure that events involving degradation of controls will promptly be evaluated and reported to licensee management and NRC as appropriate;(3) provide a description of their criteria and procedures in the NRC Bulletin 01-01, Supplement 1, published on July 27,1993, clarified which events need to be reported within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />, and which could be reported within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. AEOD performed an independent review of this issue and also considers the item resolved.
Actiom (b)
Reevaluate NRC operating experience review and feedback program for fuel facilities. Revise the program as appropriate. (Responsible Office: NMSS)
Disposition:
Ongoing The staff determined that completion of this item was dependent on issuance of the revised Part 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content of ISA documents.
NMSS is presently going through a review process with licensees in an effort to develop a better understanding with licensees concerning the objectives of new Part
- 70. Even though new Part 70 has not been issued in final form, FCSS staff has initiated actions to upgrade Manual Chapter 2600 and associated inspection procedures. Once the revised Part 70 is issued in its final form, any additional required changes to the manual chapter or inspection procedures will be initiated (Reference 23). This item is scheduled to be completed by December 30,1996.
Action: (c)
Develop NRC inspection guidance for licensee event reporting and reviews for fuel facilities. Issue new guidance as appropriate. (Responsible Office: NMSS/AEOD)
Disposition:
Ongoing The staff determined that completion of this item was dependent on issuance of the revised Part 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content of ISA documents. NMSS is presently going through a review process with licensees in an effort to develop a better understanding with licensees concerning the objectives of new Part 70. Even though new Part 70 has not been issued in final form, FCSS staff has initiated actions to upgrade Manual Chapter 2600 and associated inspection procedures (Reference 23).
Once revised Part 70 is issued in its final form, any additional required changes to the manual chapter or inspection procedures will be initiated. This item is scheduled to be completed by December 30,1996.
Action: (d)
Extend the independent NRC operating experience program to nuclear fuel fabrication facilities. Examine the existing operating experience review program for other licensee groups not in the scope cf AEOD activities. Revise the program as appropriate. (Responsible Office: AEOD)
Disposition:
Resolved AEOD has implemented three major actions to extend NRC's independent operating experience program to fuel facilities (Reference 22). The first action was to increase staff and contractor resources for the material events analysis program. With the recent AEOD reorganization, the Nuclear Material Assessment Section was formally expanded from two to five staff members. One staff member was assigned as primary NUREG-1272, Appendix E 8
Nuclear Materials-Staff Actions l
reviewer and one staff member was assigned as secondary reviewer of reported events involving fuel cycle facilities and operations. The Idaho National Engineering Laboratory (INEL) was contracted to review and code material events including fuel cycle events.
The second action was to develop an enhanced material events database. The database was developed under contract wi h INEL and an NRC contractor. The t
enhanced database includes expanded data elements for fuel cycle facility operating data. AEOD/INEL began at the end of September 1994 to distribute an interim version of the database in diskette form to Agreement States and NRC program offices. The final version of the database is scheduled to be operational by the end of 1995 and will be accessible via the NRC AUTOS network.
The third action involved the enhancement of the material event review process.
AEOD implemented an event tracking system to track the review of nuclear material related operating data reported to the NRC, including fuel cycle events. Its salient features are the review of events by a primary and secondary reviewer to determine the safety significance, and documenting the results of the review in a database.
Events that are the subject of Preliminary Notifications of Occurrences, Morning Reports, or Event Notifications are reviewed by the Nuclear Materials Assessment Staff on a daily basis. Other reported events not meeting the above criteria are reviewed on a weekly basis. Events determined to be significant (including events identified as potential Abnormal Occurrences) from the standpoint of public health and safety are followed-up with NMSS and Regional offices as appropriate to review actions taken, and may be selected for an AEOD independent study (Reference 22).
The responsible office considers this item resolved, and an independent review confirmed this conclusion.
References:
1.
NUREG-1450, " Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991," August 1991.
2.
