ML20137Z956

Report to Congress on Abnormal Occurrences.Fiscal Year 1996

ML20137Z956
Person / Time
Issue date:	04/30/1997
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V19, NUREG-90, NUREG-90-V19, NUDOCS 9704250153
Download: ML20137Z956 (47)

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NUREG-0090 Vol.19 Report to Congress on Abnormal Occurrences l

Fiscal Year 1996 U.S. Nuclear Regulatory Commission 1

Office for Analysis and Evaluation of Operational Data f" " %,,t g l a p' g

9704250153 970430 h!.!Ih@i@. . '

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i AVA. LABILITY NOTICE i j

Availability of Reference Materials Cited in NRC Publications l

l Most documents citod in NRC publications will be available from one of the following sources:

1. i 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 1

Although the listing that follows represents the majority of documents cited in NRC publica-tions, it is not intended to be exhaustive. j Referenced documents available for inspection and copying for a fee from the NRC Public i Document Room include NRC correspondence and internal NRC memoranda: NRC bulletins, I circulars, information notices, inspection and investigation notices; licensee event reports; '

vendor reports and correspondence; Commission papers; and applicant and licensee docu-mentt and correrpondence. ,

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- i 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 Federr' agencies and reports prepared by the  ;

Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission.

i Documents available from public and special technical libraries include all open literature items, such as books, journal articles, and transactions. Federal Register notices, Federal and State legislation, and congressional reports can usually be obtained from these libraries, i Documents such as theses, dissertations, foreign reports and translations, and non-NRC con-  ;

forence proceedings are available for purchase from the organization sponsoring the publica- '

tion cited.

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

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Copies of industry codes and standards used in a substantive manner in the NRC regulatory l process are maintained at the NRC Library, Two White Flint North,11545 Rockville Pike, Rock-l ville, MD 20852-2738, for uss by the public. Codes and standards are usually copyrighted 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 10018-3308. j 1

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' NUREG-0090

' Vol.19 l

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j Report to Congress on Abnormal Occurrences i

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Date Published

April 1997 4

J Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555-0001 pa aseo 1 (g..... )

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Abnormal Occurrences, Fiscal Year 1996 ,

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f Previous Reports in Series

! NUREG 75/090 (January-June 1975), published October 1975. )

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

NUREG-0090, Vols. I through 18, No. 3 (January-March 1978 through July-September 1995), published

! June 1978 through February 1996. No Vol.18, No. 4, was published because annual reporting on a fiscal-year l l basis started with publication of the report for fiscal year 1996.

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Abnormal Occurrences, Fiscal Year 1996 ABSTRACT Section 208 of the Energy Reorganization Act of brachytherapy misadministrations, and five 1974 (PL 93-438) identifies an abnormal involved radiopharmaceutical misadministrations, occurrence (AO) as an unscheduled incident or Eight AOs submitted by the Agreement States are event that the Nuclear Regulatory Commission included. One involved stolen radiography (NRC) determines to be significant from the cameras, one involved a ruptured source, one

, standpoint of public health or safety. The Federal involved release of radioactive material while Reports Elimination and Sunset Act of 1995 (PL being transported, one involved a lost source, two

104-66) requires that AOs be reported to involved medical brachytherapy Congress on an annual basis. This report includes misadministrations, and two involved those events that NRC determined to be AOs radiopharmaceutical misadministrations. Four  ;

during fiscal year 1996. updates of previously reported AOs are included i in this report. Three "Other Events of Interest" This report addresses eighteen AOs at events are being reported, and one previously NRC-licensed facilities. Two involved events at reported "Other Events ofInterest" event is being nuclear power plants, eleven involved medical updated.

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Abnormal Occurrences, Fiscal Year 1996 CONTENTS Page Abst ra ct . . . . . . . . . . . . . . . . . . . . . . . . . .. . ............. ..... .... .......... ............ iii Preface .............................. ............................... .................. ix I n t rod u ct i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Th e Regul at o ry Syst e m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Repo rtable Occu rrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Agre e m e n t S t at es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Foreign Info rm at io n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Reopening of Closed Abnormal Occurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x Report to Congress on Abnonnal Occurrences, Fiscal Year 1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Nuclear Power Plants . . . . . . . . . . . . . . . . . . . ..... .................................. 1 96-1 Plant Trip With Multiple Complications at Wolf Creek Nuclear Generating Station . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 96-2 Containment-Bypass Leakage via Disconnect Hydrogen-Monitor Lines at Braidwood Units 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Fuel Cycle Facilities (Other than Nuclear Power Plants) ...... ........ ............... ... 3 Other NRC Licensees (Industrial Radiographers, Medical Institutions, Industrial Users, etc.) ..................... .......................................... 3 96-3 Medical Brachytherapy Misadministrations by Jos6 L. FernAndez, M.D., in Mayagnez, Pue rto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 96- 4 Medical Brachytherapy Misadministrations by Phillip J. W. Lee, M.D.,

in H o nol ul u, H awaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4

96-5 Medical Brachytherapy Misadministration at Harper Hospitalin D e t roi t, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 96- 6 Medical Brachy;herapv Misadminirtration at New England Medical ,

Center in Boston, Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7  !

l 96-7 Medical Brachytherapy Misadministration at William Beaumont Hospital l in Royal O ak, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8  !

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96- 8 Medical Brachytherapy Misadministration at Com nunity Hospitals of Indiana in Indianapolis, Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 96-9 Medical Brachytherapy Misadministrations at EquiMed, Inc., in Lehighton, Pe n n sylvani a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 96-10 Medical Brachytherapy Misadministration at the University of Wisconsin in M adison, Wisconsin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 y NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 Page 96-11 Medical Brachytherapy Misadministration at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 96-12 Medical Brachytherapy Misadministration at Macombe Hospital Center in Warre n, M ichigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 96-13 Medical Brachytherapy Misadministration at Unity Hospitalin Fridley, Mi n n e so t a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 96-14 Radiopharmaceutical Misadministration at Universal Imaging in Taylor, Michigan.................................................................. 12 96-15 Radiopharmaceutical Misadministration at Miami Valley Hospital in D ayt o n, O h i o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 96-16 Radiopharmaceutical Misadministration at St. Joseph Mercy Hospital in Ann Ar bor, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 96-17 Radiopharmaceutical Misadministration at the Veteran Affairs Medical Center in Charleston, South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 96-18 Radiopharmaceutical Misadministration at Queen's Medical Center in Hon ol ul u, H awaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Agreem ent State Licensees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 AS 96-1 Stolen Cobalt-60 Radiography Cameras .................................. 16 AS 96-2 Rupture of a Source Owned by Little Bit Wireline at an Oil Well near Winnie, Texas . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 AS 96-3 Release of Radioactive Material in Lemont, Illinois, From a Package That Was Accidently Destroyed While Being Transported by Associated Couriers of Maryland Heights, Missouri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 AS 96-4 Lost Source at Deseret Generation and Transmission Cooperative's Bonanza Power Plant in Vernal, Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 AS 96-5 Medical Brachytherapy Misadministration at Duke University Medical Center in Durham, North Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 AS 96-6 Medical Brachytherapy Misadministrations at the University of Mississippi Medical Center in Jackson, Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . 20 AS 96-7 Radiopharmaceutical Misadministration at Baptist Medical Center Princeton in B'rmingham, Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 AS 96-8 Radiopharmacentical Misadministration at Methodist Medical Ce nter in Peoria, Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Appendix A- Abnorm al Occurrence Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 NUREG-0090, Vol.19 vi

Abnormal Occurrences, Fiscal Year 1996 l

Page l Appendix B - Update of Previously Reported Abnormal Occurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 j O t he r N RC Licensees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 94-23 Medical Brachytherapy Misadministration at North Memorial Medical Center in Robbinsdale, Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 27 '

Agre ement State Licensees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 AS 88-5 Medical Teletherapy Misadministration at Sacred Heart Hospital in Cumberland, Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 l AS 88-6 Multiple Medical Teletherapy Misadministrations at Sacred Heart Hospital in Cumberland, Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 AS 93-13 Lost or Stolen Radiation Source at BPB Instruments, Inc.,

in M i dl and, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Appendix C - Other Events of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1. Problems at Millstone Units 1,2, and 3, and Haddam Neck . . . . . . . . . . . . . . . . . . . . . . 31

2. Emergency Core Cooling System Analyses Deficiencies a t M aine Yanke e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

3. Ingestion of Phosphorus-32 at the Massachusetts Institute of Technology in Cambridge, Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Appendix D - Update of Previously Reported Other Events of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1. Safety Relief Valve Inoperability at Millstone Unit 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 l

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Abnormal Occurrences, Fiscal Year 1996 PREFACE l

Introduction description ofits nature and probable consequences.

l Section 208 of the Energy Reorganization Act of NRC has determined that, of the incidents and I 1974 (PL 93-438) identifies an abnormal occurrence (AO) as an unscheduled incident or events reviewed for this reporting period, only event that the Nuclear Regulatory Commission those that are described in this report meet the (NRC) determines to be significant from the criteria for reporting as AOs. Information standpoint of public health or safety. The Federal reported on each AO includes date and place, Reports Elimination and Sunset Act of 1995 (PL nature and probable consequences, cause or 104-66) requires that AOs be reported to causes, and actions taken to prevent recurrence.

Congress on an annual basis. This report includes those events that NRC determined to be AOs Appendix B contains updated information on during fiscal year 1996. Previously reported AOs.

NRC identifies an AO for the purpose of this Appendix C contains information on incidents that report using the criteria in Appendix A. The can be perceived as significant but do not involve a criteria were initially promulgated in an NRC major reduction in the level of protection policy statement that was published in the Federal provided for public health and safety. These Register on February 24,1977 (Vol. 42, No. 37, events are not reportable as AOs but are provided pages 10950-10952). as "Other Events ofInterest."

This policy statement was published before medical licensees were required to report The Regulatory System misadministrations to NRC and few of the examples in the policy statement were applicable The system oflicensing and regulation by which to medical misadministrations. Therefore, in 1984, NRC carries out its responsibilities is NRC adopted additional guidance for AO implemented through the wies and regulations in reporting of medical misadministrations. These Title 10 of the Code ofFederal Regulations. This guidelines augment the NRC policy statement includes public participation as an element. To l examples and are summarized in Table A-1 in accomplish its objectives, NRC regularly conducts l Appendix A. licensing proceedings, inspection and enforcement l activities, evaluation of operating experience, and l The events included in this report were confirmatory research, while maintaining  ;

determined to be potential AOs using the programs for establishing standards and issuing reporting criteria which were in effect during fiscal technical reviews and studies. ,

year (FY) 1996. The Commission recently )

approved new AO reporting criteria which it had In licensing and regulating nuclear power plants directed the NRC staff to develop, and which will and the uses of byproduct nuclear materials, NRC be published in the FederalRegister. These new follows the philosophy that the health and safety criteria will be used starting in FY 1997. of the public are best ensured by establishing multiple levels of protection. These levels can be  ;

In order to provide wide dissemination of achieved and maintained through regulations information to the public, a Federal Register notice

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specifying requirements that will ensure the safe is issued on NRClicensee AOs. Copies of the use of nuclear materials. The regulations include notice are distributed to the NRC Public design and quality assurance criteria appropriate Document Room and all Local Public Document for the various activities licensed by NRC. An Rooms. At a minimum, each notice must contain inspection and enforcement program helps ensure the date and place of the occurrence and a compliance with the regulations.

l ix NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 Reportable Occurrences Agreement States i' Section 274 of the Atomic Energy Act, as Operating experience is an essential input to the amended, authorizes the Commission to enter regulatory process for assuring that licensed into agreements with States whereby the activities are conducted safely. Licensees are Commission relinquishes and the States assume required to report certam incidents or events t

, , . regulatory authority over byproduct, source, and NRC. This reporting helps to identify deficiencies special nuclear materials (in quantities not

and to ensure that corrective actions are taken t capable of sustaining a chain reaction).

prevent recurrence.

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

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

and the nuclear power industry have ongoing NRC on reportable events.

efforts to improve the operational data systems, . . .

i which include not only the type and quality of In early 1977, the Commission determined that

! reports required to be submitted, but also the AOs happening at Agreement State licensed methods used to analyze data. In order to more facilities should be meluded in the periodic i effectively collect, collate, store, retrieve, and reports to Congress. The AO criteria included m, 1 evaluate operational data, the information is Appendix A are applied umformly to incidents I

maintained in computer-based data files. and events that occur at NRC and Agreement i State licensed facilities. Procedures have been

. developed and implemented, and AOs reported by Three primary sources of operational data are the Agreement States to NRC are included in the Licensee Event Reports (LERs) submitted periodic reports to Congress.

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

NRC participates in an exchange of information i

Except for records exempt from public disclosure with various foreign governments that have ,

by statute and/or regulation, information nuclear facilities. This foreign mformation is n ning o e occurrences at fac ities gg gperating exper ce and in i esea h and

! routinely disseminated by NRC to the nuclear [egulatory activities. Reference to fore 1gn i industry, the public, and other interested groups inf rm tion may occasionally be made m, the A O as these events occur. rep rts to Congress; however, only domestic AOs are reported.

Dissemination includes special notifications to 4

licensees and other affected or interested groups, Reopening of Closed Abnormal

and public announcements. In addition, Occurrences information on reportable events is routinely sent i to the NRC's Local Public Document Rooms NRC reopens previously closed AOs if significant

] throughout the United States and to the NRC new information becomes available. Similarly, l Public Document Room in Washington, D.C. previously reported "Other Events of Interest" Congress is routinely kept informed of reportable are updated if significant new information

, events occurring in licensed facilities. becomes available.

