ML20203C514
| ML20203C514 | |
| Person / Time | |
|---|---|
| Issue date: | 01/06/1998 |
| From: | Mcgaffigan E NRC COMMISSION (OCM) |
| To: | Hoyle J NRC OFFICE OF THE SECRETARY (SECY) |
| Shared Package | |
| ML20203C441 | List: |
| References | |
| SECY-97-288-C, NUDOCS 9802250204 | |
| Download: ML20203C514 (12) | |
Text
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. NOT ATIO N VOTE RESPONSE SHEET TO: John C. Hoyle, Secretary FROM: COMMISSIONER MCGAFFIGAN
SUBJECT:
SECY-97-288 - REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 1997 Approved i Disnpproved Abstain Not Participating Request Discussion COMMENTS:
See attached comment and edited pages.
SIGNATURE
((lU()
Release Vote / V/ 4% 6.,/Md DATE(j U Withhold Vote / /
Entered on "AS" Yes No
- 282"!aRi748a' CORRESPONDENCE PDR
'7 5 $7 7 %)? O f/
4 Comminaioner McGaffiaan's Comments on SECY 97 288:
. I approve the proposed FY 1997 Abnormal Occurrence (AO) Report to Congress and the l proposed letters to Congress forwarding the AO Report subject to the edits indicated on the attached pages. I agree with the comments of Commissioner Dicus that the staff should modify Appendix C to include certain events involving the loss of control of licensed materials resulting in their entering the public domain. I also agree with the staff's approach as described in a note to the Commissioner Assistants dated January 2,1998 to include Agreement State AOs in the Eadatal Register notice for consistency with the annual report to Congress. Conforming changes to the AO report are indicated on the attached pages vill and x.
The H:n:rcble Albert J. Gore, Jr. "
President of the United States Senate 6 .e+1* W I[N' b Washington, D.C. 20510 ya , ; cA .
Dear Mr. President:
I am forwarding the U. S. Nuclear Regulatory Commission's (NRC's) Report to Congress on Abnormal Occurrences, Fiscal Year 1997" for events at nuclear facilities. These repcrts are required b of th4;y 80 Section abnormal208 of the(AO) occurrence Energy Reorganization is an unscheduled incident orAct eventofthat 1974 the (PL 93-438).
- x. In the conte Com'mTssion determines to be significant from the standpoint of public health or safety. The Federal Reports Elimination and Sunset Act of 1995 (PL 104-66) requires that AOs be reported to Congress annually. g, 4
The report addresses three AOs at acilities licensed or otherwise regulated by NRC. One AO involved an event at a nuclear po r and one involved an overexposure ( plant, one involved a brachytherapy misadministratio X two involved overexposure and tw involved radiopharmaceutical misadministrations. Recent X information about a previo ly repo ed AO is also included in this report.
d a w k e.t s.
Sincerely, Shirley Ann Jackson
Enclosure:
' Report to Congress on Abnormal Occurrences, Fiscal Year 1997" i
1 Insert:
"The report also addresses four AOs at facilities licensed by the Agreement States. Agreement States are those States that have entered into a formal agreement with NRC pursuant to Section 274 of the Atomic Energy Act (AEA) to regulate certain quantities of AEA material at facilities located within their borders. Currently, there are thirty Agreement States. Regarding the Agreement State AOs, ..
- ATTACHMENT 1 i
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The Honorable Newt Gingrich Speaker of the United States House of Representatives Washington. D.C. 20515
Dear Mr. Speaker:
I am forwarding the U. S. Nuclear Regulatory Commission's (NRC's)" Report to Congress on Abnormal Occurrences, Fiscal Year 1997" for events at nuclear facilities. These reports are requ' $}y Section 208 of the Energy Reorganization Act of 1974 (PL 93-438). In the context j oft af, an abnormal occurrence (AO) is an unscheduled incident or event that the <
Commission determines to be significant from the standpoint of public health or safety. The Federal Reports Elimination and Sunset Act of 1995 (PL 104-66) requires that AOs be reported to Congress annually. .
f-d ( wo<ka The report addresses three AOs atgacilities licensed or otherwise regulated by NRC. One AO involved an event at a nuclear power plant, one involved a brachytherapy misadministration, and one involved an overexposureP"egr AOs enLouiicd iiy iiiw Awownmra Stater re % dei b two involved overexposure and involved radiopharmaceutical misadministrations. Recent information about afrev' y reported AO is also included in this report.