Memorandum from J. Taylor to NRC staff, " Staff Actions Resulting from the Investigation of the Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991 (NUREG-1450)," August 13, 1991.
3.
Memorandum from E. Jordan to J. Taylor, " Staff Actions in Response to the Investigation of the Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility Findings" (NUREG-1450), September 6,199L 4.
Memorandum from R. Bernero to J. Taylor, " Staff Action Plan Responding to the Investigation of the May 29,1991, Incident at the General Electric (GE)
Nuclear Fuel and Component Manufacturing Facility"(NUREG-1450)
September 9,1991.
5.
Letter to S.D. Ebneter to W. Ogden, "NRC Incident Investigation Team Report Follow up"(NUREG-1450), August 13, 1991.
6.
NRC Inspection Report No. 70-1113/91-0, August 12,1991.
7.
Letter from J. Stohr to W. Ogden, " Management Meeting Summary," October 2, 1991.
8.
Letter from B. Wolfe (GE) to J. Taylor (NC), August 26,1991.
9 NUREG-1272, Appendix E
~-
~-
AEOD Annual Report,1994-FY 95 9.
Letter from W. Ogden to J. Taylor, August 27,1991,
- 10. NRC Inspection Report No. 70-1113/91-04, December 23,1991.
- 11. NRC Inspection Report No. 70-1113/91-09, January 15,1992.
- 12. NRC Inspection Report No. 70-1113/91-06, January 22,1992.
13.
Regulatory Guide 3.67, " Standard Format and Content for Emergency Plans for Fuel Cycle and Materials Facilities," January 1992.
- 14. Letter from G. Bidinger to T. P. Winslow, January 7,1992.
- 15. NRC Bulletin No. 91-01, " Reporting Ioss of Criticality Safety Controls,"
October 18,1991.
16.
NUREG-1324, " Proposed Method for Regulating Major Materials Licensees,"
dated February 1992.
17.
Memorandum from R. Bernero to J. Taylor, " Staff Actions Resulting from the Investigation of the May 29,1991, Incident at General Electric (GE)
Wilmington," dated September 29,1993.
- 18. Memorandum from R. Bernero to J. Taylor, " Completion ofItem 1.F to General Electric Staff Action Plan, Response to Investigation of the May 29,1991, Incident at the General Electric Nuclear Fuel and Component Manufacturing Facility"(NUREG-1450), dated August 2,1993.
- 19. Memorandum from E. Jordan to R. Bernero, " Completion of Items LE and 2.D to General Electric Staff Action Plan, Response to Investigation of the May 29, 1991, Incident at the General Electric Nuclear Fuel and Component Manufacturing Facility," dated September 13,1993.
- 20. Memorandum from R. Bernero to J. Taylor, "Cepletion of Item 3.B to General Electric (GE) Staff Action Plan, Response to liveshFon of the May 29,1991, Incident at the GE Nuclear Fuel and Compone01 Manufacturing Facility" (NUREG-1450), dated December 2,1992.
21.
Memorandum from R. Bernero throrgi H. Thompson to J. Taylor, " Staff Actions Resulting From the Investigaios of the Incident at General Electric Wilmington," dated October 6,1994.
22.
Memorandum from E. Jordan to J. Taylor, " Staff Action Plan Responding to Investigation of the May 29,1991, Incident at the General Electric (GE) Nuclear Fuel and Component Manufacturing Facility (NUREG-1450)," dated October 12,1994.
23.
Memorandum from E. Q. Ten Eych t( S. Rubin, " Status of Staff Actions,"
dated October 30,1995.
NUREG-1272, Appendix E 10
s Nuclear Materials-Staff Actions Action Source:
IIT Report on %ss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16,1992 (NUREG-1480)," dated March 12,1993 (Reference 1).
