ML20199L239

Office for Analysis and Evaluation of Operational DATA.1997 Annual Report (Nuclear Materials)

ML20199L239
Person / Time
Issue date:	11/30/1998
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-1272, NUREG-1272-V11-N02, NUREG-1272-V11-N2, NUDOCS 9901270174
Download: ML20199L239 (108)

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AVAILABILITY NOTICE Availability of Reference Materials Cited in NRC Publications NRC publications in the NUREG series, NRC regu- NRC Public Document Room lations, and Title 10, Energy, of the Code of Federal 2121 L Street, N.W., Lower Level  !

Regulations, may be purchased from one of the fol- Washington, DC 20555-0001 lowing sources: < http://www.nrc. gov /NRC/PDR/pdr1.htm >

1 -800-397-4209 or locally 202-634-3273

1. The Superintendent of Documents Microfiche of most NRC documents made publicly l available since January 1981 may be found in the l

[ Box 3 0 2 '

Washington, DC 20402-9328 Local Public Document Rooms (LPDRs) located in

<http://www. access.gpo. gov /su docs >

the vicinity of nuclear power plants. The locations of the LPDRs may be obtained from the PDR (see 202-512 -1800 previous paragraph) or through:

2. The National Technical Information Service <http://www.nrc. gov /NRC/NUREGS/

Springfield, VA 22161-0002 SR1350/V9/ipdr/html>

<http://www.ntis. gov /ordernow>

703-487 -4650 Publicly released documents include, to name a few, NUREG-series reports; Federal Register no-The NUREG series comprises (1) technical and ad- tices; applicant, !icensee, and vendor documents ministrative reports, including those prepared for and correspondence; NRC correspondence and internal memoranda; bulletins and information no-international agreements, (2) brochures, (3) pro-ceedings of conferences and workshops, (4) adju- tices; inspection and investigation reports; licens-dications and other issuances of the Commission ee event reports; and Commission papers and the,ir attachments.

and Atomic Safety and Licensing Boards, and (5) books. Documents available from public and special tech-nical libraries include all open literature items, such A single copy of each NRC draft report is available as books, journal articles, and transactions Feder-free, to the extent of supply, upon written request al Register notices, Federal and State legislation, as follows: and congressional reports. Such documents as theses, dissertations, foreign reports and transla-Address: Office of the Chief Information Officer tions, and non-NRC conference proceedings may Reproduction and Distribution be purchased from their sponsoring organization.

Services Section U. S. Nuclear Regulatory Commission Copies of industry codes and standards used in a Washington, DC 20555-0001 substantive manner in the NRC regulatory process are maintained at the NRC Library, Two White Flint E-mail: <GRW1@NRC. GOV >

' North, 11545 Rockville Pike, Rockville, MD Facsimile: 301 -415 - 2289 20852-2738. These standards are available in the library for reference use by the public. Codes and A portion of NRC regulatory and technical informa-standards are usually copyrighted and may be tion is available at NRC's World Wide Web site:

purchased from the originating organization or, if

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<http://www.nrc. gov >

American National Standards Institute All NRC documents released to the public are avail- 11 West 42nd Street able for inspection or copying for a fee, in paper, New York, NY 10036-8002 microfiche, or, in some cases, diskette, from the < http://www. ansi.org >

Public Document Room (PDR): 212 - 642-4900

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Regulations, may be purchased from one of the fol- Washington, DC 20555-0001 .

lowing sources: < http://www.n rc. gov /N R C/PD R/pd r1. htm > l 1 -800-397-4209 or locally 202-634-3273 1

1. The Superintendent of Documents U.S. Government Printing Office Microfiche of most NRC documents made publicly i RO. Box 37082 available since January 1981 may be found in the l

Washington, DC 20402-9328 Local Public Document Rooms (LPDRs) located in

<http://www. access.gpo. gov /su docs > the vicinity of nuclear power plants. The locations 202- 512 -1800 of the LPDRs may be obtained from the PDR (see previous paragraph) or through:

2. The National Technical Information Service <http://www.ntc. gov /NRC/NUREGS/

Springfield, VA 22161 -0002 SR1350/V9/lpdr/html> l

<http://www.ntis. gov /ordernow>

703-487- 4650 Publicly released documents include, to name a l

few, NUREG-series reports: Federal Register no-The NUREG series comprises (1) technical and ad, tices; applicant, licensee, and vendor documents ministrative reports, including those prepared for and correspondence; NRC correspondence and international agreements, (2) brochures, (3) pro- intemal memoranda; bulletins and information no-ceedings of conferences and workshops, (4) adju- tices; inspection and investigation reports; licens-dications and other issuances of the Commission ee event reports; and Comm,ssion i papers and the,r i attachments.

and Atomic Safety and Licensing Boards, and (5) books. Documents available from public and special tech-nical libraries include all open literature items, such A single copy of each NRC draft report is available as books, journal articles, and transactions, Feder-free, to the extent of supply, upon written request al Register notices, Federal and State legislation, as follows: and congressional reports. Such documents as theses, dissertations, foreign reports and transla-Address: Office of the Chief Information Officer tions, and non-NRC conference proceedings may Reproduction and Distribution be purchased from their sponsoring organization.

Services Section U. S. Nuclear Regulatory Commission Copies of industry codes and standards used in a Washington, DC 20555-0001 substantive manner in the NRC regulatory process E-mail: are maintained at the NRC Library, Two White Flint

<GRW1@NRC. GOV >

Facsimile: 301 - 415- 2289 North, 11545 Rockville Pike, Rockville, MD ,

20852-2738. These standards are available in the library for reference use by the public. Codes and A portion of NRC regulatory and technicalinforma-tion is available at NRC's World Wide Web site:

standards are usually copyrighted and may be purchased from the originating organization or, if they are American National Standards, from-

<http://www.nrc. gov >

American National Standards Institute All NRC documents released to the public are avail- 11 West 42nd Street able for inspection or copying for a fee, in paper, New York, NY 10036-8002  :

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Previous Reports in Series

• i The following semiannual or annual reports have been prepared by the Office for Analysis and Evaluation of Operational Data ( AEOD). i e Semiannual Report. January - June 1984, AEODIS405, September i984 i

e SemiannualReport, July- December 1984, AEOD/5502, April 1985  ;

e AnnualReport 1985, AEOD/S601, April 1986 j i

e Report to the U.S. Nuclear Regulatory Commission on Analysis andEvaluation of Operational Data I 1986, NUREG-1272, AEOD/S701, May 1987 l

e Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational Data 1987 NUREG-1272, AEOD/S804 Vol. 2, No.1. Power Reactors, October 1988 Vol. 2. No. 2, Nonreactors, October 1988 .

e Oficefor Analysis and Evaluation of Operational Data 1988 Annual Report, NUREG-l272 Vol. 3, No.1, Power Reactors, June 1989  !

Vol. 3, No. 2, Nonreactors, June 1989  !

e Oficefor Analysis and Evaluation ofOperational Data 1989 Annual Report, NUREG-1272 I Vol.'4, No.1, Power Reactors, July 1990  !

Vol. 4 No. 2. Nonreactors, July 1990 e Officefor Analysis and Evaluation ofOperational Data 1990 Annual Report, NUREG-l272 Vol. 5, No.1, Power Reactors, July 1991 Vol. 5, No.' 2, Nonreactors, July 1991 r

4 e

Oficefor Analysis and Evaluation of Operational Data 1991 Annual Report, NUREG-1272

}

Vol. 6, No.1, Power Reactors, July 1992, j Vol. 6, No. 2, Nonreactors, August 1992 .

• Oficefor Analysis and Evaluation ofOperational Data 1992 AnnualReport, NUREG-1272 i Vol. 7, No.1 Power Reactors, July 1993 Vol. 7, No. 2, Nonreactors, October 1993 e Officefor Analysis and Evaluation ofOperational Data 1993 Annual Report, NUREG-1272 l Vol. 8, No.1. Power Reactors, November 1994 '

Vol. 8, No. 2, Nuclear Materials, May 1995  !

e Oficefor Analysis andEvaluation ofOperational Data 1994-FY95 Annual Report, NUREG-1272 I Vol. 9, No.1, Power Reactors, July 1996 i Vol. 9, No. 2, Nuclear Materials, September 1996 l

Vol. 9, No. 3, Technical Training, September 1996 i

e Oficefor Analysis and Evaluation ofOperational Data 1996 Annual Report, NUREG-1272 I Vol.10, No.1, Power Reactors, December 1997 i

Vol.10, No. 2, Nuclear Materials, December 1997  !

Vol.10, No. 3 Technical Training, December 1997  !

Nuclear Materials ABSTRACT The United States (U.S.) Nuclear Regulatory In this annual report, NUREG-1272, Vol. I 1, the Commission's Office for Analysis and Evaluation staff describes activities conducted caring FY 1997.

of Operational Data (AEOD) has published repons The repon is published in three pans. In NUREG-of its activities since 1984. The first repon covered 1272, Vol. I1, No. 2, covering nuclear materials, the January through June of 1984, and the second staff presents a review of the events and concerns repon covered July through December of 1984. associated with the use oflicensed material in After those first two semiannual repons, AEOD applications other than power reactors. In NUREG-published annual repons of its activities from 1985 1272, Vol. I 1, No.1, covering power reactors, the through 1993. Beginning with the report for 1986, staff presents an overview of the operating experi-AEOD Annual Repons have been published as ence of the nuclear power industry from the NRC NUREG-1272. Beginning with the repon for 1987, perspective. In NUREG-1272, Volume 11, No. 3, NUREG-1272 has been published in two parts, covering technical training, the staff presents the No. I covering power reactors and No. 2 covering activities of the Technical Training Center ir nonreactors (changed to " nuclear materials" with suppon of the NRC's mission. Throughout these the 1993 repon). AEOD changed its ar.nual report repons, whenever infonnation is presented for a fmm a calendar year (CY) to a fiscal year (FY) calendar year, it is so deri; nated. Fiscal year report, and added pan 3 covering technical training, information is designated by the four digits of the beginning with the combined Annua! Report for fiscal year.

CY 1994 and FY 1995, NUREG-1272, Vol. 9.

iii

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

Nuclear Materials  !

1

. CONTENTS t

l t

Page Abstract . .... ........ .. ... ....... . .... .. ............................ . . . . . . ....................................iii 1

- Abbre viat i ons ... . . . ..... .. .. . ... ..... .. . . .. .. .. .. . .. .. . . .. . . .. .. . . . . .. . . ... ... . .. ... .. . ... .... ..... . . ........ . . . ... . .. . .. vii Ex ecu tive Su mmary ..... .. ..... ... .. . .... .......... .. .. .. . . ... .... ........................................................ix 1 Introduction... .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... ...............................I 2 Operating Experience Feedback .. .. ........................................,...........3 2.1 Nuclear Material Events Database. . . . . . . . . . . . . . . . . . . . . . . . . . ...............3 2.2 - Medical Misadministrations .... ..... . ............ . ... ....... ....... . .. .. . . . . . . . . . ........4 2.3 Radiation Overexposures .... . . .... ... ...... .... .... . ..... .. . . . .......... .........................6 2.4 Loss of Control of Licensed Material . .... .... ....... .. . . .. .... .. .... ... . -. ..... ... ... ...... .... 7 2.5 Leaking Source s . .......... . .... ....... . ..... ... ........ .. .... .... . .... . . . . . . . . . . . . . . . . ... .. 8 2.6 Release of M aterial .... . . . .......... . .. .... . ........ .......... ... ... ... . . . . . . . . . . . . . . . . . . . . . . ... 9 2.7 Transponation Events .... .... ... ... ......... ........ . .. ... . .. . ... ... ... ....................................9 2.8 Equipment Problems ..... ... . ... .. ..... ........ . . .. .. ... ... ... ...............................10 2.9 Fuel Cycle Facility Event s ... .. . . . .. ... .. .... ..... .......... .... . . .. ..... . ..... . .......... .. ... . ... I 1 2.10 Test, Research, and Training Reactors .... .. ....................................................I1 2.11 Annual Radiation Exposure Data.... .... ....... .. ...... .. . . . . . . . . . . . . . . . .............................I1 3 Abnormal Occurre nces ...... ... ......... . .. . ........... .. ... . . ..... .... ... ..... ............................15 3.1 Abnormal Occurrence Reporting ... .. .. ... ..... .. .. . .... .. ...... ........... ...........................15 3.2 Abnormal OccmTence Report for 1997 . . ........... .. . . .. .. . .. .. .... ...... ........ ... ..... . 15 4 Othe r AEOD Ac ti vitie s .... ... ......... . ... ......... . ...... .... .... .. ... .. . .. .........................17 4.1 Agreement State Operational Experience Data .. ...............-..................................17 4.2 Gaseous Diffusion Plant Abnormal Occurrence Criteria.. ......... ........ . . . . . . . . . . . . . . . . . .. . 17 5 Incident Response .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 19 5.1 NRC Operations Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....................19 5.2 Emergency Response . ... . ...... ... ....... .. ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19 5.3 NRC Operations Center Data for 1997. ........ ... .... .. . ... .. .................20 5.4 Emergency Exercises. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... ... 22 5.5 State Outreach .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .... 23 5.6 Coordination with Other Federal Agencies ........ . .. . ..... ... . ...................23 5.7 Gaseous Diffusion Plant Activities .. .. ......... . ... . .. ..... . . . . . . . . . . . . . . . . . . . . . . . . .

24 6 Incident Investigation Program._ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... . ... 25 6.1 Incident Investigation Team Events.... . . . . .... . . .... . . . . . . . . . . . .. . 25 l

6.2 Augmented Inspection Team Events ...... . . . . . . . . . . . . . . . . . . . . . . . . ... . . . .. 25

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1997 AEOD Annual Report [

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\ i Committee to Review Generic Requirements . ...........................................................27 i

7 l 7.1 . CRG R is sue s ... . . ... ........ . .. ....... . .. . . ... .. . . . . . . . ...............................28  !

7.2 Value Added by the CRGR Review ..... ....... . ... ........ . . ..... . . . . .........................28 t r

Appendices l L l l A Nuclear Materials Data by Event Type .. ..... ..... . .... . .. . . . . . . . . . .....................A i B Summary of 1997 Abnormal Occurrences . ............. .. .... . . .. ........................................B .

C Repons and Videotapes issued From 1981 Through 1997 . ... . .. ... .. . ....... . ........C i D Status of AEOD Recommendations . .. ... .. .... . . . . . . . . . . . . . . . . . . . . . . . . . . . ..........D [

-E Status of NRC Staff Actions for Events Investigated l by Incident Investigations Teams .... .. ... .. .. .... .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... . E [

Tables  ;

t 2.1 Nuclear Materials Reponable Events Submitted to the NRC and to Agreement States in 1997 by Event Type . .......... ... . .... .... . . .... ....... ... 4  :

2.2 Reportable Medical Misadministrations Submitted  :

to the NRC and to Agreement States in 1997 .......... ... ....... ... ... ..... ... .. . . .... .. . ... .. .... ...... .. . ... 6 2.3 Reponable Radiation Overexposures Submitted  ;

to the NRC and to Agreement States in 1997 ... . ...... .. ............. . .. .. ... .. .. . . ........ . . .. ..... ... . ... 6 l 2.4 Loss of Control of Licensed Material Reportable Events Submitted

to the NRC and to Agreement States in 1997 ......... . . . .. .. .. .. . .. .. .... ... . . ..... ... .. ........ . . . .. . 7 2.5 Reportable Equipment Problems Submitted  ;

to the NRC and to Agreement States in 1997...................-....................................................10 -

2.6 Annual Exposure Data for NRC Industrial Radiography Licensees CY 1990 to CY 1996 . . . ...... .. ....... . .. . ........ .. ... .... .. ....................................12 2.7 Annual Exposure Data for NRC Manufacturing and Distribution Licensees l CY l990 to CY 1996...... ... ................................... ...................................12 {

2.8 Annual Exposure Data for NRC Low-Level Waste Disposal Licensees l CY I 990 to CY 1996 .......... .. .. .... .... .... ... . . . . . . . . . . ..................................13  ;

2.9 Annual Exposure Data for NRC Independent Spent Fuel Storage Licensees  !

CY 1990 to CY 1996 . ... ..... ...... ....... .. ............-..........................................................13  !

2.10 Annual Exposure Data for NRC Fuel Fabrication and Processing Licensees l CY 1990 to CY l 996...... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....................I4 l 5.1 Events Reported to the NRC Operations Center in 1997 ..... . . . . . . . . . . . . . . . ... . . 21  !

5.2 Classifician of Events Under Licensee Emergency Plans )

CY 1989 through 1997 .......... ... . . . . . . . . . . . . . . . . . . . . . . . . ....................................22

]

5.3 Alens Reponed by NRC-Licensed i Nuclear Materials Facilities in 1997.. .. . .. . ....... -. . ...... ... . . . . . . . .. . .. . .. .. 22  ;

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I ABBREVIATIONS l j

l A G i ACMUI- Advisory Committee on Medical Uses gBq gigabecquerel  !

ofIsotopes GDP gaseous diffusion plant l AEOD Analysis and Evaluation of Operational GE General Electric Company l Data (NRC Office for) GL Generic Letter (NRC)

AO abnormal occurrence Gy gray ,

ARG Accident Review Group '

H B HDR high-dose-rate I Bq becquerel l BRC Bureau of Radiation Control I (State of Texas) I iodine IDNS Illinois Department of Nuclear Safety C IDOT Illinois Department of Transportation  ;

CAL Confirmatory Action Letter (NRC) IIP Incident Investigation Program  !

cGy centigray IIT Incident Investigation Team l CFR Code of Federal Regulations IN Information Notice  :

Ci curie - in inches .

cm centimeter ISA integrated safety analysis Co cobalt CRGR Committee to Review Generic M i Requirements (NRC) MBq megabecquerel l cSv centisievert mci millicuries i CY calendar year MC Manual Chapter (NRC) [

MD Management Directive (NRC) i D MDI Many Diversified Interests,Inc.  ;

DNA deoxyribonucleic acid MIT Massachusetts Institute of Technology i ml milliliter E mm millimeter  !

EDO Executive Director for Operations rmem millirem i (NRC) mSv millisievert ,

l F N  !

FCSS' Fuel Cycle Safety and Safeguards NaI sodium iodide NIST NationalInstitute of Standards and

],

(NMSS Division of)

FR FederalRegister Technology l' FRERP Federal Radiological Emergency NMED Nuclear Material Events Database Response Plan NMSS Nuclear Material Safety and Safeguards FRP Federal Response Plan (NRC Office of) l NRC U.S. Nuclear Regulatory Commission

, NRR Nuclear Reactor Regulation (NRC

• Office of) i i

vii  !

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l 1997 AEOD Annual Report O RPC Radiation Protection Committee (MIT)

OGC Office of the General Counsel (NRC) RPO Radiation Protection Officer (MIT)

ORISE Oak ridge Institute for Science and RSO radiation safety officer  !

Education RTM Response Technical Manual l l OSP Office of State Programs (NRC) j S I

! t l P SF&CG standard format and content guidance  !

l P&GD policy aini guidance directive SNM special nuclear material i

Sr strontium-90 Q SRP Standard Review Plan  ;

Sv sievert  !

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QMP quality management program R T l RCM Response Coordination Manual TDH Texas Department of Health  !

REM radiation equivalent man TEDE total effective dose equivalent  ;

RES Nuclear Regulatory Research (NRC TRTR Test, Research, and Training Reactors Office of)

RI Region I(NRC) U RII Region II(NRC) U.S. United States i RIII Region III(NRC) USEC United States Enrichment Corporation l RIV Region IV (NRC) t i

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l-NUREG-1272, Vol.11, No. 2 viii t

I !,-

Nuclear Materials EXECUTIVE

SUMMARY

General Operating Experience Feedback The Office for Analysis and Evaluation of Opera- NRC and Agreement State nuclear materials tional Data (AEOD) was created in 1979 to provide licensees am required by Title 10 of the Code of a strong, independent capability to analyze and FederalRegulations, comparable Agreement State evaluate operational safety data associated with regulations, or license conditions, to submit repons activities licensed by the United States (U.S.) of events that meet established criteria. The follow-Nuclear Regulatory Commission (NRC). AEOD is ing types of nuclear materials events are reponable:

l also responsible for the NRC's incident Response. .

Incident Investigation, Diagnostic Evaluation, and medical misadministrations of radiation or radiophannaceuticals to patients Techmcal Training Programs. In addition AEOD provides administrative and technical suppon to the -

radiation overexposures NRC's Committee to Review Generic Require-ments. AEOD also obtains industry feedback on I ss f c ntroloflicensed material these activities. .

problems with equipment that uses licensed The AEOD programs constitute the essential m terial ris therwise associated with the use cense material independent review and assessment of power reactor and nuclear materials safety performance, .

releases of material or contamination and complement the reviews of operating events leaking radioactive sources performed by the regions, the Office of Nuclear Reactor Regulation, and the Office of Nuclear .

problems during the transponation of licensed Material Safety and Safeguards. AEOD performs a material quality verification function that ensures feedback of important operational safety lessons. AEOD pr blems occurring at fuel cycle facilities findings and recommendations continue to be .

problems occurring in nonpower reactors addressed through generic correspondence, in the resolution of generic issues, and in initiatives taken AEOD collects, reviews, and assigns codes to by industry. inf rmation about nuclear materials events reponed by NRC licensees and Agreement States. In 1993 AEOD has published annual reports ofits activities AEOD developed a new database, the Nuclear since 1985. AEOD changed its annual report from a Material Events Database (NMED), that was calendar year (CY) to a fiscal year (FY) repon designed to allow multiple events in a single repon beginning with the combined Annual Repon for CY to be appropriately recorded. For example, a report 1994 and FY 1995, NUREG-1272, Vol. 9. In this may describe a loss of control of licensed material report, NUREG-1272 Vol. I1, No. 2, the staff and an overexposure. In such a case, both events presents a review of the events and concerns during would be recorded in the NMED and both would be FY 1997 associated with the use oflicensed materi- identified by the same repon number. An interim, als in applications other than power reactors. standalone version of the NMED was distributed to Throughout this repon, whenever information is the Agreement States in October 1994. Installation presented for a calendar year, it is so designated. of the NMED within NRC headquarters was Fiscal year information is designated by the four completed in June 1996, and the NMED was digits of the fiscal year, distributed to Agreement States in September 1996.

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1997 AEOD Annual Report Approximately 7,000 NRC licensees and 15,000 calculated to be 0.117 centisievert (cSv)(117 Agreement State licensees submit reports of events. mm). Four whoic-body occupational overexpo-NRC licensees submit reports directly to the NRC sures ranged from 5.77 cSv (5.77 rem) to 16 cSv regional or headquarters offices. Agreement State (16 rem). Three of these were accumulated wer a licensees submit reports to the States, which in tum 3-month monitoring period as a result of rad ogra-voluntarily transmit summary reports to the NRC phy activities; the fourth one came from usit:g a under an informal information sharing agreement. portable moisture density gauge, an activity ' hat In 1997 there were 593 events involving radiologi- only rarely produces reports of overexposures.

cal material licensed to nuclear materials licensees There were also two overexposures to the hands of and nonpower reactors that were required to be people handling radiopharmaceuticals, and a skin reported under NRC or equivalent Agreement State dose of 482 cSv (482 rem) to an individual's regulations. Two of those events were reported to thumb that became contaminated with a beta-Congress as abnormal occurrences (AOs). (There emitting isotope while working in a radiopharma-were five events reported to Congress as AOs in ceutical facility. The skin dose was reported to 1997, however only two of them occurred in the Congress as an AO.

time period covered by this report.)

There were 558 other nuclear materials events, There were 27 reportable medical including loss of control of licensed material, misadministrations that occurred in 1997, including leaking sources, release of material, transportation 1 that was reported to Congress as an AO. In 26 of events, equipment problems, fuel cycle facility these events, there were little or no adverse effects problems, and problems at test, research, and on the patients' health and no follow-up medical training reactors. None of these events were re-care was required. In the remaining case, the ported to Congress as AOs.

patient, who had been prescribed a diagnostic dose for a thyroid scan and uptake procedure, received in error a whole-body dose for a cancer evaluation.

Other AEOD Activities This larger dose may induce hypothyroidism, which In its final " Policy Statement on Adequacy and will require the patient to take thyroid hormone for Compatibility of Agreement State Programs," the the rest of his life. The main factors contributing to staff proposed that Agreement State event report-these misadministrations were (1) inattention to ing be required as an element of compatibility. The detail (dose calibrator set improperly, afterloader/ Commission approved the policy statement on i applicator placed in the wrong position), (2) September 3,1997; now. Integrated Material l communications problems (not understanding the Performance Evaluation Program (IMPEP) teams l referring physician's request, incorrect data used in review event reporting for adequacy dunng l dose planning), and (3) errors in calculation of the IMPEP evaluations. This promotes standardized j treatment plan. Corrective actions reported by material event reporting between Agreement State licensees included creating a new procedure, and NRC licensees.

modifying an existing procedure, retraining, and . .

improving the quality management plan. The Commission asked the staff to determine if the AO criteria need to be modified for fuel cycle Eight events in 1997 caused eight people, includ- facilities to explicitly include those facilities that ing one member of the public, to receive radiation are not licensed by the NRC but that are otherwise in excess of the exposure limit.The non-occupa- regulated by the NRC, such as the gaseous diffu-tional overexposure resulted from a technician sion plants. The staff determined that revised entering the room of a brachytherapy patient (Ir- criteria were needed for the gaseous diffusion 192 implant) and drawing a blood sample frcm the plants. These criteria were developed and became patient. The dose received by the technician was effective in 1997.

NUREG-1272, Vol. I 1, No. 2 x

I Nuclear Materials Incident Response Incident Investigation Program Nuclear materials licensees reponed two alens in No nuclear materials events in 1997 were judged 1997. The NRC did not enter the monitorinF :.r Ae to have a level of safety significance sufficiently ;

for eittar of these events. 'Ihere were no nuwicar high to warrant either an Incident Investigation matenals events reponed at the Site Area Emer- Team investigation or an Augmented Inspection i gency levelia 1997. Team inspect:on.