NUREG-0090, Vol.19 x 4

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Abnormal Occurrences, Fiscal Year 1996 s

REPORT TO CONGRESS ON ABNORMAL OCCURRENCES i FISCAL YEAR 1996 NUCLEAR POWER PLANTS Using the criteria and guidelines in Appendix A of discharges directly in front of the train's trash this report, the following events which occurred at rack.

nuclear power plants during this reporting period were det ermmed to be sigmficant enough to be At approximately 2:00 a.m. on January 30,1996' reported a::an AO. operators at Wolf Creek received alarms indicating that the traveling screens for the circulating water (CW) system were becoming 96-1 Plant 'IYip With Multiple blocked. The site watch reported that the

Complications at Wolf Creek traveling screens for Bays 1 and 3 were frozen and Nuclear Generating Station that water levels in these bays were approximately 3

2.44 meters (8 feet) below normal. The ESWS The following information pertaining to this event was started with the intent to separate the ESWS is also being reported concurrently in the Federal from the service water (SW) system. However, Register. Appendix A (see General Criteria No.3) the ESWS was incorrectly aligned, which reduced of this report notes that major deficiencies in warming flow to the ESWS suction bays (the <

design, construction, use of, or management lineup was corrected approximately 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> later).

controls for licensed facilities or material can be At approximately 3:30 a.m., operators received a considered an AO. service water low pressure alarm (CW system bays were subsequently determined to be at 3.66

Date and Place -January 30-31,1996; Wolf Creek Nuclear Generating Station, a Westinghouse- meters (12 feet] below normal) and an electric fire

• pump started. The shift supervisor then directed a designed pressurized water reactor nuclear power manual reactor / turbine trip. Following the scram, plant, operated by the Wolf Creek Nuclear five control rods failed to fully insert (from 12 to Operating Corporation and located about 5.63 30 steps out). The event was further complicated kilometers (3.5 miles) northeast of Burlington, because the turbine driven auxiliary feedwater Kansas. pump developed a packing leak and was declared inoperable. The loss of CW system bay level was Nature and Probable Consequences -One train subsequently determined to be caused by ice i of the essential service water system (ESWS) was blockage of the traveling screens, which was inoperable due frazill ice blockage of the intake caused by freezing water from the spray wash  !

trash racks, and the second train was degraded. system.

! The ESWS removes heat from plant components which require cooling for safe shutdown of the Train "A" ESWS pump was tripped and declared  ;

I reactor or following a design basis accident. The inoperable at 7:47 a.m. due to low dischi.rge i

ESWS consists of two redundant trains, provides pressure and high strainer differential pressure.

emergency makeup to the spent fuel pool and At about 5:45 p.m. the operators declared Train component cooling water systems, and is the "A" operable based on an engmeermg evaluation.

safety related water supply to the auxiliary However, the pump was stopped 1-1/2 hours later feedwater system. Freeze protection for the at approximately 7:30 p.m. when the pump ESWS is a design provision, and is provided by a exhibited further oscillations in flow and pressure, warming line from each ESWS train which At approximately 8:00 p.m., operators noted that ESWS Train "B" suction bay level was 4.57 meters (15 feet) below normal and decreasing slowly.

I Operators placed additional heat loads on Train iminot, ic, c7y,tais called frazii were formed when wind and tem. "B" and the suction bay levels subsequently perature conditions caused water in the ultimate-heat-sink reser- recovered. At 10:14 p.m., the operators again vior to become supercooled (cooled to a few hundredths of a de' gree below the freezing point without solidification). The frazilice started Train "A" ESWS, but later secured it, at s

crystals mixed with the supercooled water, and adhered to the ob. 10:27 p.m., due to decreasing flow and pressure.

jects (i.e., trash racks) with which they collided. At about 9:00 a.m. on January 31,1996, divers 1 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 inspected the suction bay of Train "A" and noted 96-2 Containment-Bypass Leakage complete blockage of the trash racks by frazil ice. via Disconnected Hydrogen-The condition of the Tram "B" trash racks was not Monitor Lines at Braidwood l

determmed because the pump was running. The ice blockage was cleared later that day using Units 1 and 2 heating, and air sparging of the trash racks. The following information pertaining to this event is also bemg reported concurrently in the Federal Register. Appendix A (see General Criteria No. 2) 1 Cause or Causes -The root cause of this event of this report notes that a major reduction in the was deficiencies in the ESWS warming line design. degree of protection to public health and safety l from a major degradation of essential This problem was exacerbated by the initial incorrect alignment of the ESWS. A 1976 design safety-related equipment can be considered an calculation specified a warming line flow rate of AO.

, 15,142 liter / minute (4000 gpm) to prevent frazil ice. This calculatinn assumed a warming line Date and Place - February 15,1995; Braidwood Unit 2, a Westinghouse-designed pressurized 4

temperature of 2 C (3*F) above freezing. This water nuclear reactor plant, operated by asumption was never validated: The warming line Commonwealth Edison Company and located temperature during the event was only approximately 0.5 C (1 F) above freezing. about 38.6 kilometers (24 miles) south southwest f J liet, Ilhnois.

Additionally, due to the elevations and

configuration of the warming line, portions of th Nature and Probable Casequences - On im, e operated with partial pipe flows. Flow November 9,1994, the liccusee completed a through the h,nes was estimated to have been 9464

, containment integrated Icak rate test (ILRT). For 1 iter /mmute (2500 gpm) and, with the imtial this test, the 6.35-milliraeter (0.25-inch) l ,

improper imeup, warmmg flow was estimated t containment penetration hydrogen sensing lines be 6435 liter / minute (1700 gpm),less than half the for trains "A" and "B" were disconnected and a design specification. balloon placed on the end to identify any leakage.

The procecture did not specify whether to disconnect the sensing line inside the hydrogen Actions Taken To Prevent Recurrence

momtor cabinet or outside. The operators who i lined up the test disconnected the lines inside the Licensee -The hydraulics of the ESWS discharge cabinet. The licensee's investigation concluded l that when other operators restored the system 4 to the ultimate heat sink, and the warming line to the ESWS pumphouse, have been changed to from the test, they observed the exterior sensing establish and distribute the proper amount of flow lines and assumed that the lines were i to the ESWS warming line. The licensee has reconnected. Therefore, the sensing lines j installed back pressure orifices to establish the remained disconnected inside the cabinet.

I required flow rates. This work was completed by On January 31,1995, the operations department October 1,1996' wrote a problem identification report to identify a 1 growing difference in the hydrogen readings on NRC - NRC entered a monitoring phase following the "A" and "B" trains which are taken during i'

the Notification of an Unusual Event at 9:00 a.m. each shift. On February 15,1995, during on January 30,1996. During February 6 through troubleshooting, the "A" train lines were found to February 15,1996, NRC conducted an Augmented be disconnected, approximately 3 months after i Inspection Team inspection at Wolf Creek as a being disconnected. Surveillance tests performed result of this event. NRC issued a civil penalty of on December 11,1994, and January 25,1995, i

$300,000 because of violations as a result of this provided opportunities to detect the deficiency event. with the "A" train but were miwed. It could not be conclusively determined when the "B" train was restored. Two maintenance workers had a

! This event is closed for purpose of this report. recollection of discovering balloons on the sensing lines in a hydrogen monitoring cabinet in late 1994. Maintenance records indicate these

• • • • • • • • individuals worked on the "B" train on i

NUREG-0090, Vol.19

~

2 1

Abnormal Occurrences, Fiscal Year 1996 December 20,1994. IIowever, computer and Cause or Causes - The cause of this event was a

operator logs for the "B" train appear to have procedural deficiency in that the ILRT procedure been accurately reading containment hydrogen did not provide adequate guidance on where the following the ILRT. containment penetration hydrogen sensing lines should be disconnected. Additionally, the The hydrogen monitors are normally isolated. operator tasked with reconnecting the However, during a loss of coolant accident, the containment penetration hydrogen sensing lines, i Emergency Operating Procedures direct the after the ILRT was completed, did not display a operators to put them m, to service to monitor questioning attitude when he found that the lines

containment hydrogen concentration. This would appeared to be reconnected.

create an unfiltered release path from the containment to the auxiliary building. The Actions Taken To Prevent Recurrence j licensee calculated that, under worst case i conditions using guidance from NUREG-1465,

' Accident Source Terms for Light-Water Nuclear Licensee - Corrective actions included revision of Power Plants," regulatory dose limits could be ILRT h.ne up and restoration sheets to provide exceeded within approximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />. NRC adequate guidance on where disconnections and review found the licensees calculations to be connections are to be performed. Additionally, a conservative. There are area radiation monitors General Information Notice was issued to all site

) near the hydrogen monitors. These area radiation Personnel highlighting the human performance monitors alarm in the control room and the alarm Problems identified from this event.

response procedures call for notification of Radiation Protection personnel to survey the area. NRC - Escalated enforcement was exercised on

! Additionally, there are radiation monitors in the this issue and the licensee was assessed a $100,000 auxiliary building exhaust that would assist the civil penalty. Information Notice 96-13, operators in identifying the leak. The " Potential Containment Leak Paths Through containment bypass flow path could be isolated Hydrogen Analyzers," was issued to alert other remotely from the control room and it appears licensees to this event.

credible that the leak could be isolated prior to exceeding regulatory limits. This event is closed for the purpose of this report.

ll i

l FUEL CYCLE FACILITIES

] (Other than Nuclear Power Plants)

, Using the criteria and guidelines in Appendix A of determined to be significant enough to be i this report, no events which occurred at fuel cycle reported as an AO.

j facilities during this reporting period were 1

i OTIIER NRC LICENSEES

. (Industrial Radiographers, Medical Institutions, Industrial Users, etc.)

Using the criteria and guidelines in Appendix A reporting period were determined to be of this report, the following events which significant enough to be reported as an AO.

occurred at other NRC licensees during this 4

3 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 96-3 Medical Brachytherapy Ferndndez assumed that the hand written Misadministrations by Jos6 L. information on the label attached to the manuf ctum s carcing case was conect and Fernsndez, M.D., in Mayagnez, proceeded to treat patients.

Puerto R.ico

. . On October 18,1995, during a routine inspection, The following information pertam. .mg to this event an NRC inspector questioned the labeled dose is also being reported concurrently m, the Federal rate on the eye applicator device and the resultant Register. Appendix A (see Event Type 5[a],[d]) of

, , , administered doses. Dr. Ferndndez was unable to this report notes that admimstermg therapeutic

, provide documentation to answer the questions.

radiation such that the actual dose is greater than Ile then voluntarily ceased the administration of 1.5 times the prescribed dose, or the event radiation doses and requested a calibration of the (regardless of any health effects) affects two or device by the manufacturer. The actual dose rate more patients at the same facility, should be was found by the manufacturer to be 53 cGy per considered an AO. second (53 rad per second); i.e., more than twice the assumed dose rate.

Date and Place - Between January 14,1994,and October 10,1995; Joss L. Ferndndez, M.D.; Dr. Ferndndez and NRC reviewed the computer Mayag0ez, Puerto Rico, sorted records of all administrations using the eye applicator device and determined that between Nature and Probable Consequences - On January October 24,1994, and October 10,1995,87 14,1994, Dr. Ferndndez acquired an eye patients had received radiation doses which were applicator device, which contained a strontium-90 approximately twice the prescribed dose.

(Sr-90) source of approximately 3219 Ilowever, the computer sort was not complete, megabecquerel (87 millicurie) activity, from the since Dr. Ferndndez later discovered an estate of a deceased licensee in Mayag0ez, Puerto additional 17 cases which occurred between Rico. (Eye applicator devices are used for the January 1994 and October 1995. Dr. Ferndndez supplemental treatment of non-malignant growths notified the patients about the misadministrations.

on the eye after surgey is performed.) NRC NRC contracted a medical consultant to review knew that Dr. Ferndndez acquired the Sr-90 the medical aspects of the misadministrations.

source because the estate was acting under a Confirmatory Action Letter (CAL) to maintain The NRC medical consultant, who reviewed control of the Sr-90 source and to either dispose patient records for the 87 patients initially ofit or transfer control of it to an authorized identified, determined that 25 of the patients were recipient. Since Dr. Ferndndez was already an at higher risk for complications. These 25 patients NRC licensee for another Sr-90 source in San were initially prescribed treatment doses of 1500 Juan, Puerto Rico, his license was amended so to 2880 cGy (1500 to 2880 rad), but received doses 1 that he was an authorized recipient when the of 3312 to 6360 cGy (3312 to 6360 rad) instead.

transfer took place. (After the transfer took Of these 25 patients,12 were then prescribed place, Dr. Ferndndez was licensed to have two second treatment doses of 1000 to 2160 cGy (1000 sources.) NRC did not require Dr. Ferndndez to to 2160 rad), but received doses of 2208 to 4770 receive additional training in the use of the Sr-90 cGy (2208 to 4770 rad) instead. Additionally, two source after he acquired it from the estate because of these 25 patients were prescribed third he was already an authorized user for a Sr-90 eye treatment doses of 1500 to 3000 cGy (1500 to 3000 applicator as defined by 10 CFR 35. rad), but received doses of 3313 to 6625 cGy (3313 to 6625 rad)instead. The highest total dose When Dr. Ferndndez took possession of the eye received by a patient was 13,603 cGy (13,603 rad) applicator device, it was in the manufacturer's to the surface of the eye, with an estimated 544 carrying case. A label attached to the carrying cGy (544 rad) to the lens of the eye.

case contained the following hand written information: (1) the dose rate for the device, The NRC medical consultant believes that the which was calibrated as 24 centigray (cGy) per long-term consequences of the misadministrations second (24 rad per second); (2) the instrument to the 25 highest dose patients could include: (1) used to calibrate the dose rate; (3) the date when increased risk of cataracts; and (2) increased risk  !

the dose rate was calibrated; and (4) the name of ofinfections, due to severe thinning or ulceration the individual who performed the calibration. Dr. of the sclera, which could cause blindness if not NUREG-0090, Vol.19 4

Abnormal Occurrences, Fiscal Year 1996 detected early and aggressively treated. No to resume operations. A second CAL was issued adverse health effects were reported during a confirming that Dr. Ferndndez would perform an reexamination of seven of these 25 patients by Dr. in-depth review of his records to identify the Ferndndez. However, the NRC medical misadministrations and to notify the patients.

consultant indicated that the possible adverse consequences to these patients may not appear for a period of up to 10 years after irradiation. After Dr. Ferndndez requested termination of his license, NRC issued an order, which required him to maintain the Sr-90 sources in locked, safe Cause or Causes - Dr. Ferndndez used an storage until the sources were transferred to an incorrect dose rate for the Sr-90 source, as calibrated by a medical physics consultant authorized recipient, to transfer the Sr-90 source employed by the deceased former licensee, to within 90 days, to identify and notify any develop treatment plans. additional patients who may have received misadministrations, to obtain the services of an independent medical physics consultant with J

The incorrect dose rate calibration occurred when expertise in therapy dosimetry calculations, and to the former licensee had a medical physics Perform several other tasks specified in the order.

consultant calibrate the Sr-90 source, after the Dr. Ferndndez currently has a possession only original calibration certificate was lost. The license until his sources are properly transferred medical physics consultant used an inappropriate and his request for termination has t)een granted measurement instrument for the calibration, by the NRC. In addition, NRC is requesting that which gave an erroneous dose rate calibration of the Puerto Rico Health Department perform 24 cGy per second (24 rad per second). (The label along-term follow-up of these patients.

attached to the carrying case of the eye applicator device indicated that the medical physics consultant calibrated the Sr-90 source in NRC also issued Information Notice 96-66, September 1990.) "Recent Misadministrations Caused by Incorrect Calibrations of Strontium-90 Eye Applicators,"

on December 13,1996, to alert all medical use Also, Dr. Ferndndez had no Quality Management licensees authorized to use Sr-90 eye applicators Program (QMP) as required by 10 CFR 35.32, of misadministrations caused by incorrect source which could have helped in detecting the strength determinations of Sr-90 eye applicators.

calibration error. Medical use licensees, as

, required under 10 CFR 35.32, must establish a QMP to provide high confidence that radiation Dr. Ferndndez purchased the medical practice and will be administered as directed by the authorized the Sr-90 source from the estate of the deceased user,

' former licensee, Dr. Luis A. Vdzquez of Mayagnez, Puerto Rico. Consequently, Dr.