Item 1:
Adequacy of Oncology Senices Radiation Protection Program Actiom (a)
Review by Oncology Services Corporation (OSC) corrective actions in response to the finding of ineffectiveness of the radiation safety program. (Responsible Office: RI)
Disposition:
Resolved In a memorandum from Robert M. Bernero, Director, NMSS to James M. Taylor, dated June 22,1994, the staff stated that alllicensee actions in response to staff action item 1.a.3 have been completed (procedural compliance and use of radiation instruments and response to off-normal conditions). On April 8,1993, Region I stated that inspections would be performed at the Harrisburg and Pittsburgh facilities within six weeks of their review of these corrective actions.
On April 22-27, and May 3-5,1993, Region I conducted a special safety inspection at the Harrisburg and Pittsburgh facilities (Inspection Report #030-31765/93-001). The report covered all the areas under Action item la (1-4), with no identified violations.
The inspection report concluded that all appropriate staff were trained in general radiation safety and RSO oversight, normal and emergency procedures were developed, while clarifying the reporting and oversight responsibilities of the corporate RSO. The report concluded that the licensee's staff were trained on use of the new normal and emergency procedures. The inspectors reviewed training records and verified training at both OSC's facilities. The inspectors reviewed three major areas in training (GET training, Omnitron training, and personnel qualification training).
The regional inspectors observed procedural adherence during daily routine safety checks of equipment, treatment planning procedures, patient surveys, and responses to status alarm equipment conditions. In addition, the inspectors determined that an internal independent audit was performed by Dr. Jack Krohmer, an independent consultant. The audit found weaknesses in three major areas and identified corrective actions. The licensee stated that these corrective actions had been implemented during the audit. The inspectors subsequently concluded that all audit findings and recommendation were addressed appropriately. AEOD completed an independent review and considers this item resolved.
Action: (b)
Evaluate whether NRC regulations and guidance need to be modified to explicitly define the functions and responsibilities of the radiation safety officer (RSO) and the authorized user. (Responsible Office: NMSS)
Disposition:
Ongoing Draft NUREG 1515 " Management of Radioactive Material Safety Programs at Medical Facilities," was distributed for peer review and discussed with the Advisory Committee on the Medical Uses of Isotopes at the November 1993 and May 1994 meetings. The NUREG was published for public comment in January 1995. The staff will evaluate the need to further defme and provide guidance on the responsibilities of the RSO and authorized user during a major revision of Part 35 tentatively scheduled for 1999 following review of the National Academy of Sciences report on 11 NUREG-1272, Appendix E
AEOD Annual Report,1994-FY 95 NRC's medical use program. Additionally, Policy and Guidance Directive (P&GD)
FC 85-7, " Standard Review Plan for Applications for Type A Licenses of Broad Scope," was published in June 1994. This provided guidance on the duties and responsibilities of the RSO and authorized users (References 2 and 3).
Action: (c)
Evaluate the performance and design of PrimAlert-10 Area Radiation Monitors (ARMS) and take appropriate followup action. (Responsible Office: NMSS/ Regions)
Disposition:
Resolved The staff has written to the manufacturer of PrimAlert-10 monitors (Victoreen) and requested an evaluation of the potential for nonionizing radiation fields or electromagnetic fields (associated with iinear accelerators) to cause spurious alarms by the PrimAlert-10 ARM as well as similar models used by medical licensees, such as the PrimAlert-50 ARM. Victoreen responded to the staff's letter in October 1993, but did not answer all of the staff's concerns regarding high energy instrument response. The staff forwarded a second letter to Victoreen dated February 9,1994, requesting additional specific information on instrument response at the high energy spectrum. NMSS's evaluation of Victoreen's response to the high energy instrument response issue was satisfactory with no further concerns. Since the staff did not identify any generic issues, and since all generic instrument concerns had been answered by Victoreen, plans to proceed with an Information Notice or Temporary Inspection Instruction was appropriately cancelled. Additionally, at the American Association of Physicists in Medicine Summer School, NRC staff discussed this issue with the school participants. AEOD completed an independent review and considers this item resolved.
