ML20202C205

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Forwards Insp Rept 30-01214/97-01 on 971016-1114.No Violations Noted.Two Apparent Violations Being Considered for Escalated Enforcement Action IAW General Statement of Policy & Procedure for NRC Enforcement Actions
ML20202C205
Person / Time
Site: 03001214
Issue date: 11/26/1997
From: Scarano R
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To: Cullen S
VETERANS ADMIN. MEDICAL CENTER, SAN FRANCISCO, CA
Shared Package
ML20202C209 List:
References
30-01214-97-01, 30-1214-97-1, EA-97-529, NUDOCS 9712030283
Download: ML20202C205 (5)


See also: IR 07100016/2011014

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EA 97 529

Sheila Cullen

Actin 3 Medical Center Director

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4150 Clement Street

San Francisco, California 94121

SUBJECT: NRC INSPECTION REPORT 030-01214/97 01

Dear Ms. Cullen:

On October 27,1997, the NRC completed a special, anaounced inspection of licentad

activities at your f acility in San Francisco, California. The inspection was conducted in

response to an event involving the loss of a phosphorus 32 (P 32) source from your facility

that was reported to NRC on September 2,1997. The findings of the inspection were

discussed with you and other members of your staff on October 27,1997. Additionally, a

telephonic exit briefing was subsequently conducted with the Associate Medical Center

Director and Radiation Safety Officer on November 14,1997.

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

being considered for escalated enforcement action in accordance with the ' General

Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy),

NUREG 1600. These apparent violations involved: (1) the failure to verify that the

contents of a package containing three P 32 vials agreed with the packing list for the

shipment received and to survey the package for contamination before it was disposed to

normal trash; end (2) the unauthorized disposal of a single P 32 vial to normal,

non-radioactive trash. The apparent violations identified above are described in detail in the

onclosed report.

The inspection disclosed that on August 18,1997, a shipping package enclosing three

vials. each containing approximately 30S microcuries of P-32, was initially received,

opened, suiveyed, logged in, and the contents checked by radiation safety office staff.

The package was closed and a short timo lates transferred to a research laboratory where it

was re-opened by an authorized user. However, the authorized user failed to adequately

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check the shippinD records and contents of the package when it was opened and only two

of the three vials were removed. The package containing the third vial was then disposed

to normal trash whhout a radiation survey to determine that it was empty and free of

contamination. The package was apparently collected by a housekeeper and ultimately

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buried in a waste landfill. The third vial was. discovered missing on August 20,1997, and

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has not been recovered.

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November 26,1997

Department of Veterans Affairs

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Root causes of the event appeared to be a lack of attention to detail by the laboratory's

authorized user when checking the contents of packages received, and his lack of

knowledge about the requirement to survey packages before their disposal to normal trash.

Although these problems appear to have been limited to only one laboratory and authorized

user, the lack of control of licensed material in your facility is a radiation safety and

regulatory concern.

The circumstances surrounding the apparent violations, the significance of the issues, and

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the need for lasting and effective corrective action werc discussed with you during the exit

briefing on October 17,1997, and with the Associate Director on November 14,1997.

Your immediatc actions to promptly and properly respond to the event were noteworthy.

Follow up corrective actions included issuing a vloiation notice to the responsible

laboratory, conducting additional training of authorized users that emphasized the

importance of carefully checking the contents of packages when received and surveying

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packages before their disposal to normal trash, and making administrative changes to the

licensed program involving the receipt of radioactive material, it also appears that any

radiation exposeres received by licensee personnel and members of the public who handled

the " empty" package af ter it was released to normal trash were small and well below NRC

dose limits.

As a result, it may not be necessary to conduct a predecblonal enforcement conference in

order to enable the NRC to make an enforcement decision. However, a Notice of Violation

is not presently being issued for these inspection findings. Before the NRC makes its

enforcement decision, we are providing you an opportunity, within 30 days of the date of

this letter, to either (1) respond to the apparent violations addressed in this inspection

report or (2) request, within 7 days of the date of this letter, a predecisionel enforcement

conference.

Your response should be clearly marked as a " Response to Apparent Violations in

inspection Report No. 030-012143/97 01 and should include for each apparent violation:

(1) the reason for the apparent violation, or, if contested, the basis for disputing the

apparent violation, (2) the corrective steps that have been taken and the results achieved,

(3) the corrective steps that will be taken to avoid further violations, and (4) the date when

tull compliance wi1 be achieved. Your response should be submitted under oath or

affirmation and may reference or include previous docketed correspondence, if the

correspondence adequately addresses the required response, if an adequate response is

not received within the time specified or an extension of tirne has not been granted by the

NRC, the NRC will proceed with its enforcement decision or schedule a predecisional

enforcement conf erence.

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in presenting your corrective action, you should be aware that the promptness and

comprehensiveness of your actions w!;l be considered in assessing any civil penalty for the

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November 26,1997

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apparent violations. The guldance in the enclosed NRC Information Notice 96 28,

" SUGGESTED GUIDANCE REl.ATING TO DEVELOPMENT AND IMPLEMENTATION OF

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CORRECTIVE ACTION" may be helpful.

If you choose not to provide a response and would prefer participating in a predecisional

enforcement conference, please contact Dr. D. Blair Spitzberg at (81*i) 860 8191 within

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7 days of the date of this letter.

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In addition, please be advised that the number and characterization of apparent violations

described in the cnclosed inspection report may change as a result of further NRC review.

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

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matter.

In accordance with 10 CFR 2.700 of the NRC's " Rules of Practice," a copy of this letter,its

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enclosures, and your response (if you choose to provide one) will be placed in the NRC

Public Document Room (PDR). To the extent possible, your response should not include

any personal privacy, proprietary, or safeguards information so that it can be placed in the

POR without redaction.

Should you have any questions concerning this inspection or the enclosed report, please

contact Dr. Spit-berg at the telephone number noted above.

Sincerely,

) : __

Ross A. Scarano, Director

Division of Nuclear Materials Safety

Docket No.: 030-01214

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License No.: 0^-00421 -05

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Enclosures:

1. NRC Inspectinn Report 030-01214/97-01

2. NRC Enforcement Policy, NUREG 1600

3. NRC Information Non.e 96 28

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cc w/ enclosure 1:

California Radiation Control Program Director

Department of Veterans Affairs-

National Health Physics Program (115HP)

915 North Grand Boulevard

St. Louis, MO 63106

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November 26,1997

Edwin M. Leidholdt, Jr., Ph.D.

Radiation Safety Program Manager (134 RAD)

Department of Veterans Affairs

Western Region

301 Howard Street, Suits 700

San Francisco, CA 94105 2241

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