Ferndndez has the records of all of the Actions Taken To Prevent Recurrence administrations that were made using the Sr-90 source while it was licensed to Dr. Vdzquez. In a Licensee - Dr. Ferndndez initially ceased letter to Dr. Ferndndez dated October 28,1996, operations until the eye applicator device was NRC confirmed with Dr. Ferndndez that he would properly calibrated; reliable dosimetric data was Preserve the patient records of the former licensee available to perform the dose administrations; and and perform a computer search to identify the a QMP was developed and submitted to NRC for Patients who were treated with the eye applicator, review. Dr. Ferndndez subsequently decided to NRCis considering options for the review of these cease using the Sr-90 source and to terminate his records to determme how many additional license. (The QMP was never implemented.) misadmimstrations occurred when the m, correctly calibrated Sr-90 source was in the possession of the former licensee.

NRC - A CAL was issued to confirm that Dr.

Ferndndez would submit a QMP for use of the eye applicator device, and that he would cease This event is riot closed for the purpose of this operations until approval was received from NRC report.

5 NUREG-0090, Vol.19

1 Abnormal Occurrences, Fiscal Year 1996 j l

Cause or Causes -The licensee did not know how to calculate the decay of the Sr-90 source, and "S*d a line r functi n rather than a logarithmic 96-4 Medical Brach 7therapy .

function. In addition, the licensee used an Misadm.inis. trations by Phillip J.

incorrect half-life for Sr-90; however, this error W. Lee, M.D., in Honolulu, was less significant.

Hawaii Actions Taken To Present Recurrence The following information pertaining to this event is also being reported concurrently in the Federal Licensee - The licensee had the Sr-90 eye Register. Appendix A (see Event Type 5[d]) of this applicator calibrated at NIST and learned how to report notes that administering a therapeutic dose calculate the decay of the Sr-90 source.

from a sealed source such that the errors in source calibration and time of exposure result in a NRC - NRC requested that the licensee have the  ;

calculated total treatment dose differing from the Sr-90 eye applicator calibrated at NIST and  !

prescribed treatment dose by more than 10 taught the licensee how to calculate the decay of percent, and the event (regardless of any health the Sr-90 source. NRC is conducting an effects) affects two or more patients at the same inspection, which will remain open until the NRC facility, can be considered an AO. medical consultant finishes reviewing the cases i and provides an assessment of the potential health i Date and Place - May 6,1995, through November effects to the patients. Enforcement action may i 16, 1995; Phillip J. W. Lee, M.D.; Honolulu, be taken in the future if necessary.

Hawaii.

This event is closed for the purpose of this report.

Nature and Probable Consequences - During an ********

NRC inspection, it was determined that the licensee had incorrectly performed calculations for the decayed activity of a strontium-90 (Sr-90) 96-5 Medical Brachytherapy source in an eye applicator. Consequently, the Misadministration at Harper licensee had the Sr-90 eye applicator calibrated by the National Institute of Standards and Hospi tal in Detroit, MichiEan Technology (NIST). Based on calibration data The following information pertaining to this event provided by NIST, NRC and the licensee is also being reported concurrently in the Federal determined that 17 misadministrations involving Register. Appendix A (see Event Type 3 in Table 16 patients had occurred between May 6 and A-1) of this report notes that a therapeutic November 16,1995. (Two of the exposure to any part of the body not scheduled to misadministrations involved one patient who was receive radiation can be considered an AO treated on both eyes.) The delivered doses were from 21.1 to 22.7 percent greater than the Date and Place - November 24,1995; Harper prescribed total dose of 4000 centigray (cGy) Hospital; Detroit, Michigan.

(4000 rad). (The total dose was to be delivered in four fractions of 1000 cGy [1000 rad] each.) Nature and Probable Consequences - A patient was being treated with a strontium-90 eye The licensee and referring physicians did not applicator for pterygium (a growth over the eye observe any adverse consequences to the patients. which causes gradual blindness). The patient was The licensee noted that the misadministered doses prescribed three 800-centigray (800 rad) were within the ranges recommended for this type treatments lasting 30 seconds each. Each of the of treatment. NRC contracted a medical treatments was to be administered to the medial consultant to review the cases and make an side of the left eye. However, the second independent assessment of the potential health treatment was mistakenly administered to the effects to the patients. As of the date of this lateral side of the left eye. The physician realized report, the reviews of the NRC and its consultant the error and immediately treated the correct side were ongoing. with the prescribed dose.

The licensee notified the patients of the The patient was notified of the misadministration misadministration, and given a written report. The patient's referring NUREG-0090, Vol.19 6

Abnormal Occurrences, Fiscal Year 1996 physician was notified. An NRC medical applicator. During treatment a source became consultant evaluated the effects cf the dislodged and delivered radiation to the patient's misadministration and concurred with the licensee thigh, which was an unprescribed treatment site.

that the patient was not expected to suffer any adverse health effects. The licensee subsequently calculated that the I consequent dose to the patient's thigh was 71 Ccuse or Causes -The patient's chart was upside centigray (cGy) (71 rad), as compared to 65 cGy down and the treating physician incorrectly (65 rad) which would have been delivered to the interpreted the sketch of the left eye on the thigh at 20 centimeters (7.87 inches) distance from  ;

diagram that specified the treatment site. (The the applicator during the total procedure if i diagram was part of the written directive for performed as prescribed.

treatment using the strontium-90 eye applicator; however, it did not show the nose, top of the page, During a routine NRC inspection conducted on I or bottom of the page.) Also, the second April 10-12,1995, the NRC inspector noted the i

treatment was administered by a different incident report and brought it to the attention of physician and physicist than the first treatment. NRC management. NRC subsequently determined that the event was a Actions Taken To Prevent Recurrence misadministration and notified the licensee. The licensee consequently submitted the required Licensee -The licensee revised the diagram so notifications to NRC, and notified the patient in that it shows the nose, thereby making it obvious writing of the misadministration.

which is the left eye and which is the right eye.

Cause or Causes - A malfunction of the aging NRC -- NRC conducted a special safety inspection.

gynecological applicator and a possible lack of A Notice of Violation was issued for faihng t attention to details by the personnel involved in ensure that the admm, istration was in accordance loading the applicator caused the with the written directive. Since the inspection misadministration.

showed that actions had been taken to correct the violation and to prevent recurrence, no reply t Actions Taken To Prevent Recurrence the violation was required.

Licensee - The licensee replaced the This event is closed for the purpose of this report. ,

malfunctionmg gynecological applicator. In

........ addition, the licensee now requires that two persons perform loading of the gynecological applicator to insure that the sources are in and 96-6 Medical Brachytherapy that the ovoids are taped to insure that the sources do not come out inadvertently.

Misadministration at New England Medical Center in NRC-The NRC again reviewed the information Boston, Massachusetts provided by the licensee and determmed that violation of the licensee's Quality Management The following information pertaining to this event is also being reported concurrently in the Federal Plan had occurred. An NRC medical consultant Register. Appendix A (see Event Type 3 in Table reviewed the circumstances of the misadmuustration, determined that the licensee A-1) of this report notes that a therapeutic had used an inaccurate source-to-thigh distance in exposure to any part of the body not scheduled to its dose calculation, and determined that the receive radiation can be considered an AO.

patient received a dose of 864 cGy (864 rad) to the Date and Place - November 10,1993; New thigh instead of 71 cGy (71 rad) as calculated by England Medical Center; Boston, Massachusetts. the licensee. The medical consultant stated that the patient experienced no ill effects.

Nature and Probable Consequences - A patient with carcinoma of the cervix metastatic to the This event is closed for the purpose of this report.

brain was being treated with an intercavity implant ********

using cesium-137 sources in a gynecological 7 NUREG-0090, Vol.19

4 Abnormal Occurrences, Fiscal Year 1996

, 96-7 Medical Brachytherapy administration of the prescribed dose in

! Misadministration at William compliance with the physician's written directive.

Beaumont Hospital in Royal This event is closed for the purpose of this report.  ;

Oak, Michigan l The following information pertaining to this event is also being reported concurrently in the Federal Register. Appendix A (see Event Type 3 in Table 96-8 Medical Brachytherapy

, A-1) of this report notes that a therapeutic Misadministration at exposure to any part of the body not scheduled t Community Hospitals '

receive radiation can be considered an AO.

ofIndiana in Indianapolis,

! Date and Place - March 19,1996; William Indiana Beaumont Hospital; Royal Oak, Michigan.

The following information pertaining to this event is also being reported concurrently in the Federal J

Nature and Probable Consequences - A patient 2 with cancer of the vagina was prescribed Register. Appendix A (see Event Type 3 in Table treatment with a high dose rate (HDR) remote A-1) of this report notes that a therapeutic afterloader brachytherapy unit having an exposure to any part of the body not scheduled to ,

iridium-192 source. The treatment plan specified receive radiation can be considered an AO. '

a step size of 2.5 millimeters (mm) (0.098 inches).

Date and Place - August 16,1996; Community j A wrong step size of 5.0 mm (0.197 inches) was Hospitals of Indiana; Indianapolis, Indiana.

. entered into the HDR unit's computer control

program. Therefore, a part of the body not Nature and Probable Consequences - A patient scheduled to receive radiation was exposed. was prescribed a 500 centigray (cGy) (500 rad)

. treatment for an esophageal tumor using a high The licensee calculated that the skin of the dose rate remote afterloader unit having an patient's thighs, which was the wrong treatment iridium-192 source. Because of a treatment site, received a maximum unintended dose of 500 planning error, a non-prescribed treatment area centigray (500 rad) because of the approximately 27 millimeters (mm) (1.06 inches

misadministration. An NRC medical consultant determined that the patient should have no side [in]) below the tumor volume received a maximum

, dose of 465 cGy (465 rad) instead of the estimated effects as a consequence of the m,sadministration. i dose of 50 to 100 cGy (50 to 100 rad).

The patient and the referrm, g physician were notified of the misadministration. The patient was notified of the misadministration.

. The licensee expects no adverse health effects to Cause or Causes -The wrong step s.ize was the patient. A NRC medical consultant was entered into the HDR remote afterloader retained to review the case.

brachytherapy unit's computer control program.

Cause or Causes - Because of a treatment Actions Taken To Prevent Recurrence planning error, the source was placed approximately 27 mm (1.05 in) below the tumor Licensee - The licensee revised its " physics volume worksheet" to include the step length as an

, additional entry; developed a checklist for the Actions Taken To Prevent Recurrence 2

physicist /dosimetrist to verify the treatment plan parameters, and posted it on the treatment Licensee - A table of offset distances for the console; and instituted a policy that all treatment various sources and catheter lengths used by the plan parameters must be verified, and the licensee was placed in the licensee's quality verification recorded, prior to each treatment. control manual.

4 NRC - NRC conducted a special safety inspection, NRC - NRC conducted a special safety inspection.

where one apparent violation was noted. This was This item is closed for the purpose of this report.

the failure of the licensee's Quality Management Program to provide assurance of correct ********

NUREG-0090, Vol.19 8

Abnormal Occurrences, Fiscal Year 1996 96-9 Medical Brachytherapy Actions Taken To Prevent Recurrence Misadministrations at EquiMed, Licensee - The licensee's authorized user and the Inc., in Lehighton, Pennsylvania HDR physicist will extract the pre-treatment The following information pertaining to this event Printout of the input parameters from the IIDR is also being reported concurrently in the Federal treatment console, review the input data for Register. Appendix A (see Event Type 3 in Table acmacy, and compare it with the wntten directive. Both the authonzed user and the HDR A-1) of this report notes that a therapeutic exposure to any part of the body not scheduled to Ph,ysicist will then initial the printout before the HDR treatment is initiated.

receive radiation can be considered an AO.

NRC- NRC determined tim e a incidents Date and Place - December 31,1995; EquiMed, occurred because the licen.w did not follow its Inc.; Lehighton, Pennsylvania. QMP. NRC contracted a n. , die d consultant to evaluate the health effects on the patients from Nature and Probable Consequences - Tw the misadministrations. Subseqututly, the patients were presenbed vagmal treatment with a consultant determined no probable rieterministic high dose rate (HDR) remote afterloader

, ,,, effects of the radiation exposure to the .mintended brachytherapy unit havmg an indium-192 source. site were expected.

The presenbed total dose for each patient was between 2000 and 2200 centigray (cGy) (2000 and This event is closed for the purpose of this report, ,

2200 rad), and was to be delivered in five '

fractional doses over a period of several weeks.