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xi Executive Summary

Nuclear Materials 1 INTRODUCTION l

The United States (U.S.) Nuclear Regulatory AEOD also obtains industry feedback on these Commission (NRC) licenses the use of reactor- activities.

produced isotopes, the milling of uranium, and the The AEOD programs, taken as a whole, constitute subsequent processing of natural uranium, enriched the essential independent review and assessment of  ;

uranium, and other special nuclear material (SNM).

In 1997 the NRC directly regulated licensees in 20 nuclear m terials safety performance, and comple-States, the District of Columbia, and the U.S. ment the reviews of operating events performed by territories. The remaining 30 States, known as the regions and the Office of Nuclear Material l

Agreement States, have entered into agreements Safety and Safeguards. AEOD performs a quality l with the NRC under Section 274 of the Atomic verification function that ensures feedback of {

Energy Act, as amended, whereby the NRC relin- imp nant operational safety lessons. AEOD l quishes and the States assume regulatory authority findings and recommendations continue to be over the use of byproduct materials, source materi- addressed through generic correspondence, in the als, and other SNM in quantities tommall to resolution of generic issues, and in initiatives taken sustain a chain reaction. by industry.

The NRC's Office for Analysis and Evaluation of AEOD consists of three divisions organized as j Operational Data (AEOD) was created in 1979 to f llows: the Incident Response Division, compris-provide a strong, independent capability to analyze ing the Response Operations Section, the Response operational data. AEOD implements this role for Coordination Section, and the Operations Officer nuclear materials applications by collecting and Section; the Safety Programs Division, comprising j maintaining nuclear materials event data in the the Reactor Analysis Branch and the Reliability and Nuclear Material Events Database, analyzing and Risk Assessment Branch; and the Technical Train-evaluating these operating experience data, provid. ing Division, comprising the Reactor Technology ing feedback on lessons leamed and, as appropriate, Training Branch, the Specialized Technical Training recommending actions to reduce the probability that Branch, and the Technical Training Support Branch.  !

operational events will recur or will lead to more AEOD changed its annual report from a calendar senous events. year (CY) to a fiscal year (FY) repon beghming AEOD is also responsible for the NRC's Incident with the combined Annual Repon for CY 1994 and Response, Incident Investigation, Diagnostic FY 1995, NUREG-1272, Volume 9. In this report, i Evaluation, and Technical Training Programs. The NUREG-1272, Vol. I 1, No. 2, covering nuclear Incident Response Program provides a coordinated materials, the staff presents a review of the events NRC emergency response to ongoing events and concerns during 1997 associated with the use of through the NRC Operations Center. The Incident licensed materials in applications other than power Investigation Program offers a structured NRC reactors. Throughout this repon, whenever infonna-investigative response to significant operational tion is presented for a calendar year, it is so desig-events according to their safety significance. The nated. Fiscal year information is designated by the Diagnostic Evaluation Program independently four digits of the fiscal year. The report also con-assesses licensee perfonnance at selected reactor tains the following appendices:

facilities. The Technical Training Program provides - Appendix A summarizes the 1997 nuclear mittal and continuing techmcal trammg for NRC materials events by event type staff and contractors. In addition, AEOD supph,es administrative and technical support to the NRC's

• Appendix B summarizes the 1997 nuclear Committee to Review Generic Requirements. materials abnormal occurrences 1

1997 AEOD Annual Report Appendix C lists nuclear materials reports and in the report on power reactors, NUREG-1272, Vol.

< videotapes issued by AEOD from CY 1981 11, No.1, the staff presents an overview of the 1997 through 1997 operating experience of the nuclear power industry from the NRC perspective. In NUREG-1272,

• Appendix D presents the Status of Recommen-Volume 11, No. 3, covering technical training, the dations m MMD nuclear materials studies '

staff presents the activities of the Technical Training

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• Appendix E presats the status of staff actions Center in suppoit of the NRC's mission. .

Nsulting from the findings of NRC Incident Investigation Teams for nuclear materials events l

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NUREG-1272,W1. O, No. 2 2

Nuclear Materials 2 OPERATING EXPERIENCE FEEDBACK The primary concern with the use of radioactive a a problem in a fuel cycle facility materials is the potential for overexposure, which can cause cancer or, in severe cases, death. Extrem-a pr blem in a nonpower reactor ity or localized skin exposures from radioactively AEOD collects, reviews, and codes information hot panicles are a lesser health concern but are still about nuclear materials events. Approximately imponant to the NRC in assessing the effectiveness 7,000 NRC licensees and about 15,000 Agreement of byproduct materials control. State licensees submit repons of events that are required to be reported. Licensees also voluntarily One measure of the effectiveness of a licensee's submit reports of events that are not required to be control of regulated materials is the collective dose reported. Voluntary repons are not considered when received by all employees who work with, or may evaluating operating experience and are therefore be present in the vicimty of, nuclear materials.

not included in this annual report. NRC licensees Licensees are required to provide appropriate submit reports directly to the NRC regional or momtonng equipment to, and to require the use of headquarters offices. Agreement State licensees such equipment by, each person who is likely t submit reports to the States, which then transmit receive a dose in any calendar quarter exceeding 25 summary repons to the NRC under an information-percent of the allowable limits specified in Part 20 sharing agreement. Non-licensees also report events of Title 10 of the Code of Federal Regulations (10 involving radioactive material to the NRC and to CFR). Licensees are also required to monitm and Agreement States. Those events that involve control activities that can lead to exposing their radioactive material licensed under the Atomic employees or the general public to radiation.

Energy Act are included in this report. In addition, the NRC obtains reports of events from other 2.1 Nuclear Material Events sources, such as NRC inspection reports, and, casi nally, fr m n n-licensees, including mem-Deh bers of the public. The NRC in tum reports to NRC and Agreement State nuclear materials licens. Congress any unscheduled incidents or events that ces are required by 10 CFR, comparable Agreement it determines to be significant from the standpoint i State regulations, and license conditions, to submit of ublic P health and safety. Such events are desig- I reports on any of the following events: nated as abnormal occurrences ( AOs).

a medical misadministration of radiation or From CY 1981 through CY 1992 AEOD coded radiopharrnaceuticals to a patien't nuclear materials event data and maintained them in two databases, one containing records of medical

• a radiation overexposure misadministration events and the other containing records of other reponed nuclear materials events.

• a loss of control of licensed material In 1993 AEOD developed a new database, the e a problem with equipment that uses licensed Nuclear Material Events Database (NMED), that material or is otherwise associated with the use was designed to allow multiple events in a single oflicensed material report to be appropriately recorded. For example, a report may describe both a loss of control of

• a release of material or contamination licensed material and an overexposure. In such a case, both events would be recorded in the NMED

• a leaking radioactive source and both would be identified by the same report

• a problem during the transportation of number. In developing the database structure, licensed material AEOD received substantial input from the NRC U

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1997 AEOD Annual Report Headquarters Offices of Nuclear Materials Safety Table 2.1 Nuclear Materials Reportable Events and Safeguards, State Programs, and Nuclear Submitted to the NRC and to Agreement States Regulatory Research; the regional offices; and the in 1997 by Event Type Agreement States. Most of this information oc-curred during AEOD-sponsored workshops held in Type of Event Number November 1993 and May 1994. An interim, stand .

alone version of the NMED was distributed to the Misadministrations 27 Agreement States in October 1994. Installation of Radiation overexposures 8 the NMED within NRC headquarters was com- Loss of control oflicensed material 248 pleted in June 1996. A new NMED data entry, Leaking sources 15 search, and report program was fully operational in the third quaner of CY 1996 and was distributed to Release of material 38 Agreement States in September 1996. Transportation 53 The NMED contains about 14,000 detailed records Equipment problems 145 of reported events, including voluntary reports, as Fuel cycle facility problems 55 well as information for identifying associated 4

. Test, research, and training reactors reports, such as inspection reports. NRC data since CY 1981 are available, as well as Agreement State Total 593 data from CY 1991. The NMED contains records of fraterial events for all categories of materials Note: Not all Agreement State repons had been received at the licensees, including nonpower reactors. Radiation time this table was prepared.

overexposure events since 1993 for commercial power reactors are also maintained in the NMED. This can resuk in a patient receiving an unintended r excessive dose or a dose to the wrong treatment In 1997 there were 593 events involving radiologi- .

site. Occasionally a radiopharmaceutical is admmis-cal material licensed to nuclear materials licensees tered to the wrong patient. Excessive exposures to and nonpower reactors that were required to be m nitored employees and uncontrolled exposures to reported to the NRC. Two of these events were the general public are also a concem m the medical reported to Congress as AOs. (There are five events use f radioacuve matenals. However, such mci-in the 1997 Report to Congress dn Abnormal dents are relatively rare, considering the hundreds Occurrences, NUREG-0090, Vol. 20, however only f thousands of procedures performed each year.

two of them occurred during the time period covered by this report.) Table 2.1 shows the number The Misadministration Rule, which became effective of reportable events in 1997 by type submitted both on November 10,1980, required NRC medical to the NRC and to Agreement States as of the date licensees to report medical misadministrations to the of preparation of this report. NRC.'Ihis rule was revised in 1987 to require Agreement States to have reporting requirements for medical misadministrations that are compatible with 2.2 MedicalMisadministrations the NRC seponing requirements. Licensees in The NRC and Agreement States regulate certain Agreement States would then report aspects of reactor-produced radionuclides used in misadministrations to the appropriate regulatory imclear medicine and therapeutic radiology in agency in their state. Agreement State agencies 1 ad 3 accordance with 10 CFR Part 35," Medical Use of years to promulgate such rules. Therefore, Agn.e-Byproduct Material." The major concerns with the ment State licensees were required to repon meJeal use of radioactive materials in medical applications misadministration events by 1991. The Agreement arise from either a licensee's failure to effectively States repon these events to NRC. Reponing of control licensed material or from other human events data involving Atomic Energy Act (AEA) errors, such as dispensing a radiopharmaceutical material, including medical misadministrations, is a that does not comply with the written directive, compatibility requirement for Agreement States.

NUREG-1272, Vol. I 1. No. 2 4

Nuclear Materials The Quality Management Program and misadministrations are associated with procedures Misadministration Rule, which became effective in in which large doses of radiation are administered ,

1992, requires a quality management program and to patients to achieve a therapeutic effect; diagnos-contains revised definitions of, and reporting tic misadministrations are associated with clinical j requirements for, medical misadministrations. As or investigative procedures requiring comparatively l part of this rule, the misadministration definitions small doses of radiation. However, some I were changed to apply to the following six types misadministrations involving the use of Nal-125 or of procedures: Nal-131 for diagnostic purposes may deliver un nen ses in the therapeutic range to the administration of diagnostic radiopharmaceuticals, l including less than 1.11 megabecquerels (MBq) pt np thyroid. Not all therapeutic overdoses result m sigmficant r diation-mduced cimical (30 microcuries [pCi]) Nal-125 or Nal-131 effects to patients. Some patients receive a dose of

• diagnostic administrations of Nal-125 or Nal-

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radiation that is less than that prescribed. In these 131 radiopharmaceuticals in quantities greater cases, if the error is found in time, the total pre- l than 1.11 MBq (30 Ci) scribed dose can still be achieved. /l

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M administration of therapeutic radiopharmaceuticals In 1997 the NRC and Agreement States regulated (other than Nal-125 or Nal-131) approximately 7,000 licensees in 50 states, the

. District of Columbia, and the U.S. territories that gamma stereotactic radiosurgery use radionuclides m. radiation therapy and nuclear

+

teletherapy medicine applications. These facilities submitted reports of 27 misadministrations that occurred in a

brachytherapy 1997.These events are listed in Appendix A-1 to The criteria for misadministrations vary and include this report. Table 2.2 lists the reported medical such errors as treatment of the wrong organ or misadministrations by type of procedure. Sodium patient, use of the wrong radiopharmaceutical, iodide and brachytherapy misadministrations administration of a dose that differs from the together account for about 70 percent of the re-prescribed dose, or an incorrect administration ported misadministrations. One of the sodium route or treatment mode. The specific definitions iodide misadministrations was reported to Congress are in 10 CFR Pan 35. as an AO (AS 97-4; see Section 3.2 of this volume.)

The remainder of the reponed misadministrations I The term " diagnostic misadministration," as used in were about evenly distributed between diagnostic NRC regulations, refers to the misadministration of radiopharmaceuticals, therapeutic radiopharmaceu-radioisotopes in such nuclear medicine studies as ticals, and teletherapy. There was also one reponed I renal, bone, and liver scans. " Therapeutic gamma stereotactic radiosurgery misadministration. l misadministration" refers to the misadrninistration Within the scope of review of the data for this report, of radiation in the treatment of patients using Co-60 no significance can be ascribed to the relative (the extemal use of radiation from a single Co-60 number of reponed misadministrations, other than to source for therapeutic treatment), gamma stereotac- observe that the more frequently administered l tic radiosurgery (the external use of radiation from procedures show a relatively higher number of about 200 small Co-60 sources for therapeutic reponed misadministrations.

treatment), brachytherapy (the insertion or implan-tation of sealed sources containing radioactive The causes of the reponed misadministrations material for therapeutic treatment), or radiopharma- were reviewed and separated into three categories:

human errors related to inattention to detail, ceutical therapy (the ingestion or injection of radioactive materials for therapeutic treatment). c mmunication problems, and treatment planning errors. About one half of the causes reported for the The potential or actual effect of a therapeutic misadministrations were related to inattention to misadministration generally differs from that of a detail: dose calibrator set improperly, afterloader/

diagnostic misadministration. Therapeutic applicator placed in the wrong location, and failure 5 Operating Experience

1997 AEOD Annual Report Table 2.2 Reportable Medical Misadministrations patients exceeding planned treatments are not Submitted to the NRC and to Agreement categorized as overexposures. Only doses to l States in 1997 patients not intended to be treated are included in '

l this section.)

Procedure Number There were 8 events in 1997 that resulted in 8 Diagnostic radiopharmaceutical 2 Pe0Pl e, including one member of the public, rec iving radiation doses in excess of regulatory Sodium iodide 10 hmits. (See Table 2.3.) Additional information on Therapeutic radiopharmaceutical 2 these events is listed in Table A-2 of Appendix A to Gamma sto eotactic radiosurgery I this report.The non-occupational overexposure resulted from a technician entering the room of a Teletherapy 3 brachytherapy patient (Ir-192 implant) and drawing Brachytherapy 9 a blood sample from the patient. The calculated dose received by the technician was 0.117 cSv (117  ;

Total 27 mrem). Industrial radiography accounted for about {

40 percent of the occupational overexposures of all types and 75 percent of the whole-body occupa-tional overexposures. The whole-body overexpo-of the technologist to verify that the entire dose was sures ranged from 5.3 cSv (5.3 rem) to 16 cSv (16 admimstered. The causes reported for about 25 rem) and were due to radiographers accumulating percent of the misadministrations were about the dose over the quarterly monitoring period rather equally distributed between communications than to specifically identified events.

problems (referring phys,cian's i request misunder-stood) and treatment planning errors (incorrect data One occupational overexposure was a whole-body used in therapy dose planning). Causes were not dose to the user of a portable moisture density reported for the remaining 25 percent of the gauge.These gauges typically contain an 8 to 10 -

misadministrations. The cause for one millicurie (mci) Cs-137 source and a 40 mci Am-misadministration was attributed to an equipment 241/Be neutron source used in a way that mini-problem - a lightning strike made a teletherapy mizes exposure to the user. Significant whole-body machine inoperable. Among the corrective actions exposures from using portable moisture density  ;

reported by licensees were creating a new proce- gauges are rarely reported.

dure, modifying an existing procedure, retraining, Two of the occupational overexposures were and improving the quality management plan. radiation doses to the hands of two individuals handling radiopharmaceuticals: the dose to one 2.3 Radiation Overexposures The occupational dose limits for radiation workers Table 2.3 Reportable Radiation Overexposures are defined, in 10 CFR 20.1201, " Occupational Submitted to the NRC and to Agreement States dose limits for adults," to be equivalent to a whole- in 1997 body dose of 5 centisieverts (cSv)(5 rem) per year. The dose limit for non-radiation workers Type of Licensee Number of Number of (members of the public)is 0.1 cSv (100 millirem Reports Individuals

[ mrem]) per year, in accordance with 10 CFR 20.1301, " Dose limits for individual members of Medical / Academic 1 1 the public." In addition, the occupational dose Research/ Commercial 4 4 limits for minors are defined, in 10 CFR 20.1207, Industrial Radiography 3 3

" Occupational dose limits for minors," to be 10 percent of the annual limits for adult workers. Totals 8 8 (Medical misadministrations resulting in doses to NUREG-1272, Vol. I 1, No. 2 6

Nuclear Materials person's hand was 131 cSv (131 rem) and the dose There were 248 loss of control of material events in to the other individual's hand was 52 cSv (52 rem). 1997 that were reponed to the NRC. Table 2.4 The remaining occupational overexposure was a shows the distribution of reported events by loss 609 cSv (609 rem) skin dose to an area of a category. Table A-3 in Appendix A to this repon person's thumb that became contaminated with gives information on who reponed the event, the a beta-emitting isotope while working in a radiop- radionuclide, and the activity lost. The radionuclide harmaceutical facility.This event was reponed as activities in these events ranged from undetermined AO 97-2. trace amounts of Nal-131 in municipal waste to approximately 3.9 terrabecquerel (108 Ci) of Ir-192 2.4 Loss of Control of Licensed c ntained in a radi graphy exposure device.

Material Of the categories of repons of lost material summa-rized in Table 2.4, " Lost by licensees" is three times Loss of control of licensed material occurs when as great as the next highest category," Stolen licensed material is not under the direct physical or licensed material." Events in the " Lost by licens-J administrative control of a nuclear materials ces" category can generally be characterized as a licensee. This can be due to actual loss, administra-loss of material from inventory, in that the material tive loss, unauthorized abandonment or disposal, or is usually discovered lost during an inventory of the theft. Discovery of licensed material in the public devices that contain the material or when there is a domain is also considered a loss-of-control event  !

need to use the device or the material. In most cases even if the licensee failed to recognize the loss.

it is not known how the material was lost. Examples I The primary safety concern is that, while the oflosses in this category are lost industrial gauges material is out of the licensee's control, it may (Cs-137), static eliminators (Po-210), gas chro-adversely affect public health and safety, whether matographs (Ni-63), and self-luminous devices or not it is later recovered.

(H-3). About one half of the devices and material Pan 20 of 10 CFR contains the reponing require. are eventually found, usually within the licensee's ments for all loss-of-control events except for well. facility. The majority of material lost in this cat-logging sources that have been declared egory were low activity sources in a shielded irretrievable. Well-logging sources may be aban- configuration. On the other hand, about 20 percent doned (left in place) in accordance with the require. of the events were lost industrial gauges containing ments of 10 CFR 39.77 and guidelines approved by the NRC and the Agreement States.

Table 2.4 Loss of Control of Licensed Material Licensed material can generally be lost in one of Reportable Events Submitted to the NRC and to the following six ways: Agreement States in 1997 i

missing from imlentory (gauging measuring ,

devices, calibration sources) stolen (most often portable moisture density Lost by licensees 136 E* E#

Stclen licensed material 42

• abandoned by licensee Abandoned licensed material 2

• inadvenently sent to commercial landfills (mostly medical waste) Material found at landfills / incinerators 21

• inadvenently shipped to metal scrap yards Material found at scrap yards 18 (usually contaminated metal or industrial Abandoned well logging sources 29 measurmg gauges)

• well-logging sources that are abandoned Total 248 downhole (usually Cs-137 and Am-241) l 7 Operating Experience

1997 AEOD Annual Report 100 mci to 2 curie (Ci) Cs-137 sources. In addition, the two involving AEA material, were also reported l about 2 percent of the reported events were lost to the NRC and were in the NMED. An AEOD

' radiography sources;in two cases the radiography study on lost material events undertaken under i

devices were temporarily lost during shipment and contract with the Idaho National Engineering and in one case the radiography device fell off of the Environmental Laboratory that is scheduled to be licensee's vehicle. All of the devices were recovered published in 1998 will provide a quantitative intact. Other events were stolen radiography assessment in this area and include an assessment devices; in two cases the devices were lost when the of data on lost sources, including data maintained in vehicle containing the devices was stolen. All of the the Yusko database.

devices were recovered intact. No overexposures The causes of the reponed lost material events were reported to have occurred from lost or stolen generally involved inadequate accounting proce-sources in this category.

dures, failure to follow procedures, and ineffective Portable moisture density gauges, which contain an security measures. Radiation monitors installed at 8 to 10 rnCi Cs-137 source on a retractable rod and commercial landfills and scrap-metal yards can an internal 40 mci Am-241 source, are the most reduce the amount of licensed material entering commonly stolen licensed devices. They are used in such facilities. Among the corrective actions that highway and other construction projects involving were reported were retraining personnel on proce-soil compaction and paving. They are thought to be dures for handling and oversight of licensed mate-targeted for theft because they are valuable and rial, developing new procedures for using devices ponable. The NMED lists approximately 25 to 30 containing licensed material, and improving how thefts of moisture density gauges each year. Some licensed material is labeled and handled.

of the stolen gauges were left unsecured, but the typical repon is of a properly stored and locked 2.5 Leaking Sources gauge being stolen from a locked and seemingly secure facility. AEOD has undertaken a study to Sealed sources are constructed of licensed radioac-identify the causes of the thefts oflicensed material tive material welded in a metal capsule or encapsu- 2 (including portable moisture density gauges), the lated within a sealant such as metallic foil or a recovery rate for stolen gauges, and the relative risk ceramic. Periodic leak tests from every 3 months to to public health and safety. every 3 years are required, depending upon the s ur c nstruction and the method of encapsula-Of the 248 reports of lost material received by the tion. Test results of more than 185 Bq (0.005 pCi)

NRC in 1997,18 were repons of material found at of removable contamination is considered evidence scrap-metal facihties and 21 were repons of mate-of leakage. Detecting leaking sources early is nal found at sanitary landfills. This is about twice essential to preventing significant facility contami-the number of events reported for these categories nation, personnel contamination, and personnel for this penod as were reponed for the previous exposures. Sources that are ruptured because of a year. We are unable, withm the scope of this review, physical impact or that are ground up in a recycling to determine whether the higher numbers for this facility are not counted as leaking sources. Events year reflect a higher rate of occurrence or a higher of this nature are captured in other event categories.

rate of reporting. Another database containing records of reports of radioactive material found at in 199715 events involving 15 leaking sources were scrap-metal facilities is one maintained by James reported to the NRC. 'Ihese events are listed in Table Yusko of the Commonwealth of Pennsylvania, A-4 of Appendix A to this report. Of the 15 leaking Depanment of Environmental Protection. A review sources,33 percent involved Ni-63 in electron-of the data in the Yusko database for 1997 found 46 capture detectors contained in gas chromatographs.

reports of material found at scrap-metal facilities, These sources are covered with a thin film and are 18 of which involved non-Atomic Energy Act prone to minor leakage with normal use. Another (AEA) material. In another 26 reports the isotope 20 percent of the leaking sources contained Cs-137 was not identified. The remaining two repons used in gauges and a calibration source. The remain-involved AEA material. Six of the events, including der of the repons involved sources of Sr-90 Fe-55, NUREG-1272, Vol. I 1, No. 2 8

Nuclear Materials Cm-244, and Cl-36.There were no reported person- The other personnel contamination events did not nel exposures resulting from the leaking sources. involve exposures or uptakes that exceeded regula-There was a report of facility contamination as a tory limits. These events were minor contamination result of a leaking Sr-90 source. events affecting radiopharmacy workers (Tc-99m),

All licensees took prompt corrective action by research laboratory workers (P-32), and military removing the leaking sources from service. Most pers nnel(H-3) using self-luminous devices.

Thirty-five percent of the events mvolved low levels licensees returned the leaking sources to the equip-inent manufacturer to have the source replaced. f c ntamination of hmited areas of floors and Severallicensees disposed of the sources. w rk spaces with H-3,1-131, P-32, Tc-99m.

Another 20 percent of the events involved military personnel handling damaged self-luminous devices.

2.6 Release of Material In about one-half of all events, there was a release Among those events categorized as " release of of material or contamination at either a medical or licensed material" are spills and gaseous or effluent acadernic facility or a military installation. About I releases, during which licensed material is either 20 percent of the events occurred at released to the environment (air or water) or causes radiopharmacies. The remainder of the events either personnel or facility contamination exceeding (1) occurred at fuel facilities or other facilities {

regulatory limits. Such events are required to be licensed to handle byproduct material, or (2) )

reported to the NRC or to Agreement States by 10 involved a common carrier. Few of the reports  !

CFR 20.2202 and 20.2203 or comparable Agree- indicated what coirective actions were taken to l ment State regulations. Certain contamination prevent similar events. Of the corrective actions that events that occur at facilities are also included in were reported, the principal ones were additional this category and are required to be reported to the training, new equipment purchases, and design NRC or to Agreement States by 10 CFR 30.50, changes made to existing equipment.

40.60,50.72,50.73 and 70.50 or comparable Agreement State regulations. . I 2.7 Transportation Events '

There were 38 events in 1997 involving the release oflicensed material that were reported to the NRC; Transportation events involve shipments of pack-they are listed in Table A-5 of Appendix A to this ages that have removable radioactive surface report. The 38 events involved release of material or contamination or radiation levels that exceed NRC contamination of personnel or facilities, or both. limits. Licensed material shipments that are in accidents or that are damaged during shipment are l Two of the events involved uranium hexafluoride '

also counted as transportation events. Transporta-(UF,) releases to air reported by a production l tion events are reported to the NRC or to the facility and a gaseous diffusion plant. The releases Agreement States as required by 10 CFR Part 71 were caused by equipment problems and were and 10 CFR 20.1906 or comparable Agreement l below regulatory limits and confined to plant sites.

State regulations.