Item 2:
Adequacy of NRC Protocols for Informing the Public and Authorities of Radiation Exposures Resulting from Licensed Activities Actiom (a)
Evaluate the NRC's process for assessing exposures and consequences, and notifying individuals and authorities following an elevated exposure. (Responsible Office:
NMSS/NRR/OGC)
Disposition:
Resolved The staff has developed guidance to address this recommendation for material licensees based on the experience of the Amersham source incident. This guidance was previously approved by the EDO; however, it is being revised to incorporate the lessons learned from the III and will be issued as Inspection Manual Chapter 1302.
The staff is in the process of addressing resolution of comments, and expects to issue the manual chapter by February 28,1994.
As stated in SECY-94-256, dated 10/12/94, " Annual Report on the Medical Use Program Including Status Reports On Implementation of the Medical Management Plan and Quality Management Program and Misadministrations Rule," the staff has developed guidance to address this recommendation for materials licensees based on the experience of the Amersham source incident. 'Ihis guidance has previously been approved by the EDO and has been incorporated in a March 7,1994 revision to Inspection Manual Chapter (IMC) 1302, " Action I.evels for Radiation Exposures and Contamination Associated with Materials Events InvoMng Members of the Public."
Manual Chapter 1302 contains detailed guidance to assist regional and NMSS staff in selecting the appropriate response level for radiation exposures or contamination NUREG-1272, Appendix E 12
Nuclear Materials-Staff Actions levels, and in notifying exposed members of the public. In addition, the IMC has attached four documents which provide information on event followup, contamination levels associated with an' event, examples of acceptable radiation and contamination levels used in past events, and a sample notification letter to be sent to affected members of the public to notify them of their assessed doses.
MC 1302 and NMSS's response to action item 2a appear to satisfactory address staff action item 2a. AEOD completed an independent review and considers this item resolved.
Action:(b)
Evaluate the need to further define licensee responsibility for assessing radiation exposure and notifying members of the public and authorities. (Responsible Office:
NMSS/NRR)
Disposition:
Resolved (Pending AEOD Independent Review)
The staff received guidance from Office of General Counsel regarding the applicability of Parts 19 and 20 to licensees for assessing radiation exposure and notifying members of the public and authorities. A final rule, making minor clarifying modifications to Parts 19 and 20 regarding reports to members of the public required by Part 20, was published on July 13,1995 (60 FR 36038) and became effective on August 14,1995. Additionally, MC 1302 and MD 8.10 were issued and provide additional guidance on notifying local authorities in response to an event involving the release of licensed material into the public dor ain. The Responsible Office considers this item resolved (Reference 2).
Item 3:
Adequacy of Regulatory Oversight of Sealed Sources and Devices and Medical Licenses Action:(a)
Evaluate the need to update licensing and inspection guidance and requirement for high-dose-rate (HDR) afterloaders. (Responsible Office: NMSS/RES)
Disposition:
Ongoing The staff has undertaken several efforts in this regard. A NRC Bulletin 93-01,
" Release of Patients After Brachytherapy Treatment With Remote Afterloader Devices," was sent to all remote afterloader users, imposing specific requirements, including the following: the physical presence of the physician, the authorized user, and the physicist or RSO during patient treatments; device-specific training; and patient surveys following treatment. Policy and Guidance Directive 86-4 was revised to incorporate the requirements of the bulletin. A Temporary Instruction was issued to provide guidance on routine inspection of HDR afterloaders. In addition, contract efforts were undertaken for quality control / quality assurance plans for remote afterloaders and human factors evaluations related to brachytherapy. The results of these various efforts will be incorporated into a user need memorandum to RES to revise Part 35.
Policy and Guidance Directive 86-4 is being revised and will be included as a module to Regulatory Guide 10.8, Revision 2. Training was provided to the regions on the guidance in P&GD 86-4 in September 1994. A brachytherapy issues paper, which included a discussion of the requirements for HDR afterloaders, was prepared for discussion with the Advisory Committee on the Medical Use of Isotopes (ACMUI) and the regulated community. The comments received along with the contractor's findings will be evaluated and incorporated into the proposed revisions to 10 CFR Part 35, when indicated (Reference 2).