Each fractional dose was to be between 400 and 500 cGy (400 and 500 rad). 96-10 Medical Brachytherapy For one of the treatment fractions,500 cGy (500 Misadministration at the rad) was to be delivered to each patient over a University of Wisconsin in treatment length of 5 centimeters (cm) (1.97 Madison, Wisconsin inches [in]) using a step size of 5 millimeters (mm) The following information pertaining to this event (0.197 in). However, a wrong step size of 10 mm is also being reported concurrently in the Federal l (0.394 in) was entered into the HDR unit's control Register. Appendix A (see Event Type 3 in Table console, and a length of 10 cm (3.94 in) was A-1) of this report notes that a therapeutic treated instead of the presenbed length of 5 cm exposure to any part of the body not scheduled to (1.97 in). Therefore, radiation was dehvered t receive radiation can be considered an AO.

the wrong treatment site for each patient.

Date and Place - October 19,1995; University of The licensee concluded that each patient received Wisconsin; Madison, Wisconsin.

312 cGy (312 rad) instead of the prescribed dose of 500 cGy (500 rad) (an underdose of 37.6 Nature and Probable Consequences - A patient 1 percent), and an additional length of 5 cm (1.97 had two separate lung tumors, one in the lower in) received an unintended dose of 312 cGy (312 section of the right lung and one in the middle rad), section of the left lung. The patient was prescribed a total treatment dose of 1600 The licensee did inform the patients of the centigray (cGy) (1600 rad), with each tumor to misadministrations, and does not expect the receive a total dose of 800 cGy (800 rad). The patients to have any adverse effects from the total treatment dose was to be administered in misadministrations. four fractions of 400 cGy (400 rad) each over 2 days using a high dose rate (HDR) remote Cause or Causes - A wrong step size was entered afterloader unit having an iridium-192 source.

into the HDR unit's control console because the Each fraction was to be administered in two parts; licensee did not follow its Quality Management a 200 cGy (200 rad) dose to the lower section of Procedures (QMP). The QMP requires that the right lung followed by a 200 cGy (200 rad) treatment planning information be checked by the dose to the middle section of the left lung.

person entering the data in the control console, Catheters of appropriate length were inserted into and then verified by the authorized user. each lung to guide the source during treatment; 9 NUREG-0090, Vol.19

l l

Abnormal Occurrences, Fiscal Year 1996 i.e., a long catheter was inserted into the right NRC - NRC conducted a special safety inspection lung and a short catheter was inserted into the left in conjunction with a routine inspection. A Notice lung. of Violation was issued for failing to establish adequate procedures to ensure that final While the HDR controller was inserting the treatment plans were in accordance with the source into the left lung during the first treatment written directive. The licensee responded in fraction, the source stopped moving when it writing and no additional actions were required.

touched the bottom of the short catheter in the ,

left lung even though the HDR controller was This event is closed for the purpose of this report.

attempting to move it further into the left lung. ........

Because the intended treatment sites had been reversed during treatment planning and were subsequently programmed into the HDR 96-11 Medical Brachytherapy controller, the controller had positioned the Misadministration at Thomas source in the middle of the right lung during the Jefferson University Hospital in first part of the first treatment fraction and was Philadelphia, Pennsylvania attempting to position the source in the lower part of the left lung during the second part of the first The following information pertaining to this event treatment fraction. Consequently, the middle of is also being reported concurrently in the Federal the right lung had received an unintended dose of Register. Appendix A (see Event Type 3 in Table 200 cGy (200 rad) during the first part of the first A-1) of this report notes that a therapeutic treatment fraction. exposure to any part of the body not scheduled to receive radiation can be considered an AO.

After the error was discovered, the correct treatments were dehvered. The patient was Date and Place - August 14,1995; Thomas notified of the misadmimstration both verbally Jefferson University Hospital; Philadelphia, j and in writing. The referring physician was also Pennsylvam.a, notified.

Nature and Probable Consequences - A patient was undergoing brachytherapy treatment of the An NRC medical consultant evaluated the palate; i.e., the roof of the mouth. A total of 64 misadministration and concluded that the patient iridium-192 seeds, having a total activity of 1102.6 would not have organ damage or long term megabecquerel (29.8 millicurie), were inserted biological effects. into six catheters. Four of the catheters were sutured inside the mouth, and two were placed in Cause or Causes - When planning the treatment, the nostrils.

the treating physicist deviated from standard protocol and used different dummy sources to While making a routine visit to the patient, the obtain clearer opaque x-ray markers for source Prescribing physician noticed that two catheters location. Upon recording the data, the planned were outside of the patient's mouth and had been source locations for each treatment fraction were taped to the patient's right cheek. Also, one of reversed. An independent verification of the the two catheters remaining in the mouth was treatment plan by a second physicist did not loose and its sutures were removed. Because the include a review of the x-rays for proper source catheters were not properly positioned, the location, so the error was not immediately Physician terminated the treatment.

discovered.

The radioactive seeds were subsequently removed.

1. patient was informed both verbally and in Actions Taken To Prevent Recurrence ..

writmg that the sources had become dislodged and had consequently delivered radiation to the wrong Licensee - The licensee revised its Quality treatment site. It was determined that the Management Program to include an independent patient's cheek received a dose of 70 centigray (70 review of the x-rays for source location by a rad).

second physicist. Also, when there is a deviation from the protocol, the results must be Cause or Causes - While responding to a call documented and reviewed by a second physicist. from the patient, a nurse noticed that two of the NUREG-0090, Vol.19 10

Abnormal Occurrences, Fiscal Year 1996 catheters were loose and subsequently taped them of the applicator. The nurse placed the source to the patient's check. The nurse had not been into the portable shielding that was available in trained to recognize that the radioactive seeds the room and notified the radiation safety officer.

were moved from their intended positions. The radiation safety officer immediately returned to the patient's room with the physician, who Actions Taken To Prevent Recurrence inserted the source into the right ovoid for the remainder of the prescribed 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> of Licensee - Refresher in-service training was given treatment.

to the nurses who care for brachytherapy patients.

Emphasis was placed on identifying radioactive The licensee calculated that the unintended skin sources and handling them properly under normal dose to the patient's upper inner thighs was 5 and emergency conditions. Also, the nurses will centigray (cGy) (5 rad). NRC concurred with the be briefed on the details of a planned treatment at licensee's calculation and did not obtain a medical the time the sources are implanted with emphasis consultant. The dose of 5 cGy (5 rad) is within the on radiation safety issues. Finally, physicians will occupational exposure limit and is not expected to visit implant patients at least twice daily during result in deleterious effects to the patient. The treatment. patient and physician were notified of the misadministration.

NRC - After conducting an investigation, NRC determined that the event was a Cause or Causes - When the radiation oncologist niisadministration. An NRC medical consultant manually afterloaded the sources from the right concluded that no significant injury would be and left carriers into the ovoids, difficulty was expected. A Notice of Violation was issued with encountered in identifying the correct carrier for one Severity Level IV violation. the right ovoid. Also, the hinge on the correct carrier for the right ovoid was tight. The This event is closed for the purpose of this report. radiationoncologist believed that the sealed source dislodged from the carrier bucket when the

• • • • • • • • problem with the hinge was encountered.

. Actions Taken To Prevent Recurrence 96-12 Medical Brachytherapy Misadministration at Macombe Licensee - To prevent recurrence, the licensee Hospital Center in Warren, will: (1) ensure that the carrier bucket hinges are Michigan working properly prior to loading the source into the bucket; (2) inscribe the handles of the ovoid The following information pertaining to this event carriers, with "R" for right ovoid and "L" for left is also being reported concurrently in the Federal ovoid, so that they can be readily identified Register.- Appendix A (see Event Type 3 in Table without difficulty; (3) require the physicist to A-1) of this report notes that a therapeutic observe the radiation oncologist during the exposure to any part of the body not scheduled to afterloading procedure in order to detect a receive radiation can be considered an AO. dislodged source; and (4) require that the radiation oncologist complete a visual check of the Date and Place - March 11,1996; Macombe bed sheets and immediate area before leaving the l Ilospital Center; Warren, Michigan. room. I Nature and Probable Consequences - A patient NRC - NRC conducted a special safety inspection.

was undergoing a cervical boost brachytherapy NRC issued a Notice of Violation for failing to treatment v,ith a manually afterloaded standard meet the objective that each administration is in gynecological applicator using cesium-137 accordance with a written directive. The sources. Approximately 100 minutes after the inspection showed that actions had been taken to treatment was started, a nurse found one of the correct the violation and to prevent recurrence.

sources from the applicator lying on the sheet between the patient's legs. The dislodged source This event is closed for the purpose of this report.

contained 1.29 gigabecquerel (34.8 millicurie) of cesium-137 and was intended for the right ovoid ********

11 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 96-13 Medical Brachytherapy oncology department following the implant of the Misadministration at Unity apphcator device.

Hospital in Fridley, Minnesota Actions Taken To Prevent Recurrence The following information pertaining to this event Licensee - The licensee revised its is also being reported concurrently in the Federal written-directive form to require the treating Register. Appendix A (see Event Type 5[b]) of this physician to enter the cap size when ovoids are report notes that administering a therapeutic dose used, and for a second person to verify that the such that the actual dose is less than 0.5 times the information was entered. If the entry on the form prescribed dose should be considered an AO. is not made, the person confirming the information must independently verify which size Date and Place - August 19-20,1996; Unity ovoid caps were used.

Hospital; Fridley, Minnesota.

NRC - NRC conducted a special safety inspection Nature and Probable Consequences - A patient on September 9,1996. No violations of NRC was prescribed a dose of 2500 centigray (cGy) requirements were identified during the course of (2500 rad) for a gynecological brachytherapy this inspection.

procedure, using a gynecological applicator This event is closed for the purpose of this report.

contammg cesium-137 sources in two ovoids.

Because 3-centimeter (cm) diameter caps had ........

been used on the ovoids of the gynecological applicator, instead of the intended 2-cm diameter caps, the patient received a dose of 1186 cGy 96-14 RadioPh,armaceutical (1186 rad) to the vaginal surface. M.isadministration at Universal Imaging in Taylor, Michigan With the addition of the external beam therapy that the patient had received prior to this The following information pertaining to this event treatment, the total admimstered dose was 5680 is also being reported concurrently in the Federal cGy (5680 rad). The treating physician Register. Appendix A (see Event Type 1 in 'lable determmed that the total admmistered dose was A-1) of this report notes that administering a within the medically accepted range of treatment, radiopharmaceutical other than the one intended, and that no negative effects to the patient were where the actual dose is greater than five times the prescribed dose, can be considered an AO.

expected. The treatmg physician did not plan to administer any further radiation treatments to the Date and Place - March 18,1996; Universal patient to compensate for the underdose. Imaging, Inc.; Taylor, Michigan.

The patient was notified of the misadministration Nature and Probable Consequences - A patient both verbally and in writing. The referring was prescribed a 7.4 megabecquerel (MBq) (200 physician was also notified. microcurie [ Ci]) dosage ofiodide-123 (I-123) for a thyroid scan, but was administered 7.4 MBq (200 Cause or Causes - There was poor pCi) ofiodide-131 (I-131) instead.

communication between the treating physician .. .

and the dosimetrist who prepared the treatment The referring physician's directive stated that plan regarding the size of the ovoid caps to be I-123 was to be used. (This is the only isotope of used for the treatment. (The treating physician i dine used at the facility.) A technologist then may select 2-cm diameter caps,3-cm diameter accidently ordered the I-131 from the nuclear caps, or no caps at all from an applicator kit, Pharmacy. A second technologist recogmzed that depending on the anatomy of the patient.) In the I-131 was different from the I-123 routinely addition, licensee personnel may have become used, but assumed that it was presenbed and desensitized to the possibility that an ovoid cap admimstered it anyway.

size different than 2-cm in diameter could be The licensee estimated that the dose to the used; the treating physician failed to follow-up on patient's thyroid was 104 centigray (104 rad).

earlier instructions to the dosimetrist to ver:fy the l correct cap size used; and the applicator kit was The referring physician was notified of the I not returned immediately to the radiation misadministration. The referring physician NUREG-0090, Vol.19 12

Abnormal Occurrences, Fiscal Year 1996 decided not to notify the patient because the Register. Appendix A (see Event Type 4 in Table information would be harmful to the patient. A-1) of this report notes that if an actual diagnostic dose of a radiopharmaceutical is An NRC medical consultant reviewed the event greater than five times the prescribed dose it can and determined that the impact of the be considered an AO.

misadministration on the status of the patient's health was very low, and that no specific medical follow-up care was necessary. Date and Place - September 21,1995; Miami Valley Hospital; Dayton, Ohio.

Cause or Causes - The misadministration was apparently caused by a lack of sufficient oversight of heensed activities, madequate trammg, and Nature and Probable Consequences - A patient failure to establish a written protocol for ordering was administered a 2.8 megabecquerel (MBq) (77 and venfying radiopharmaceuticals. microcurie [ Ci]) dosage ofiodine-131 (I-131) for a thyroid uptake study, rather than the prescribed Actions Taken To Prevent Recurrence dosage range of 0.19 to 0.37 MBq (5 to 10 Ci) of I-131. The b,eensee determ,med that the dose to Licensee - The licensee implemented the the patient's thyroid was 80.85 centigray (80.85 following corrective actions: (1) all technologists rad).

were informed not to use any radiopharmaceutical that was not listed in the licensee's " Prescribed The patient was informed of the Dosage List"; (2) orders must be sent to the misadministration in writing. The patient's nuclear pharmacy via facsimile, rather than over referring physician was also notified.

the telephone; (3) the nuclear pharmacy was instructed not to deliver I-131, I-125, or any other therapeutic radiopharmaceutical to the licensee; An NRC medical consultant determined that no (4) all technologists were informed in writing not adverse health effects are expected from the to proceed if they were unsure of any procedute; additional dosage.

and (5) copies of radiopharmaceutical orders and their activities were to be checked against receipts. ..

Cause or Causes - A nuclear medicme The licensee is not required to have written technologist inadvertently picked-up the wrong directives to follow. This is because it does not capsule, and in accordance with the licensee's perform therapy of any kind, does not use I-125 practice did not calibrate the dosage in the dose or I-131 in quantities greater than 1.11 MBq (30 calibrator pnor to admmistration. The beensee's pCi), and has no Quality Management Program. staff did not believe there was a requirement to assay dosages below 1.11 MBq (30 Ci).

NRC- NRC conducted an inspection. Based on the results of the inspection, eight apparent violations were identified and are bem, g Actions Taken To Prevent Recurrence considered for escalated enforcement action. A predecisional enforcement conference was held to Licensee - The licensee implemented procedures discuss the apparent violations and any potential to require that all dosages must be assayed enforcement action is pendmg. regardless of their activity, and to review the assay E' "" *

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

NRC - NRC conducted a special safety inspection.