Of the remaining 36 events, about 31 percent In 1997 53 transportation events were reported to mvolved personnel contamination, including the the NRC; they are listed in Table A-6 of Appendix contamination of a member of the pubhc wh A to this report. Contaminated shipments / packages handled a damaged tritium exit sign. This person and vehicle accidents each accounted for about 36 did receive an uptake, but it was below the regula-percent of the reponed events. Most of the contami-tory hmit for tritium. One contamination event nated packages were being shipped between mvolved a radiopharmaceutical worker who con-radiopharmacies and hospitals. One exception taminated his thumb by workmg with defective wu an event with a contaminated Sealand ISO gloves. As a result, the worker received a skin dose container shipped from Spain.

of about 609 cSv (609 rem). This event is also listed in Table A-2 of Appendix A to this report and is Most of the vehicles involved in accidents were discussed in Sections 2.3 and 3.2. transporting radiopharmaceuticals to and from i

9 Operating Experience

1 l

1997 AEOD Annual Report l 1

hospitals or portable moisture density gauges to Table 2.5 Reportable Equipment Problems and from construction sites. Three exceptions were Submitted to the NRC and to Agreement States two train accidents and a flatbed trailer accident. In 1997 In one train accident, a car carrying 12 Mo-99/

Tc99m generators derailed; in the other, a train Type of Equipment Number carrying a contaminated turbine rotor hit a bridge.

The flatbed trailer accident involved a shipment of Industrial gauges 38 four 2.5 ton solid UF, cylinders. In none of the Industrial radiography devices 17 vehicle or train accidents was shielding lost or Fuel processing 54 radioactive material lost.

Irradiators 8 In about 20 percent of the reported transportation Medical equipraent 3 events, the packages being shipped either exceeded Radioluminescent devices 2 regulatory hmits or they were damaged m sh,p- i ment. No personnel exposures were reported to Teletherapy units 2 have resulted from the shipment of packages that High-dose-rate units 2 exceeded regulatory limits. On the other hand, Gamma knives I several areas of one facility were contaminated by Scaled sources 10 one of the damaged packages.

Welllogging equipment 1 The remainder of the events concerned packages Exhaust hoods I that were lost from a transport vehicle or high Non-Power reactors I radiation levels in the cab of a transpon vehicle. No radiation exposures or releases of material exceed. Other 5 ing regulatory limits resulted from these events.

Total 145 2.8 Equipment Problems There were 145 equipment problems reponed to the reported problems were associated with the drive NRC in 1997; they are listed in Table A-7 of Appen- cable connector for radiography cameras. In 1998 ,

dix A to this report and are summarized in Table 2.5. the NRC will issue a NUREG and an information j notice to discuss and highlight these problems. 1 Twenty-six percent of the 145 reported equipment About 3 percent of the reported equipment prob-problems involved industrial gauges; about one-half lems involved radiotherapy equipment, teletherapy of them were moisture density gauges, most of unis, and high-dose-rate brachytherapy units. Two which sustained damage from vehicles at construc- reports on teletherapy units were caused by, in one  !

tion sites. One event, which concerned a "hard t case, a loose wire connection and, in the other case, '

extend" source rod, may have contributed to a 52 a bumed relay that caused problems extending and I cSv (52 rem) exposure to the operator's hand. retracting the source. Two repons on HDR Equipment problems with gauges other than brachytherapy units described, in one case, a moisture density gauges occurred due defective machine malfunction due to a technician bumping parts, fire, or mechanical impact. the table containing the device and,in the other l About 37 percent of the reported equipment g - case, a faulty limit switch which caused an unin-lems occurred at fuel facility plants, most of v uch tended extension of the source. No medical were gaseous diffusion plants. These events typi- misadministrations were reponed to have occurred cally involved plant systems associated with the because of these events.

maintenance of proper criticality controls. An Among the remaining equipment problems were a analysis of these events is not withm the scope of leaking St-90 source due to damage to the source, this repon.

and damaged H-3 devices used in military sighting Twelve percent of the equipment problems involved and targeting systems that resulted in low levels of industrial radiography equipment. About half of the contamination to several people and work acas.

NUREG-1272, Vol. I 1, No. 2 10

Nuclear Materials 2.9 Fuel Cycle Facility Events by universities, the Federal Government, and commercial companies.

Fuel cycle facility events include criticality, loss of a control that is required to prevent criticality, or a Four TRTR events were reponed in 1997. Three

~

release involving any of the non-radioactive chemi- were related to equipment problems and one was cals that are used in the fabrication of uranium related to human error - someone forgot to remove reactor fuel. The criteria for reponing fuel cycle an alarm bypass key from the emergency control facility events are found in 10 CFR Pan 50,10 CFR Panel. There were no adverse effects on public Pan 70, and NRC Bulletin 91-01. health and safety as a result of the reponed events.

The NRC regulates all commercial fuel cycle facilities where uranium ore is processed and 2.11 Annual Radiation Exposure reactor fuel is fabricated. The nine major fuel Data cycle facilities are one UF, production facility and According to the National Council on Radiation eight uranium fuel fabrication facilities. In addi-Protection and Measurements, the average total tion, two gaseous diffusion uranium enrichment i effective dose equivalent (TEDE) to a person in the plants, owned by the Department of Energy but Umted States is approximately 0.36 cSv (360 leased to and operated by the U.S. Enrichment

• '**) Pu year, mostly fmm natural sources of l Corporation, came under NRC regulatory over- .

radiation.The average person m the Umted States l sight in early 1997.

receives a TEDE of about 0.05 cSv (50 mrem) per There were 55 reponed fuel cycle facility events year from medical applications. The entire fuel that occurred in 1997. Seventy-five percent of the cycle, including operation of reactors, contributes  !

reports were submitted by gaseous diffusion plants less than 0.001 cSv (1 mrem) per year. All other l (GDPs). Fony five percent of all of the reponed human-controlled sources of radiation combined events involved the loss or degradation of criticality add up to a TEDE of approximately 0.006 cSv (6 controls; the majority of them exceeded the admin- mrem) per year.

istrative limits of fissionable material in a given The NRC regulates both reactor and nonreactor area as defined by a license condition or a criticality applications of nuclear materials. All NRC licens-safety analysis. No personne3 exposures or offsite ces are required to monitor employee exposure to releases that exceeded regulatory hmits resulted radiation and radioactive materials at levels suffi- i from the reponed fuel cycle events.

cient to demonstrate compliance with the occupa-tional dose limits specified in 10 CFR Part 20.

2.10 Test, Research, and Training Radiation exposures from the operation of power reactors is discussed in NUREG-1272, Vol. I1, No.

Reactors 1; it is also compared to radiation exposures from The NRC regulates all reactor facilities, including nuclear materials applications in that report.

Power reactors and test, research, and training Personnel exposure data from CY 1990 through CY reactors (TRTRs). NUREG-1272, Vol. I 1 No.1, 1996 (the latest year for which data are available) covers power reactors and presents an overview of are g en in a s 2Mmugh 2R for tb Mow-the operating experience of the nuclear power industry from the NRC perspective. The operating jng five categories of materials licensees: (1) industrial radiography, (2) manufacturing and experience of TRTRs is described here. The NRC regulates the TRTR facilities in accordance with pistribution, (3) low-level waste disposal, (4) independent spent fuel storage, and (5) fuel fabrica-10 CFR Part 50.

tion and processing. Exposure data for Agreement

' There are 58 TRTR facilities currently licensed by State licensees are not in these tables because the the NRC - 45 with operating licenses,8 with Agreement States are not required to supply this possession-only licenses, and 5 with dismantling information to the NRC. Because licensees submit orders. The TRTR facilities are owned and operated revisions, late repons, or retractions, data are 11 Operating Experience

. - - - . . --=.

1997 AEOD Annual Repon Table 2.6 Annual Exposure Data for NRC Industrial Radiography Licensees CY 1990 to CY 1996 ,

No. of Average Workers Collective Average Measurable l No. of. With TEDE Individual TEDE per No. of Monitored Measurable Person-cSv TEDE-cS- Worker-cSv Year Licensees Individuals TEDE (rem) (rem) (rem) 1990 258 6523 4458 2120 0.33 0.48 1991 248 6820 4649 2160 0.32 0.46 1992 246 6703 4265 1864 0.28 0.44 l 1993 176 4721 3007 1596 0.34 0.53 1994 139 3230 2351 1415 0.44 0.60 1995 139 3530 2465 1338 0.38 0.54 I

1996 139 3631 2537 1385 0.38 0.55 Table 2.7 Annual Exposure Data for NRC Manufacturing and Distribution Licensees CY 1990 to CY 1996 No. of Average Workers Collective Average Measurable No. of With TEDE Individual TEDE per No. of Monitored Measurable Person-cSv TEDE-cSv Worker-cSv Year Licensees Individuals TEDE (rem) (rem) (rem) 1990 58 4203 2279 693 0.16 0.30 1991 59 4930 1952 722 0.15 0.37 1992 67 5210 2250 784 0.15 0.35 1993 58 4913 2254 680 0.14 0.30 1994 44 2941 1251 580 0.20 0.46 1995 36 2666 1222 595 0.22 0.49 19 % 36 2628 1239 556 0.21 0.45 NUREG-1272, Vol. I 1, No. 2 12

Nuclear Materials Table 2.8 Annual Exposure Data for NRC Low-level Waste Disposal Licensees (

CY 1990 to CY 1996 L No. of Average Workers Collective Average Measurable No. of With TEDE Individual TEDE per No. of Monitored Measurable Person-cSv TEDE-cSv Worker-cSv >

Year Licensees Individuals TEDE (rem) (rem) (rem)

I990 2 784 115 26 0.03 0.23 1991 2 905 147 39 0.04 0.27 1992 2 467 82 37 0.08 0.45 1993 2 432 76 21 0.05 0.27 1994 2 202 83 22 0.11 0.27 1995 2 212 56 8 0.04 0.15 1996 2 165 67 8 0.04 0.12 l

l Table 2.9 Annual Exposure Data for NRC Independent Spent Fuel Storage Licensees CY 1990 to CY 1996 No. of Average Workers Collective Average Measurable No. of With TEDE Individual TEDE per No. of Monitored Measurable Person-cSv TEDE-cSv Worker-cSv Year Licensees Individuals TEDE (rem) (rem) (rem) 1990 2 56 22 6 0.11 0.27 1991 2 41 24 4 0.10 0.17 1992 2 290 85 11 0.M 0.13 1993 2 135 52 14 0.10 0.26 1994 1 158 89 42 0.27 0.47 1995 1 104 49 51 0.49 1.M 19 % 1 97 53 54 0.56 1.06 13 Operating Experience

1 i

1997 AEOD Annual Report Table 2.10 Annual Exposure Data for NRC Fuel Fabrication and Processing Licensees CY 1990 to CY 1996 No. of Average l Workers Collective Average Measurable I No. of With TEDE Individual TEDE per '

No. of Monitored Measurable Person-cSv TEDE-cSv Worker-cSv Year Licensees Individuals TEDE (rem) (rem) (rem) 1990 11 14,505 3871 422 0.03 0.11 1991 11 11,702 3929 378 0.03 0.10  :

1992 11 8439 5%1 545 0.06 0.11 1993 8 9649 2611 339 0.04 0.13 1994 8 3596 2847 1147 0.32 0.40 '

1995 8 4106 2959 1217 0.31 0.41 ,

19 % 8 4369 3061 878 0.20 0.29 updated as appropriate. This may cause minor There has been a decreasing trend in the number of changes in the data published from year to year. individuals who received a measurable TEDE The data are taken from the Radiation Exposure among most categories of licensees. Over this same Information Reporting System funded by the period, the average measurable TEDE per worker NRC's Office of Nuclear Regulatory Research. has increased for most categories of licensees. In all

1. 1. '# Wem. e ama8e Incasu Per In CY 1996 NRC radiography licensees had the .

worker is far below the allowable limits of 10 CFR highest collective TEDE. Independent spent fuel Part 20' storage licensees had the highest average measur-able TEDE per worker. Low-level waste disposal licensees and independent spent fuel storage licensees had relatively low collective TEDE.

I i

l l

NUREG-1272, Vol. I 1, No. 2 14

Nuclear Materials 3 ABNORMAL OCCURRENCES 3.1 Abnormal Occurrence Reporting and are compatible with the Commission's pro-grams for such material. In early 1977 the Commis-Section 208 of the Energy Reorganization Act of sion determined that. events that meet the criteria for 1974 (PL 93-438) identifies an abnormal occur- AOs that occur at facilities licensed by Agreement rence (AO) as an unscheduled incident or event that States should be included in the periodic report to i the Nuclear Regulatory Commission (NRC) ceter- Congress. Procedures have been implemented for ,

mines to be significant from the standpoint of the evaluation of nuclear materials events to deter-public health or safety. The NRC identifies an AO mine those that should be reported as AOs. AOs using revised criteria that were initially promal reported by the Agreement States to the NRC are gated in an NRC policy statement that was pub- included in the periodic repon to Congress. The lished in the Fedemi Register on February 24, AO criteria are applied uniformly to events that 1977, This policy statement was published before occur at facilities regulated by the NRC or by the medical licensees were required to report medical Agreement States.

misadministrations to the NRC, and few of the examples in the policy statement were applicable to these misadministrations. In 1996 the NRC 3.2 Abnormal Occurrence Report published revised AO criteria to add criteria for for 1997 medical misadministrations, and in 1997 the NRC The 1997 AO report (NUREG-0090, Vol. 20) revised the AO criteria to add criteria for gaseous diffusion plants. These revised criteria were used c ntains five nuclear materials AOs. (Some of these j events occurred before 1997 but the m, formation j to relect events to be included in the 1997 AO required to determine if they met the AO criteria I report to Congress.

was not previously available.) One of these AOs Section 274 of the Atomic Energy Act, as amended, occurred at a facility licensed by the NRC and authorizes the Commission to enter into agreements involved an occupational overexposure. Four AOs with States whereby the Commission relinquishes were submitted by the Agreement States; two of and the States assume regulatory authority over them were overexposures of workers or a member byproduct, source, and special nuclear materials (in of the public, and two were radiophannaceutical quantities not capable of sustaining a chain reac- misadministrations.These AOs are described in tion). Agreement States must maintain programs Appendix B to this report.

that are adequate to protect public health and safety 15

Nuclear Materials

. 4 OTHER AEOD ACTIVITIES 4.1 Agreement State Operational on potential AOs in the NRC's Public Document Experience Data Room (PDR) as soon as possible after the staff determines that the incident is a potential AO. The To establish standards for collecting material event staff has established procedures to implement this data from Agreement States and to encourage directive. Second, the staff was to determine if voluntary reponing of material events, a trial modifications to the AO criteria for fuel cycle program for Agreement State reponing of events facilities are necessary to explicitly cover those began in April 1995. The program was evaluated facilities that are not licensed by the NRC but that  !

after approximately 6 months and the results were are otherwise regulated by the NRC, such as the sent to the Commission in late 1996. In its final gaseous diffusion plants. The staff determined that

" Policy Statement on Adequacy and Compatibility revised criteria were necessary for the gaseous of Agreement State Programs," the staff proposed diffusion plants. These criteria were developed and that Agreement State event reporting be required as became effective in 1997. Finally, the staff was an element of compatibility. The Commission directed to report to the Commission on how the approved the policy statement on September 3, NRC will identify unintended medical radiation 1997; as a result, Integrated Material Performance exposures to an embryo / fetus or a nursing child, Evaluation Program (IMPEP) teams review event describe the staff's experience with voluntary reponing for adequacy during IMPEP evaluations. reporting; and address whether, if it does not This promotes standardized material event reporting recommend a mechanism to identify unintended between Agreement State and NRC licensees. medical radiation exposures to an embryo / fetus or a nursing child, the final AO criteria should be revised t mit reference to these types ofincidents.

U Gem Dhb PW The staff is preparing a Federal Register notice Abnormal Occurrence Criteria requesting public comnents on this issue.

As explained in Chapter 3 of this volume, AEOD In 1997, in keeping with the changes to the AO l prepares the NRC annual report to Congress on criteria, AEOD finalized the revision of NRC abnormal occurrences (AOs). Also as explained in Management Directive 8.1, " Abnormal Occunence Chapter 3, revised medical misadministration AO Reporting Procedure," which contained the new AO reporting criteria became effective in 1996. When reporting criteria, the requirement for publishing an approving the new AO criteria, the Commission annual AO report on a fiscal-year basis, and the directed the staff to implement three new require- requirement for using the PDRs to quickly let the ments. First, the staffis to file incident information public learn about potential AOs.

17

i Nuclear Materials I l

i 5 INCIDENT RESPONSE

! AEOD maintains and implements the NRC's amounts specified in 10 CFR Parts 30,40, and 70.

l Incident Response Program with the suppon of In addition, all NRC-cenified gaseous diffusion >

l other headquarters and regional offices. Within the plants are required to maintain emergency plans.

framework of this program, AEOD receives data The emergency response requirements for indepen-l and reports for both emergency and non-emergency dent spent fuel storage installations located on the events from licensees followed by an appropriate sites of NRC-licensed nuclear power reactors are NRC response. The response for the more serious included in the emergency plans required for these emergencies is through an incident response sites. Other facilities or activities that the NRC organization that has representatives from several licenses to possess or utilize nuclear materials are 1 headquaners offices and the responsible regional not required by the Code offederal Regulations

, office. The NRC's response organization also (CFR) to maintain emergency plans; however, their l coordinates with other Federal agencies and with NRC licenses rnay require them to do so.

State and local govemments.

Power and non-power reactor licensees utilize the ,

following four emergency classes, in order of 1 5.1 NRC Operations Center increasing severity:

l The NRC Operations Center, in the Two White

• Unusual Event - a condition involving potential ,

Flint Nonh building in Rockville, Maryland, is the degradation of the level of plant safety that does l focal point for NRC communications with its not represent an immediate threat to public licensees, State agencies, and other Federal agen. health and safety. j' cies about events that occur in the commercial . Alert - a condition involving actual or potential nuclear sector. It is continuously staffed by a substantial degradation of the level of plant l Headquaners Operations Officer who is a nuclear safety where any offsite radiological releases are systems engineer trained to receive, evaluate, and expected to be limited to small fractions of the respond to all types of events. The NRC Operations Environmental Protection Agency protective Center features a state-of-the-art information action guideline exposure levels.

management system that integrates voice, video, and data subsystems to suppon the timely and

• Ste Area Emernency - a condition involving effective flow of information during the NRC's actual or likely major failures of one or more response to an incident. Pl ant functions required for protection of the public or involving conditions with potential for a vignificant offsite radiological release but 5.2 Emergency Response where a core melt situation is not indicated.

NRC-licensed facilities have a variety of emergency . General Emereency - a condition invciving plan requirements. Both production and utilization actual or imminent substantial core degradation

! facilities (power and non-power reactors) are or melting with potential for loss of containment.

required to maintain plans for responding to emer- .

Emergencies for nuclear materials licensees are gencies that could affect the health and safety of the categonzed into one of the following two public. Facilities or activities that are licensed to classes,in rder ofincreasing severity:

l possess and utilize byproduct material, source material, or special nuclear material are required to .

Alert - for an NRC-licensed nuclear materials maintain emergency plans for responding to a facility, this indicates that events may occur, are radiological release only if these licensees possess in progress, or have occuned that could lead to a quantities of nuclear material that exceed the release of radioactive material but that the i

19

1997 AEOD Annual Report release is not expected to require a response regional response centers by teams of expens. At by offsite organizations to protect individuals this point, the primary responsibility of the respon- l off site. sible region is to prepare to dispatch a team to the '

site. During the Standby Mode, the NRC response

- Site Area Emngenr1 - for an NRC-licensed is led from the NRC Operations Center.

nuclear materials facility, this indicates that I

events may occur, are in progress, or have If the event threatens public health and safety, the occurred that could lead to a significant release NRC will enter the Initial Activation Mode and of radioactive material and that could require a will promptly send a team from the regional office response by offsite organizations to protect to the site to lead the NRC response. Until the Site individuals off site. Team is in place, the NRC response will continue to be led from the NRC Operations Center. Within the Although not required by the CFR, some nuclear NRC Operations Center, teams of specialists will materials licensees may also utilize the Unusual evaluate the status of reactor critical safety func-Event emergency class for events with lower tions and will independently evaluate protective safety sigmficance.

actions recommended by the licensee for imple-In the event of an emergency at an NRC-licensed mentation by State and local authorities. All com-facility (or one associated with an NRC-licensed munications with the media, State and Federal activity), the licensee would place an emergency officials, international organizations, Congress, and telephone call to the NRC Operations Center, after the White House will also be coordinated from the notifying appropriate State and local agencies and NRC Operations Center. During this mode, repre-within I hour of the event. For Site Area Emergen. sentatives from six other Federal agencies report to cies and for events for which an NRC response may the NRC Operations Center to give direct support to be appropriate, the regional administrator and an the NRC as Lead Federal Agency.

Executive Team member (typically the Director of Once the NRC site team arrives on the scene and is the Office of Nuclear Material Safety and Safe- prepared to accept the operational authority and guards [NMSS]) will discuss the event in a confer- responsibility for the Federal response, the NRC ence call with the licensee. enters the Expanded Activation Mode. The The NRC's response to an event may range from Director of Site Operations, typically the regional routine follow-up to a complete activation of both administrator, will report to the licensee's Emer-gency Operations Facility (or its functional equiva-  !

the regional Incident Response Center and the NRC Headquaners Operations Center. The NRC utilizes lent) near the site. The lead responsibility for the following distinct modes for responding to assessing reactor safety, protective measures, and events at its licensed facilities: Normal, Standby, liaison activities then shifts from headquarters to Initial Activation, and Expanded Activation. the NRC team at the site. The NRC Operations Center will then provide logistical and technical For the Normal Mode, the lowest level of re- support to the NRC Site Team as necessary.

sponse, the NRC will not fully staff the NRC Operations Center or the Incident Response Center , ,

located in the applicable regional office, but it may 5.3 NRC Operations Center Data  !

take some other action such as sending out a for 1997 l special inspection team or staffing the response . .

In addition to emergency event notifications, the centers with a few select experts to monitor the NRC Operations Center receives many notifications event. The latter is referred to as the Monitoring f events that do not meet the threshold for emer-Phase of the Normal Mode.

gency classification.These include events required Standby Mode, the next level of response, is to be reported as well as events voluntarily re-entered when an event is judged to be sufficiently ported. Actions taken by the Headquarters Opera-uncenain or complex that the situation needs to be tions Officer in response to such notifications range continuously monitored from the headquaners and from preparing computer repons and log entries NUREG-1272, Vol. I 1, No. 2 20

Nuclear Materials followed by appropriate notifications, to setting up Site Area Emergency level.) The NRC did not enter emergency conference calls between licensee the Monitoring Phase of the Normal Mode for representatives and senior NRC regional and either of the two Alens reponed by nuclear materi-headquaners representatives. For very significant als licensees. However, the NRC did enter the events, conference calls may result in the activation Monitoring Phase of the Normal Mode for the of the agency's Incident Response Plan. following two nuclear materials events:

Table 5.1 shows the total number of events reported -

Mattingly Testing Service; Billings, Montana; to the NRC Operations Center during 1997. These April 4,1997 - A nuc' ir radiography camera notifications were submitted primarily by nuclear containing a locked Iridium-192 shielded source power plant licensees. A small subset of these was stolen from a locked storage building that notifications involved events classified by licensees was placarded with a radioactive symbol.

into one of the emergency classes. There was a large .

New Jersey Department of Environmental increase in the number of events reported to the NRC Protection; Cream Ridge, New Jersey; May 10, Operations Center by fuel facilities this year (131 1997 - An individual ingested tritium gas or total versus 17 last year). This was mainly attributed liquid from broken exit sign tritium tubes in to the transfer of regulatory authority over gaseous Union, New Jersey.

diffusion plant operations from the Department of Energy to the NRC on March 3,1997. NRC staff members monitored both of these events from their offices and often used NRC Operations Table 5.2 shows the number of each type of emer- Center communications capabilities. Site teams gency event reported annually from CY 1989 were also dispatched from the regional offices. Ir.

through 1997. Table 5.3 lists the emergency events addition, the NRC requested an Aerial Measuring reported by NRC-licensed nuclear materials facili- System aircraft from the Department of Energy to ties to the NRC Operations Center during 1997. assist in locating the source material in the stolen (No nuclear materials events were reported at the Mattingly radiography camera.

Table 5.1 Events Reported to the NRC Operations Center in 1997 Non. Well Logging /

Emergency Power Fuel Power Transport /

Class Reactor Facility Reactor Hospital Materials Other Total Non-Emergency 1,458 129 2 54 140 102 1,885 Unusual Event 49 0 0 0 0 0 49 Alert 2 2 0 0 0 0 4 Site Area Emergency 0 0 0 0 0 0 0 General Emergency 0 0 0 0 0 0 0 Totals 1,509 131 2 54 140 102 1,938 21 Incident Response

1997 AEOD Annual Report l

Table 5.2 Classification of Events Under Licensee Emergency Plans l CY 1989 through 1997 Emergency CY CY CY, CY CY CY CY CY CY Class 1989 1990 1991 1992 1993 1994 1995 1996 1997 Unusual Event 197 151 170 135 103 97 66 67 49 Alert 13 10 9 20 8 4 8 10 4 Site Area Emergency 0 1 2 1 1 0 0 1 0 General Emergency 0 0 0 0 0 0 0 0 0 Totals 210 162 181 156 112 101 74 78 53 Table 5.3 Alerts Reported by NRC. Licensed Nuclear Materials Facilities in 1997 Plant Event No. Date Description of Event Duration Allied-Signal 31461 12/16/96 Onsite release of uranium hexaflouride gas caused 31 minutes by a dust collector shutting down due to a power outage Babcock and 31883 03/04/97 Local evacuation following a spill of uranyl nitrate 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> and Wilcox (=100 liters) in the low enriched uranium down 22 minutes blending area i

5.4 Emergency Exercises boundary. NRC responders follow the radiological -

materials safety and protective measures aspects of Emergency exercises are held periodically to ensure the simulated event; communicate with licensee, that NRC, licensee, local, State, and other Federal State, and Federal responders; and make recom- .

response organizations remain proficient in dealing mendations to an NRC Executive Team in the l with each type of emergency. The NRC's primary NRC Operations Center. In 1997 the NRC head- l role in these exercises is to independently assess quarters and regional offices participated in a full- l licensee actions, assist the licensee when requested, scale emergency exercise with the Portsmouth  ;

review the protective action recommendations that Gaseous Diffusion Plant on September 12,1997. i the licensee makes to State and local authorities, The NRC also conducted a site team exercise with and facilitate communications between the licensee General Electric Wilmington on July 16,1997. In and other response organizations. To prepare for addition, tabletop exercises were conducted with an exercise, the licensee develops a postulated the Portsmouth and Paducah Gaseous Diffusion accident scenario that normally goes well beyond Plants on November 7,1996, and with the Envi-the facility's design br. sis and that results in the ronmental Protection Agency (EPA) on September release of some radioscrivity outside the facility's 30,1997. The tabletop exercise with Portsmouth/

NUREG-1272, Vol. I 1, No. 2 22

Nuclear Materials Paducah was the first exercise conducted in prei a . FRP and the Federal Radiologica! Emergency ration for NRC regulation of the gaseous diffusioc Response Plan (FRERP) are integrated. Funher-plants, which began on March 3,1997. During the more, significant work has been done in preparing i tabletop exercise with the EPA, AEOD assisted for nuclear, biological, and chemical terrorist NRC Region I in conducting the early phase of I events. As a result of the NRC regulatory oversight

" lost source" exercise at the Philadelphia Electric of the gaseous diffusion plants, AEOD staff worked  ;

Company's emergency operations facility in with other Federal agencies through the Environ-Coatesville, Pennsylvania. This was the first exeui;e ... ntal Protection Agency's (EPA's) National of its kind with the NRC supporting the EPA. P.esponse Team to ensure that proper coordination takes place among Federal agencies with statutory responsibility to respond to chemical emergencies.