13 NUREG-1272, Appendix E
-~
AEOD Annual Report,1994-FY 95 Action:(b)
Evaluate the relative merits of a performance-based approach versus schooling or certification to verify the radiation safety knowledge of HDR afterloader users.
(Responsible Office: NMSS/NRR)
Disposition:
Ongoing The staff will condet an evaluation as requested and continue to discuss this issue with the ACMUI. The staff will incorporate this issue into the user need memorandum described in Action 3(a). above, as appropriate.
The staff's plan to evaluate all current training and experience criteria will include a determination regarding the relative merits of different training approaches to ensure that all users have adequate radiation safety knowledge. The staff plans to hold facilitated public workshops during the major revision of Part 35 to discuss this issue.
Action:(c)
Evaluate the licensing interface among the NRC, U.S. Food and Drug Administration (FDA), and States / Agreement States for sealed sources and devices, including licensee requirements for design reviews and QA/QC. Develop a Memorandum of Understanding (MOU) with the FDA to further clarify respective roles. (Responsible Office: NMSS/OSP/OGC)
Disposition:
Resolved The staff reviewed the FDA's description ofits regulatory review of devices such as the Omnitron 2000, and met with FDA staff to clarify the NRC/FDA interface which was signed on August 26,1993. NMSS procedures for implementation of the MOU were drafted and circulated for comment on October 15,1993. The procedures will be issued as an Inspection Manual Chapter by March 31,1994.
The staff will also review the interface between the NRC and the Agreement States with respect to approval of sealed sources and devices, and will make appropriate recommendations for improving the definition of that interface.
In SECY-94-256, dated 10/12/94, " Annual Report on the Medical Use Program Including Status Reports on Implementation of the Medical Management Plan and Quality Management Program and Misadministrations Rule," the staff stated that they have reviewed FDA's description ofits regulatory review of sealed sources and devices such as the Omnitron 2000 and met with FDA staff to clarify the NRC/FDA interface. A MOU has been drafted between the NRC and FDA and was signed on August 26,1993. NMSS procedures for implementation of the MOU were drafted and circulated for comment on October 15,1993. The staff forwarded a paper to the Commission dated June 23,1994, to describe implementation of the MOU. The Policy and Procedures memorandum 1-45 was issued on August 25,1994 to identify management contacts to facilitate the exchange ofinformation.
As part of the newly-established interface between NRC and the FDA, the NRC and FDA staff have jointly investigated radiation therapy events occurring at two NRC-licensed facilities, both of which were caused by the same treatment planning error. Thejoint staff also investigated and took action to address a device failure involving a high-dose-rate remote afterloading brachytherapy device.
In addition to collaborating on inspections, NRC and FDA staff conduct routine monthly meetings to exchange information of mutual interest. The first annual NUREO-1272, Appendix E 14
~
Nuclear Materials-Staff Actions meeting between agency management was held on August 25,1994 to ensure adequate implementation of the MOU. NRC and FDA staff will continue to conduct monthly meetings.
AEOD's independent review of staff action 3c found one area where documentation was weak. AEOD could not ascertain from existing IIT status documentation whether the NRC-states / agreement states interface was adequate. A discussion of this matter could not be found in the latest OSC IIT staff action update that was attached to the October 13,1994 SECY letter regarding the update on the " Quality Management Program and Misadministrations Rule." Upon a phone discussion with Janet Schlueter, co-contact of the SECY letter, Janet stated that NMSS's review of the states / agreement states interface was determined to be adequate in its current status and role and no followup action was required, although not specifically stated as so in the October 13,1994 SECY letter. Based upon the phone conversation with NMSS, this documentation discrepancy does not appear to be crucial to closeout of this staff action item, therefore NMSS's actions appear to be adequate. AEOD completed an independent review and considers this item resolved.