J w.<he<S Sincerely, Shirley Ann Jackson
Enclosure:
" Report to Congress on Abnormal Occurrencea, Fiscal Year 1997" P9s w - Ssa 1
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PREFACE lNTRODUCTION Section 208 of the Energy Reorganization Act of 1974 (PL 93-438) identifies an abnormal occurrence (AO) as an unscheduled inc! dent or event that the Nuclear Regulatory Commission (NRC) determines to be significant from the standpoint of public health or safety. The Federal Reports Elimination and Sunset Act of 1995 (PL 104 66) requires that AOs be reported to Congress annually. This report includes those events that NRC determined to be AOs during fiscal year 1997.
NRC identifies an AO for the purpose of this report using the criteria in Appendix A. The criteria .
were initially promulgated in an NRC policy statement that was published in the Federal Realster on February 24,1977 (Vol. 42, No. 37, pages 1095010952). This policy statement was published before medicallicensees were required to report medical misadministrations to NRC, and few of the examples in the policy statement were applicable to these misadministrations. Therefore, in 1984, NRC adopted additional guidance for AO reporting of medical misadininistrations.
In 1996, NRC revised the AO criteria, including criteria for medical misadministrations, and published them in the Federal Reaister (December 19,1996: 61 FR 67072). Again in 1997, NRC revised these criteria to include AO criteria for gaseous diffusion plants and published them in the Federal Reaister (April 17,1997: 62 FR 18820). The events included in this report were determined to be AOs based on the 1997 revised AO criteria that are summarized in Appendix A. gy ,
To provide wide dissemination of information to the public, a Federal Real notice is issued cn events reported by facilities licensed by or otherwise regulated by NRCfthat have been %
determined to be AOs At a minimum, each nc,tice must contain the date and place of the occurrence and a description of its nature and probable consequences. Information on activities licensed by Agreement States is, publicly available at the State level. Copies of X the notice are distributed to the NRC Pubile Document Room (PDR) and all Local Pub!!c Document Rooms (LPDRs). Pote tial AOs reported by NRC licensees are placed in the PDR before NRC prept 4 the AO repo to Congress. PoteatM AOs identified by Agreement States are placed in the POR upon rece t by NRC via NRC's Regulatory information Distribution System.
cho NRC has determined that, of the inciderits and events reviewed for this reporting period, only those that are described in this report meet the criteria for reporting as AOs. Information r: ported for each AO ir.cludes the date and place, nature and probable consequences, cause or causes, and actions taken to prevent recurrence.
Appendix B presents recent information on previously reported AOs as it become , available.
Appendix C gives information on events that the Commission determines con oe of interest to Congress and the public. These events are not reportable as AOs but are provided as Other Events of interest."
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regulatory authority over byproduct, source, and special nuclear materials (in quantities not capable of sustaining a chain reaction). Agreement States must maintain programs that are adequate to protect public health and safety and compatible with the Commission's program for y such material. M , h wn. t g % t. S W ,
In eariy 1977, the Commission determined that events that meet the criteria for AOs occurring at Agreement State licensed facilities should be included in the periodic report to Congress. '
Agreement States report event information to NRC in accordance with c.cmpatibility criteria establisned by the Policy Statement on Adequacy and Compatibility of Agreement State ProDrams, published in the Federal Register (September 3,1997): 62 FR 46517. Procedures have been developed and implemented for the evaluation of material events to determine those that should be reported as AOs. AOs reported by the Agreement States to NRC are included in 1 the periodic report to CongressyThe AO criteria included in Appendix A are applied uniformly to events that occur at facilities ragulated by NRC and the Agreement States, wA L. fiaaxal b nom m J b gudL FOREIGN INFORMATION g g a p [.h r _& % 4 gM., .
