ML20198R318

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Forwards Insp Rept 30-32210/97-01 & Investigation Case 4-97-060 on 971104-1230.Twenty-two Apparent Violations Identifed & Being Considered for Escalated Enforcement Actions
ML20198R318
Person / Time
Site: 03032210
Issue date: 01/21/1998
From: Scarano R
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To: John Moses
WOOD RIVER MEDICAL CENTER, SUN VALLEY & HAILEY, ID
Shared Package
ML20198R321 List:
References
30-32210-97-01, 30-32210-97-1, EA-97-613, NUDOCS 9801230281
Download: ML20198R318 (5)


See also: IR 07100104/2012030

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Jon Moses, CEO -

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- SUBJECT:- - NRC INSPECTION REPORT 030 32210\\97-01 (NRC INVESTIGATION

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CASE 4-97-060) .

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Dear Mr Moses:

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On November 5,1997, the NRC completed the onsite portion of an inspection at your facility

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. In Sun Valley, Idaho. The purpose of the inspection was to determine whether licensed

activities conducted at your facility were being performed in accordance with NRC -

requirements and the conditions of your license. At the conclusion of the on-site portion of -

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this inspection, a preliminary exit briefing was conducted with members of your staff to

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discuss the inspection findings. On December 30,1997, a telephonic exit bricfing was-

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conducted with you. The enclosed report presents the scope and results of that inspection.'

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Based on the results of this inspection,22 apparent violations were identified and are being

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. considered for escalated enforcement action in accordance with the " General Statement of

Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600.

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The'more significant apparent violations included failures to: (1) ensure that an authorized

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' user properly supervised an individual working under his supervision, (2) maintain

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- management oversight and control of the radiation safety program, (3) ensure that the

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radiation safety committee met quarterly, (4) conduct quarterly ALARA reviews, (5) review -

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annually the radiation safety programi (6) provide radiation safety refresher training,' (7) notify'

= the NRC of the' discontinuation of an authorized user's duties, (8) seek amendment to the

license prior to relocating an area of use, (9) obtain the NRC's written consent prior to

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implementing a change of control of licensed activities, and (10) maintain complete and

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accurate informatbn with respect to records of required surveys. The circumstances -

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associated with the' apparent violations noted above, as well as the remaining 12 apparent

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violations, are described in detail in the enclosed report.

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- 'As noted in the enclosed report, several of these apparent violations were identified by your

consultant prior to the NRC inspection. In' addition, we understand that corisctlve actions

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had been initiated at the time of the inspection for some of the apparent violations.

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The apparent violation involving a failure to maintain complete and accurate information in

survey records is of particular concem because the NRC expects information required by

regulations to be complete and accurate in all material respects as required by 10 CFR 30.9.

This apparent violation was reviewed during an investigation conducted by the NRC Office of

Investigations. Our investigation verified that a former employee admitted to having falsified

information in survey records maintained to demonstrate compliance with 10 CFR Part 35.

Based on the information developed during the investigation, the Office of Investigations has

concluded that the employee deliberately falsified the survey records so as to make it appear

that required surveys had been performed on a number of occasions when, in fact, they had

not.

Based upon the nature and number of apparent violations described above, we are

concerned about the management oversight and control of your radiation safety program. A

closed, transcribed predecisional enforcement conference to discuss these apparent

violations has been scheduled for February 6,1998, at 9:00 a.m. (CST). The decision to

hold a predecisional enforcement conference does not mean that the NRC has determined

that violations have occurred or that enforcement action will be taken. Accordingly, no Notice

of Violation is presently being issued for these inspection findings. In addition, please be

advised that the number and characterization of apparent violations described in the enclosed

inspection report may change as a result of further NRC review.

The conference is being held to obtain information to enable the NRC to make an

enforcement decision, such as a common understanding of the facts, root causes, missed

opportunities to identify the apparent violations sooner, corrective actions, significance of the

issues and the need for lasting and effective corrective action, in particular, we expect you

to address actions taken or planned to improve management oversight and control of your

program in order to ensure future compliance with NRC requirements. In addition, this is an

opportunity for you to point out any errors in our inspection report and for you to provide any

information conceming your perspectives on (1) the severity of the violations, (2) the

application of the factors that the NRC considers when it determines the amount of a civil

penalty that may be assessed in accordance with Section VI.B.2 of the Enforcement Policy,

and (3) any other application of the Enforcement Policy to this case, including the exercise of

discretion in accordance with Section Vll. In presenting your corrective actions, you should

be aware that the promptness and comprehensiveness of your actions will be considered in

assessing any civil penalty for the apparent violations. The guidance in the enclosed NRC

Information Notice 96-28, " SUGGESTED GUIDANCE RELATING TO DEVELOPMENT AND

IMPLEMENTATION OF CORRECTIVE ACTION," may be helpful (Enclosure 3).

You will be advised by separate correspondence of the results of our deliberations on this

matter, No response regarding these apparent violations is required at this time.

In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and

its enclosures will be placed in the NRC Public Document Room.

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Wood River Medical Center

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-Should you have any questions concerning this letter or the enclosed report, please contact

Richard Leonardi at (817) 860-8187 or D. Blair Spitzberg, Ph.D., at (817) 860-8191.

Since ly,

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Ross A. Scarano, Director

Division of Nuclear Materials Safety

Docket No. 030-32210

License No. 11-27355-01

Enclosures:

1. NRC Inspection Report 030-32210/97-01

2; NRC Enforcement Policy, NUREG 1600

3. NRC Information Notice 96-28

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Idaho Radiation Control Program Director

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