Action:(d)
Revise the inspection guidelines to trigger consideration for licensees whose programs have significantly expanded or changed. (Responsible Office: NMSS)
Disposition:
Resolved (Pending AEOD independent review)
The staff revised the guidance in Manual Chapter 2800, " Materials Inspection Program," to provide guidance on inspection of satellite facilities, field offices, and temporary job sites. Policy and Guidance Directive 94-04 was issued June 21,1994 to provide guidance for the staff reviewers in identifying programs that have undergone significant growth and warrant on-site inspection.
The revised Manual Chapter 2800 was issued March 30,1995. He staff is developing additional guidance to assist the staff in review of applications requesting authorization for use of NRC licensed material at multiple facilities under one license. The Responsible Office considers this item resolved (Reference 2).
Action:(e)
For near-term, and where indicated, conduct inspections of licensees whose programs have significantly expanded or changed since the last routine inspection. (Responsible Office: NMSS/ Regions)
Disposition:
Resolved When the staffissued a memorandum to the Regions requesting that they poll the licensing staff. The objective of this action was to identify licenses whose programs (i.e., number of sites, scope of licensed activities, and/or possession limits) have significantly expanded or changed within the last two years. However, the memorandum did not determine when inspections have been conducted since the changes, and where they have not, conducted inspections at those facilities.
The Regions proposed a schedule for conduct of inspections by March 31,1994. The expected completion date of inspection was May 9,1994.
In SECY-94-256, dated October 12,1994, " Annual Report on the Medical Use Program Including Status Reports on Implementation of the Medical Management Plan and Quality Management Program and Misadministrations Rule," the staff 15 NUREG-1272, Appendix E
~
AEOD Annual Report,1994-FY 95 stated that they issued a memorandum to all the Regions (memorandum to the Regions dated Jul whose programs (y 9,1993) requesting they poll licensing staff to identify licensee i.e., number of sites, scope of licensed activities, and/or possession limits) have significantly expanded or changed within the last two years, determine if inspections have been conducted since the changes, and where they have not, conduct inspections at those facilities.
The regions responded by proposing to conduct inspections at those facilities where significant changes have been made and have those inspections completed by March 31,1994. NMSS reported in the SECY letter that all regional inspections were completed by February 28,1994. AEOD reviewed the Region I Special Inspection Report #030-31765/93-001, "Special announced, safety inspection conducted April 22 to May 5,1993 of OSC's Harrisburg and Pittsburgh, Pennsylvania facilities" and found this inspection complied with the staff action directive. AEOD completed an independent review and considers this item resolved.
Item 4:
Lack of Guidance for Nonradioactive Waste Collectors and Brokers for Handling Highly Radioactive Material Action:
Evaluate the need for assisting the nonradioactive waste processing industry in establishing guidance for detecting and obtaining expert assistance for handling radioactive materials. (Responsible Office: NMSS/OSP)
Disposition:
Resolved The staff has initiated efforts to prepare guidance. Specifically, the staff met with representatives from the Agreement States and the waste processing industry on June 29,1993, to develop the guidance which will incorporate lessons learned from the III During October 1993, the staff received diverse comments from the industry and Agreement Stats concerning its draft guidance. Addressing these comments resulted in a slippage of the due date from January 31,1994, to March 31,1994. Two forms of guidance will be issued: (1) emergency response information to be distributed to facility workers, and (2) more detailed technical guidance for managers of waste processor facilities. The guidance will incorporate lessons learned from the IIT The expected completion date was March 31,1994.
In SECY-94-256, dated 10/12/94, " Annual Report on the Medical Use Program Including Status Reports on Implementation of the Medical Management Plan and Quality Management Program and Misadministrations Rule," the staff stated they have already initiated efforts to prepare guidance for detecting and obtaining expert assistance for handling of radioactive materials. The guidance incorporate lessons learned from the III The staff met with representatives from the Agreement States and the waste processing industry on June 29,1993, to develop the guidance. 'livo forms of guidance were drafted by NMSS, as follows: (1) emergency response information to be distributed to facility workers, and (2) more detailed technical guidance for managers of waste processor facilities.