5.5 State Outreach An a result of this work, the EPA and the National In 1997 AEOD continued an aggressive State Och and Atmospheric Administration have buen Outreach Program designed to increase and im. more thoioughly integrated into the NRu response prove the NRC's interaction with States during Procedures. Additionally, AEOD initiated activities events and exercises. AEOD briefed State officials to develop the assessment tools needed for handling on the NRC and Federal emergency response emergencies that involve chemical as well as program, the Emergency Response Data System, radicartsve material releases. In cooperation with NRC/ State liaison during an emergency, and other Federal agencies, the role of the principal financial assistance available to responders. AEOD agencies and their associated responsibilities in also expanded the program to cover training on respoi %g to chemical as well as radiological NUREG/BR-0230, " Response Coordination emergencies at f. el cych facilities, such as the EPA Manual" (RCM-96) and the recently updated r.nd Department of Energy, were better defined.

NUREG/BR-0150, " Response Technical Manual"

\, SOD pa:ticipated wi th other Federal agencies in (RTM-96). Outreach sessions were conducted for o ding to rea1, argencies involvino M 't respondents from 22 States and numerous licensees: ~

so $ren and rep.:.cd contamination events. These m NRC Region 1 for Maine, New Hampshire, interactions led to improved procedures and under-Vermont, Massachusetts, Connecticut, New York, .

standing among key Federal agencies.

New Jersey, Pennsylvania, Maryland, and Dela-ware; in NRC Region 2 for Nonh Carolina, South In 1997 AEOD supported the Federal Emergency Carolina, and Georgia; in NRC Region 3 for Management .igency (FEh!A) in providing acci-Michigan, Indiana, Wisconsin, and Ohio and in dent assemeet training to Federal, State, and local NRC Region 4 for California, Washington, Oregon, officials on four occasions In addition. / GOD Arizona, and Missouri. Panicipants represented participated i.- the lesigr and condNt of an FRERP both the radiation health and emergency services workshop spmuc:ed by FEMA. As a member of the organizations within those States, licensees' coun- Federal Radiological Peparedness Coordinating ties, and regional Federal organizations. (Although Committee, AEOD participated in meetings to the scenarios in these exercises involved power discuss issues relating to State and local govem-reactors, the interactive process between the NRC ments response. Furthermore, ss a member of the and the State personnel is the same as for emergen- training subcommittee, exercise chcommittee, and cies involving nuclear materials licensees.) the protective action guide!ine subcommittee; AEOD participated in coordinating related activities

. . with other Federal agencien As a member of the 5.6 Coordm.ation with Other Emergency Support Faction Leaders Group, Federal Agencies AE9D participated wi3 other Federal agencies in disctcing issues relati..g to Fec!eral coordination In 1997 AEOD continued to work with other and response.

Federal agencies in completing annexes to the Federal Response Plan (FRP), such as the Radio- AEOD provide s training .o other Federal and State logical Incident Annex, which describes how the representativ.:s on polic information, severe 23 Incident Response

1997 AEOD Annual Report weather response, and emergency dose projection Paducah, Kentucky. The Act further directed the using the RASCAL program. These training NRC to establish a process under which the NRC sessions took place inhouse as well as at the will annually certify these two plants for compliance Harvard School of Public Health. with NRC standards. These standards require site-specific emergency response plans for the GDPs to 4 EOD also presented the NRC concept of opera-be reviewed and approved before certification. I tions at various forums, such as the American '

Regulatory authority over GDP operations was Nuclear Society conference, the Conference of transferred from DOE to the NRC on March 3,1997.

Radiation Control Program Directors meeting, the i National Emergency Management Agencies Since DOE maintains responsibility for cenain ,

conference, Nuclear Energy Institute meetings, processes at the two GDPs, the NRC completed a  !

and the National Radiological Emergency Pre- memorandum of understanding with DOE delineat-  ;

paredness conference. ing each agency's role in the event of an emergency l

at a GDP. Agreement was reached on the selection i In addition, AEOD supported EPA in preparing for of the Lead Federal Agency when the origin of the I and co-facilitating an exercise involving a lost i

. emergency was unknown. AEOD also participated radioactive source. This was an important step in in negotiations in which agreement was reached identifying the areas of concern by the principal with DOE, USEC, and their contractors on the Federal and State agencies, adoption of an emergency classification scheme that would be consistent with the Commission's policy.

5.7 Gaseous DifTusion Plant Activities In : dilition, AEOD conducted training for NRC restvsndents which emphasized the use of response The Energy Policy Act of 1992 (the Act) amended procedures, communications among different the Atomic Energy Act of 1954 to establish a new organizations, accident assessment tools, and government corporation, the United States Enrich- preparation of Executive Team briefings. AEOD ment Corporation (USEC), for the purpose of developed RASCAL Version 2.2 to ensure that UF, managing and operating the two uranium enrich- releases can be handled by the code. The hydrogen ment plants owned and previously operated by the fluoride (HF) and the uranyl fluoride (UO2 F,)

Department of Energy (DOE): the Ponsmouth byproducts were modeled in Version 2.2 and the Gaseous Diffusion Plant in Piketon, Ohio, and the results were provided in a format directly compa-Paducah Gaseous Diffusion Plant (GDP) in rable with intervention levels. )

i 1

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NUREG-1272, Vol. I 1, No. 2 24 l

Nuclear Materials i

l 6 INCIDENT INVESTIGATION PROGRAM i

The Incident Investigation Program (IIP) ensures identify needed actions based on AIT findings; that NRC hivestigations of significant events are AEOD and other NRC offices, including NMSS, l timely, thorough, well coordinated, and formally independently review AIT reports to gain additional l administered. The scope of the IIP covers investiga- assurance that potential generic lessons are leamed l tions of significant operational events involving and communicated to the industry. As described in

! reactor and materials activities licensed by the NUREG-1303, " Incident Investigation Manual,"

l NRC. Within the framework of the IIP, the NRC AEOD has overall responsibility for administration l responds to an operational event according to its of the IIP, and NRR is responsible for maintaining l safety significance. For an event of extraordinary the procedures for an AIT response.

l safety significance, the Commission may establish an Accident Review Group (ARG) led by an . . .

individual from outside the NRC and cornposed of 6.1 Incident Investigation experts from within and outside the NRC. The ARG Team Events reports directly to the Commission and is indepen-There were no nuclear materials events in 1997 that dent of NRC management. For an event of poten-werejudged to have a level of safety significance j tially major safety sigmficance, the Executive su.7iciently high to warrant an IIT investigation.

Director for Operations (EDO) establishes an The status of actions associated with previous IIT Incident Investigation Team (IIT) to investigate the findings assigned by the EDO to various NRC event. For an event ofless safety sigmficance, the offices is documented in Appendix F to this report.

responsible NRC regional administrator may establish an Augmented Inspection Team (AIT) to investigate the event. Both IITs and AITs tre 6.2 Augmented Inspection assigned to determine the circumstances and causes Team Events of an operational event and to assess the safety significance of the event so that appropriate follow. There were no nuclear materials events in 1997 that up actions can be taken. The EDO assigns staff were judged to have a level of safety significance

actions arising from IITs; regional administraters sufficiently high to warrant an AIT investigation.

l l

l .nsus 4 .

1 25

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

Nuclear Materials 7 COMMITTEE TO REVIEW GENERIC REQUIREMENTS The Committee to Review Generic Requirements the burden on CRGR members. On April 21,1994, (CRGR) reviews all generic requirements proposed the EDO transmitted SECY-94-109 to the Commis-by the NRC staff that involve one or more classes of sion proposing to reduce the basic scope of CRGR power reactors. The CRGR consists of senior review to include only "high impact" and "contro-managers from various headquarters program versial" generic correspondence and rules before offices and, on a rctational basis, from one of the put>lic con: ment, issues that the staff has difficulty NRC regional offL s Thc .IOD Director senes resolving efter public comment, emergency and as the CRGR Chairman, and the AEOD staff urgent generic correspondence, and significant provides support for all of the Committee's activi- proposals with highly expedited schedules. A June ties. The AEOD Director also oversees plant- 15,1994, staff requirements memorandum (SRM) specific backfit activities of the NRC staffin the directed the staff not to reduce the scope of the headquarters program offices and the regional CRGR Charter but to consider, and to recommend a offices. In this period, one new member from a course of action for, enlarging the scope of CRGR region was appointed to the CRGR. The member- review to include proposed generic requirements in ship of the CRGR in 1997 was as follows: the nuclear materials area. The SRM also directed Denwood F. Ross, Director, AEOD (Chairman) the staff to look at measures that would reduce the time that mdividual CRGR members spent on Frank J. Miraglia, Deputy Director, NRR CRGR reviews. The Committee evaluated this Ption and agreed to address, on a 1-year trial basis, Malcolm R. Knapp, Deputy Director, NMSS selected nuclear materials issues identified by the Joseph A. Murphy, Director, Division of NMSS Director or by the EDO. The Committee Regulatory Applications, RES will assess whether or not the nuclear materials issues that are presented by the staff for CRGR Denn.isC. Dambly, Asr.istant General Counsel review warrant CRGR attention and, if they do, for Materials' whether the CRGR review adds significant value.

Antitrust and Special Proceedings, OGC On the basis of that assessment, the Committee will

. make appropriate recommendations to the EDO James E. Dyer, Deputy Regional Admm. .istrator, regarding continuation of the CRGR review of Region IV nuclear materials issues. This assessment will be While performing the CRGR review function, a included in the CRGR meeting minutes during the CRGR member expresses an individual profes- trial period, and it will also be reported to the EDO sional opinion about each item considered, rather in the CRGR Weekly Items of Interest to be re-than n presenting the view of his respective office, poned to the Commission. This aspect of the j The members of the CRGR determine whether expanded scope of CRGR review was included in proposed new generic requirements have sufficient the ongoing CRGR Charter revision process.

merit in terms of safety and are justified in terms of On February 9,1996, in SECY-96-032, the EDO cost (where appropriate) before reaching a consen- .

requested Comm.ission approval for this 1 year trial sus recommendation about each issue considered.

Program to include selected nuclear materials Each independent CRGR recommendation is given issues. The Commission was also mformed that the to the EDO for consideration.

CRGR has considered and adopted measures to In 1994 a staff proposal was submitted to the reduce the time spent by members on CRGR ,

Commission to reduce the scope of the CRGR reviews. When appropriate, based on lack of review and to evaluate various means of reducing controversy, low expected impact, or small potential 27

1997 AEOD Annual Report for error related to the proposed generic actions, the Kentucky, and the Allied Signal Chemicals plant in  ;

CRGR Chairman may agree to one of three courses Illinois.The purpose of the CRGR annual visits to of action: (1) defer the CRGR's review pending various facilities is to have a candid dialogue with public comment on the proposal; or (2) agree to a licensees to get their feedback on the NRC's  ;

negative consent approach which, in essence, is an regulatory backfitting activities. In 1997 neither I abbreviated review; or (3) forgo a second CRGR CRGR members nor staff met with the Nuclear [

review, thus reducing the number of dual reviews Utilities Backfitting and Reform Group.

t (i.e., review at both the proposed and final stage).

I All other staff proposals will be scheduled for regular CRGR review.

7.1 CRGRIssues On March 22,1996, the Commission approved In 1997 the CRGR held 18 meetings during which

! it reviewed 30 issues; 29 were related to nuclear Revision 6 to the CRGR Chaner, which expanded I

the scope of CRGR reviews to include, on a 1-year P wer P lants only, and 1 issue concerned both  ;

trial basis, selected nuclear materials issues re- nuclear and materials facihttes. In addition, the stafT quested by the NMSS Director or the EDO. The briefed the CRGR seven times; one of the briefings Staff Requirements Memorandum, "SECY-97-052 - was by the Office of Nuclear Matenal Safety and Safeguards. The issue and the briefing related to l Committee to Review Generic Requirements (CRGR)- Scope of Review and Periodic Review nuclear matuials are as foHows:

Activities," dated April 18,1997, asked the CRGR .

Briefing by the NMSS staff identifying nuclear to continue to review nuclear materials issues for materials topics for future CRGR review another year, and to also review inspection guid-  !

ance at the staff's request or at the Committee's Proposed final Revision 3 of Regulatory Guide self-initiative. Also in response to this SRM, a 5.44, " Perimeter Intrusion Alarm Systems" repon containing an annual evaluation of the l CRGR's activities and its contributions in achieving 7.2 Value Added by the ,

the agency's mission (COMSECY-96-028) was l

CRGR Review

! submitted to the Commission in August 1997. This report contained an assessment of the value added The CRGR agrees with the general office percep- ,

by the CRGR review of various generic staff tion that, in addition to preventing improper l proposals, which included the Committee's own backfits, a major role that the CRGR plays is in l self-assessment, assessments by the program offices offering an independent review of various proposed

! sponsoring the proposals, and assessments by some actions. The Committe- considered value added by l of the cognizant staff who had the primary respon- CRGR review and identified various topics re-l sibility for the proposals reviewed by the Commit- viewed during this assessment period where signifi-I tee. Also in this report were the highlights of cant value was added to the incoming staff j regional backfit training and audits done by the proposals by the CRGR review. Some of the staff CRGR staff, the feedback received from licensees proposals required review at more than one CRGR j during the CRGR annual site visit to a nuclear meeting, involved extensive staff effort to rewrite power plant and to a nuclear materials facility, and the proposals, and involved staff effort to address direct feedback received by the Committee from the Committee's comments and recommendations.

industry-supported organizations. Another repon The value added by the CRGR was reflected in an containing proposals for future CRGR review of improved focus on the safety concems and backfit nuclear materials issues selected as pan of the 1- considerations, as well as in the quality of the '

year continuation of the trial program was also product, including scope, content, tone, complete-submitted to the Commission, ness, and consistency with the Commission's In 1997 the CRGR members and staff visited the Callaway nuclear power plant in Columbia, Mis- In cenain cases, the CRGR believed that the review souri, the Gaseous Diffusion Plant in Paducah, process would have been more efficient with better NUREG-1272, Vol. I 1, No. 2 28

Nuclear Materials staff preparation for the CRGR review. For some guidance or procedures related to nuclear review items, the Committee supported the staff's materials facilities were identified. The Commit-requests for prompt action by scheduling special tee commented on the topics proposed by the CRGR meetings, and, in select cases, also by staff for which CRGR review could add value, accepting products still under development or even The Committee believed that CRGR review will accepting partial submittal of the review material. be most beneficial in certain focused areas.

In such cases, the Committee's endorsement was Topics such as backfitting procedures for the conditional on acceptability of the post-CRGR- gaseous diffusion plants, issues related to spent review changes made to the documents. Although fuel storage and transportation, and those these considerations by the CRGR appear to have conceming large fuel cycle facilities could helped the staff meet the schedule pressures, the benefit from CRGR review. The Committee Committee concluded that it was not the most noted that there are certain inherent differences efficient use ofits resources, as it necessitated in the risks associated with the operation of the repeat informal review both by the Committee and power reactors and those related to the operation the CRGR staff. of nuclear material facilities (e.g., mixed risk CRGR review added sigmficant value to one from uranium-bearing toxic compounds).The review item related to nuclear materials, as members also noted the inherent differences in summarized below:

k blihd @m fed fo&

nuclear power reactors and nuclear materials The NMSS staff presented to the Committee the facilities. They recognized the need for estab-scope and schedule of various ongoing activities lishing some ground rules to ensure consistency and identified various areas in which future and uniformity in the review of nuclear materials CRGR review may be beneficial. No inspection topics, if the CRGR were to continue in this role.

29 CRGR

APPENDIX A Nuclear Materials Data by Event Type h

Nucient Materials Table A-1 Medical Misadministrations Item License Event Type of No. Licensee Number Date City State Misadministration 960717 Bayonne Hospital 29-12253-01 11/12/96 Bayonne NJ Brachytherapy, HDR Remote Afterloader 970665 Bluefield Regional 47-19142-01 7/14/97 Bluefield WV Brachytherapy, Eye Medical Center Applicator 970049 Centre Community n 1368f-01 12/20/96 State College PA Brachytherapy, HDR Hospital Remote Afterloader 970465 Columbia Hospital 48-02417-01 5/27/97 Milwaukee WI Brachytherapy, Manual Afterloader 970035 Fort Sanders Sevier TN-R-78002K98 10/1/96 Sevierville TN Diagnostic Medical Center Radiopharmaceutical 970205 Gunderson Clinic, 48-01277 02 3/6/97 La Crosse WI Sodium Iodide Ltd.

93108 Health & Human '9-00296-10 2/18/97 Bethesda MD Sodium Iodide Services, Dept. Of 980259 Healthsouth FL-2301-2 3/27/97 Coral Gables FL Gamma Stereotactic Doctor's Hospital, Inc. Radiosurgery 971131 Kaiser Permanente CO-668-01 8/20/97 Denver CO Therapeutic Radiopharmaceutical 980( . Memorial Medical 35-27041-01 5/12/97 Tulsa OK Brachytherapy. HDR Center Remote Afterloader, 970831 Mercy Hospital 21-15638-01 8/13/97 Port Huron MI Brachytherapy, Manual Afterloader 970909 Michigan, 21 00215-04 9/15/97 Ann Arbor MI Sodium Iodide University Of 970105 Monsour Medical 37-14870-01 2/12/97 Jeannette PA Sodium Iodide Center 970805 NR NR 3/11/97 NR NY Brachytherapy, HDR Remote Afterloader, 970402 Overlook Hospital 29-03308-01 5/5/97 Summit NJ Sodiurn lodide 980176 Parkland Memorial NR 7/11/97 Dallas TX Sodium Iodide Hospital 971130 Saint Anthony CO-00152-01 8/27/97 Denver CO Therapeutic Hospital North Radiopharmaceutical 970390 Theda Clark 4S-09494-01 12/20/96 Neenah WI Sodium Iodide Regional Memorial Hospital A-1 Appendix A

1997 AEOD Annual Report Tab A-1 MedicalMisadministratiora Item Licts.;e Event Type of No. Licensee Number Date City State Misadminitration 970155 Tuomey Regional SC-10-0010 12/11/96 Sumter SC Sodium lodide Medical Center 970972 Tuomey Regional SC-10-0010 9/23/97 Sumter SC Brachytherapy, Medical Center ManualImplant 970221 University of KY-202-029-22 10/15/96 Louisville KY Brachytherapy, Louisville ManualImplant 960837 V.A. Medical 36-01395-01 12/18/96 Pon!and OR Sodium Iodide Center 970429 V.A. Medical 31-00786-02 5/9/97 Buffalo NY Sodium Iodide i Center 970846 V.A. Medical 04-00181-04 8/26/97 Los Angeles CA Teletherapy .

Center 960169 Washington 37-10363-01 12/26/96 Washington PA Diagnostic Hospital Radiopharmaceutical  ;

970358 Western Baptist KY-202-079-31 1/6/97 Paducah KY Teletherapy Hospital 970602 Western Baptist KY-202-079-31 5/19/97 Paducah KY Teletherapy Hospital i l

l I

NUREG-1272,Vol. I1.No. 2 A-2

Nuclear Ma'.erials Table A-2 Overexposures Item License Event Type of No. Dose No. Licensee Number Date City Shi. Exposure Exposed (Rem) 971045 Columbia NR I1/6/96 El Paso TX Whole Body, 1 0.117 Regional Non-Oncology Center Occupational 971058 H & G Inspection NR 12/31/96 Houston TX Whole Body, 1 5.8 Company Inc. Occupational 97 % 96 ICN CA-1828-30 12/31/96 Irvine CA Extremity, 1 52 Pharmaceuticals Occupational 970434 Mallinckrodt 24-04206-01 5/14/97 Maryland MO Skin, 1 609 Medical, Inc. Heights Occupr.tional 960699 Professional 45-25088-01 11/6/96 Bristol VA Whole Body, i 16 Service Occupational Industries, Inc.

971054 Syncor NR 12/15/96 Houston TX Extremity, 1 131.4 International Occupational Corporation 970320 Texas Industrial NR 10/1/96 Houston TX Whole Body, 1 5.3 Occupational 960816 Tulsa Gamma 35-17178-01 35388 Tulsa OK Whole Body, 1 8.3 Ray, Inc. Occupational A-3 Appendix A

1997 AEOD Annual Report l

I Table A-3 Loss of Control of Material Events Item Lice.sso Event '

No, . Licensee Number Date City State Isotope Activity (Ci) l l

970655 A. G. We cenaar CO-212-01 7/10/9'i Denver CO Am-Be 0.044 Cs-137 0.009 960802 ABB Prxess 34-00255-03 12/2/96 Columbus OH St-90 0.07 Automation,Inc. Kr-85 0.25 970101 Air Force, 42-23539-01A 2/6/97 Brooks AFB TX Sr-90 0.001 Department of the 970428 Air Force, 42-23539-OlA 5/12/97 Brooks AFB TX Am-241 <0.001 Department of the 970444 Air Fcece, 42-23539-01A 5/15/97 Broolcs FJ TX Th-230 NR Department of the 971096 Air Force, 42-23339-01 A 7/15/97 Brooks AFB TX H-3 10.4 Department of the H-3 12 970795 Air Force, 42-13539-01 A 8n/97 Brooks AFB TX Cs-137 0.08f Deputment of the 971037 Air Force, 42-23539-01 A 9/ M 7 Brooks AFB TX H-3 0.19 Department of the H-3 0.19 H-3 0.19 H-3 0.19 H-3 0.19 970180 All American CA-5547-33 11/8/96 Corona CA Cs-137 0.008 Asphalt Am-Be 0.04 970919 Allegheny General SNM-1484 3/25/97 Pittsburgh PA Pu-238 NR Hospital 970936 ALP Lighting, Inc. General License 8/4/97 Pennsauken NJ Po-210 0.003 980215 Alpha Testing, Inc. NR 9/4/97 Dallas TX Am-Be 0.044 Cs-137 - 0.011 970656 Ambric Engineering, 37-20968-01 6/25/97 Philadelphia PA Cs-137 0.008 l Inc.

l 960580 Amersham Corp. 20-12836-01 11/23/96 Burlington MA Ir-192 108 l

960820 Amersham Corp. 20-12836-01 12/10/96 Burlington MA Ir-192 64.4 970436 Anheuser Busch, General License 5/5/91 St. Louis MO Am-241 0.1 l l

Inc. Am-241 0.1 980266 Arco Engineering & FL-1622-1 8/26/97 Miami FL Am-Be 0.0a Testing Consultants Cs-137 0.008 970015 Ardman & FL-972-08 In/97 West Palm FL Cs-137 0.008 Associates Beach Am-Be 0.04 960659 Arizona State General 10/26/96 NR AZ H-3 20 University NUREG-1272, Vol. I1, No. 2 A-4

Nuclear MateriAs Table A-3 Loss of Control of Material Events Item License Event No. Licensee Number Date City State Isotope Activity (Ci) 960624 Army. Dept. of the General 10/15/96 Fort Sill OK H-3 25 970093 Army, Dept. of the - 12-00722- % 10/27/96 Rock Island IL H-3 10 Rock Island Arsenal 970131 Army, Dept. of the - 12-00722-13 11/1/96 RockIsland IL Am-241 <0.001 Rock Island Arsenal 970085 Army, Dept. of the - 12-00722-06 11/25/96 Rock Island IL H-3 120 Rock Island Arsenal 970088 Army, Dept. of the - 12-00722-06 12/6/96 Rock Island IL H-3 10 Rock Island Arsenal 970074 Army, Dept. of the - 12-00722-06 12/10/96 Rock Island IL H-3 120 Rock Island Arsenal 970083 Army, Dept. of the - 12-00722-13 2/7/97 Rock Island IL Am-241 <0.001 Rock Island Arsenal 970864 Army, Dept. of the - SUC-1380 2/27/97 Rock Island IL C dep NR Rock Island Arsenal 970237 Army, Dept. of the - 12-00722-13 3/13/97 Rock Island IL Am-241 <0.001 Rock Island Arsenal 970668 Army, Dept. of the - 12-00722-13 3/25/97 Rock Island IL Am-241 <0.001 i Rock Island Arsenal  !

970443 Army, Dept. of the - 12-00722-14 3/27/97 Rock Island IL Ni-63 0.01 Rock Island Arsenal 970349 Army, Dept. of the - 12-00722-13 4/22/97 Rock Island IL Am-241 <0.001 Rock Island Arsenal . Ni-63 0.01 970403 Army, Dept. of the - 12-00722-06 5/2/97 Rock Island IL H-3 10 Rock Island Arsenal 980240 Army, Dept. of the - 12-00722-13 7/1/97 Rock Island IL Am-241 <0.001 Rock Island Arsenal 970853 Army, Dept. of the - 12-00722-13 8/28/97 Rock Island IL Am-241 <0.001 Rock Island Arsenal 970911 Army, Dept. of the - 12 00722-04 9/16/97 Rock Island IL Am-241 <0.001 Rock Island Arsenal 980189 Atser Corp. NR 7/10/97 Houston TX Am-Be 0.04 Cs-137 0.008 980262 Auto Shred Non-Licensee 6/16/97 Pensacola FL Am-241 0 Recycling 971052 B. J. Industries NR 12/13/96 Mentone TX Cs-137 0.05 960723 B. J. Services Co., 42-l % 49-01 12/20/96 Houston TX Cs-137 0.1 U.S.A.