NRC issued a Notice of Violation for failing to 96-15 Radiopharinaceutical measure dosages containing less than 1.11 MBq

, . . (30 Ci) before they were administered to patients Misadn1tnistration at Miarnt for medical use. The licensee responded in Valley Hospital in Dayton, Ohio writing and no additional actions are required.

The following information pertaining to this event is also being reported concurrently in the Federal This event is closed for the purpose of this report.

13 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 supervised user (technologist) to follow instructions in accordance with the written 96-16 Radiopharmaceutical di'***i"

4 Misadministration at St. Joseph This event is closed for the purpose of this report.

Mercy Hospital in Ann Arbor, ,,,,,,,,,

Michigan The following information pertaining to this event 96-17 Radiopharmaceutical l

is also being reported concurrently in the Federal Misadministration at the l 2

Register. Appendix A (see Event Type 4 in Table Veteran Affairs Medical l J A-1) of this report notes that if an actual .

! diagnostic dose of a radiopharmaceutical is Center in Charleston, South

greater than five times the prescribed dose it can Carolm, a be considered an AO.

The following information pertaining to this event is also being reported concurrently in the Federal

Dite and P, ice - April 9,1996; St. Joseph Mercy Hospital; Ann Arbor, Michigan. Register. Appendix A (see Event Type 5[b]) of this report notes that administering a thergeutic dose Netan and Probable Consequences - A patient such that the actual dose is less than 0.5 times the j Fescribed dose should be considered an AO.

was admirHered a 596 megabecque:el (MBq)

(16.1 millieu.ie [ mci]) dosage ofiodine-131 Date and Place - January 9,1996; Veteran Affairs rather than the prescribed 122 MBq (3.3 mci) Medical Center; Charleston, South Carolina.

, dosare ofI-131 for a dwgnostic stucy of the neck and chest. Nature and Probable Consequences - An 2

outpatient was administered 277.5 megabecquerel The misadministration was discovered after a vial, of a prescribed 573.5 intended for another patient, was assayed and (MEq)

MBq O J.5 l7.5 mci)millicurie dosage of so[mCij) d;ne-131 (I-131) in i found to contain 122 MBq (3 3 mci) instead of liquid form. The error was discovered when the the expected 633 MBq (17.1 mci). The patient licensee rechecked the prescription vial with a was notified of the misadministration. The dose calibrator after the administration to verify patient's referring physician was also notified. that the patient had received all of the prescribed i dose. The licensee discovered that approximately The patient's thyroid gland had been removed 296 MBq (8 mci) of the prescribed dosage had previously and therefore the licensee anticipated been retained in the vial cap, and consequently minimal medical consequences. NRC contracted was not administered to the patient. The patient

, with the Oak Ridge Institute for Science and was informed of the event and was subsequently

Education to conduct an assessment of the I-131 administered an additional 296 MBq (53 mci) to dose to the patient. The assessment en %3d make up for the underdosage. The licensee also that since the patient had no thyroif

, notified the referring physician of the maximum dose was misadmimstered ^ misadministration. The licensee expects no

pat:ent's bladder wall and was equal to 48.3 adverse effects to the patient from the l centigray (48.3 rad). misadministration.

Cruse or Causes - The technologist, when Cause or Causes - The root cause for the adtrinistering the dosage, mistakenly picked up a misadministration was a proriounced reaction of wrong radiopharmaceutical vial. the I-131 with the vial cap, thereby allowing a significant portion of the radioactive material to Actions Taken To Prevent Recurrence bih itself to the cap.

Licensee - Licensee personnel failed to Actions Taken to Prevent Recurrence completely follow the written Quality Management Program. Licensee - The licensee's Radiation Safety Officer investigated the incident. Bioassays were

! NRC - NRC conducted a special safety inspection. conducted on the indivi lais who handled and NRC issued a Notice of Violation for failure M Se administered the I-131 d( , and all were found NUREG-0090, Vol.19 14 4

.. - = _ . - _ . . -. . - - . . . --- . - -

Abnormal Occurrences, Fiscal Year 1996 to be negative. The licensee also revised its policy P-32 in a 0.5 mi volume. The appropriate syringe and procedures to require that only 1-131 in was to be chosen based upon the results of the capsule form be used in the future, fluoroscopy.

NRC - NRC conducted a special inspection to Because of poor communication, a technologist review the circumstances surrounding the erroneously prepared one syringe containing 6.179 misadministration, and identified no violations of MBq (0.167 mci) in a 0.25 ml volume and another NRC requirements. syringe containing 12.32 MBq (0.333 mci) in a 0.5 mi volume. The syringes were not labeled.

The State Agency is working with the nuclear pharmacy that filled the prescription and the Based upon the results of the fluoroscopy, the intermediate processor of the 1-131, both South administering physician chose the syringe with the Carolina state licensees, to determine the cause of 0.25 ml volume, believing that it contained 18.5 the event. The nuclear pharmacy informed its MBq (0.5 mci) of P-32. l.. Never, the 0.25 mi customers of the event.

volume contained only 6.179 MBq (0.167 mci),

which was one-third of the intended dosap.

After the administration, the technologist who This event is closed for the purpose of this report.

prepared the dosages asked why both syringes had

• • • • • • • + not been used and explained how they were prepared.

96-18 Radiopharmaceutical The patient was notified of the misadministration in writing.

Misadministration at Queen's Medical Center in Honolulu, The two physicians involved with the Hawaii misadministration have not observed any adverse health effects to the patient, and do not expect  ;

The following information pertaining to this event uv. NRC determined that a medical consultant l is also being reported concurrently in the Federal eld not be required to review the case.

Register. Appendix A (see Event Type 5[b]) of this report notes that administering a therapeutic dose Cause or Causes - The details of the prescribed of a radiopharmaceutical differing from the dosages were not properly communicated to the prescribed dose by more than 10 percent, and the l actual dose is less than 0.5 times the prescribed technologist who prepared the two syringes, the details were not independently confirmed by other  !

dose, can be considered an AO.

licensee personnel, and the written procedure for preparing the dosages did not specify multiple Date and Place - December 8,1995; Queen's ,

syrmge volumes.

Medical Center; Honolula, Hawaii.

Nature and Probable Consequences - A patient Actiow Taken To Prevent Recurrence was prescribed a dosage of 18.5 megabecquerel Lict nsee - The licensee now requires the (MBq) (0.5 millicurie {mCij) of phosphorus-32 Presaribing physician to establish a standard (P-32) to be administered to the wrist for activity and volume for each treatment site, and treatment of symptoms related to rheumatoid arthritis, but was administered 6.179 MBq (0.167 the injecting physician to verbally repeat this information and ask the technologist to verbally nCi) instead. The dosage was administered via a confirm it prior to the administration.

saline solution, NRC - NRC conducted a special inspection and Prior to treatment, the volume of the patient's issued a Notice of Violation for deficiencies in the wrist-joint space was to be determined using Quality Management Program.

fluoroscopy so that the proper volume ofliquid would be injected. Also, two syringes were to be This event is closed for the purpose of this report.

- prepced. One was to contain 18.5 MBq (0.5 mci) of P-32 in a 0.25 milliliter (ml) volume, and ********

the other was to contain 18.5 MBq (0.5 mci) of 15 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 j AGREEMENT STATE LICENSEES Using the criteria and guidelines in Appendix A of on-site building and that the metal door to the this report, the following events which occurred at building was welded shut.

Agreement State licensees during this reporting

period were determined to be significant enough

! to be reported as an AO. During the period of March 1995 to January 1996, all structures on the site were demolished and all salvageable equipment was sold, with the AS %1 Stolen Cobalt-60 **C?pti n f the building containing the Co-60 Radiography Cameras radiography cameras. When the salvage company vacated the site, the site had no security and Appendix A (see For All Licensees, Example 6) of People removed anything of value that could be this report notes that a substantiated case of s Id as scrap. TDH/BRC consequently notified actual or attempted theft or diversion oflicensed the bankruptcy court ofits concern about the material or sabotage of a facility should be security of the Co-60 radiography cameras.

considered an AO.

On February 27,1996, three thieves broke into the Date and Place - February 27 to March 5,1996; building containing the Co-60 radiography 1(ouston, Texas. cameras by removing the metal door that had been welded shut, stole the cameras, and sold Nature and Probable Consequences - 1.arpen of them to a scrap yard. The scrap yard then sold Texas (Larpen) was a radiography company that them to an intermediary dealer who sent them to owned two cobalt-60 (Co-60) radiography a recycling facility. The recycling facility refused cameras. The Co-60 sources in the cameras had to accept the cameras because they were activities of 1.31 terabecquerel (TBq) (35.3 curie radioactive, and the intermediary dealer

[Ci]) and 0.32 TBq (8.6 Ci) respectively. Larpen consequently returned them to the scrap yard by provided radiography services to a truck. When the cameras arn,ved at the scrap steel-manufacturing company at the company's yard, the 1.31 TBq (35.3 Ci) Co-60 source, which 37-acre site. was accidentally unshielded while in transit, was thrown to the ground by the delivery man and When the steel-manufacturing company went f rgotten. The scrap yard resold the cameras to bankrupt, the Texas Department of Health Bureau other scrap yards. However, no one at the scrap of Radiation Control (TDH/BRC) issued orders yard knew that the unshielded Co-60 source was to Larpen in October 1992 to stop operating, and laym, g on the ground. The unshielded source lay ordered all ofit.c mdioactive sources to be n the ground for 100.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> until it was located impounded in pe Larpen subsequently filed by TDH/BRC on March 5,1996. TDH/BRC also for bankruptcy ano ns name was consequently located the other camera on the same day. Both changed to Many Diversified Interests, Inc. cameras and their Co-60 sources were then (MDI),in compliance with the law. Upon secured at an authorized disposal company. After learning of the MDI bankruptcy, TDH/BRC the sources were recovered and secured, the verified that the Co-60 radiography cameras were trustee for bankrupt MDI had to obtain secured in a building on the site. Permission from the bankruptcy court for the disposal company to dispose of the cameras.

TDH/BRC wrote to the bankruptcy court on June 24,1994, and to the trustee for bankrupt MDI on The unshielded Co-60 source irradiated scrap July 11,1994, to request that the Co-60 yard workers and the scrap-yard manager's two radiography cameras be properly disposed of, but small children. The delivery man who touched the no actions were taken. On July 29,1994, source received radiation burns to the thumb and TDH/BRC formally notified the bankruptcy court, middle finger of his right hand. Five police through the Texas Attorney General's Office, that officers who investigated the theft of the cameras it was a creditor and party ofinterest in the were also irradiated by the source. Two bankrup;cy of MDI. TDH/BRC then ensured that TDH/BRC personnel who located and secured the the Co-60 radiography cameras were secure in an source received doses of 1.5 millisievert (mSv)

NUREG-0090, Vol.19 16

Abnormal Occurrences, Fiscal Year 1996 (150 millirem [ mrem]) and 5.2 mSv (520 mrem) AS 96-2 Rupture of a Source Owned respectively. by Little Bit Wireline at an Oil Well near Winnie, Texas i

TDII/BRC estimated the possible radiation doses .

Appendix A (see For All Licensees, Example 10) that were received by the mdividuals who were f this report notes that a major deficiency in exposed to the unshielded Co-60 source. Since design, construction, or operation havm, g safety the estimates indicated that the doses may have been as high as 600 mSv (60 rem), the scrap yard imp lications reguinng immediate remedial action should be considered an AO.

workers, the children, the policemen, and the thieves had their blood tested to determine their Date and Place - September 15,1995; Winnie, doses. Cytogenetic studies by the Department of Texas.

Energy's Radiation Emergency Assistance Nature and Probable msequences - An 111,000 Center / Training Site in Oak Ridge, Tennessee, determined that their doses were less than 100 megabecquerel (MBw 3 curie [Ci]) i americium-241/ beryllium source owned by Little mSv (10 rem). Also, the doses to the general Bit Wireline was found to be leaking after it was public conducting business at the scrap yard were recovered from an oil well near Winnie, Trras, determined to be less than 5.0 mSv (500 mrem). where it had been stuck. The Texas Depaument of Health, Bureau of Radiation Control (BRC),

The three thieves were arrested for stealing the was notified of the event. BRC subsequently cameras and the owner, manager, and manager's found th'at the radiation level of the leaking source wife of the scrap yard were arrested for receivmg was 10 microsievert per hour (1 millirem per stolen goods, hour), and that the well site and associated equipment were contaminated. {

Cause or Causes - The devices were stolen from a BRC reported the event to NRC, and asked for I facility where they were being stored by assistance from the Department of Energy TDH/BRC after a heensee went bankrupt. IDOE). DOE subsequently transported tie TDH/BRC has severely limited j,unsdiction over leaking source to Los Alamos Natior.al radiography sources m cases where a licensee ) aboratory where it was determined that the declares bankruptcy and any action must be taken ' emaining source activity was approximately through the bankruptcy court. 37,000 MBq (1 Ci).

DOE was also asked to evaluate 10 individuals, Actions Taken To Prevent Recurrence including the licensee, for internal contamination.

The individuals were sent to the Oak Ridge Licensee --The licensee is in bankruptcy and is n Institute for Science and Education (ORISE) for longer a viable company. All assets of the whole body scans and urinalysis. ORISE company are handled by a trustee appointed by determined that the whole body scans and the bankruptcy court. The cameras and sources urinalysis for the individuals were negative, and are bemg disposed of by the trustee. that there was no reason to bdieve that anyone had received a significant internal exposure.

State Agency - TDH/BRC is trying to determine if Cause or Causes -It is believed that there are two there are requirements and controls that can be ways in which the source may have been ruptured.

Pl aced on the trustees of bankrupt companies. The first is that it was ruptured by a milling tool possessmg radioactive materials. TDH/BRCis

, which was used to recover it. The second is that it also participating m a working group composed of was lodged between the oil well casing and representatives from the Nuclear Regulatory another assembly known as a " screen and liner" Commission and other Agreement States t which had also become stuck, and was ruptured review the loss of control of radioactive sources, during operations to recover the " screen and with emphas,si on bankruptcy situations. ,.