The staff received diverse comments on its draft guidance from the industry and Agreement States during the month of October 1993. However, because the staff had been previously awaiting Commission direction on SECY-94-073, regarding a 1993 incident involving contaminated steel that was imported from Mexico, publication of NUREG-1272, Appendix E 16
Nuclear Materials-Staff Actions this guidance was cancelled on March 31,1994. Instead, AEOD, NMSS, and the Regions will refer reports of emergencies involving unidentified radioactive material in the possession of an indhidual or group without an NRC or Agreement State license to the EPA,in accordance with the Lead Federal Agency provisions of the draft Federal Radiological Emergency Response Plan. This track is considered closed as of September 1994. AEOD completed an independent review and considers this item resolved.
Item 5:
Cause of Source Wire Failure Action:
Evaluate Southwest Research's final report on the source wire failure and document the findings. (Responsible Office: NMSS/OSP)
Disposition:
Resolved The staff received the final report for Southwest Research which confirmed the staff's hypothesis regarding the cause of the source-wire breakage. The contractor's final report was transmitted to the Commission via a memorandum dated October 27,1993. The responsible office considers this item resolve.
AEOD's independent review of the October 27,1993 memorandum which summarizes Southwest Research's investigation appeared to be through and addresses the root cause of wire failures. The investigation revealed that clinical source wires which were shipped or stored in teflon-lined storage casks consistently suffered hydrogen-type embrittlement and failed in a brittle manner similar to the in-service wire failures. This type of failure was not typical for the type of alloy wire used on the omnitron source wire (Nitinol alloy). The investigation also indicated emirons of moisture, low temperature, and high radiation were not likely to increase the probability of brittle failure to the Nitinol alloy.
On the basis of the results of the investigation, Southwest Research Institute concluded Gat the root cause of the in-service failures of the source wires was environm mtally-induced embrittlement due to the breakdown of the teflon lining of the storap cask sleeves in the presence of a high-radiation field and subsequent reaction or interaction with the Nitinol alloy. AEOD completed an independent review and considers this item resolved.
References:
1.
NUREG-1480, " Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16, 1992," February 1993.
2.
Memorandum from J. Taylor to Office Directors and Regional Administrators,
" Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16,1992," dated March 12,1993.
3.
Memorandum from R. Bernero to J. Taylor, " Status Report on Staff Action Plan Responding to the Investigation of the Loss of an Iridium-192 Source and therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16,1992 (NUREG-1480), dated February 6,1994.
4.
Memorandum from Robert M. Bernero, Director, NMSS to James M. Taylor, dated Februaiy 10,1994, " Status Report on Staff Action Plan Responding to Investigation ofloss of an Ir-192 Source and Therapy Misadministration at IRC Center, Indiana, Pennsylvania on November 16,1992 (NUREG-1480)."
17 NUREG-1272, Appendix E
AEOD Annual Report,1994-FY 95 5.
Inspection Report #030-31765/93-001, "Special announced, safety inspection conducted April 22 to May 5,1993 of OSC's Harrisburg and Pittsburgh, Pennsylva'nia faci!ities."
6.
Memorandum from Robert M. Bernero, Director, NMSS to James M. Taylor, dated June 22,1994, " Revised Staff Actions in Response to Investigation of Loss of an IR-192 Source and Therapy Misadministration at IRC Center, Indiana, Pennsylvania on November 16,1992 (NUREG-1480)."
7.
SECY-94-256, dated October 12,1994, " Annual Report on the Medical Use Program Including Status Reports on Implementation of the Medical Management Plan and Quality Management Program and Misadministrations Rule."
8.