A-5 Appendix A

1997 AEOD Annual Report l l

Table A 3 Loss of Control of Material Events ,

l Item License Event No. Licensee Number Date City State Isotope Activity (Ci) 960640 Babcock & Wilcox SNM-0145 10/18/96 Vandergrift PA U-He NR Co. Th-230 NR 971034 Baker Hughes 17-27437-01 8/30/97 Broussard LA Cs-137 2 Oilfield Operations, Am-Be 5 Inc.

970560 Baptist Hospital of FL-0614-2 10/28/96 Miami FL I-131 NR Miami 970030 BASF Corp. NC-032-0760-1 1/13/97 RTP NC Ni-63 0.008 Ni-63 0.008 970794 BFI Non-Licensee 4/15/97 Clinton IL I-131 NR 980377 BFI Little Dixie Non-Licensee 2/24/97 Jackson MS I-131 NR Landfill 980378 BFI Three Rivers Non-Licensee 4/4/97 Eem MS I-131 NR Landfill 970122 Bhate Engineering TN-R-A1009- 2/21/97 Millington TS Cs-137 0.01 C-00 Cs-137 0.01 Am-Be 0.0' Am-Be 0 J4 970920 Bill Miller, Inc. 35-19048-01 9/17/97 Henryetta 0K Ir-192 46 970718 Bowser-Morner, Inc. 34-17390-01 7/25/97 Dayton OH Cs-137 0.009 Am-Be 0.04 970555 Browning Ferris Non-Licensee 10/14/96 Miarni FL I-131 NR Industries 970709 California State CA-031919 3/12/97 Northridge CA Ni-63 0.014 University 960632 CAT Engineering FL-2611-01 10/15/96 Coral Gables FL Am-Be 0.044 Consultants Cs-137 0.009 971053 Chaparral Steel NR 3/31/97 Midlothian TX Fe 55 0.01 Fe-55 0.01 970263 Chem-Nuclear 39-23004-01 3/27/97 Columbia SC NR <0.001 Systems,Inc.

980149 Cherrington Scrap Non-Licensee 6/5/97 Oak Hill OH Cs-137 0.3 Metal, Inc.

970838 Cincinnati, 34- % 903-05 8/22/97 Cincinnati OH I-125 <0.001 University Of I-125 <0.001 1-125 <0.001 960832 CIS-US Inc. 20-20973-01 12/17/96 Bedford MA I-131 0.203 971110 Cole Industries General 11/1/96 Elizabethtown KY Po-210 0.01 License NUREG-1272, Vol. I1, No. 2 A-6

l Nuclear Materials Table A-3 Loss of Control of Material D ents item License Event No. Licensee Number Date City State isotope Activity (Ci) 971079 Consolidated General License 3/1/97 Wisconsin WI Po-210 0 Papers, Inc. Rapids 970771 Crown Recycling Non-Licensee 2/25/97 ' Riverhead NY l-131 <0.001 970717 CSU CA 1874-36 10/15/96 San CA Cs-137 NR Bernadino 970836 CTL Engineering. 34-18533-01 8/20S7 Columbus OH Cs-137 0.009 Inc. Am-Be 0.04 971005 Dames & Moore, CA-4393-19 3/3/97 Los Angeles CA Am-Be 0.04 Inc. Cs-137 0.008 970852 Defense Distribution 37-30062-01 8/4/97 Chambersburg PA H-3 3 Depot 960633 Delta Testing & 17-26873-01 10/19/96 New Orleans LA Cs-137 0.008 Inspection, Inc. Am-Be 40 l 970217 Doverspike Brothers 37-28449-01 3/12/97 Punxsutawney PA t 's-137 0.2 Coal Co.

970882 Dowell 42-27055-01 7/10/97 Houston TX Cs-137 NR Schlumberger, Inc. Am-Be NR 980078 Dowell 42-27055-01 9/26 S 7 Houston TX Cs-137 1.7 Schlumberger, Inc. Am-Be 16 980325 Durham Landfill Non-Licensee 4/15 S 7 Durham NC Tc-99M NR 970598 E.I. Dupont General License 5/30/97 Chamberworks NJ Ni-63 0.015 Denemours and Co. Inc.

960748 Eastern Well 34-12927-01 12/24/96 Wooster OH Am-Be 3 Surveys, Inc. Cs-137 2 970225 EBA Engineering. MD-07144-01 3/13/97 Baltimore MD C.-s37 0.008 Inc. Am-Be 0.04 960473 Edgewater Manor General License 12/20/96 Edgewater NJ H-3 140 Apartmunts Park 970158 Environmental 21-15470-02 2/28/97 Ann Arbor MI Ni-63 0.008 Control Technology Co.

970417 Federal Express Non-Licensee 12/17/96 NR NH I-131 NR 970584 Federal Express Non-Licensee 2/18/97 Memphis TN Xe-133 NR 970394 Federal Express Non-Licensee 4/30/97 Memphis TN Cr-51 0.001 970634 Federal Express Non-Licensee 6/29/97 NR CA Xe-133 0.23 A-7 Appendix A

1997 AEOD Annual Report Table A-3 Loss of Control of Material Events item License Event No. Licensee Number Date City State Isotope Activity (Ci) 970482 Florida Hospital FL-0069-7 1/20/97 Altamonte FL Cs-137 0.038 Medical Center Springs 970505 Florida State FL-0032-10 5/2/97 Tallahassee FL Am-241 <0.001 University, Radiation Safety Office 960718 Framatom/Cogema NR 11/13/96 NR VA U-le NR 970182 Fremont Medical CA-2518-51 10/25/96 Yuba City CA Ir-192 <0.001 Center 970202 General Electric Co. SNM-1097 3/6/97 Wilmington NC U-le NR 970350 GME Consultants, IL-01274-22 4/21/97 Bridgeview IL Cs-137 0.009 inc. Am-Be 0.044 970288 GME Engineering SC-0522 100/96 Greenville SC Cs-137 NR Am-Be NR 970765 Goodrich Testing TN-R-19192 8/2/97 NR TN Cs-137 0.008 and Engineering Am-Be 0.04 970691 Goodson and CO-441-04 5/21/97 Lakewood CO Cs-137 0.009 Associates, Inc. Am-Be 0.044 970/03 Granada Hills CA-1463-70 4/4/97 Granada Hills CA Tc-99M <0.001 Community Hospital 980178 H&G Inspection, NR 7/16/97 Houston TX 1r-192 60 Inc.

980191 Halliburton LA-2353-L01 9/24/97 Houston TX Am-Be 18.5 Cs-137 1.5 .,

970238 Halliburton Co. 42-01 % 8-07 11/25/96 Houston TX Am-241 18.5 Cs-137 1.5 970239 Halliburton Co. 42-01068-07 11/29/96 Houston TX Cs-137 1.5 Am-Be 10.3 970165 llallibunon Co. NR 3/3/97 Houston TX Cs-137 1.5 Am-Be 8 980109 Hallibunon Co. NR 3/7/97 Houston TX Am-Be 18.5 Cs-137 1.5 970850 Halliburton Co. 42-01068.07 5/11/97 Houston TX Cs-137 NR Am-Be NR 970855 Halliburton Co. 42-01068-07 5/13/97 Houston TX Cs-137 1.5 Am-Be 8 980079 Halliburton Co. 42-01068-07 8/21/97 Houston TX Cs-137 1.5 Am-Be 19 NUREG-1272, Vol. I1, No. 2 A-8

Nuclear Materials Table A-3 Loss of Control of Material Events Item License Event  ;

No. Licensee Number Date City State Isotope Activity (Ci) 970007 Hanford incinerator Non-Licensee 12/30/96 South Winsor CT I-131 NR Facili'y 960635 Health & Human 02-13990-01 10/8/96 Phvenix AZ P-32 <0.001 i Services, Dept. Of 970058 Health & Human 19-00296-10 1/10/97 Bethesda MD I-125 0.001 Services, Dept. Of l

980092 Hercules NR 2/6/97 Houston TX Cs-137 0.008 Engineering & Am Be 0.04 Testing Services 980160 Hercules NR 7/25/97 Houston TX Cs-137 0.01 Am-Be 0.04 i 970296 Hewlett Packard 07-28762-01 3/24/97 Wilmington DE Ni-63 0.015 i 970904 Hewlett Packard 07-28762-01 5/9/97 Wilmington DE Ni-63 0.015 Ni-63 0.015 970041 Hillis-Carnes 19-30304-01 1/13/97 Annapolis MD Cs-137 0.01 Engineering Am-Be 0.04 Associates, Inc.

970583 Holston Valley TN-R-82033-97 1/25/97 Kingston TN I-131 NR l Hospital 980154 Honeywell Micro IL-92109-31 6/5/97 Freepon IL Po-210 0.01 Switch 9'70438 Hospital San Pablo 52-21325-01 4/15/97 Bayamon PR Cs-137 <0.001 Cs-137 <0.001 Co-60 0 Co-60 0 Co-57 0 Co-57 0 980168 IHS Geotech CMT NR 7D/97 San Antonio TX Cs-137 0.008 Am-Be 0.04 980153 Illinois, University of IL-01271-01 1/1/97 Champaign IL Ni-63 0.015

/ Urbana 970036 Industrial TN-R-33017-197 10/2/96 Chattanooga TN Co-60 0.6 Laboratories Co-60 3 Co-60 12 970452 Interior. Dept.of the 22-19667-01 5/22/97 Minneapolis MN Kr-85 0.005

! Kr-85 0.005 l Kr-85 0.005 i Kr-85 0.005 Kr-85 0.005 960730 Jaca & Sierra 52-19064-01 12/31/96 San Juan PR Cs-137 0.01 Testing Am-Be 0 05 Laboratories A-9 Appendix A

.6 _. .,_.-sm _ a. A a e + 4 -- - -

1997 AEOD Annual Report Table A 3 Loss of Control of Material Events Item License Event No. Licensee Number Date City State Isotope Act vity (Ci) i 970797 Jeanette Municipal Non-Licensee 8/8/97 Jeanette PA I-131 NR Authority 970621 Kaw Valley 15-26870-01 6/)6/97 Junction KS Cs-137 0.008 Engineering & Am-Be 0.04 Development, Inc.

970386 Kentucky Electric KY-201-130-5 4/28/97 Ashland KY Cs-137 NR Steel 970854 Koch Engineering 07-28386-01 8/28S 7 Nevcark DE Cs-137 0.022 Co., Inc. Cs-137 0.001 Cs-137 0.066 970841 Law Engineering, 35-27045-01 8/2567 Tulsa OK Am-Be 0.04 Inc. Cs-137 <0.001 970847 Law Engineering, 45-21498-01 8/2767 Chantilly VA Cs-137 0.008 Inc. Am-Be 0.04 970968 Leslie W. Williams. 03-12-0155-01 10/22/96 Las Vegas NV Sr-90 NR DVM 970447 Libson Incinerator Non-Licensee 5/20/97 Taftville CT I-131 NR 970006 Lisbon Incinerator Non-Licensee 12/23/96 Moosup CT I-131 NR Facility 970701 Los Angeles County CA-0508-70 3/7/97 Downey CA I 131 NR Ranchos Los Anugos Medical Center 960821 Lower Bucks SNM-1800 12/10/96 Bristol PA Pu-238 4.8 Hospital 970932 Lower Bucks SNM-1800 6/2/97 Bristol PA Pu-238 NR Hospital 980264 Lucent Technology General 7/21/97 Orlando FL H-3 6.3 License 971028 M P Enterprises General 9/15/97 Brookfield WI Po-210 0.004 License 980321 Mack Molding Co. NC-049-1356- 7/3/97 Statesville NC Po-210 0.01 OG 970872 Macon Office of GA 1211-1 9/1/97 Albany GA Cs-137 0.009 Geosciences Am-Be 0.044 970201 Marion Steel Co. 34-21123-01 3n/97 Marion OH Cs-137 0.5 970293 Mattingly Testing 25-21479-01 4/4/97 Great Falls MT Ir-192 25 Services, Inc.

NUREG-1272,Vol. I1.No. 2 A-10

l Nuclear Materials i Table A-3 Loss of Control of Material Events Item License Event No. Licensee Number Date City State Isotope Activity (Cl) 971081 Memorial Hospital 13-18881-01 8/27/97 South Bend IN I-125 NR 970321 Merck & Co., Inc. 29-00117-06 4/11/97 Rahway NJ 1-125 <0.001 970637 Metaphysics NR 7/2/97 Atlanta GA I-125 NR 970281 Metro South Non-Licensee 2/5/97 Oregon City OR I-131 NR Transfer Station 970287 Metro South Non-Licensee 2/25/97 Oregon City OR Sn-113 NR Transfer Station 960751 Michigan State 21-00021-29 10/21/96 East Lansing MI Cf-252 0 University 980013 Micron Technology General License 8/28/97 Boise ID Po-210 <0.001 970392 Millstone, Unit 1 DPR-0021 5/1/97 Waterford CT Pu-239 0 l 970016 Milwaukee County 48-04193-01 12/10/96 Milwaukee WI I-125 <0.001 Medical Complex 970028 Mobile Nuclear NR 1/3/97 North NC Cs-137 0.00025 Medicine Service Wilkesboro 980094 Motorola, Inc. NR 2/12/97 Seguin TX Po-210 0.01 Po-210 0.01 Po-210 0.01 Po 7'" 0.01 980094 Motorola, Inc. NR 2/12/97 Seguin TX Po .u e 0.01 Po-210 0.01 970509 Mt. Sinai Hospital NR 6/3/97 New York NY I-125 0.176 970054 . Navy, Dept. of the 45-23645-0lN 1/21/97 Portsmouth VA Am-241 0 Am-241 0 970948 Navy, Dept. of the 45-23645-01N 9/14/97 Portsmouth VA Am-241 0 Am-241 0 970949 Navy, Dept. of the 45-23645-01N 9/15/97 Portsmouth VA Am-241 0 Am-241 0 l 970700 NDC Systems CA-1451-19 2/18/97 Irwindale CA Kr-85 0.2 970421 New Jersey Dept Non-Licensee 5/10/97 Union NJ H3 20 of Environmental Protection i

1 l

l A-11 Appendix A

1997 AEOD Annual Report l

Table A-3 Loss of Control of Material Events Item License Event No. Licensee Number Date City State Isotope Activity (Ci)

, 971049 Non-Destructive NR 10/22/96 Clute TX Ir-192 NR I

Inspection Corp. Ir-192 NR Ir-192 NR Ir-192 NR 1r-192 NR Ir-192 NR 980371 North Mississippi MS-378-01 1/16/97 Tupelo MS I-131 NR Medical Center 970813 North Shore NR 4/14/97 Manhasset NY I-125 <0.001 University Hospital 1

970193 Northwestern Non-Licensee 3/3/97 Sterling IL Cs-137 0.05 l l-Steel and Wire .

' l 970151 NR NR 12/27/96 NR SC Cs-137 0.1 l 970075 Nuclear Pharmacy Il-27398-01MD 1/29/97 Boise ID I-131 0.01 ,

l of Idaho, Inc. i 980280 Nucor Steel Corp. General License 2/26/97 Norfolk NE H-3 7.5 980280 Nucor Steel Corp. General License 2/26/97 Norfolk NE H3 7.5 H-3 7.5 H-3 75 ,

t 970177 Nutting Engineers FL-934-1 3/4/97 Boynton Beach FL Am-Be 0.04 of Florida, Inc. Cs-137 0.008 970198 Ohio State 34-00293-02 2/26/97 Columbus OH P-32 <0.001 University 970340 Ohio State 34-00293-02 3/28/97 Columbus OH P-32 <0.001 l

University 970270 Oregon State OR-90005 11/18/96 Corvallis OR Cf 252 <0.001 University 970553 Palm Beach Solid Non-Licensee 10/4/96 West Palm FL I-131 NR Waste Authority Beach 970051 Paradyme Corp. FL-G-0018-1 12/4/96 Largo FL Po-210 0.01 960720 Pinkerton Chevrolet General License i1/13/96 Salem VA Po-210 <0.001 Po-210 <0.001 970666 Porocel Corp. AR-637 7/14/97 Little Rock AR Cs-137 0.02 l 970379 Portland Adventist OR-90158 3/25/97 Portland OR I131 0.0001 Medical Center l 960670 Ponsmouth General 45-09102-02 10'15/96 Portsmouth VA Cs-137 <0.001 Hospital 970754 Potomac Hospital 16618 7/31/97 Woodbridge VA I-125 <0.001 NUREG-1272, Vol. I1, No. 2 A-12 l

i

Nuclear Materials Table A-3 Loss of Control of Material Events Item License Event No. Licensee Number Date City State Isotope Activity (Ci) 970787 Precision Products General License 3/24/97 College Park MD Po-210 0.027 i Group,Inc.

970009 Private Individual Non-Licensee 1/2/97 South VT 11-3 20 Berlington 970267 Private Individual Non-Licensee 3/27/97 Lake Elsinore CA Sr 90 <0.001 970262 Professional Service 12-16941-01 3n/97 Lombard IL Am-Be 0.04 Industries, Inc.

970575 Providence OR-90312 4/4/97 NR OR I 131 NR Milwaukie Hospital j 980233 Pruett Industries, CA-6098-15 9/8/97 Bakersfield CA I 131 <0.001 Inc.

970442 R.M. Wester and 21-20091-01 5/17/97 Saint Peters MO Am-241 <0.001 l Associates i 970185 RadcliffInspections NR 10/10/96 Long Beach CA Ir-192 17 971003 Regents of CA-1335-19 6/4/97 Los CA P-32 0.005 l University Angeles -

I of California -

Los Angeles ,

l 970289 Regional Medical TN R-79160- 10/31/96 Memphis TN I-125 <0.001 Center of Memphis L97 970316 Rhone Engineers NR 110/96 Dallas TX Am-Be 0.04 Cs-137 0.008 970050 Ricker, Atkinson, AZ-7-405 1/10/97 Phoenix AZ Am Be 0.04 McBee & Associates Cs-137 0.04 970897 Riverside Regional 45-09001-01 5/28/97 Newport News VA Tc-99M NR Medical Center 970250 Rochester Non-Licensee 3/19/97 Rochester MI I-131 NR Manufacturing 970866 Roger Adams GMC General 4/21/97 Rolla MO Po-210 NR License 960696 Rone Engineers, TX-LO2356 1In/96 Dallas TX Cs-137 0.008 Inc. Am-Be 0.04 970869 Royal Green Non-Licensee 8/27/97 Temple PA Am-241 0.1 Metal Recyclers Am-241 0.1 A-13 Appendix A ,

i

1997 AEOD Annual Report Table A 3 Loss of Control of Material Events item License Event

- No. Licensee Number Date City State Isotope Activity (Ci) 970707 RSA Laboratories, 06-30007-01 6/5/97 Hebron CT Sr-90 <0.001 Inc. St- 90 0 001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.(X)1 St-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001  ;

Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 1 Sr-90 <0.001 Sr-90 <0.001 Sr-90 <0.001 970516 Saint Elizabeth 29-04333-01 4/18/97 Elizabeth NJ 1-131 0.02 Hospital 970817 Saint Joseph's NR 10/1466 Syracuse NY Tc-99M NR Hospital 970578 Saint Jude TN-R-79056-196 11/12/96 Memphis TN I-125 <0.001 Children's Research Hospital l 970477 Saint Luke's FL-0269-1 5/21/97 Jacksonville FL Am-241 0.014 Hospital Association 970318 Saint Mary of the NR 11/14/96 Lubbock TX Pu-238 3 Plains -

970375 Salem Hospital OR-90151 3/10/97 Salem OR Tc-99m NR 980158 Sandoz Agro, Inc. IL-017%-01 7/9/97 Des !>laines IL C-14 <0.001 970008 - Sanitary Services Non-Licensee 12/27/96 NR CT l-131 NR Corp.

970775 SCC Corp. Waste Non-Licensee 3/10/97 Holtsville NY I-131 <0.001 Transfer Station 980177 Schlumberger NR 6/12/97 Houston TX Cs-137 1.7 Technology NUREG-1272, Vol.11, No. 2 A-14

Nuclear Materials Table A 3 Loss of Control of Malerial Events Item License Event No. Licensee Number Date City State Isotope Activity (Ci) 980188 Schlumberger NR 7/16/97 Sugarland TX Am-Be 16 Technology Cs-137 1.7 970130 Schlumberger 42-00090-03 2/19/97 Houston TX Cs-137 1.7 Technology Corp. Am-Be 16 970582 Schlumberger 42-00090-03 6/17/97 Houston TX H-3 1.5 Technology Cerp.

970304 Schlumberger, Inc. NR 10/8/96 Houston TX Am Be 16 Cs 137 1.7 971068 Schlumberger, Inc. NR 12/18/96 Houston TX Cs-137 1.7 960690 Scientific Inspection TN-R-33092-C 11/4/96 Chattanooga TN Ir-192 67.0 Technologies, Inc.

970081 Sheffield Steel Corp. 35-19883-01 2/7/97 Sand Springs OK Cs-137 0.2 970946 Shell Chemical Co. 34-13012-01 7/14/97 Belpre OH Cf-252 <0.001 971011 Soils Engineering, CA-3473-15 8/1/97 Bakersfield CA Am-Be 0.0 Inc. Cs-137 0.0 970027 Southern Can Co. Non-Licensee 1/6/97 Memphis TN Am-241 NR 980225 Southern Pine MS-GL-316 4/28/97 Picayune MS Cm-244 0.013 Wood Preserving Am-241 <0.001 970338 Spectratek Services NM-TA-0172 4/16/97 Albuquerque NM Am-24] 0.0002 980124 Sperry-Sun Drilling NR 4/28/97 Houston TX Am-Be 4.0 Cs-137 2.0 970080 Sperry-Sun Drilling 42-26844-01 12/23 S 6 Houston TX Am-Be 3.0 Services, Inc. Cs-137 2.0 970455 Sperry-Sun Drilling 42-26844-01 2/9/97 Houston TX Cs 137 <0.001 Services, Inc. Cs-137 2.0 Cs-137 <0.001 Am-Be 3.0 970323 Sperry-Sun Drilling 42-26844-01 4/13/97 Houston TX Am-Be 3.0 Senices, Inc. Cs-137 2.0 970606 Sperry-Sun Drilling 42-26844-01 4/21/97 Houston TX Cs-137 2.0 Services, Inc. Am-241 4.0 l 970851 Sperry-Sun Drilling 42-26844-01 6/10/97 Houston TX Cs-137 2.0 j l Services, Inc. Am-Be 3.0 <

i 970935 Sperry-Sun Drilling 42-26844-01 7/22/97 Houston TX Cs-137 2.0 Services. Inc. Am-Be 4.0 971033 Sperry-Sun Drilling 42-26844-01 8/24/97 Houston TX Cs-137 2.0 ,

Services, Inc. Am-Be 3.0 l l

l A-15 Appendix A l l

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

1997 AEOD Annual Report l l

Table A-3 Loss of Control of Material Events Item License Event No. Licensee Number Date City State Isotope Activity (Ci) 970510 Steel of West Non-Licensee 6/4/97 Huntington WV Cs-137 0.5 ,

Virginia 970351 Steclastic Co. General License 4/2267 Akron OH Am-241 0.15 l Am-241 0.15 l 970068 Stevens Graphics, General License 1/24/97 Birmingham AL Po-210 <0.001 Inc. Po-210 <0.001 Po-210 <0.001 980123 Structural Metals Non-Licensee 3/3/97 Seguin TX Cs-137 NR 970215 Sullivan Transfer Non-Licensee 3/10/97 Holtsville NY I-131 NR Co.

970347 Summit, Inc. MA-30-1800 4/1867 Everett MA Am-Be 0.04 Cs-137 0.008 980199 Sunny Ridge KY-40!-092-1 6/18B7 Phelp KY Cs-137 0.064 Enterprises 970702 Syncor International CA-3317-14 3/2987 Tonance CA Tc-99m NR Corp. i 970649 Syncor International TN-R-19149- 5/12/97 Nashville TN I-131 NR Corp. A98 970448 Toledo Hospital 34-01710-05 5/22/97 Toledo OH I-125 <0.001 970532 Torrington Non-Licensee 6/10/97 Torrington CT Tc-99m NR  ;

incinerator 970005 Transfer Station Non-Licensee 12/31/96 New Haven CT I-131 NR 970908 Tri-state Testing TN-R-33105 9/15/97 Chattanooga TN Am-Be 0.05 ,

& Drilling Co. Cs-137 0.01 960701 Troxler Electronics NC-032-0182-1 10/23/96 Research NC Cf-252 <0.001 Laboratories, Inc. Triangle Pk 970839 Uintah Engineering, UT-24000-46 8/21/97 Vernal UT Cs-137 <0.001 Inc. .Am-Be 0.05 960672 United Metro AZ-7-227 12/17/96 Tucson AZ Am-Be 0.1 1 Materials, Inc.

)

970311 Universal FL-ll36-4 4/9/97 Rockledge FL Am-Be 0.04 ,

Engineering Cs-137 0.008 1 970589 University of NM-BM-0233 2/24/97 Albuquerque NM P-32 <0.001 New Mexico 970581 University of TN.R-79019- 1/8/97 Memphis TN S-35 0.02 Tennessee 197 970097- UTS of 20-28399-01 1/25/97 Stoneham MA Am-Be 0.04 Massachusetts, Inc. Cs-137 0.008 NUREG-1272,Vol. I1 No. 2 A-16

.=- __ - - . - . .- .. . . - - . - . - - - - .-

Nuclear Materials Table A 3 Loss of Control of Material Events Item License Event No. Licensee Nurnber Date City State Isotope Activity (Ci) i 970868 V.A. Medical Center G4-00421-05 8/l8/97 San Francisco CA P-32 <0.001 970930 W.I. Gore and NR 9/8/97 Cheny Hill MD Kr-85 0.86 Associates 970623 Walter Reed Army 08-01738-02 6/10/97 Washington DC I-125 <0.001 Medical Center j 980367 Waste Management Non-Licensee 9/15/97 Chicago IL I-131 NR 970259 WCI Steel, Inc. 34-25956-01 3/25/97 Warren OH Co-60 NR 970844 Weavexx Corp. 32-18405-02 8/26/97 Wake Forest NC Am-241 0.08 970567 West Florida FL-1087-4 11/26/96 Pensacola FL I-131 NR Regional Medical Center, Inc.