..ne r.

This event is closed for the purpose of this report. Actions Taken To Prevent Recurrence Licensee - The licensee's facility was

• • • • • • • • contaminated by the ruptured source and access to 17 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 it has been restricted. The licensee is no longer regulatory limits. (It should be noted that even performing well logging. though the licensee [Medi-Physics, Inc.] was not responsible for the event,its personnel were at the State Agency - BRC ordered the licensee and scene to collect all debris and decontamination affected companies to restrict access to the materials for transport to its facility.)

contaminated equipment and land, to characterize the contamination, and to decontaminate the Cause or Causes - The event was caused by the equipment and land. Further enforcement action failure of the driver of the delivery van to secure is pending. the rear door of the van. The package fell out of the van when the door opened.

This event is closed for the purpose of this report.

Actions Taken To Prevent Recurrence Licensee - The licensee for the spent nuclear medicine generator was not responsible for the AS 96-3 Release of Radioactive accident, and consequently was not required to Material in Lemont, Illinois, take corrective action it is not known if the From a Package That Was carrier, Associated Couriers, took any corrective Accidently Destroyed While etion.

Being hnsported by State Agency - Since this w is a violation by a Associatul Couriers of moving vehicle on a public raadway, enforcement Maryland Heights, Missouri action was brought against th, carrier by the Illinois Department of Transpertation (IDOT),

Appendix A (see For All Licensees, Example 11) based on information supplied i.y IDNS. IDOT of this report notes that serious deficiency in assessed a civil penalty of $2,700 ed received full management or procedural controls in major paymcnt of the penalty on December M 199.5.

areas should be considered an AO.

Since this was the first violation on record by this Date and Place - October 3,1995; Lemont, carrier, no further action was taken. An order Illinois. may be issued in the future for recovery of response costs, but no further punitive penalty is Nature and Probable Consequences - A spent anticipated.

nuclear medicine generator containing approximately 666 megabecquerel (18 millicurie) This event is closed for the purpose of this report.

of molybdenum-99/ technetium-99m fell from a moving delivery van operated by Associated Couriers of Maryland Heights, Missouri. It was then struck by an unidentified vehicle and AS 96-4 Lost Source at Deseret destroyed. The contamination that wr.s released was spread on both lanes of the roadway by a Generation and hansmission sudden ram and the spray from movm, g vehicles. Cooperative's Bonanza Power Plant in Vernal, Utah A Radiological Assessment Team nom Argonne National Laboratory was the first to arriva at the Appendix A (see For All Licensees, Example 10) of this report notes that a major deficiency in scene of the accident. The team transferred control of the scene to representatives of the design, construction, or operation having safety implications requiring immediate remedial action Ilhnois Department of Nuclear Safety (IDNS) when they arrived, but remamed at the scene to should be considered an AO.

assist the IDNS representatives. The roadway was Date and Place - January 31,1996; Deseret decontaminated to a near surface dose rate of 3 Generation and Transmission Cooperative's microsievert per hour (03 millirem per hour), at Bonanza Power Plant; Vernal, Utah.

which time it was reopened. Since no contamination migrated from the roadway, doses Nature and Probable Consequences - A 370 l to members of the public were negligible. Doses megabecquerel (10 millicurie) cesium-137 source to emergency workers were significantly below was found to be missing from its housing. The NUREG-0090, Vol.19 18

Abnormal Occurrences, Fiscal Year 1996 source was part of a KayRay/Sensall Model 7062 AS 96-5 Medical Brachytherapy BP fixed density gauge which was mounted to a fly Misadministration at Duke ash chute. The gauge had been in service since October 18,1984.

University Medical Center in  :

Durham, North Carolina l False signals from the gauge started to appear on Appendix A (see Event Type 1 in Table A-1) of January 9,1996, the day after a vibrator was this report notes that a therapeutic exposure attached to the fly ash chute. Several attempts which results in any part of the body receiving were made to identify and correct the problem unscheduled radiation should be considered an from January 9 until January 31,1996, when it was AO.

discovered that the source-housing shutter mechanism was broken and the source was Date and Place - March 12,1996; Duke missing. University Medical Center; Durham, North Carolina.

Several people tried unsuccessfully to find the Nature and Probable Consequences - A patient source by systematically searching the plant site )

was presenbed a dose of 650 centigray (cGy) (650 using radiation detection survey instruments.

rad) to the bronchus using an Omnitron 2000 high Consequently, five persons may have received an dose rate (HDR) remote afterloading exposure to radiation. However, it is highly brachytherapy unit havmg an iridium-192 source.

improbable that anyone received a measurable The HDR umt was to be used with a catheter that level of exposure. was 150.25 centimeter (cm) (59.15 inch) long.

However, during patient setup, the wrong Cause or Causes -The licensee believes that the catheter-length value of 125.25 cm (49.31 inch) vibrator which was attached to the fly ash chute on was entered into the HDR's computer treatment January 8,1996, was probably responsible for Pl annmg software, destroying the source-housing shutter mechanism and precipitating the loss of the source. Upon completion of the treatment, the attending physician recogmzed the misadministration and Actions Taken To Prevent Recurrence notified the radiation oncologist of the error. The patient and the referring physician were then Licensee - To prevent recurrence, the licensee notified by the radiation oncologist.

modified its radiation protection program to require that a semi-annual check be made to Since the catheter length entered into the HDR's verify that the source is in its housing; that computer treatment planning software was 125.25 vibration isolators be used to mount the source em (49.31 inch), and a 150.25 cm (59.15 inch) long housing; and that the source housing be positioned catheter was attached to the HDR, the source did so that the opened shutter block lays en the not completely traverse the length necessary to bottom of the housing. treat the bronchus with 650 cGy (650 rad). As a result, the wrong treatment sites received State Agency-The Utah Division of Radiation unplanned exposure; the right check received 90 Control notified the Illinois Radiation Control to 130 cGy (90 to 130 rad) and the right eye Program of the event involving KayRay/Sensall, a received 35 to 50 cGy (35 to 50 rad). The gauge manufacturer, licensed in the State of radiation oncologist anticipates no short or long Illinois. The Illinois Radiation Control Program term health effects from the misadministration.

is taking action with its licensee (KayRay/Sensall) . ..

Cause or Causes - The misadmimstration was regarding the possibility of any generic issues. caused by human error. The wrong catheter The State of Utah is continuing its investigation length was entered into the HDR's computer and plans to follow-up at the next inspection of its treatment plannm, g software.

licensee (Deseret Generation and Transmission Cooperative's Bonanza Power Plant), which was Actions Taken To Prevent Future Recurrence advanced because of this event.

Licensee - To prevent recurrence, the licensee This event is closed for the purpose of this report. added redundancy to its internal checklists to verify that the correct catheter length is entered in

• • • • • • • • the HDR's computer treatment software.

19 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 0

1 i

State Agency-The State Agency agrees with the configurations for three patients at the same time.

licensee's action to prevent recurrence.

I The loads were color-coded for each patient to l prevent mix-ups. On removal of the sources, the l This event is closed for the purpose of this report. medical physicist discovered that Patient A's and l

• • • • • • • • Patient B's loads were switched, even though the i i color-codes were correct for the patients. Patient C was not affected. The medical physicist stated AS 96-6 Medical Brachytherapy that he must have switched the loads prior to Misadministrations at the c I r-c ding the loads for the patients.

University of Mississippi Actions Taken To Prevent Recurrence Medical Center in Jackson, .

Licensee - The licensee immediately implemented Mississippt new procedures for loading brachytherapy sources Appendix A (see Event Type 5[d]in Table A-1) of into patients, which require the medical physicist this report notes that administering a therapeutic to only prepare and load sources for one patient dose from a sealed source such that the at a time.

treatmentdose differs from the prescribed dose by State Agency-The State Agency conducted an more than 10 percent and the event affects two or investigation. The State Agency concurred with more patients at the same facility can be the licensee's evaluation of the event and the considered an AO.

corrective action implemented by the licensee. No y lad ns were dted.

Date and Place - May 21,1996, through May 23, 1996; University of Mississippi Medical Center; This event is closed for the purpose of this report.

Jackson, Mississippi.

Nature and Probable Consequences -Two ,

patients were prescribed manual gynecological AS 96-7 Radiopharmaceutical  !

brachytherapy procedures using cesium-137 (Cs-137) sealed sources loaded m, a gynecological

. Misadministration at Baptist l applicator. Medical Center Princeton in Birmingham, Alabama l Patient A was prescribed a total dose of 4000

, Appendix A (see Event Type 4[a]in Table A-1) of centigray (cGy) (4000 rad) in two fractional this report notes that administering a diagnostic l

treatments of 2000 cGy (2000 rad) each. Patient B dose of a radiopharmaceutical differing from the I was prescribed a total dose of 2275 cGy (2275 rad)

, prescribed dose by more than 50 percent, and the m one treatment. However, the medical physicist

, actual dose is greater than five times the noticed while removing the sources from Patient prescribed dose, should be considered an AO. I A that the Cs-137 sources for the two patients ,

were switched. The medical physicist immediately Date and Place - January 8,1996; Baptist Medical l went to Patient B's room and removed the sources Center Princeton; Birmingham, Alabama.

from Patient B.

Nature and Probable Consequences - A l As a result of the error, the administered second 67-year-old male patient suspected of having i fractional treatment dose for Patient A was 1342 Graves disease was prescribed 0.37 l cGy (1342 rad), for an underdose of 33 percent. megabecquerel (MBq) (10 microcurie [ Ci]) of Also, Patient B was administered a treatment dose iodine-131 (I-131) for a thyroid uptake study, of 2698 cGy (2698 rad), for an overdose of 19 The nuclear pharmacy delivered 3.7 MBq (100 percent. Ci) by mistake, and a nuclear medicine technician subsequently administered the 3.7 MBq The licensee notified the referring physician and (100 Ci) to the patient. The administered the patient's relatives of the misadministrations. diagnostic dose exceeded the prescribed diagnostic dose by a factor of 10; i.e., the Cause or Causes - The licensee stated that this diagnostic dose to the thyroid was approximately event occurred because of human error. The 350 centigray (cGy) (350 rad)instead of 35 cGy medical physicist prepared three source (35 rad).

NUREG-0090, Vol.19 20

Abnormal Occurrences, Fiscal Year 1996 The results of the thyroid uptake test confirmed ********

that the patient had Graves disease and the patient was therapeutically treated with 555 MBq .

(15 millicurie) of I-131 the next day. Because the AS 96-8 Radiopharmaceut.ical patient was treated with a therapeutic dose of Misadministration at I-131, there was no consequence or adverse Methodist Medical Center health effect to the patient as a result of the in Peoria, Illinois diagnostic misadministration. The patient's attending physician decided that there was no Appendix A (see Event Type 5[b]) of this report

, need to notify the patient of the diagnostic notes that administering a therapeutic dose such

misadministration. that the actual dose is less than 0.5 times the prescribed dose should be considered an AO.

Cause or Causes - The misadministration was caused by two errors. Date and Place - November 27,1995; Methodist Medical Center; Peoria, Illinois.

The first error occurred at the nuclear pharmacy, Syncor of Birmingham, Alabama, where the wrong Nature and Probable Consequences - An date was entered into a computer. As a result, a outpatient received 177.6 megabecquerel (MBq) 3.7 MBq (100 Ci) 1-131 capsule was incorrectly identified as being the lowest activity capsule in (4.8 millicurie (12 mci) dosage[mCij) ofio dine-131. The error wasof a inventory. Consequently, a 3.7 MBq (100 Ci) later discovered when the nuclear pharmacy I-131 capsule was sent to Baptist Medical Center received two of the three capsules in a return Princeton instead of the prescribed 0.37 MBq (10 shipment. The referring physician and the patient Ci) I-131 capsule. were informed of the misadministration. The patient was then administered an additional The second error occurred at Baptist Medical dosage of 370 MBq (10 mci) to make up for the Center Princeton, where a technician failed to underdose. The radiologist reported no harmful recognize that the activity of the capsule received effects to the patient from the misadministration.

from the nuclear pharmacy did not match the written directive for the prescribed activity. Cause or Causes - The primary cause was the failure of the technologist to verify the number of Actions Taken To Prevent Recurrence capsules delivered by the pharmacy. This was the first dosage sent by the pharmacy in multiple Licensee - Baptist Medical Center Princeton capsules, so the technologist was unaware of the posted a copy ofits written directives for each need to check.

routine diagnostic procedure in the nuclear medicine department and confirmed that the Actions Taken To Prevent Recurrence nuclear pharmacy had a copy on file.

Licensee - The licensee's staff was made aware of State Agency-The State Agency discussed the the error in order to prevent recurrence. Also, misadministration with both the nuclear pharmacy the pharmacy was requested to cease the practice and Baptist Medical Center Princeton and of distributing multiple capsules for a single determined that a special inspection was not prescription.

warranted. The State Agency sent an information notice to the State nuclear medicine licensees and State Agency-The State Agency accepted the nuclear pharmacies requesting that each verify licensee's report and corrective action as with the other the values of activity utilized on any appropriate. No further action was requested.

written directives that they may use in ordering or dispensing radiopharmaceuticals. This event is closed for the purpose of this report.

This event is closed for the purpose of this report.

21 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 APPENDIX A ABNORMAL OCCURRENCE CRITERIAl The following criteria used to determine an averaged over a period of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, exceed 50 abnormal occurrence (AO) were set forth in an times the regulatory limit of Appendix B, NRC policy statement published in the Federal Table II,10 CFR Part 20 [CFR 20.403(b)(2)].

Register on February 24,1977, (Vol. 42, No. 37, pages 10950-10952). 4. Radiation or contamination levels in excess of design values on packages, or loss of An event will be considered an AO ifit involves a confinement of radioactive material such as major reduction in the degree of protection of the (a) a radiation dose rate of 1000 mrem per public health or safety. Such an event would hour three feet from the surface of a package involve a moderate or more severe impact on the containing the radioactive material, or (b) public health or safety and could include but need release of radioactive material from a not be limited to: package in amounts greater than the regulatory limit.