Memorandtim from Elizabeth Q. Ten Eyck, Director, Division of fuel cycle Safety and Safeguards, NMSS to Stuart D. Rubin, Chief, Diagnostic Evaluation and Incident Investigation Branch, Incident Response Division, AEOD, " Status of Staff Actions," dated October 30,1995.
9.
Memorandum from Stewart D. Ebneter, Regional Administrator, to Edward L Jordan, Director, AEOD, " Status of Staff Actions," dated October 31,1995.
NUREG-1272, Appendix E 18
NRC FORM 335 U.S. NUCLEAR REGULATORY COMMISSX)N
- 1. REPORT PAJMBER (2 49)
(Arsigned by NRC, Add Vol.,
NRCM 1102, Supp., Rev. and Addendum Num-22oi,3202 BIBLIOGRAPHIC DATA SHEET bar*- aar 1 (See instructions on tr. revers.)
NUREG-1272 V L 9, No. 2
- a. TrTLE AND SuenTLE
- 3. DATE REPORT PUBUSPED Office for Analysis and Evaluation of Operational Data MONTH I
YEAR 1994-FY 95 Annual Report - Nuclear Materials i
September 1996
- b. AUTHOR (5)
- 6. TYPE OF REPORT Annual summary of operational experience for nuclear materials
- 7. PERIOD COVERED (inclusive Dates)
CY 1994-FY 1995 a
- 8. PERFORMING ORGANIZATION = NAME AND ADDRESS (if NRC, provide DMsen, Ofice or Regmn, U.S. Nuclear Regulatory Cornmission, and malling address; if contractor, provide name and malling address.)
Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555-0001
- 9. EPONSORING ORGANIZATION - NAME AND ADDRESS (tf NRC, type "Same as above"; it contractor, prov6de NRC DMslon. Office or Region, U.S. Nuclear Regulatory Commission, and malling address.)
Same asin item 8
- 10. SUPPLEMENTARY NOTES s
- 11. ABSTRACT (200 words or sess)
'Ihis annual repon of the U.S. Nuclear Regulatory Commission's Office for Analysis and Evaluation of Operational Data (AEOD) describes activities conducted during CY 1994 and FY 1995. The report is published in three parts.
NUREG-1272, Vol. 9, No.1, covers power reactors and presents an overview of the operating experience of the nuclear power industry from the NRC perspective, including comments about the: trends of some key performance measures. The report also includes the principal findings and issues identified in AEOD studies over the past year and summanzes information from such sources as licensee event reports, diagnostic evaluations, and reports to the NRC's Operations Center. NUREG-1272, Vol. 9,.No. 2, covers nuclear materials and presents a review of the events and concerns associated with the use of licensed material in nonreactor applications, such as personnel overexposures and medical misadministrations. Both reports also contain a discussion of the Incident Investigation Team program and summanze both the Incident Investigation Team and Augmented Inspection 'Ieam repons. Each volume contains a list of the AEOD reports issued from 1980 through FY 1995. NUREG-1272, Vol. 9, No. 3, covers technical training and presents the activities of the Technical Thuning Center in support of the NRC's mission.
- 12. KEY WORDS/DESCRIPTORS (Ust words or phrases that will assist researchers in locating the report.)
- 13. AVAILAB1UTY STATEMENT nuclear materials nonreactors non-power reactors Unlimited Nuclear Material Events medical misadministration radiation exposure
- 14. SECURITY CLASSIFICATION Database radiation overexposure loss of control of (Tha esse) leaking sources release of material licensed material Unclassified transponation events equipment problems fuel cycle facility (rais aspor13 test, research, and training abnormal occurrences operating expenence Unclassified reactor mcident response NRC staff actions is. NuMeER OF excEs Incident Investigation AEOD recommcadations AEOD repons Program AEOD studies Operations Center data Committee to Review emergency response gaseous diffusion is. eRice Generic Requirements NRC FORM 335 (2-89)
on recycled paper Federal Recycling Program
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