980116 Westem Atlas NR 4/21/97 Houston TX Cs-137 2.0 International, Inc. Am-Be 18.0 970610 Western Atlas 42-02964-01 6/24/97 Houston TX Cs-137 <0.001 International, Inc.

970883 Western Atlas 42-02964-01 6/28/97 Houston TX Am-Be NT International,Inc. Cs-137 NR 970200 Western Wake Medical Center NC-092-0297-4 3/9/97 Cary NC Tc-99m 0.039 970344 Westinghouse SNM-1107 3/20/97 Columbia SC U-235 NR Electric Corp. U-235 NR ,

i 970594 White Salvage Non-Licensee 1/2/97 Ripley TN Am-241 NR  ;

l A-17 Appendix A

1997 AEOD Annual Report Table A-4 Leaking Sources Item Radio-No. Licensee Number Date City State nuclide 970865 Battelle Columbus SNM-0007 6/18/97 Columbus OH Ni-63 Laboratories 971116 Commerce, Dept. Of SNM-0362 8/12/97 Gaithersburg MD Sr-90 970608 Digitallogging,Inc. 35-19815-0 4/24/97 Tulsa OK Cs-137 970639 Emory University GA-153-1 6/30/97 Alanta GA Sr-90 971115 Fort Howard Paper Co. 48-13485-0 8/l8/97 Green Bay WI Ni-63 970231 Health & Human Services, Dept. Of 17-09756-0 12/18/96 New Orleans LA Ni-63 970233 Idaho State University Il-27280-0 1/13/97 Pocatello ID Fe-55 970662 Maryland Dept. of Health and Mental Hygiene MD-07-040- 2/28/97 Baltimore MD Ni-63 980222 McKenna General Hospital NR 8/18/97 New Braunfels TX Cs-137 970609 Metorex, Inc. 37-28461-0 4/22/97 Langhorne PA Fe-55 980102 Nonh Texas, University Of NR 3/21/97 Denton TX Cm-244 960691 Ohmart Corp. 34-00639-0 11/5/96 Cincinnati OH Cs-137 970372 Smithkline Beecham Clinical Laboratories CA-0094-7 1/27/97 Van Nuys CA Ni-63 l 970112 Tennessee Radiological Health NR 12/13/96 Knoxville TN Cl-36 971070 TN Technologies NR 1/22/97 Round Rock TX Cs-137  !

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i NUREG-1272,Vol. I1, No. 2 A-18

.I Nuclear Materials l l

Table A 5 Release of Material Events j Item Licensee Release Radio-No. Licensee Number Date City State Type nuclide 970164 Air Force, 42-23539-01 AF 3/3/97 Brooks AFB TX Person 1-125 i

Dept.of the Surface 1-125 4 970398 Alaron Corp. 37-20826-01 5/5/97 Wampum PA Surface Co-60 960830 Allied-Signal,Inc. SUB-0526 12/16/96 Metropolis IL Air LT6 970410 American 24-21362-01 2/12/97 Saint Louis MO Surface ' C-14  ;

Radiolabeled Chemicals f

970333 Army, Depac.rnent 12-00722-13 4/14/97 Rock Island IL Surface Am-241 of the - Rock Island Arsenal 970246 Army, Departrr.ent 12-00722-06 3/21/97 Rock Island IL Surface H-3 I

of the - Rock Person H-3  !

Island Arsenal 970176 Army, Department 12-00722-06 2/28/97 Rock Island IL Person H-3 f of the - Rock Surface H-3 Island Arsenal 970334 Army, Department 12-00722-06 4/14/97 Rock Island IL Surface H-3 of the - Rock Island Arsenal 970354 Army, Department 12-00722-06 4/23/97 Rock Island IL Surface H-3 of the - Rock Island Arsenal 970090 Army, Department 12-00722-06 2/3/97 Rock Island IL Surface H-3 of the - Rock Island Arsenal 970086 Army, Depanment 12-00722-06 2/6/97 Rock Island IL Surface H-3 l of the - Rock j Island Arsenal '

960716 Army, Department 12-00722- % 11/786 Rock Island IL Surface H-3 of the - Rock Island Arsenal 970153 Army, Department 12-00722-06 2/2167 Rock Island IL Surface H-3  ;

of the - Rock i Island Arsenal l l

960673 Babcock & SNM-0042 10/30/96 Lynchburg VA Surface U-235  !

Wilcox Co. i 960785 Du Pont Merck 20-28598-01 12/166 Nonh Billerica MA Surface Mo-99 I Pharmaceutical Co. Surface Tc-99M I 970639 Emory University GA-153-1 6/3087 Atlanta GA Surface Sr-90 970464 Federal Express Non-Licensee 5/29S7 Baton Rouge LA Surface U-DEP 980200 Garden State 29-28554-01 6/1167 Belleville NJ Surface I-131 Cancer Center A-19 Appendix A

1997 AEOD Annual Report Table A-5 Release of Material Events Item Licensee Release Radio-No. Licensee Number Date City State Type nuclide 970914 Hospital Ramon $2-13598-03 9/17/97 Mayaguez PR Surface I-131 De Betances 980157 Koch Engineering IL-00109-01 7/7/97 Canton IL Surface Na-24 970439 Larchmont 29-23540-01 5/14/97 Mount Laurel NJ Person Tc-99M Imaging Associates 970434 Mallinckrodt 24-04206-01 Maryland MO Surface Re-186 Medical Inc. Heights Person Re-186 970791 Michael Reese IL-86-01097-01 2/18/97 Chicago IL Surface Tc-99m Hospital &

Medical Center 970830 Middletown 34-08279-02 8/13/97 Middletown OH Surface I-131 Regional Hospital 970591 Minnesota, 22-00187-46 6/16/97 Minneapolis MN Person P-32 University of Surface P-32 970421 New Jersey Dept. Non-Licensee 5/10/97 Union NJ Person H-3 of Environmental Surface H-3 Protection 970095 Palisades DPR-0020 2/5/97 South Haven MI Person NR 970862 Puerto Rico, 52-01946-07 8/10/97 San Juan PR Person 1-131 University of Surface I-131 960657 South Florida FL-806-1 10/24/96 Tampa FL Surface P-32 Research Compliance Office, 1 University of 970592 Spectratek Services NM-TA-0172 3/25/97 Albuquerque NM Surface Ir-192 Person Ir-192 980165 Syncor NR 5/28/97 Dallas TX Surface Tc-99M 970511 Syncor 04-26507-01MD 6/3/97 Allentown PA Surface Tc-99M Intemational Corp.

970404 Syncor 04-26507-01 5/6/97 Saint Louis MO Person Tc-99M Intemational Surface Tc-99M Corp.

960695 Syncor FL-1264-10 11/6/96 Gainesville FL Surface Tc-99M International Corp.

970933 Temple, 37-00697-31 9/24/97 Philadelphia PA Surface P-32 University of Person P-32 the Comm. Sys.

971067 Texas A & M NR 2/22/97 College Station TX Surface S-35 University NUREG-1272,Vol.11, No. 2 A-20

Nucleu Materials Table A 5 Release of Material Events Item Licensee Release Radio-No. Licensee Number Date City State Type nuclide 970251 U.S. Enrichment USEC-O 3/20/97 Piketon OH Air UF6 Corp.

970594 White Salvage Non-Licensee 1/2/97 Ripley TN Surface Am-241 I

A-21 Appendix A,

1997 AEOD Annual Report Table A-6 Transportation Events Item License Eveat No. Licensee Number Dr,te City Sttte 970622 Abington Memorial Hospital 37-0(M32-02 6!24 S 7 .exar PA l 1

970398 Alaron Corp. 37-20826-01 5/5/97 'V iper.s PA 970031 Alaron Corp. 37-20826-01 12/30/96 'r . .y er PA 970719 Babcock & Wilcox Co. SNM-0042 7/25hi Ly /.aburg VA 960832 CIS-US, Inc. 20 20973-01 12/17/96 Alord MA 970942 Cotter Corp. NR 9/30S 7 k Men CO 960836 Davies Medical Center NR 12/16/96 San J.wisco CA j 960590 Du Pont Merck Pharmaceutical 20-28598-01 10/4/96 North Billerica MA Co. ,

I 970587 Federal Express Non-Licensee 2/21/97 Memphis TN 970417 Federal Express Non-Licensee 12/17/96 NR NH 980267 Ficrie,'a Department of F1 0109-01 8/28/97 Jacksonville FL Lansportation 980265 Florida Department of FL-0109-01 8/12/97 Lake City FL Transponation 980263 Florida Department of F1 0109-01 6/27/97 Gainesville FL Transportation 970556 Florida Depanment of FL-0109-01 10/16/96 Gainesville FL Transponation 970562 Florida Depanment of FL-0109-01 11/5/96 Gainesville FL Transponation 970226 Frank Barker Associates,Inc. 29-28783-01 3/17/97 PeonnnocE NJ 970415 Good Samaritan Hospital 34-00991-02 5/8/97 Cincinnati OH i 980234 ICN Pharmaceuticals CA-1828-30 1/22/97 Irvine CA 970132 Lala, Michael, M.D., P.C. 21-24380-01 2/25/97 Orchard Lake MI 970439 Larchmont Imaging Associates 29-23540-01 5/14/97 Mount Laurel NJ l 970653 Mallinckrodt Medical,Inc.. 24-04206-01 7/8/97 Maryland Heights MO 970003 Mallinckrodt Medical,Inc. 24-04206-llMD 12/31/96 Saint Louis MO l P~'640 Mallic:krodt Nuclear Medicine 29-28064-01 7/8/97 Pinebrook NJ 970638 MallinireodI,Inc. NR 7/2/97 Ponland OR 970029 Mecos.a County General 21-18566-01 1/8/97 Big Rapids MI Hospital 970472 Mercy Catholic Medical Center 37-00993-05 5/29/97 Darby PA 970679 Missouri Highway & 24-20415-01 7/17/97 Jefferson City MO Transportation NUREG-1272,Vol. I1, No. 2 A-22

Nuclear Materials Table A 6 'IYansportation Events item License Event No. Licensee Number Date City State l

970060 Monticello DPR-0022 1/22/97 Monticello MN 970069 Monticello DPR-0022 1/26/97 Monticello MN 970763 Northwest Airlines A;r Freight Non-Licensee 10/18/96 Queens NY 970070 P.E.T. Net Pharmaceuticals FL-2728-1 I/27/97 Tampa FL l

960626 Roadway Express Non-Licensee 10/16/96 White Sa ids NM 970799 Rutprs University NR 12/10/96 New Brunswick NJ 960739 Siemens Power Corp. SNM-1227 10/1/96 Richland WA 970094 Siemens Power Corp. SNM-1227 1/24/97 P.chland WA 970624 Source Production and NR 6/24/97 Sant Rose LA Equipment Co.

960702 Susquehanna, Unit 1 NPF-('J14 11/11/96 Berwick PA 960625 Syncor International Corp. 04 26507-01 10/8/96 St. Paul MN

, 960695 Syncor International Corp. It 1264-10 11/6/96 Gainesville FL l 960777 Syncor International Corp. 37-l',461-01MD 11/27/96 Sharon Hill PA 960835 Syncor Internat ional Corp. 04 26507-OlMD 12/18/96 Saint Paul MN l 970511 Syncor International Corp. 0 5-26507-OlMD 6/3/97 Allentown PA 970907 Syncor International Corp. 0126507-OlMD 9/15/97 Allentown PA 970453 Syncor International Co y MS-493-01 1/9/97 Flowood MS 9707 % Syncor Internationr' Corp. NR 8/8/97 Louisville KY 970297 Syncor Internatioral Corp. NR I1/6/96 NR FL 970404 Syncor IraernaGonal Corp. 04-26507-01 5/6/97 Saint Louis MO l

l 970761 Syncor International Corp. NR 10/2/96 Buffalo NY 970152 Syncor International Corp. NR 2/27/97 Silver Springs MD 980231 Syncor Pharmacy Services NH-42-0146 4/24/97 Woburn MA 980184 Terra Engineers NR- 6/30/97 Lubbock TX 971067 Texar A & M University NR 2/22/97 College Station TX 970033 Twin Ports Testing,Inc. 48-23476-01 10/18/96 Superior WI i

A-23 Appendix A

1997 AEOD Annual Report Table A-7 Equipment Problems i Item Licensee Event No. Licensee Number Date City State Equipment i 960666 ABB Process 34-00255-0 10/27/96 Columbus OH Gauge, Thickness Automation, Inc.

]

l 970284 Abbott Laboratories NC-064-096 4/2/97 Rocky NC Irradiator Mountain 971014 Agra Earth and CA-2370-3 LM7 Anaheim CA Gauge, Ponable, 1 Environmental Moisture / Den.

970636 Ambric Engineering, 37-20968-0 6 2N97 Philadelphia PA Gauge, Other Inc.

970229 Army, Department 19-17250-0 1/20/97 Adelphi MD Alarm, Personnel i of the Warning 970720 Army, Department 19-17250-0 7/25197 Adelphi MD Irradiator of the 960716 Army, Department 12-00722-0 11/7/96 Rock Island IL Radioluminescent of the - Rock Island Gun Sight Arsenal 970153 Army, Depanment 12-00722-0 2/21/97 Rock Island IL Radioluminescent of the - Rock Island Gun Sight Arsenal 970333 Army, Department 12-00722-1 4/14/97 Rock Island IL Detector, of the - Rock Island Chemical Agent Arsenal 980174 AT Laboratories, Inc. NR 6/28/97 Dallas TX Gauge, Portable, Moisture / Den.

970492 Atlantic Testing NR 3/10/97 Melbourne FL Gauge, Ponable, Laboratories Moisture / Den.

i 960623 Babcock & Wilcox SNM-0042 10/15/96 Lynchburg VA Line, Sampling )

Co.

960673 Babcock & Wilcox SNM-0042 10/30/96 Lynchburg VA Pipe, Other l Co.

960678 Baxter Healthcare 52-21175-0 10/29/96 Aibonito PR Interlock, Corp. Irradiator 960719 Baxter Healthcare 52-21175-0 11/13/96 Aibonito PR Irradiator Corp.

970941 Baxter Healthcare 52-21175-0 9/30/97 Aibonito PR Protective System Corp.

970750 Bowser-Morner, Inc. 34-17390-0 7/25/97 Dayton OH Gauge Portable, Moisture / Den l 960616 BP OilToledo 34-07269-0 10/12/96 Toledo OH Gauge. Density i Refinery 1

t 970445 Braun Intenec Corp. 22-16537-0 3/26/97 Minneapolis MN Camera, Radiography i

l NUREG-1272, Vol. I1, No. 2 A-24

Nuclear Materials Table A-7 Equipment Problems item Licensee Event No. Licensee Number Date City State Equipment 970245 Braun Intenec OR-90633 10/2266 NR OR Gauge, Portable, Nonhwest Moisture / Den.

970590 CIBA-GEIGY Corp. 07-20696-0 6/18/97 Newport DE Gauge, Level 971116 Commerce, SNM-0362 8/1267 Gaithersburg MD Scaled Source Department of 970961 Cornfonh Consultants OR-90652 8/6/97 McMinnville OR Gauge, Portable, Moisture / Den.

970934 Crow Butte SUA-1534 8/12/97 Denver CO Pond, Evaporation Resources, Inc.

970271 Dee Forest Products OR-93164 11/19/96 Hood River OR Scaled Source 970782 Design Plumbing NY-2479-3 4/20/97 StatenIsland NY Gauge, Other

& Heating Scrivce 971010 Diaz-Yourman & CA-6001-3 4/18/97 Tustin CA Gauge, Portable.

Associates Moisture / Den.

970608 Digital Logging,Inc. 35-19815-0 4/24/97 Tulsa OK Scaled Source 08-224 Drash Consulting NR 9/25/97 San Antonio TX Gauge, Portable, Moisture / Den.

970228 Edwards Pipeline 35-23193-0 12/18/96 Tulsa OK Camera, i Testing, Inc. Radiography 970878 Edwards Pipeline 35-23193-0 7/17h7 Tulsa OK Camera, Testing, Inc Radiography 970639 Emory University GA-153-1 6/30/97 NR GA Sealed Source 980268 Florida Department of FL-0109-01 9/10/97 Bartow FL Gauge, Portable, Transponation Moisture / Den.

970435 Florida Department of TN-R-79171 5/6/97 Memphis TN Dust Collection Transponation System 960814 General Dynamics 06-01781-0 10/30/96 Groton CT Camera, Corp. Radiography 960671 General Electric Co. SNM-1097 10/29/96 Wilmington NC Scrubber, Centrifuge 960803 General Electric Co. SNM-1097 11/30/96 Wilmington NC Calciner 970076 General Electric Co. SNM-1097 2/2/97 Wilmington NC Filter, Exhaust 970345 . General Electric Co. SNM-1097 4/19/97 Wilmington NC Furnace, Other 970401 General Electric Co. SNM-1097 5/5/97 Wilmington NC Tank 970711 Geobase, Inc. CA-5461-3 3/14/97 Laguna Hills CA Gauge, Portable.

Moisture / Den.

970032 Geomechanics, Inc. 37-17332-0 1/11/97 Elizabeth PA Gauge, Ponable, Moisture / Den A-25 Appendix A

1997 AEOD Annual Report Table A-7 Equipment Problems item Licensee Event No. Licensee Number Date City State Equipment 9707 % Geotechnical CA-4674-0 5/30/97 Fremont CA Gauge, Other Engineering, Inc.

970874 Geotechnology, Inc. 24-24459-0 9/6/97 St. Louis MO Gauge, Portable, Moisture / Den.

971077 Global X-Ray & NR 2/11/97 Aransas TX Camera, Testing Corp. Pass Radiography 970232 Globe X-ray 35-15194-0 12/2/96 Tulsa OK Camera, Service, Inc. Radiography 970469 Gonzales X-Ray LA-4641-LO 5/22/97 NR LA Camera, Radiography 971020 Gorian & Associates CA-30515 7/23/97 Westlake CA Gauge, Ponable, Village Other 971069 H&G Inspection NR 1/9/97 Houston TX Camera, Radiography Radiography 960628 H.C. Nutting Co. 34-18882-0 10/15/96 Cincinnati OH Gauge, Ponable, Moisture / Den.

970233 Idaho State University Il-27280-0 1/13/97 Pocatello ID Scaled Source 970879 Illinois Power Co. IL-01523-01 9/5/97 Decatur IL Gauge, Other 970867 Indiana Department 13-26341-0 8/27/97 Greenfield IN Gauge, Portable, ofTransportation Moisture / Den. -

960678 Industrial NDT 13-06147-0 7/10/97 Indianapolis IN Camera, Services Division Radiography 970788 1somedix, Inc. IL-01123-02 5/27/97 Libertyville IL Irradiator 980181 Johnson & Johnson NR 6/25/97 Sherman TX Irradiator Medical, Inc.

970854 Koch Engineering 07-28386-0 8/28/97 Newark DE Container, Co., Inc. Shipping 971057 Longview Inspection NR 12/9/96 La Porte TX Camera, Radiography 970964 Longview Inspection OR-9%21 8/29/97 Portland OR Camera, Radiography 971000 Los Angeles City CA-5904-1 5/2/97 Los Angeles CA Gauge, Portable, Other 970858 Marshall Miller & 45-17195-0 8/18/97 Bluefield VA Well Logging Tool Associates 960734 Massachusetts 20-03814-8 11/15/96 Boston MA Pump, Other General Hospital 980186 Maxim Technologies NR 6/3/97 Dallas TX Gauge, Portable, Moisture / Den.

NUREG-1272, Vol. I1, No. 2 A-26

Nuclear Materials Table A-7 Equipment Problems Item Licensee Event No. Licensee Number Date City State Equipment 980222 McKenna General NR 8/18/97 New BraunfelsTX Scaled Source Hospital 970609 Metorex, Inc. 37-28461-0 4/22/97 Langhorne PA Scaled Source 970755 Michigan, State of 21-03039-0 7/6/97 Lansing MI Gauge, Portable, Moisture / Den.

971133 Michigan, State of 21-03039-0 7/30/97 Lansing M1 Gauge, Portable, Moisture / Den.

970770 MQS Inspections,Inc. NY-1349 0 2/18/97 Elk Grove IL Camera, Village Radiography 970884 MQS Inspections,Inc. 12-00622-0 9/8/97 Elk Grove IL Camera.

Village Radiography 970408 Navy, Department 45-23645-0 10/11/96 Portsmouth VA Camera, of the Radiography 980102 North Texas, NR 3/21/97 Denton TX Scaled Source University of 970906 Nucor Steel Co. NR 9/14/97 Armorel AR Gauge, Density 970877 Nucor Steel Corp. NE-07-04-0 9/3/97 Norfolk NE Gauge, Level 960691 Ohmart Corp. 34-00639-0 11/5/96 Cincinnati OH Scaled Source 970762 Paratt-Wolff, Inc. NY-2171-3 10/3/96 East NY Gauge, Syracuse Other 960833 Piedmont Hospital NR 12/18/96 Atlanta GA HDR Unit 960699 Professional Service 45-25088-0 11/6/96 Bristol VA Gauge, Portable, Industries, Inc. Moisture / Den.

970786 Ratrie, Robbins, MD-05-116 7/3187 Baltimore MD Gauge, Portable, and Schweitzer Asphalt Cont.

970849 S. K. McBryde, Inc. NR 5/1987 Summerfield NC Camera, Radiograpiry 970946 Shell Chemical Co. 34-13012-0 7/1467 Belpre OH Gauge, Level 960819 Siemens Power Corp. SNM-1227 12/10/96 Richland WA Breaker Box 970242 Smurfit Newsprint OR-90266 10/1/96 Newberg OR Gauge Other Corp.

971030 Spec Group NR 8/20/97 Trafford PA Camera, Holdings, Inc. Radiography 960784 Sterigenics IL-01220-01 10/3/96 Gurnee IL Irradiator 970861 Syncor International 04-26507-0 8/29/97 Allentown PA Fan, Exhaust Corp.

980118 Technical Welding NR 4/26/97 Pasadena TX Camera, Laboratory Radiography A-27 Appendix A l

1997 AEOD Annual Report Table A-7 Equipment Problems item Licensee Event No. Licensee Number Date City State Equipment 970112 Tennessee NR 12/13/96 Knoxville TN Scaled Source Radiological Health 970308 Texas Nuclear NR 10/14/96 Round Rock TX Gauge, Level Technologies 971070 'IN Technologies NR 1/22/97 Round Rock TX Gauge. Other 9701 % U.S. Enrichment Corp. USEC-K 3/4/97 Paducah KY Alarm, Criticality 970663 U.S. Enrichment Corp. USEC-K 3/12/97 Paducah KY Fire Suppression System 970219 U.S. Enrichment Corp. USEC-K 3/14/97 Paducah KY Valve, Other 970224 U.S. Enrichment Corp. USEC-K 3/18/97 Paducah KY Alarm, Criticality 970236 U.S. Enrichment Corp. USEC-K 3/l8/97 Paducah KY Sprinkler System  ;

970235 U.S. Enrichment Corp. USEC-K 3/19/97 Paducah KY Sprinkler System 970251 U.S. Enrichment Corp. USEC-O 3/20/97 Piketon OH Valve, Other j 970247 U.S. Enrichment Corp. USEC-K 3/20/97 Paducah KY Sprinkler System 970261 U.S. Enrichment Corp. USEC-K 3/16/97 Paducah KY Fire Suppression System 970260 U.S. Enrichment Corp. USEC-K 3/27/97 Paducah KY Fire Suppression System 970286 U.S. Enrichment Corp. USEC-K 4/3/97 Paducah KY Fire Suppression System 970303 U.S. Enrichment Corp. USEC-K 4/7/97 Paducah KY Alarm, Criticality 970515 U.S. Enrichment Corp. USEC-O 4/7/97 Piketon OH Cylinder, UF6 Product 970312 U.S. Enrichment Corp. USEC-O 4/9/97 Piketon OH Fire Suppression System 970313 U.S. Enrichment Corp. USEC-K 4/9/97 Paducah KY Fire Suppression System 97034i U.S. Enrichment Corp. USEC-O 4/9/97 Piketon OH Autoclave 970342 U.S. Enrichment Corp. USEC-K 4/9/97 Paducah KY Autoclave 970327 U.S. Enrichment Corp. USEC-K 4/14/97 Paducah KY Fire Suppression System 970336 U.S. Enrichment Corp. USEC-K 4/15/97 Paducah KY Fire Suppression System 970339 U.S. Enrichment Corp. USEC-K 4/16/97 Paducah KY Fire Suppression System 970353 U.S. Enrichment Corp. USEC-K 4/23/97 Paducah KY Autoclave 970357 U.S. Enrichment Corp. USEC-K 4/23/97 Paducah KY Fire Suppression System NUREG 1272 Vol.11 No. 2 A-28

Nuclear Materials I

Table A-7 Equipment Probierns item Licensee Event No. Licensee Number Date City State Equipment 970382 U.S. Enrichment Corp. USEC-K 4/24/97 Paducah KY Fire Suppression System 970388 U.S. Enrichment Corp. USEC-K 4/24/97 Paducah KY Autoclave 970383 U.S. Er.t.tchment Corp. USEC-K 4/25/97 Paducah KY Fire Suppression System 970384 U.S. Enrichment Corp. USEC-K 4/26/97 Paducah KY Fire Suppression System 970385 U.S. Enrichment Corp. USEC-K 4/28/97 Paducah KY Fire Suppression System 970389 U.S. Enrichment Corp. USEC-K 4/30/97 Paducah KY Fire Suppression System 970395 U.S. Enrichment Corp. USEC-K 5/1/97 Paducah KY Fire Suppression System 970399 U.S. Enrichment Corp. USEC-K 5/4/97 Paducah KY Fire Suppression System 970425 U.S. Enrichment Corp. USEC-K 5/12/97 Paducah KY Fire Suppression System 970426 U.S. Enrichment Corp. USEC-K 5/13/97 Paducah KY Fire Suppression System 970427 U.S. Enrichment Corp. USEC-O 5/13/97 Piketon OH Autoclave 970440 U.S. Enrichment Corp. USEC-O 5/18/97 Piketon OH Autoclave 970451 U.S. Enrichment Corp. USEC-K 5/2287 Paducah KY Alarm, Criticality 970450 U.S. Enrichment Corp. USEC-O 5/23/97 Piketon OH Autoclave 970473 U.S. Enrichment Corp. USEC-K 5/3097 Paducah KY Breaker 970475 U.S. Enrichment Corp. USEC-O 6/1/97 Piketcn OH Autoclave 970636 U.S. Enrichment Corp. USEC-K 7/1/97 Paducah KY Alarm, Criticality 970664 U.S. Enrichment Corp. USEC-K 7/13/97 Paducah KY Electrical Device 970667 U.S. Enrichment Corp. USEC-K 7/1467 Paducah KY Autoclave 4

970728 U.S. Enrichment Corp. USEC-O 7/25 S 7 Piketon OH Boiler 970756 U.S. Enrichment Corp. USEC-K 8/1/97 Paducah KY Autoclave 970860 U.S. Enrichment Corp. USEC-K 8/31/97 Paducah 3 Autoclave 970903 U.S. Enrichment Corp. USEC-O 9/13S7 Piketon OH Cascade Data Processing System 970925 U.S. Enrichment Corp. USEC-K 9/18S 7 Paducah KY Pin Connector 970918 U.S. Steel Corp. 13-26104-0 5/25S7 Gary IN Gauge, Thickness 960456 Union Carbide NR 12/5 S 6 Seadrift TX Gauge, Level A-29 Appendix A

1997 AEOD Annual Report Table A-7 Equipment Problems Item Licensee Event No. Licemee Number Date City State Equipment 970693 University Hospital CO-870-01 4/21/97 Denver CO Applicator, Delcose 970431 University of R-125 12/20/96 Lowell MA Reactor Building Massachusetts Lowell Air System Research Reactor 970827 University of NR 12/9/96 Rochester NY Irradiator Rochester 960703 V.A. Medical Center 04-00181-1 11/27/96 Los Angeles CA Teletherapy Unit 971071 Wichita General NR 1/23/97 Wichita Falls TX Teletherapy Unit 970680 Williamette Industries OR-90141 5/1/97 NR OR Gauge, Other 960815 William Beaumont 21-01333-0 11/29/96 Royal Oak MI HDR Unit Hospital 970669 Wills Eye Hospital 37-00783-0 2/3/97 Philadelphia PA Gamma Knife Unit l l

I l

NUREG-1272, Vol.11, No. 2 A-30

APPENDIX B Summary of FY 1997 Abnormal Occurrences 1

1 l

i

Nuclear Materials CONTENTS 97-2 Overexposure of a Worker at Mallinckrodt,Inc., in Maryland Heights, Missouri . . B- 1 AS 97-1 Multiple Transuranic Overexposures to a Worker at Isotope Products Laboratories in Burbank, California . . .B-2 AS 97-2 Overexposure of a Radiographer and an Untrained Technician at Wolf Creek Mine in Walker County, Alabama . . . .B-2 AS 97-3 Radiopharmaceutical Misadministration at Mad River Community Hospital in Arcata. California. .