1. Moderate exposure to, or release of, radioactive material licensed by or 5. Any loss oflicensed material in such otherwise regulated by the Commission; quantities and under such circumstances that substantial hazard may result to persons in

2. Major degradation of essential safety-related unrestricted areas.

equipment; or

6. A substantiated case of actual or attempted

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

facilities or material. 7. Any substantiated loss of special nuclear Examples of the types of events that are evaluated material or any substantiated inventory ,

in detail using these criteria are: discrepancy that is judged to be significant relative to normally expected performance For All Licensees and that is judged to be caused by theft or ,

diversion or by substantial breakdown of the 1

1. Exposure of the whole body of any individual accountability system.

to 25 rem or more of radiation; exposure of .

the skin of the whole body of any individual 8. Any substantial breakdown of physical to 150 rem or more of radiation; or exposure security or matenal control (i.e., access of the feet, ankles, hands or forearms of any control, containment, or accountability systems) that sigmficantly weakened the individual to 375 rem or more of radiation [10 , ,

pr tection agamst theft, diversion, or CFR 20.403(a)(1)], or equivalent exposures sabotage.

from internal sources.

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

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

10. A major deficiency in design, construction, or dose received exceeds 0.5 rem in one operation having safety implications requiring calendar year [10 CFR 20.105(a)). immediate remedial action.

3. The release of radioactive material to an 11. Seriotu deficiency in management or unrestricted area in concentrations which, if procedural controls in major areas.

i."he events included in this report were determined to be potential 12. Series of events (where individual events are A0s using the reporting critena which were in effect during fiscal not of major impor!Dnce), recurring yeer (FY)199& The Cornmission recently approved new AO re- incidents, and incidents with implications for porting criteria which it had directed the NRC staff to develop, and . . .

similar facilities (gelenc mcidents) that which will be published in the Federal Register. These new criteria will be used starting in FY 1997, creatc major Safety concern.

l 23 NUREG-0090, Vol.19

.- - - --.- -- -- -. _ .. . -_. ~-.

j Abnormal Occurrences, Fiscal Year 1996 For Commercial Nuclear Power Plants For Fuel Cycle Licensees

1. Exceeding a safety limit of license Technical 1. A safety limit oflicense Technical

' Specifications [10 CFR 50.36(c)]. Specifications is exceeded and a plant

2. shutdown is required [10 CFR 50.36(c)].

Major degradation of fuel integrity, primary i

coolant pressure boundary, or primary 2. A major condition not specifically considered containment boundary. in the safety analysis report or Technical 3.

Specifications that requires immediate

~

Loss of plant capability to perform essential remedial action.

safety functions such that a potential release of radioactivity in excess of 10 CFR Part 100 3. An event that seriously compromised the guidelines could result from a postulated ability of a confinement system to perfonn its transient or accident (e.g., loss of emergency designated function.

core cooling system, loss of control rod system). Medical Misadministrations f 4. Discovery of a major condition not As discussed in the Preface to this report, the specifically considered in the Safety Analysis NRC policy statement on AOs was published Report (SAR) or Technical Specifications that before licensees were required to report medical requires immediate remedial action, misadministrations to the NRC. Therefore, during 1984, NRC developed guidelines for

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

potential release of radioactivity in excess of 10 CFR Part 100 guidelines could result from As noted in the Preface, revised guidelines have a postulated transient or accident (e.g., loss of been developed because new medical crergency core cooling system, loss of misadministration definitions became effective on coatro! rod system). January 27,1992.

1 NUREG-0090, Vol.19 24

Abnormal Occurrences, Fiscal Year 1996 4

Table A-1 NRC Guidelines for Selecting Medical Misadministration Events for Abnormal Occurrence (AO) Reporting AO Reporting Threshold l Event Type Diagnostic Exposure Therapeutic Exposure (1) Administering a radiopharma- If the improper administration If the improper administration i results in any part of the ceutical or radiation from a results in any part of the body sealed source other than the body receiving unscheduled receiving unscheduled radiation, an one intended. radiation, an AO report should AO report shculd be proposed for be proposed if: any such ever.t.

(a) the actual dose to the [f the parts of the body

wrong body part is eceiving radiation '

greater than five times improperly would have

' received radiation anyway, the upper limit of the 2

normal range of had the proper administration exposures prescribed been used, an AO report for diagnostic procedures should be proposed if:

involving that body part, or (b) there are clinical (a) the actual dose is greater indications of any than 1.5 times that intended adverse health effects to the above described body 1 to the wTong body part. parts, or, .

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

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

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

1 (2) Administering a radio- An AO report should be An AO report should be pharmaceutical or radiation proposed if: proposed for any such event.

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

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

25 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 i

Table A 1 (Continued)

-NAlre '-

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

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

dose of a radiopharma- proposed if:

ceutical differing from the prescribed dose by more than 50 percent. (a) the actual dose is greater than five times the prescribed dose, or, (b) the event results in adverse health effects worse than expected for the normal range of exposures prescribed for the diagnostic procedure.

(5) Administering a Not applicable. An AO report should be therapeutic dose of proposed if:

a radiopharmaceutical differing from the prescribed (a) the actual dose is greater dose by more than 10 percent; than 1.5 times the prescribed or administering a therapeutic dose,or, radiation dose from a sealed source such that errors in the (b) the actual dose is less than source calibration, time of 0.5 times the prescribed exposure, and treatment dose, or geometry result in a calculated total treatment dose {

(c) the event results in adverse from the final prescribed health effects worse than l total treatment dose by more would be expected for the than 10 percent. normal range of exposures prescribed for the therapeutic procedure, or, (d) the event (regardless of any health effects) affects two .

or more patients at the I same facility. l (6) Recurring or series of For either diagnostic or therapeutic exposures, an AO report should be events (regardless of the proposed for recurring events or a series of events (in which each individual l number of patients or misadministration is not of major importance) that create a significant facilities involved). public health or safety concern. l 1

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

NUREG-0090, Vol.19 26

Abnormal Occurrences, Fiscal Year 1996 APPENDIX B UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES During this reporting period, the following updates of previously reported AOs were received.

. OTHER NRC LICENSEES 94-23 Medical Brachytherapy site during brachytherapy treatment for metastatic Misadministration at North lung cancer.

Memorial Medical Center in The AO report is updated as follows:

Robbinsdale, Minnesota c

This AO was previously reported in i NRC conducted a special inspection, conducted an NUREG-0090, Vol.17, No. 4, " Report to investigation, and held a predecisional Congress on Abnormal Occurrences" enforcement conference. Consequently, NRC October-December 1994, issued a letter informing the licensee that information regarding the misadministration and The AO criterion used was Event Type 1 in Table actions taken to prevent recurrence are A-1 of Appendix A. a therapeutic exposure that adequately addressed in the NRC docketed results in any part of the body receiving reports and in the transcript of the conference.

unscheduled radiation. (Because of a Therefore, NRC will not take any enforcement typographical error, the report incorrectly stated action regarding the misadministration.

that the criterion was listed under Event Type 5.)

This event is closed for the purpose of this report.

At the time it was reported that a patient received 1380 centigray (1380 rad) to a wrong treatment AGREEMENT STATE LICENSEES AS 88-5 Medical Teletherapy The AO report is updated as follows:

Misadministration at Sacred It was determined that no additional follow-up l Heart Hospital in action was necessary.

Cumberland, Maryland Thh event is closed for the purpose of this report. j This AO was originally reported in ********

NUREG-0090, Vol.11, No. 4, " Report to Congress on Abnormal Occurrences,"

October-December 1988, under the title " Medical AS 88-6 Multiple Medical Teletherapy Therapy Misadministration." Misadministrations at Sacred Heart Hospital in ,

The AO criterion used was a moderate or more severe impact on public health or safety, as stated Cumberland, Maryland in the second paragraph of the General Criteria. This AO was originally reported in NUREG-0090, Vol.11, No. 4, " Report to At the time it was reported that an 81-year-old Congress on Abnormal Occurrences,"

patient had received a therapeutic dose of 1400 October-December 1988, under the title centigray (1400 rad) at the base of the brain, " Multiple Medical Therapy Misadministrations."

instead of the prescribed right maxillary sinus, because the oncologist had improperly aligned At that time it was initially reported that over a one port of the teletherapy unit. 13-month period 33 patients undergoing radiation 27 NUREG-0090, Vol.19

. - .- . --- -. -. - - - _ - - ~ . .

3 Abnormal Occurrences, Fiscal Year 1996 therapy to the brain had received radiation overall root cause of the misadministrations exposures from a cobalt-60 (Co-60) teletherapy was lack of management oversight of the 3 machine that exceeded the prescribed dose by SHH radiation safety program. The more than 75 percent. Before the licensee diagnoses and planned treatments were notified the State Agency of the appropriate. H,owever, SHH did not provide misadministrations, 20 patients had died either all the notifications to the referring

during the course of their treatment or after the physicians and patients as required by conclusion of treatment. Maryland law.

1 This AO was originally closed out in the (2) The State did not resolve conflicting i October-December 1988 AO report nformation that it obtam, ed from inteiviews 4 (NUREG-0090, Vol.11, No. 4). It was and consultant's reports and the State did not subsequently reopened when NRC and the State adequately follow-up on information the of Maryland initiated a joint review of the series State received on concerns about whether of misadministrations in response to issues that Patients' relatives or guardians were informed I

were raised during NRC testimony at an August of the misadmmistrations. Before the.jomt

' 1993 Congressional hearing. review was conducted, the State Attorney General had concluded that the State staff's The AO report is updated as follows: action in 1989 to limit public access to the State s mvestigation records was i

inappropriate.

l In response to issues that were raised during NRC j testimony before a Congressional hearing of the

, (3) The NRC staff provided timely support to the l House of Representatives Subcommittee on State at the time of the misadministrations Environment, Energy, and Natural Resources in and accurately reported information received.

August 1993, a review of the misadministrations However, NRC did not adequately follow-up was jointly conducted by NRC and the State of on allegations received on the SHH Maryland. The purpose of the joint review was to: misadministrations, did not follow-up with

! (1) determine the facts of the misadministrations, the State on the results ofits investigation, and if Sacred Heart Hospital (SHH) complied and did not review the State's actions in j with Maryland regulations; (2) determine the

• Agreement State reviews before 1993.

adequacy of the State's handling of the case; and (3) evaluate NRC's involvement in the State's Subsequent to the completion of this joint review,

! review and oversight of the Maryland Agreement NRC and the State of Maryland committed to State program, implement corrective actions to address the report's findings and recommendations.

The results of thejoint review are summarized below: The results of the joint review are documented m, a report entitled, " Report On NRC/ State Of Maryland Joint Review Of The Sacred Heart (1) The direct cause of the misadministrations ,

was the use of an incorrect computer file Hospital Misadmimstrations In 1987-1988. NRC associated with the Co-60 teletherapy f rwarded the report to Congressional oversight machine. This computer file had not been committees and Senate and Congressional updated to reflect actual Co-60 source representatives for the State of Maryland.

activity. There were many contributing factors to why the computer file was not This event is closed for the purpose of this report.

updated before its use and why it took so long ........

to detect the error. These factors included inadequate communications, change over in consultant services, inadequate verification of AS 93-13 Lost or Stolen Radiation treatment procedures and dosimetric Source at BPB Instruments, calculations, and failure to recognize the Inc., in Midland, Texas significance oflonger treatment times. The direct cause and the contributing factors This AO was previously reported in led the joint review team to conclude that the NUREG-0090, Vol.16, No. 4, " Report to NUREG-0090, Vol.19 28

l Abnormal Occurrences, Fiscal Year 1996 h

Congress on Abnornial Occurrences" source was not located and may have been lost or October-December 1993. stolen.

The AO criterion used was Example 5 of"For All The AO report is updated as follows:

Licensees" of Appendix A, a loss oflicensed material in such quantities and under such The State of Texas cannot determine whether or circumstances that a substantial hazard may not the source was stolen or lost. The State 4 res. tit. discussed the loss of the source with licensee personnel, had it could not be determined ifit was lost or stolen.

At the time it was reported that a 555 gigabecquerel (15 curie) americium / beryllium This event is closed for the purpose of this report.

i l

29 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 APPENDIX C OTHER EVENTS OF INTEREST "Other Events of Interest" are reported because operating license, NRC regulations which include they can be perceived as being significant but have 10 CFR 50.59, and the Millstone Unit 1 UFSAR. i been determined not to involve a major reduction 4 in the level of protection provided for public NU established an Event Response Team (ERT) health or safety; therefore they are not reportable to determine the causes for the inaccuracies i as AOs. During this reporting pWod, the contained in the Millstone Unit 1 UFSAR. The following events are being reported as "Other ERT issued a report ofits findings which stated Events of Interest." that:

• The original 1986/1987 UFSAR contained l err rs and omissions; I

1. Problems at Millstone Units 1,2, and 3, and Haddam Neck

• Administrative control programs such as Design Control, Corrective Action, and l Millstone Unit 1 is a General Electric-designed Commitment Tracking did not fully address <

boiling water reactor nuclear power plant (NPP)' regulatory requirements; Millstone Unit 2 is a Combustion Engineering-designed pressurized water reactor . NU did not fully implement the administrative (PWR) NPP, and Millstone Unit 3 is a control programs, and NU did not see the Westinghouse-designed PWR NPP. All three UFSAR as a document that was required to be NPPs are operated by Northeast Utilities, and are accurate; located about 5.15 kilometers (3.2 miles) west-southwest of New London. Co.inecticut.

• NU internal correspondence, and events Haddam Neck is a Westinghouse-designed PWR involving the design basis from 1985 through a

NPP, operated by Northeast Utilities and located 1996, showed that information was about 20.9 kilometers (13 miles) east of Meriden, communicated to NU management which Connecticut. identified weaknesses and risks associated with the UFSAR and design bases; that NU Problems were found at Millstone Units 1,2, and management made commitments to correct 3, and Haddam Neck during follow-up ofissues these deficiencies; and that the commitments to correct these deficiencies were ineffective, raised in a 10 CFR 2.206 petition to NRC dated August 21,1995. partially implemented, or not done; and l i

• NU oversight did not identify the information l The petition requested that NRC shut down which was communicated to NU management, I Millstone Unit 1 and take enforcement action its significance, or the effectiveness of the i based on alleged violations oflicensed activities corrective actions taken to prevent recurrence. i related to operation of spent fuel pool cooling i systerns and refueling practices. Follow-up of the The ERT report also stated that similar (

issues raised in the 10 CFR 2.206 petition, configuration management conditions may exist at  ;

including the findings from investigations NU-licensed Millstone Units 2 and 3, and I conducted by the Office of the Inspector General, Haddam Neck.

found that certain activities at Millstone Unit 1 may have been conducted in violation of license Because of the number of operational and design requirements and that refueling activities may not concerns involving Millstone Unit 2, NRC have been conducted consistent with the Updated requested that NU provide information on the Final Safety Analysis Report (UFSAR). actions that it took to ensure that future operation Northeast Utilities (NU) was required to report of Millstone Unit 2 would be conducted in on actions that it will take to ensure that future accordance with the license, NRC regulations, and operation of Millstone Unit I would be conducted the UFSAR. NRC also requested that NU in accordance with the terms and conditions ofits provide information regarding its corrective 31 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 actions at Millstone Unit 3 and Haddam Neck, as NRC with added confidence and assurance that well as its future corrective action plans. facilities are operated and maintained within the

, design bases, and any deviations are reconciled in During an NRC special inspection at Millstone a timely manner.

Units 2 and 3 and Haddam Neck, NRC found deficiencies at each of these units that were This event does not meet the abnormal similar to those found at Millstone Unit 1. occurrence reporting criteria because even though Millstone Unit 3 was shut down after it was there were a number of deficiencies identified, it determined that containment isolation valves for has been determined that these deficiencies did the auxiliary feedwater turbine-driven pump were not result in a major reduction in the level of inoperable and were not in compliance with NRC protection provided for public health and safety.

regulations, and because additional design and .

configuration problems were identified. NRC This event is closed for the purpose of this report.

then requested that NU provide information on ........

the actions that it took to ensure that future operation of Millstone Unit 3 would be conducted in accordance with the license, NRC regulations, 2. Emergency Core Cooling System Analyses and the UFSAR. Haddam Neck was shutdown Deficiencies at Maine Yankee when it was determined that the containment air Maine Yankee is a Combustion recirculation system may not operate as required Engineering-designed pressurized water reactor under certam accident scenanos.

nuclear power plant, operated by Maine Yankee

. Atomic Power Company and located ubout 16.1

The NRC special inspection team issued tw kilometers (10 miles) north of Bath, Maine.

separate reports, one for Millstone Units 2 and 3

and another for Haddam Neck that presented its In December 1995, NRC received information findings and conclusions. One conclusion was asserting that inadequate analyses were knowingly that the concerns identified at Millstone Units 1, performed to support license amendments to 2, and 3, and Haddam Neck reflect a lack of increase the rated thermal power at which Maine understanding of, and respect for, the Yankee may operate. It was also asserted that preservation of the design and licensing bases for these inadequate analyses were misrepresented to the units. This resulted in lack of attention to NRC in seeking the license amendments, which '

detail, thoroughness, and appropriate rigor in were subsequently granted by NRC.

engineering efforts and management oversight.

There was also a failure to adequately track As a result of this information, NRC conducted a identified deficiencies and associated corrective technical review and evaluation of the actions. circumstances and records surrounding these applications to increase the maximum rated To alert other licensees to what may be a generic thermal power at Maine Yankee. Based upon the deficiency, NRC issued Information Notice (IN) NRC staff's review. .NRC determined that the 96-17," Reactor Operation Inconsistent with the computer code RELAP5YA, which the licensee Updated Final Safety Analysis Report." IN 96-17 for Maine Yankee proposed for use for Cycle 15 transmitted the executive summary of the NU small-break loss-of-coolant accident (SDLOCA)

ERT report, as well as one of the letters that NRC analyses to demonstrate compliance with the sent to NU which expressed its concerns about the emergency core cooling system (ECCS) operational problems that were found at Millstone requirements specified at 10 CFR 50.46(a), has Units 1,2, and 3, and Haddam Neck. As a result not been applied in a manner conforming to the of the substantial number of design and licensing requirements of 10 CFR 50, Appendix K; nor has bases issues at Millstone Station and Haddam it been applied in a manner conforming to the Neck and the concern that similar problems could conditions specified in the staff's safety evaluation exist at other nuclear facilities, the NRC issued (SE) dated January 30,1989, as necessary for letters in October 1996 to all licensees requesting NRC acceptance of the use of RELAP5YA for information pursuant to 10 CFR 50.54(f) SBLOCA analyses for Maine Yankee.

regarding the adequacy and availability of design Specifically, the licensee has not demonstrated bases information. The purpose of these letters that the code will reliably calculate the peak fuel was to obtain information that will provide the cladding temperature for all break sizes in the NUREG-0090, Vol.19 32

Abnormal Occurrences, Fiscal Year 1996 SBLOCA spectrum for Maine Yankee; nor has the required integrated containment analysis to be the licensee submitted the justification for the submitted.

code options selected, in accordance with condition 7 of the staff's SE; nor has the licensee This event is closed for purpose of this report.

submitted other justifications and sensitivity ,,,,,,,,

studies to satisfy conditions 4,8,9, and 12 of the January 30,1989 SE.

3. Ingestion of Phosphorus-32 at the la addition, as a result of the NRC staff's review Massachusetts Institute of Technology in of the containment analysis, the staff finds that Cambridge, Massachusetts many conservatisms have been removed from the

, On August 19,1995, a researcher at the ongmal analyses. Although the revised method

, Massachusetts Institute of Technology (MIT) gives results withm, design limits, the revised Center for Cancer Research in Cambridge, analysis is not an analysis of record. Massachusetts, reported that he had discovered that he was internally contaminated with On January 3,1996, NRC issued a confirmatory radioactive material during a routine survey. MIT order and demand for information to the licensee subsequently determined that the researcher had for Maine Yankee to restrict the power level for ingested phosphorus-32 (P-32). On October 12, restart, and to stipulate the requirements for 1995, MIT informed the researcher that its final return to operation at the previous licensed estimate of his intake was 21 megabecquerel maximum power of 2700 megawatt thermal (MBq) (579 microcurie (pCi]), which was just (MWt). The requirements are as follows: under the regulatory limit of 22 MBq (600 Ci).

MIT's estimate was based on urine sample and

1. Maine Yankee is limited to operation at 2440 whole-body counting data. On October 16,1995, MWt (90.37 percent of the previous licensed MIT reported the event to NRC.

power).

Oa October 17, NRC established an Incident

2. The licensee is required to submit a SBLOCA In estigation Team (IIT) to investigate the event.

analysis that does not rely on RELAP5YA for The IIT concluded that the licensee's final intake Maine Yankee operation at power up to 2700 and dose estimates were in accordance with MWt. The analysis must meet the accepted scientific references and NRC guidance.

requirements of 10 CFR 50.46, However, recognizing the uncertainties mvolved m

" Acceptance criteria for emergency core the use of models to simulate human cooling systems for light water nuclear power characteristics, the IIT determmed that the m, take reactors"; NUREG-0737," Clarification of was probably within the range of 19-28 MBq TMI Action Plan Requirements," Items (500-750 Ci). An NRC medical consultant II.K.3.30 and 31,"SBLOCA Methods" and concluded that no symptoms or acute effects I should be observed from an m, take of this level.

" Plant-specific Analysis," respectively; and NUREG-0737 Item II.K.3.5, " Automatic Trip The IIT also found that there was inadequate of Reactor Coolant Pumps During LOCA." storage and control of heensed radioactive material at the MIT Center for Cancer research.

3. The licensee is required to submit an . The IIT concluded that the ingestion of P-32 was mtegrated contamment analysis accountmg possibly the result of a deliberate act by a for relevant changes to the facility. This knowledgeable individual. Ilowever, it was not analysis must demonstrate that the maximum

, determined how the ingestion occurred.

calculated design basis accident containment Consequently, a root cause could not be pressure meets the design basis pressure for determined.

Maine Yankee (379.2 kPa gauge [55 psi gauge]). The IIT's report, " Ingestion of Phosphorus-32 at Massachusetts Institute of Technology, The NRR staffis reviewing the required SBLOCA Cambridge, Massachusetts, Identified on August analyses; waiting for the licensee's response to the 19,1995" (NUREG-1535) was published in staff's review questions on the required SBLOCA November 1995. NRC issued a Confirmatory analysis performed by Siemens; and waiting for Action Letter (CAL) which documented MIT's 33 NUREG-0090, Vol.19

Abnormal Occurrences, Fiscal Year 1996 agreement to immediately increase physical required by the CAL security procedures, audits, and barriers for licensed materials; to provide immediate training This event does not meet the abnormal in these measures, and to develop a long range ccurrence reporting critena because the exposure plan for improving procedures for the control of is much less than 0.25 sievert (25 rem) dose threshold involving an occupational worker in a access to areas where hcensed materials are used.

controlled area.

l NRC subsequently determined via an on-site j inspection that MIT was taking the actions This event is closed for the purpose of this report.

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NUREG-0090, Vol.19 34

Abnormal Occurrences, Fiscal Year 1996 APPENDIX D 4

UPDATE OF PREVIOUSLY REPORTED OTHER EVENTS OF INTEREST During this reporting period, the following update Millstone Unit 1 and at other facilities with two-stage valves manufactured by Target-Rock.

of a previously reported "Other Events of Interest" event was received. The licensee addressed this problem by replacing i three of the pilot valves with valves having their i

1. Safety Relief Valve Inoperability at disk made of platinum stellite alloy, as )

recommended by the Boiling Water Reactor Millstone Unit I Owner's Group (BWROG).

This "Other Events of Interest" item was previously reported in NUREG-0090, Vol.17, No. This "Other Events of Interest" event is updated 4," Report to Congress on Abnormal as follows ,

Occurrenees," October-December 1994. I Based on review of operating experience of the l At the time it was reported that during scheduled pilot valves having the new disk material, the surveillance associated with a 1994 outage at licensee concluded that another solution for the Millstone Unit 1, a plant condition was found that set-point drift problem was needed. While the involved multiple failures of the safety / relief valves with the new disks were being evaluated, valves (SRVs) to operate at intended pressures the BWROG had submitted a topical report to due to set-point drift. Millstone Unit 1 is a NRC for the design of pressure sensing actuation General Electric boiling water reactor (BWR-3) switches which would actuate the SRVs with located near New London, Connecticut. It is external power when the reactor pressure reached operated by Northeast Utilities. the set-point value. NRC approved the topical report, and the licensee is implementing the The cause of the set-point pressure drift was pressure switch modification at Millstone Unit 1 attributed to oxide bonding of the seat disk in the during the current refueling outage.

pilot valve of the SRVs. SRV set-point drift is a problem that was experienced previously at This event is closed for the purpose of this report.

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___ ._ . . - - . . _ . - - -- _- - ~_ - . - - ..--

NRC FORM 3G U S NUCLEAR REGULATORY COMMISSION 1. REPORT NUMBER p-89) (Ass.graf by NRC, Add Vci., Sipp.,

NRCM 1102. Rev, and Addendum Numbers W any) m 32e2 BIBLIOGRAPHIC DATA SHEET (s insuucnon. wi es. revers.) NUREG-0090 a nTLE ANOSUomtE YOI 19

, Report to Congress on Abnormal Occurrences, uCNTN YEAR

, Fiscal Year 1996 l April 1997

4. FIN OR GRANT NUMBER j

6. AUTHOR t3J 6 TYPE OF REPORT Annual 4 7. PERIOD COVERED (induarve Datee)

Fiscal Year 1996 ,

1 6 PERFORMING ORGANIZAT;ON - NAME AND ADDRESS (it NRC, prcmde Omamn. Othee or Region, U S. Nuclear Regulatory Commesam, and mahng address; d contractor, prtude name and mahng address )

Office for Analysis and Evaluation of Operational Data U.S, Nuclear Regulatory Commission Washington, DC 20555 - 0001 CL SPOWSORING ORGANIZATION - NAME AND ADDRESS (if NRC, type *Same as above*; if Contractor, prCmde NRC Dmseon, Ofhce or Rege, U S Nuclear Regulatory Commisson, Cnd maling addrese }

Same as 8., above

10. SUPPLEMENTARY NOTES 11, ABSTRACT (200 words or less)

Section 208 of the Energy Reorganization Act of 1974 (PL 93-438) identifies an abnormal occurrence (AO) as an i unscheduled incident or event that the Nuclear Regulatory Commission (NRC) determines to be significant from the standpoint of public health or safety. The Federal Reports Elimination and Sunset Act of 1995 (PL 104-66) requires that AOs be reported to Congress on an annual basis. This report includes those events that NRC deter-mined to be AOs during fiscal year 1996.

This report addresses eighteen AOs at NRC-licensed facilities. Two involved events at nuclear power plants, eleven involved medical brachytherapy misadministrations, and five involved radiopharmaceutical misadministrations.

Eight AOs submitted by the Agreement States are included. One involved stolen radiography cameras, one in-volved a ruptured source, one involved release of radioactive material while being transported, one involved a lost source, two involved medical brachytherapy misad ninistrations, and two involved radiopharmaceutical misadmi. l nisrations. Four updates of previously reported AOs are included in this report. Three "Other Events of Interest" I events are being reported, and one previously reported "Other Events of Interest" event is being updated.

13. C2Y WORDS/DESCRIPTORS (List words or phrases that will asest researchers in locating the report) u mWW WEM Unlimited 14 SECURITY CLASSIFICATION Nuclear Power Plants; Wolf Creek Braidwood; Medical; Misadministration; Brachyther- g,,,,,,,

apy; Radiopharmaceutical; Stolen Radiography Cameras; Rupture Source; Release of ,

Unclassified Radioactive Material From Package Destroyed While Being Transported; Lost Source (1ba Report)

Unclassified iS. NUMBER OF PAGEb

16. PFuCE

^

NRC FORM 336 (2-89) u,

)

1 Printed on recycled paper

~

Federal Recycling Program

FISCAL YEAR 1996 i UNITED STATES 120555139531 US NPC-0IDM 1 1ANICCICVICY1 FIRST MS E NUCLEAR REGULATORY COMMISSION POSTAGE AND FEES PAID WASHINGTON, DC 20555-0001 URLICATIONS PPANCH USNRC TPS-PDR-NUREG PERMIT NO. G47 2WFN-6E7 WASHINr, TON OFFICIAL BUSINESS DC ?C555 PENALTY FOR PRNATE USE, $300 i

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