.B-3 AS 97-4 Radiopharmaceutical Misadministration at Tuomey Regional Medical Center in Sumter, South Carolina . . . . .B-3 l

I 1

l B-iii Appendix B

Nuclear Materials NUREG-0090, VOLUME 20 NRC Licensees 14,1997. Low levels of Re-186 contamination were found on three locations inside the employee's Report No. 97-2 Overexposure of a vehicle and on various items in the bathroom and kitchen of his home. The employee's vehicle and Worker at Mallinckrodt, Inc.' home were decontaminated. The employee was in Maryland Heights, Missouri examined by a physician who identified no immedi-a e e3 e#ce S H wem. a e n8t a rePon On May 14,1997, an employee was removing

• • • " # "*" "" ' " small p ssibility exists radioactive waste from the hot cell where rhenium-f r skm cancer to develop m. the exposed area of 186 (Re-186) was used. The employee was per-the thumb.

forming this task manually, using gloves, .mstead of remotely. When he left the area, he attempted to The cause of the event was determined to be a perform a personal contamination survey but the procedural deficiency in handling waste from the l survey meter immediately went off the scale. He Re-186 hot cell. Normally, radioactive waste in l assumed that the high count rate was due to back- other hot cells at the facility was handled with ground radiation from an adjacent radioactive remote tools. However, in this case, procedural material transpon cart and, subsequently, forgot to controls did not require remote handling of the resurvey himself in a low background area before waste. Once the employee completed the work, he left the facility that evening. Upon arrival at poor radiation work practices were exhibited as he I work the next day, he was told that his urine cross-contaminated his hands when he removed his sample, which he had submitted before going home gloves. In addition, the worker did not investigate the previous night, indicated iodine-131 (I-131) the detection of high count rates during his first radiation contamination and that he was restricted attempt to perform a contamination survey.

from working with radioactive material. At that .

The staff was instmeted on the importance of time, he performed a personal contamination survey c nducting proper personal contammauon surveys and detected significant levels of contamination on and the proper use of protective clothing. The use his left thumb which subsequently was identified as fe 86 was suspended until improvements to Re-186. The I-131 contamination level did not existing waste disposal procedures could be evalu- l exceed the AO criteria for exposure to radiation ated and implemented. Plans were made (1) to from licensed material.

compile all existing contamination protection The licensee estimates that the individual received a procedures into one contamination protection shallow-dose equivalent of 6090 millisievert (609 procedure, (2) to evaluate the use of a portal type rem) to an area of about 0.75 square centimeters monitoring system, and (3) to post personal-(0.12 square inches) on the palm side of the thumb monitoring reminder signs at all laboratory exits.

of his left hand. Lower levels of contamination

, NRC conducted a special safety inspection, pro-were found on the back of his right hand and posed a $55,000 civil penalty on December 17, fingers. On May 15,1997, the employee had 1997, and the licensee paid the civil penalty on undergone decontamination to the extent that only January 20,1998.

approximately 4 percent of the activity remained.

The licensee surveyed the offsite locations where the employee had been after leaving work on May B-1 Appendix B

1997 AEOD Annual Report Agreement State Licensees ne licensee's radiation protection program was inadequate and lacked important elements needed Report No. AS 97-1 Multiple t ensure the radiation safety ofits workers. Some of these madequacies were the lack of(1) work Transuram.eOverexposures to a permits. (2) glove boxes for cenain types of work, Worker at Isotope Products and (3) radiation procedural controls.

Laboratories in Burbank, California After the licensee's consultants conducted their The overexposures occurred between January I and review and comprehensive audit of the existing December 31,1995, when a radiochemist was radiation protection program, they made recom-assigned to make transuranic and other types of mendations to ensure future compliance with the sources. The transuranics included Pu-238, Pu-239, license and regulations. The licensee hired a Pu-240, Am-241, and Cm-244. In January 1995, competent radiation safety officer, and the radio-while making a Cm-244 source, it was discovered chemist was assigned duties that did not involve the that the exhaust fan of the fume hood where the handling or processing of radioactive materials.

source was being fabricated was not working. An The State Agency completed its investigation and is analysis of room air samples confirmed the loss of committed to closely tracking the licensee's radiation Cm-244 into the working area. protection program to ensure continued compliance.

Bioassay results disclosed that feca' and tirine samples provided by the radiochemist contained Report No. AS 97-2 Overexposure of Cm-244 and Am-241. The licensee hired dosimetry a Radiographer and an Untrained and radiation protection consultants as directed by .

the State Agency. Careful analysis of the bioassav Techm. .cian at Wolf Creek Mm.em

~

data by these consuhants, which included dose Walker County, Alabama summation and retrospective time correction for On July 1,1996, a radiographer, employed by various intakes, suggested that during 1995 the Certified Testing and Inspection of Cottondale, radiochemist received a TEDE of 38330 mSv Alabama, and a techmcian, employed by Ultron, (38.32 rem) and a CDE of 6900 mSv (690 rem) to the bone surfaces. De specific exposures were as Inc., of Mt. Vemon, Illinois, were performing follows: (1) committed effective dose equivalent industrial radiography at the Wolf Creek Mine in (CEDE) of 271.8 mSv (27.18 rem) from Cm-244, Walker County, Alabama, when they became so (2) CEDE of 80 mSv (8 rem) from Am-241,(3) distracted by problems with excessively exposed film CEDE of 4.4 mSv (0.44 rem) from Pu-238, Pu-239, that they forgot they had an exposure in progress and and Pu-240, and (4) DDE of 27.0 mSv (2.70 rem) entered the high radiation area without making a from external radiation. survey and changed the film with the source in the unshielded exposed position. The radiographer had The State Agency discovered this incident during a received prior radiation safety training, however, the routine inspection on December 5,1995, and was technician, an employee of Ultron, Inc., had not initially reported to NRC in January 1996. During received prior radiation safety training. The radiog-a follow-up inspection, the State Agency leamed raphy film and the device used to suppon the source thzt another Cm-244 incident took place and was and the film during exposures were being supplied to significant. The State Agency also learned of other the radiographer by Ultron,Inc.

exposure incidents that indicated the licensee had a deficient contamination control program, an inabil- Consequently, bc'h individuals received unintended ity to conduct internal dose assessments, and radiation exposure. The State Agency estimated inadequate management oversight. The State that the radiographer received a dose of 530 provided additional information on these events to millisievert (mSv)(53 rem) to his head and 48 mSv NRC in 1997. (4.8 rem) to the center of his body and the Ultron, NUREG-1272, Vol. I1, No. 2 B-2

Nuclear Materials Inc., technician received a dose of 110 mSv (11 Report No. AS 97-3 rem) to his head and 28 mSv (2.8 rem) to the center of his body. Neither individual reported any acute Radiopharmaceutical radiation symptoms. Misadministration at Mad River Re radiography film supplied by Ultron, Inc., had Community Hospital in Arcata, faster and different exposure characteristics than the Caliform,a film usually used by Certified Testing and thus was On February 28,1996, a patient was prescribed a being overexposed during processing in the dark-dosage of 3.7 megabecquerel(MBq)(0.1 millicu-room. The darkroom, which was supplied by rie [ mci]) of iodine-131 (I-131) for a thyroid scan Certified Testmg, utilized a homemade " safe light,"

and uptake procedure. However, the patient was which had been made a safe light by the application administered a dosage of 262.7 MBq (7.1 mci) of of red spray paint. The radiographer did not realize I-131. As a result, the patient's thyroid received a beforehand that the light would not be " safe" for dose of about 9100 centigray (cGy) (9100 rad), I the film supplied by Ultron,Inc.

instead of the prescribed dose of 130 sGy (130 The radiographer entered a designated high radia. rad). The wrong dosage was administered on tion area with his alarm ratemeter turned off and the assumption that the patient was prescribed a without following his normal practice of cranking whole body thyroid scan for a cancer metastatic in the source and surveying the guide tube and disease evaluation.

camera. The radiographer interpreted the silence The licensee stated that such a dose may induce a from the alarm ratemeter as an mdication of safe hypothyroid state requiring the patient to take l conditions. Unfortunately, when turned off, the thyroid honnone. Procedures for scheduling a alarm ratemeter gives the same indication as it does whole body scan for thyroid cancer metastases were when mdicating safe conditions. In addition, the revised to include a detailed patient preparation and radiographer did not utilize a collimator to reduce the exposure to himself and the Ultron,Inc., history. The revised procedures required that the technician' approving radiologist sign the I-131 administration policy before ordering a radiopharmaceutical. In The licensee stated that the radiographer did not addition, the nuclear medicine technologist attended develop any symptom of acute radiation exposure a continuing education program at San Francisco and that its personnel were reinstructed in the General Hospital, which included a segment on the importance of performing surveys and using a effects of studies involving therapy dosages.

collimator. The licensee committed to the State

' Agency to verify the training of all t:chnicians, The State Agency conducted numerous follow-up including those of the company that hires 'he in5Pections to ensure that the licensee's actions licensee to perform radiography. taken to prevent recurrence had been implemented.

The State Agency cited the Licensee for the follow- Report No. AS 97-4 ing four violations: (1) excessive exposure to a radiation worker, (2) excessive exposure to a RadioPharmaceutical member of the public (the Ultron,Inc., technician Misadministration ^' Toomey representative), (3) failure to prevent unauthorized Regional Medical C r er in Sumter, entry into the High Radiation Area, and (4) failure South Carolina to exercise ALARA by using a collimator. A civil penalty was considered but not imposed. The State On December 11,1996, a patient was prescribed Agency recommended that both individuals contact a dose of 74 megabecquerel(MBq)(2.0 millicurie the State and seek medical attention if any symp- [ mci]) of iodine-131 (1-131) for a treatmer.t toms of acute exposure should appear. of Graves disease. However, the patient was B-3 Appendix B

1997 AEOD Annual Report administered a 388.5 MBq (10.5 mci) dosage of The licensee will have the written order on hand I-131. As a result, the patient's thyroid received a before ordering radiopharmaceuticals from the dose of 40,400 centigray (cGy)(40,400 rad) pharmacy and will have a second person verify the

- instead of the prescribed dose of 7700 cGy (7700 dosage before administration to the patient.

rad). The wrong dosage was administered to the patient because the written order for the I-131 The State Agency accepted the licensee's report and procedure was misread by the administering corrective action as appropriate. No further action technologist. was requested.

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j APPENDIX C

, Reports and Videotapes issued From 1981 Through 1997 4

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Nuclear Materials Reports and Videotapes Issued from 1981 Through 1997 Date Title No. Author Nuclear Materials Reports Issued in 1995  :

I SpecialStudies 08/95 Human Performance Evaluation of Industrial INEL-95/0387 S. Pettijohn Radiography Exposure Events

)

07/95 Misadministrations and Other Medical Events Memorandum to H. Karagiannis D.A. Cool from Caused by Computer Errors C.E. Rossi Nuclear Materials Reports Issued in 1994 Mdeotapes 04/94 Taking Control - Safety Procedures for -

S.Pettijohn Industrial Radiographers Nuclear Materials Reports Issued in 1993 Videotapes 04/93 Good Practices in Cobalt-60 Teletherapy -

H. Karagiannis i 1

Nuclear Materials Reports Issued in 1992 j Engineering Evaltations 08/92 Repon on 1991 Nonreactor Events NUREG-1272, K. Black Vol.6,

! No.2, App. A C-1 Appendix C

1997 AEOD Annual Report Date Title No. Author Nuclear Materials Reports issued in 1992 (cont.)

Engineering Evaluations (cont.)

08/92 Report on 1991 NRC Licensee NUREG-1272 H. Karagiannis Misadministrations Vol. 6, No. 2. App. B 08/92 Report on 1991 Agreement State NUREG-1272 H. Karagiannis Licensee Nonreactor Events and Vol. 6, Misadministrations No. 2, App. C Nuclear Materials Reports issued in 1991 Engineering Evaluations 01/91 Brachytherapy Incidents Involving a N91-01 H. Karagiannis Handloading, Endobronchial Technique 07/91 Report on 1990 Nonreactor Events NUREG-1272 K. Black '

Vol.5, 1 No. 2, App. A 07/91 Medical Misadministration Report) Medical NUREG-1272 H. Karagiannis Misadministrations Reported to NRC From Vol. 5, January 1990 Through December 1990 No. 2. App. B Videotapes 02/91 Good Practices in Preparing and -

H. Karagianc.is Administering Radiopharmaceuticals Nuclear Materials Reports issued in 1990 Engineering Evaluations 06/90 Report on 1989 Nonreactor Events NUREG-1272 K. Black Vol.4, No. 2, App. A NURF.G-1272,Vol.11 No. 2 C-2

Nuclear Materials Date Title No. Author Nuclear Materials Reports Issued in 1990 (cont.)

Engineering Evaluations (cont.)

Po/90 Medical Misadministration Report) Medical NUREG-1272 H. Karagiannis Misadministrations reported to NRC From Vol.4, January 1989 Through December 1989 No. 2, App. B Nuclear Materials Reports Issued in 1989 l

Engineering Evaluations 06/89 Use of Radioactive Iodine for Infrequent Medical N901 H. Karagiannis Studies and those Performed Under an FDA Investigational Exemption of a New Drug (IND) l 06/89 Report on 1988 Nonreactor Events . NUREG-1272 K. Black ,

Vol.3,  !

No. 2, App. B  ;

l 06/89 Medical Misadministration Report ) Medical NUREG-1272 H. Karagiannis  !

lisadministrations Reported to NRC From Vol.3, l

.anuary 1988 Through December 1988 No. 2, App. B 05/89 Review of Therapy Misadministrations T908 K. Black That involved Multiple Patients and the Use of Computer Programs l

Nuclear Materials Reports Issued in 1988 Engineering Evaluations P

09/88 Review of Events at Large Pool-Type Irradiators S807 E. Trager (NUREG 1345, March 1989) 10/88 Report on 1987 Nonreactor Events N801 K. Black 10/88 Medical Misadministration Reported to NRC for N802 S. Pettijohn the Period Janua.ry Through December 1987 C-3 Appendix C

1997 AEOD Annual Report Date Title No. Author Nuclear Materials Reports Isyued in 1987 SpecialReports 10/87 Radiography Overexposure Events Involving S703 S. Pettijohn Industrial Field Radiography Engineering Evaluations 01/87 Diagnostic Misadministmtions Involving the N701 S. Pettijohn Administration of Millicurie Amounts ofIodine-131

03/87 Diagnostic Misadministrations Reported to NRC for N702 S. Pettijohn for the Period January 1986 Through December 1986 03/87 Report on 1986 Nonreactor Events N703 K. Black .

l TechnicalReview Reports 11/87 Review of Data on Teletherapy Misadministrations T711 S. Pettijohn Reported to the State of New York That Were the i

Title of PNO-1-87-74A 12/87 Distribution of Information Notices and Other T714 S. Pettijohn

" Mass Mailing" Information to Licensees That Have Users at Locations Remote From the Headquarters Locations Nuclear Materials Reports Issued in 1986 Case Studies 08/86 Rupture of an Iodine-f 25 Brachytherapy Source C601 S. Pettijohn at the University of Cincinnati Medical Center Engineering Evaluations ,

06/86 Report of 1985 Nonreactor Reponed and Five-Year N601 K. Black Assessment for 1981-1985 Reports i

NUREG-1272, Vol. I 1, No. 2 C-4

Nuclear Materials Date Title No. Author Nuclear Materials Reports Issued in 1986 (cont.)

Engineering Evaluations (cont.)

06/86 Medical Misadministrations Reported for 1985 and N602 S. Pettijohn Five-Year Assessment of 1981-1985 Nuclear Materials Reports Issued in 1985 Case Studies 12/85 Therapy Misadministrations Reponed to NRC C505 S. Pettijohn Pursuant to 10 CFR 35.42 05/85 Summary of the Nonreactor Event Repon Data N501 K. Black Base for the Period January Through June 1984 Engineering Evaluations 06/85 Summary of the Nonreactor Event Data Base for N502 K. Black the Period July Through December 1984 07/85 Repon on Medical Misadministrations for N503 S. Pettijohn January Through December 1984 Nuclear Materials Reports Issued in 1984 Case Studies 09/84 Breaching of the Encapsulation of Sealed C405 S. Pettijohn Well-Logging Sources 05/84 Report on Medical Misadministrations for N204D S. Pettijohn January Through June 1983 06/84 Nonreactor Event Repon Database for the Period N401 K. Black July Through December 1983 C-5 Appendix C

1997 AEOD Annual Repott Date Title No. Author Nuclear Materials Reports Issued in 1984 (cont.)

Case Studies (cont.)

06/84 Events Involving Undetected Unavailability of the N402 E. Trager Turbine-Driven Auxiliary FeedwaterTrain 07/84 Report on Medical Misadministrations for N403 S. Pettijohn July Through December 1983 Nuclear Materials Reports Issued in 1983 Engineering Eraluations and Technical Reviews 01/83 Nonreactor Event Report Database for the N209A E. Trager Period January Through June 1982 03/83 I-125/I-131 Effluent Releases by Material Licensees N301 S. Pettijohn 06/83 Mound Laboratory Fabricated Pu-Be Sources N302 K. Black 06/83 Americium Contamination Resulting From N303 K. Black Rupture of Well-Logging Sources 06/83 Nonreactor Event Report Database From N209B K. Black July Through December 1982 07/83 Americium-241 Sources N304 07/83 Report on Medical Misadministrations for N204C S. Pettijohn 1 January 1981 Through December 1982 l 12/83 Potentially Leaking Americium-241 Sources N3% , S. Pettijohn Manufactured by Amersham Corporation 12/83 Nonreactor Event Report Database for the N307 K. Black Period January Through June 1983 i 03/83 Internal Exposure to Am-241 NT301 K. Black l

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Nuclear Materials l

s Date Title No. Author Nuclear Materials Reports Issued in 1983 (cont.)

Engineering Evaluations and Technical Reviews (cont.)

04/83 KayRay, Inc. Reports of Suspected Leakir.; NT302 S. Pettijohn Sealed Sources Manufactured by General Radioisotope Products 08/83 Possession of Unauthorized Sealed Source / Exposure NT303 S. Pettijohn -

Device Combinations by MidCon Inspection Services, Inc.

Nuclear Materials Reports Issued in 1982 l Engineering Evaluations 02/82 Report on Medical Misadministrations for the N201 S. Pettijohn Period November 10,1980-September 30,1981 l 01/82 Buildup of Uranium-Bearing Sludge in Waste Tanks N202 K. Black 02/82 Lost Plutonium-238 Source N203 K. Black 03/82 Report on Medical Misadministrations for CY 1981 N204 S. Pettijohn 04/82 Preliminary AEOD Review ofIodine-125 Scaled N205 E. Trager Source Leakage Incidents 05/82 Eberline Instrument Corporation Part 21 Report N2% K. Black 05/82 AEOD Review ofIodine-125 Scaled Source N207 E. Trager  !

I.cakage Incidents l

l 08/82 Potentially Leaking Plutonium-Beryllium N208 S. Pettijohn '

Neutron Sources 08/82 A Summary of the Nonreactor Event Report N209 K. Black Data Base for 1981 11/82 Leaking Hoses on Self-Contained Breathing N210 K. Black i Apparatus (SCBA) Manufactured by MS A l l

l C-7 Appendix C

1997 AEOD Annual Report Date Title No. Author Nuclear Materials Reports Issued in 1981 Engineering Evaluations 03/81 Interim Report on Brown Boveri Betatron N101 E. Trager Calibration Check Source 03/81 Irradiator Incident at an Agreement State Facility N102 K. Black (Becton-Dickinson, Broken Bow, Nebraska) 04/81 Interim Report on the October 1980 Fire at the N103 E. Trager Licensee's Sweetwater Uranium Mill 04/81 Interim Report on the January 2,1981, Fire at N104 E. Trager the Atlas Uranium Mill 05/81 Interim Report on Tailings Impoundment Liner N105 E. Trager Failure at the Sweetwater Uranium Mill 08/81 Review of Reports of Leaking Radioactive Sources N106 E. Trager ,

i 12/81 Engineering Evaluation of Fire Protection at N107 E. Trager Nonreactor Facilities 12/81 Notes on AEOD Review of Emissions From Tritium N108 E. Trager Manufacturing and Distribution Licensees NUREG-1272, Vol. I1, No. 2 C-8

. . . . . _ . . . _ _. . _ ____. _ _ . . . _ . . . _ _ . _ _ _ . _ _ _ _ _ . _ _ . . . . _ _ . . _ . _ . _ _ . ~

APPENDIX D Status of AEOD Recommendations I

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Nuclear Materials l l STATUS OF AEOD RECOMMENDATIONS The Office for Analysis and Evaluation of Opera- AEOD recommendations regarding nuclear materi-tional Data (AEOD) tracking system ensures that als activities are unresolved that warrant the atten-all formal AEOD recommendations are tracked tion of the Executive Director for Operations.

until resolution. At this time, no issues involving 1

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APPENDIX E l l

Status of NRC Staff Actions for Events Investigated by Incident Investigation Teams

Nuclear Materials STATUS OF NRC STAFF ACTIONS FOR EVENTS INVESTIGATED BY INCIDENT INVESTIGATION TEAMS (NUCLEAR MATERIALS)

In accordance with NRC Management Directive adegaacy of the actions taken by the responsible 8.3, "NRC Incident Investigation Program," dated office (s), and documenting the resolution of all staff August 12,1992, the Executive director for Opera- actions.

tions (EDO) shall, upon receipt of an Incident .

Investigation Team (IIT) report, identify and assign This appendix provides the status or disposition, NRC office responsibilities for generic and plant- al ng with appropriate ref;rences, for each of the specific actions resulting from the investigation that NRC staff action items ** at the EDO assigned to the are safety significant and warrant additional atten- vari us NRC offices Gat were not documented as tion or action. Office Directors designated by the ms lved in previou', AEOD Annual Reports on Nuclear Material,. Included are actions associated EDO as having responsibility for the resolution of

• 1 e MPons on se M1 event at General issues or concerns are responsible for providing written status reports on the disposition of assigned Electric Nuclear Fuels Component Manufacturing actions. AEOD is responsible for monitoring the Facility and the 1992 event at the Indiana Regional Cancer Center.

status of assigned staff actions, evaluating the E-iii Appendix E

I Nuclear Materials Action Source: IIT Repon on the " Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991," NUREG-1450, dated August 1991 l

(Reference 1).  !

Item 1: Adequacy of Criticality Safety Reviews Action (a): Evaluate existing regulatory requirements, guidance, and review standards for enticality safety analyses of fuel facility licensees to modify processes, procedures, and facilities and develop new regulatory guidance, requirements, and review standards. (Responsible Office:

NMSS/RES) l Status: Ongoing i The NMSS Division of Fuel Cycle Safety and Safeguards (FCSS) developed an action plan (SECY-93-128) that presented an integrated approach to revamping the regulations and l guidance for fuel facility licensing and developing a Standard Review Plan (SRP) for '

license reviews. As stated in SECY-93-128, FCSS is taking a fresh look at the fuel cycle facility regulatory, licensing, and inspection programs, emphasizing activities that will offer j the greatest and/or near-term safety benefit without placing undue burden on the licensees. '

Among the principal products of the effort, a revision of 10 CFR Part 70 and its supporting regulatory guidance, and issuance of a review standard in the form of an SRP is expected. ,

The review is expected to require performance of an Integrated Safety Analysis (ISA) for l the initial application and, as appropriate, reanalysis to suppen amendment of the applica- l tion or a 10 CFR 50.59-type process. Criticality safet) would im one pan of an ISA. The i activities, described above, supersede the recommendation to consider separate action on criticality safety.

Following the development of a draft revision to .0 CFR Pan 70 in March 1995, workshops were held in May and November 1995 to solicit comments and information from interested parties. Based on this input, six alternatives were developed and presented in SECY-96-079.

The staff is currently awaiting additional guidance from the Commission before proceeding.

Action (b): Evaluate the use of safety operating specifications for radiation and nuclear safety instru-ments and controls. (Respcnsible Office: NMSS)

Status: Ongoing The staff has evaluated the need for a requirement for licensees to include in their applica-tions technical specifications for nuclear safety instrumentation and controls and concluded that it is not warranted. Instead, the staff intends to address radiation and nuclear safety instrumentation and controls in the same manner as other safety-related structures, systems, and components.

Revision to 10 CFR Pan 70 and accompanying Standard Format and Content Guidance (SF&CG) for fuel cycle facility license applications will reflect this intent. It is expected that the planned revision to Pan 70 will require licensees to perform IS As. These IS As will allow determination of defects or failures which could lead to accidents. Once the ISAs are in place, licensees will have NRC-approved analyses that ideratify eouipment, personnel, and procedures needed to assure safety. The licensing project manager und the inspection staff will ensure that a licensee does not significantly change its ISA proces without NRC approval, and that the ISA is used on an ongoing basis to evalurae any chan) ts to the E-1 Appendix E

1997 AEOD Annual Report operations. The rule will make clear that the licensee can make changes to the facility, including the plant operations and equipment, without prior Commission approval, only under certain limited conditions that involve no additional risk. This rulemaking and associated guidance will address management control and oversight of safety-related i equipment and procedures, including assurance of reliability and availability, human factors j aspects, and training regarding safety significance and deviations from the licensee's safety )

basis standard (Reference 23). This staff action has been included in the action plan in SECY-93-128. This item is on hold pending further direction from the Commission.

Action (c): Evaluate the need to change the licensing practice of incorporating a license condition by  !

reference in fuel facility licenses. Ensure that the resultant licensing practice is mutually understood by all involved in the process. (Responsible Office: NMSS)

Status: Ongoing l l

The staff has been working with the fuel facility licensees during the amendment and renewal processes to include greater specificity in their application commitments. This addresses the deficiency of having vague commitments that are difficult to inspect or  ;

enforce. The revamping of the regulations and guidance for fuel facility licensing, discussed l in action (a) above, will provide a better regulatory base for obtaining better commitments.

Presently, NMSS is going through a review process with licensees in an affort to develop a better understanding with licensees concerning the objectives of the new Part 70 (Reference 23). This item is on hold pending funher direction from the Commission.

1 Action (d): Evaluate the existing NRC programs and develop new guidance for the inspection of i changes to criticality safety controls at fuel fabrication facilities. (Responsible Office:

NMSS)

Status: Ongoing The staff determined that completion of this item was dependent on issuance of the new Part 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content of ISA documents. These will provide an improved basis for inspection guidance in this atea. NMSS is presently going through a review process with licensees in an effort to develop a better understanding with licensees concerning the objectives of the new Part 70.

Even though the new Part 70 has not been issued in final form FCSS staff has initiated actions to upgrade Manual Chapter 2600 and associated inspection procedures. Once the revised Pan 70 is issued in its final form, any additional required changes to the manual chapter or inspection proceduret will be initiated (Reference 23). This item is scheduled to be completed by December 30,1996.

Item 2: Adequacy of Facility Operational Safety Action (a): Upgrade existing inspection guidance related to management controls and oversight, including audits, personnel training, and procedure adequacy and compliance for major materials licensees. (Responsible Office: NMSS/RFS)

NUREG-1272, Vol. I 1, No. 2 E-2

Nuclear Materials Status: The staff determined that completion of this item was dependent on issuance of the revised Pan 70, the new SRP and associated SF&CG, and staff guidance documents conceming management controls and content ofISA documents. These will provide a more specific basis for improved inspection guidance. NMSS is presently going through a review process with licensees in an effort to develop a better understanding with licensees concerning the objectives of the new Part 70.

FCSS staff has initiated actions to upgrade Manual Chapter 2600 and associated inspection procedures even though new Part 70 has not been issued in final form. Once revised Pan 70 is issued in its final form, any additional required changes to the manual chapter or inspec-tion procedures will be initiated (Reference 23). This item is scheduled to be completed by December 30,1996.

Action (b): Determine the need for regulatory requirements, guidance, and standard review plans regarding management controls and oversight, including audits, personnel training, and procedural adequacy and compliance for major materials licensees. Conduct reviews or inspections at selected licensees to collect additional information on management controls and practices. If necessary, on the basis of these assessments, develop new guidance, requirements, and standards as appropriate. (Responsible Office: NMSS/RES/NRR)

Status: Ongoing in February 1992, the NMSS Materials Regulatory Task Force issued NUREG-1324, "Preposed Method for Regulating Major Materials Licensees," which se' fonh recommen-dations concerning deficiencies and needed improvements in licensing and regulation of major materials licensees. NUREG-1324 placed considerable emphasis on improving licensees' management controls because past incidents can be traced directly to breakdowns ,

in these controls. The staff was to analyze the costs and benefits of performing safety I analyses and preparing safety evaluation reports for initial materials licensint,, renewals, i and major amendment actions for the large materials plants.

The planned revision to 10 CFR Part 70, discussed in Action (a) above, will include re-quirements for management controls and oversight which are being addressed in detail in the SRP for review of applications for fuel cycle facility licenses, both in general and in chapters on specific topics, such as miclear criticality safety. The SF&CG, derived directly ,

from the SRP, will convey the details to the hcensees.  !

Policy and Guidance Directive (P&GD) FC 85-7, Revision 1;" Standard Review Plan for Applications for Type A Licenses of Broad Scope," was issued June 20,1994. ' Bis docu- l ment stresses the necessity of strong management controls and oversight to ensure that licensed activities in an extensive radioactive materials program are conducted properly.

The document also includes specific guidance on the duties and responsibilities of the l Radiation Safety Committee (RSC) and Radiation Safety Officer (RSO), to include imme-l diate termination of any activity that is a threat to public health and safety. As pan of the l l licensing process, licensees are requested to provide certification that the RSO understands and accepts all the responsibilities of the position. In addition, NUREG-1516, " Manage- j ment of Radioactive Matedal Safety Progmms at Medical Facilities," was published in l January 1995. This NUREG introduces the concept of the " management triangle" to l

l emphasize that three parties (executive management, the RSC, and the RSO) are respon-  ;

sible for providing effective oversight of the radiation safety program. '

E-3 Appendix E

i 1997 AEOD Annual Report The staff expects that review of this issue will be conducted as part of the overall Business l Process Re-engineering effort which will examine the licensing process. In the meantime, the revised licensing guidance, in addition to the revised inspection guidance contained in Manual Chapter 2800, is adequate to identify safety concerns for large materials licensees l (Reference 23). However, because of recent incidents at the National Institutes of Health l and Massachusetts Institute of Technology, the responsible office will keep this item open until a review and any needed revirJons of misting regulations and guidance are completed.

Action (c): Examine the overall inspection process for monitoring and collecting fuel facility safety j performance information. Include in the evaluation the merits of (1) a resident inspector l program; (2) more frequent inspections, including use of team inspections; (3) establish-l ment of a systematic performance appraisal and feedback program analogous to the Sys-l tems Assessment of Licensee Performance for 10 CFR Part 50 licensees. (Responsible Office: NMSS/NRR)

Status: Ongoing i

The staff determined that completion of this item was dependent on issuance of the revised Part 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content ofISA documents.

Part 70 is presently going through a review process with licensees in an effon to develop a better understanding with licensees conceming the objectives of new Part 70. Even though new Part 70 has not been issued in final form, FCSS staff has initiated actions to upgrade Manual Chapter 2600, Manual Chapter 2604, and their associated inspection procedures (Reference 23). Once revised Pan 70 is issued in its final form, any additional required ,

changes to the manual chapters or inspection procedures will be initiated. This item is )

scheduled to be completed by December 30,1996.

Item 4: Adequacy of Operating Experience Reviews Action (b): Reevaluate NRC operating experience review ,nd feedback program for fuel facilities.

Revise the program as appropriate. (Responsioie Office: NMSS)

Status: Ongoing The staff determined that completion of this item was dependent on issuance of the revised Pan 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content of ISA documents.

NMSS is presently going through a review process with licensees in an effort to develop a better understanding with licensees concerning the objectives of new Part 70. Even though new Part 70 has not been issued in final form, FCSS staff has initiated actions to upgrade Manual Chapter 2600 and associated inspection procedures. Once the revised Part 70 is issued in its final form, any additional required changes to the manual chapter or inspection procedures will be initiated (Reference 23). This item is scheduled to be completed by December 30,1996.

Action (c): Develop NRC inspection guidance for licensee event reponing and reviews for fuel facilities. Issue new guidance as appropriate. (Responsible Office: IGISS/AEOD)

Status: Ongoing l

NUREG-1272, Vol.11 No. 2 E-4

Nuclear Materials The staff determined that completion of this item was dependent on issuance of the revised Part 70, the new SRP and associated SF&CG, and staff guidance documents concerning management controls and content of ISA documents. NMSS is presently going through a

- )

review process with licensees in an effort to develop a better understanding with licensees i conceming the objectives of new Part 70. Even though new Part 70 has not been issued in final form. FCSS staff has initiated actions to upgrade Manual Chapter 2600 and associated inspection procedures (Reference 23). Once revised Part 70 is issued in its final form, any additional required changes to the manual chapter or inspection procedures will be initiated.

This item is scheduled to be completed by December 30,1996.

References:

1. NUREG-1450," Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991," August 1991.

2. Memorandum from J. Taylor to NRC staff," Staff Actions Resulting from the Investiga-tion of the Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991 (NUREG-1450)." August 13,1991.

3. Memorandum from E. Jordan to J. Taylor, " Staff Actions in Response to the Investiga-tion of the Potential Criticality Accident at the General Electric Nuclear Foel and Component Manufacturing Facility Findings" (NUREG-1450), September 6,1991.

4. Memorandum from R. Bemero to J. Taylor, " Staff Action Plan Responding to the l Investigation of the May 29,1991, Incident at the General Electric (GE) Nuclear Fuel and Component Manufacturing Facility" (NUREG-1450) September 9,1991.

5. Letter to S.D. Ebneter to W. Ogden, "NRC Incident Investigation Team Report Follow-up"(NUREG-1450), August 13,1991.

6. NRC Inspection Report No. 70-1113/91-0, August 12,1991.

Letter from J. Stohr to W. Ogden, " Management Meeting Summary," October 2,1991.

8. Letter from B. Wolfe (GE) to J. Taylor (NC), August 26,1991.

9. Letter from W. Ogden to J. Taylor, August 27,1991.

10. NRC Inspection Report No. 70-1113/91-04, December 23,1991.

I1. NRC Inspection Report No. 70-1113/91-09, January 15,1992.

12. NRC Inspection Report No. 70-1113/91-06, January 22,1992.

13. Regulatory Guide 3.67," Standard Format and Content for Emergency Plans for Fuel Cycle and Materials Facilities," January 1992.

14. Letter from G. Bidinger to T. P. Winslow, January 7,1992,

15. NRC Bulletin No. 91-01," Reporting Loss of Criticality Safety Controls," October 18, 1991.

16. NUREG-1324, " Proposed Method for Regulating Major Materials Licensees," dated February 1992.

E-5 Appendix E

1997 AEOD Annual Report

17. Memorandum from R. Bemero to J. Taylor," Staff Actions Resulting from the Investigation of the May 29,1991, Incident at General Electric (GE) Wilmington,"

dated September 29,1993.

18. Memorandum from R. Bernero to J. Taylor, " Completion of Item 1.F to General Electric Staff Action Plan, Response to Investigation of the May 29,1991, Incident at the Gen-eral Electric Nuclear Fuel and Component Manufacturing Facility" (NUREG-1450),

dated August 2,1993.

19. Memorandum from E. Jordan to R. Bernero, " Completion of Items 1.E and 2.D to General Electric Staff Action Plan, Response to Investigation of the May 29,1991, Incident at the General Electric Nuclear Fuel and Component Manufacturing Facility,"

dated September 13,1993.

20. Memorandum from R. Bernero to J. Taylor, " Completion of item 3.B to General Electric (GE) Staff Action Plan, Response to Investigation of the May 29,1991, incident at the GE Nuclear Fuel and Component Manufacturin; Facility"(NUREG-1450), dated December 2,1992.

21. Memorandum from R. Bemero through H. Thompson to J. Taylor, " Staff Actions Resulting From the Investigation of the Incident at General Electric Wilmington," dated October 6,1994.

22. Memorandum from E. Jordan to J. Taylor, " Staff Action Plan Responding to Investiga-tion of the May 29,1991, Incident at the General Electric (GE) Nuclear Fuel and Component Manufacturing Facility (NUREG-1450)," dated October 12,1994.

23. Memorandum from E. Q. Ten Eyck to S. Rubin, " Status of Staff Actions," dated ,

October 30,1995.

1 NUREG-1272, Vol. I1. No. 2 E-6  :

Nuclear Materials Action Source: IIT Repon on " Loss of an Iridium-192 Source and Therapy Misadmini.stration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16,1992 (NUREG-1480),"

dated March 12.1993 (Reference 1).

Item 1: Adequacy of Oncology Services Radiation Protection Program Action (b): Evaluate whether NRC regulations and guidance need to be modified to explicitly define the functions and responsibilities of the radiation safety officer (RSO) and the authorized user. (Responsible Office: NMSS)

Status: Ongoing Draft NUREG 1515 " Management of Radioactive Material Safety Programs at Medical Facilities," was distributed for peer review and discussed with the Advisory Committee on the Medical Uses of Isotopes at the November 1993 and May 1994 meetings. The NUREG was published for public comment in January 1995. The staff will evaluste the need to further define and provide guidance on the responsibilities of the RSO and authorized user during a major revision of Pan 35 tentatively scheduled for 1999 following review of the 4

National Academy of Sciences repon on NRC's medical use program. Additionally, Policy and Guidance Directive (P&GD) FC 85-7, " Standard Review Plan for Applications for Type A Licenses of Broad Scope," was published in June 1994. This provided guidance on the duties and responsibilities of the RSO and authorized users. (References 2&3)

Item 2: Adequacy of NRC Protocols for Informing 'he PuMic and Authorities of Radiation Expo-sures Resulting from Licensed Activities.

Action (b): Evaluate the need to funher define licensee responsibility for assessing radiation exposure and notifying members of the public and authorities. (Responsible Office: NMSS/NRR)

Status: Resolved (Pending AEOD Independent Review)

The staff received guidance from Office of General Counsel regarding the applicability of Pans 19 and 20 to licensees for assessing radiation exposure and notifying members of the public and authorities. A final rule, making minor ch;ying modifications to Pans 19 and 20 regarding repons to members of the public required by Part 20, was published on July 13,1995 (60 FR 36038) and became effective on August 14,1995. Additionally, MC 1302 and MD 8.10 were issued and provide additional guidance on notifying local authorities in response to an event involving the release of licensed material into the public domain. The Responsible Office considers this item resolved (Reference 2).

Item 3: Adequacy of Regulatory Oversight of Sealed Sources and Devices and Medical Licenses Action (a): Evaluate the need to update licensing and inspection guidance and nrquirement for high dose-rate (HDR) afterloaders. (Responsible Office: NMSS/RES)

Status: Ongoing The staff has undertaken several effons in this regard. A NRC Bulletin 93-01," Release of Patients After Brachytherapy Treatment With Remote Afterloader Devices," was sent to all remote afterloader users, imposing specific requirements including: the physical presence of the physician authorized user and physicist or RSO during patient treatments; device specific training; and patient surveys following treatment. Policy and Guidance Directive E-7 ,

Appendix E

1997 AEOD Annual Report 86-4 was revised to incorporate the requirements of the bulletin. A Temporary Instruction was issued to provide guidance on routine inspection of HDR afterloaders. In addition, contract efforts were undertaken for quality control / quality assurance plans for remote afterloaders and human factors evaluations related to brachytherapy. The results of these various efforts will be incorporated into a user-need memorandum to RES to revise Part 35.

Policy and Guidance Directive 86-4 is beinF revised and v"" be included as a module to Regulatory Guide 10.8, Revision 2. Training was providu a the regions on the guidance in P&GD 86-4 in September 1994. A brachytherapy issues paper, which included a discussion of the requirements for HDR afterloads, was prepared for discussion with the Advisory Committee on the Medical Uses ofIsotopes (ACMUI) and the regulated community. The comments received along with the contractor's findings will be evaluated and incorporated into the proposed revisions to 10 CFR Part 35, when indicated. (Reference 2)

Action (b): Evaluate the relative merits of a performance-based approach versus schooling or certifica-tion to verify the radiation safety knowledge of HDR afterloader users. (Responsible Office:

NMSS/NRR)

Status: Ongoing The staff will conduct an evaluation as requested and continue to discuss this issue with the ACMUI. The staff will incorporate this issue into the user need memorandum described in Action 3(a). above, as appropriate.

The staff's plan to evaluate all current training an i experience criteria will include a deter-mination regarding the relative merits of different training approaches to ensure that all users have adequate radiation safety knowledge. The staff plans to hold facilitated public workshops during the major revision of Part 35 to discuss this issue.

Action (d): Revise the inspection guidelines to trigger consideration for licensees whose programs have significantly expanded or changed. (Responsible Office: NMSS)

Status: Resolved (Pending AEOD independent review)

The staff revised the guidance in Manual Chapter 2800, "Matenals Inspection Program," to provide guidance on inspection of satellite facilities, field offices, and temporary job sites.

Policy and Guidance Directive 94-(M was issued June 21,1994 to provide guidance for the staff reviewers in identifying programs that have undergone significant growth and warrant on-site inspection.

The revised Manual Chapter 2800 was issued March 30,1995. The staff is developing additional guidance to assist the staffin review of applications requesting authorization for use of NRC licensed material at multiple facilities under one license. The Responsible Office considers this item resolved (Reference 2).

References:

1. NUREG-1480," Loss of an Iridium-192 Source and Therapy Misadministration at Indiana Regional Cancer Center, Indiana, Pennsylvania, on November 16,1992,"

February 1993.

NUREG-1272, Vol. I 1 No. 2 58

Nuclear Materials 2,

Memorandum from Elizabeth Q. Ten Eyck, Director, Division of fuel cycle Safety and  :

Safeguards, NMSS to Stuart D. Rubin, Chief, Diagnostic Evaluation and Incident Investigation Branch, Incident Response Division, AEOD, " Status of Staff Actions,"

dated October 30,1995.

3. Memorandum from Stewan D. Ebneter, Regional Administrator, to Edward L. Jordan, Director AEOD, " Status of Staff Actions," dated October 31,- 1995.

i l

l l

l l

l I

l i

l E-9 Appendix E

1997 AEOD Annual Report Action Source: IIT Repon on .he " Ingestion of Phosphoms-32 at Massachusetts Institute of Technology, Cambridge, Massachusetts, Identified on August 19,1995," NUREG-1535, dated Decem-ber 1995 (Reference 1).

Item 1: Security and Control of Radioactive Materials Action (a): Evaluate existing regulations, guidance, and standard review plans for security and control of radioactive materials as well as establishment of restricted, unrestricted, and controlled areas. Determine the need to develop new or revised standards, guidance, and regulations, as appropriate. (Responsible Office: NMSS/RES)

Status: Ongoing Action (b): Evaluate current regulations, guidance, and review standards with regard to accounting for and inventory of radioactive materials. Determine the need to develop requirements for inventory of material in use and additional guidance for accounting and inventory of unsealed byproduct materials in general. Develop and implement new or revised standards, guidance, and regulations, as appropriate. (kesponsible Office: NMSS/RES) i Status: Ongoing )

l Item 2: Adequacy of NRC's Events Databases i i

Action (ab Review current mechanisms for the collection, review, and dissemination of nuclear materi-als events and implement appropriate modifications. (Responsible Office: AEOD/ hiss)

Status: Ongoing Action (b): Review the Agreement States Program with regard to the compatibility of event reponing requirements and voluntary participation in providing event summaries for the NRC data base. Modify and revise, as appropriate. (Responsible Office: OSP/AEOD/NMSS)

Status: Ongoing Action (c): Evaluate the need to include similar international nuclear materials events in NRC's review ,

process. Develop mechanisms to collect and incorporate relevant information, as appropri-ate. (Responsible Office: AEOD/OIP)

Status: Ongoing Item 3: Reporting Requirements Action (a): Evaluate current regulations and guidance regarding the reporting ofinternal con-tamination and modify, as appropriate. (Responsible Office: RES/NMSS)

Status: Ongoing Item 4: Management Oversight Action (a): Evaluate existing regulations, guidance and review standards for management oversight of broad scope licensed programs with regard to the roles of the radiation safety officer, the radiation protection committee, supervision, and the authorized user, as well as the use of audits. Develop new or revised guidance, standards and regulations, as needed. (Respon-sible Office: NMSS/RES)

NUREO-1272, Vol. I 1, No. 2 E-10  ;

Nuclear Materials Status: Ongoing Action (b): Evaluate the need to put the guidance provided in Draft Regulatory Guide DG-0005 in the regulations in Part 33 and/or Part 30. Develop and implement appropriate policy to ensure that cmsistent application of the requirements is achieved and finalize the Regulatory Guide, as appropriate. (Responsible Office: NMSS/RES)

Status: Ongoing Item 5: Adequacy of NRC's Guidance and Procedures for NRC Response Action (a): Evaluate the adequacy of procedures and guidance for conduct of an Augmented Inspection l Team. Issue, if appropriate, revised procedures or modify the Management Directive to

! cover exit and entrance interviews, exchange of information with the individuals, use of transcribed interviews, media coverage and decisions to recommend that an AIT should be l upgraded to an IIT. (responsible Office: AEOD/NRR) l Status: Ongoing i

Action (b): Evaluate the adequacy of guidance for chanering IITs and AITs for events involving l deliberate acts. In particular evaluate the adequacy of guidance for interfacing with criminal investigations (Office of Investigations, State or Federal law enforcement, and local or l private police). Issue, if appropriate, revised procedures and guidance for IITs and AITs.

l (Responsible Office: AEOD)

Status: Ongoing l l l Item 6: Adequacy of NRC's Guidance and Procedures for Licensee Response to Intakes of Radio-active Material by Individuals l

l Action (a): Evaluate the adequacy of regulatory guidance for collecting data to analyze intakes of l radioactive materials, for analyzing fetal dose based upon matemal intake, for licensees seeking outside medical expenise, and for NRC staff who monitor the licensee's analysis of an intake. Issue revised guidance and procedures, as appropriate. (Responsible Office:

NMSS/RES) t l Status: Ongoing i

I

References:

1. NUREG-153.1," Ingestion of Phosphorus-32 at Massachusetts Institute of Technology, Cambridge, Massachusetts, Identified on August 19,1995," December 1995.

I l

E-11 Appendix E l

I

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

NRC FORM 335 U.S NUCLEutI.EGUtATORYCOMMISsCN 1, REPORT NUMSER 1102, 3 2 .8202 Nurr rs. It 31y)

!!!LIOGRAPHIC DATA SHEET (see ==trucsorm on e= r. =rs.) NUREG-1272 a nu mD SUenu Vol.11, No. 2

3. DATE REPORT PUBUSHED Office for Analysis and Evaluation of Operational Data 1997 Annual Report WNN YEAR l

November 1998 4 FIN OR GRANT NUMBER

6. AUTHOR (5)

6. TYPE OF REPORT

7. PERCD COVERED (inclussve Dates) l FY 1997 on, .no m.ung aoaree.. . coniraciar.

a nRr.ORMm ORGmu.c - NAue mD ADDRESS S NRC. provios Dwimm Oruce or Region u s. rw..t R.guiatc,y Comm

- .r_..Mr_uno _) l Office for Analysis and Evaluation Operational Data U.S. Nucleat Regulatory Commission Washington, DC 20555-0001 9- 6FONSORING ORGANiZATON - NAME AND ADDRESS Of NRC, type *Same as above"; d cortracsor, provice NRC Dwison, Orbce or Regiork U.S. Nucsoar Reguatory Commismon, and rnalmg address.)

Same as in item 8

10. SUPPLEMENTARY NOTES

11. ABSYRACT 900 words or less)

This annual report of the U.S. Nuclear Regulatory Commission's Office for Analysis and Evaluation of Operational Data (AEOD) describes activities conducted during 1997. The report is published in three parts. NUREG-1272, Vol 11, No.1, covers power reactors and presents an overview of the operating experience of the nuclear power industry from the NRC perspective, including comments about trends of some key performance measures. The re-port also includes the principal findings and issues identified in AEOD studies over the past year and summarizes information from such sources as licensee event reports and reports to the NRC's Opmtions Center. I NUREG-1272, Vol.11, No. 2, covers nuclear materials and presents a review of the evnts and concerns durmg i 1997 associated with the use of licensed material in nonreactor applications, such as personnel overexposures and  ;

medical misadministrations. Both reports also contain a discussion of the Incident Investigation Team program and ,

summarizes both the Incident Investigation Team and Augmented Inspection Team reports Each volume contains I a list of the AEOD reports issued from CY 1980 :hrough 1997. NUREG-1272, Vol.11, No. 3, covers technical training and presents the activities of the Technical Training Center in support of the NRC's mission in 1997.

12 KEY WLNSCRIPTORS (Last worcs or phrases that will assist researeners m iocating the report) 13 AVAILABlUTYSTATEMENT nuclear materials nonreactors non-power reactors Unlimited Nuclear Materials Events medical misadministration radiation exposure u sECuRnvCt4ssrceoN Database radiation exposure loss of control of (n= rano leaking sources release of material licensed material Unclassified transportation events equipment problems fuelcycle facility <n . upon, test, research, and training abnormal occurrences operating experience Unclassified

! reactor incident response NRC staff actions 13 uu ,BeRO,gA m i Incident Investigation AEOD recommendations AEOD reports

' Program AEOD studies Operating Center Data Committee to Review Generic emergency response gaseous diffusion 16 PRCE Requirements NRc roRM ass p-w)

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