NRC participates in an exchange of information with various foreign govemments that have nuclear facilities. This foreign information is reviewed and considered in the NRC's assessment of operating experience and in its research and regulatory activities. Reference to foreign information may occasionally be made in the AO reports to Congress; however, only domestic AOs are reported, u REOPENING OF CLOSED ABNORMAL OCCURRENCES NRC reopens previously closed AOs if significant new information about an AO becomes cvailable. Similarly, previously reported Other Events of interest" are updated if significant new information becomes available.
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(intake of radioactive material) to any individual organ or tissue other than the lens of the eye, bone marrow, and the gonads of 2500 mSv (250 rem) or more will be considered for reporting as an AO. In addition, Appendix A (see Criterion l.D.3,Other Events") of this report states that a serious deficiency in management or procedural controls in major areas will be considered for reporting as an AO.
l Date and Place Between January 1 and December 31,1995; Isotope Products Laboratories; Burbank, Califomia.
Nature and Probable Consecuences A radiochemist was assigned to make transuranic and other types of sources The transuranics utilized included the isotopes of plutonium 238 (Pu-238), Pu 239, Pu 240, americium 241 (Am-241), and curium 244 (Cm 244). During January 1995, while making a Cm 244 source, it was discovered that the exhaust fan of the fume hcod where the source was being fabricsted was not working. An analysis of room air samples confirmed the loss of Cm 244 into the working area.
Bioassay results disclosed that the fecal and urine samples provided by the radiochemist contained Cm 244 and Am 241. The licensee hired dosimetry and radiation protection consultants as directed by the State Agency. Careful analysis cf the bioassay data by these consultants, which ine!ude d - se summation and retrospective time correction for various intakes, suggested that during 1995 the radiochemist received a TEDE of 383.20 mSv (38.32 rom) and a CDE of 6900 mSv (690 rem) to the bone surfaces. The specific exposures were as follows: (1) comndtted effective dose equivalent (CEDE) of 271.8 mSv (27.18 rem) from Cm-244, (2) CEDE of 80 mSv (8 rem) from Am 241, (3) CEDE of 4.4 mSv (0.44 rem) from Pu-238, Pu 239, and Pu 240, and (4) DDE of 27.0 mSv (2.70 rem) from extema' radiation.
'K The State Agency discovered this incident during a routino inspection on December 5,199fcmt! wu)
During a follow up inspection, the State Agency leamed that another Cm 244 incident took
,4 fg place and was significant. The State Agency also leamed of other exposure incidents that I t
indicated the licensee had a deficient contamination control program, an inability to conduct b #"/*
intemal dose assessments, and inadequate management oversight. JA 5%.
%%L AQM @ m h- mb b M c. k i m , utt 4 Gwse or Causea The licdns@ee's radiation protection program7was O-inadequate important elements needed to ensure the radiation safety ofits workers. Some of these inadequacies were the lack of ( y work permits, (2) glove boxes for certain types of work, and (3) radiation procedural controls.
Actions Taken to Prevent Recurrence Licensee - After the licensee's consultants conducted their review and comprehensive audit of the existing radiation protection program, they made recommendations to ensure future compliance with the license and regulations. The licensee hired a compettnt radiation safety officer, and the radiochemist was assigned duties that did not involve the handling or processing of radioactive materials.
State Acenev The State Agency completed its investigation and is committed to closely tracking the licensee's radiation protection program to ensure continued compliance.
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This event is closed for the purpose of this report.
AS 97 2 Overexoosure of a Radioaracher and an Untra!ned Teclaician at Wolf Creek Mine in Walker County. Alabama Appendix A (see Criterion I.A.1, "For All Licensees") of this report states that any unintended radiation exposure to an adult (any individual 18 years of age or older) resulting in an annual total effective dose equivalent (TEDE) of 250 millislevert (mSv) (25 rem) or more; or an annual sum of the deep dose equivalent (DDE) (extemal dose) and committed dose equivalent (CDE)
(intake of radioactive material) to any individual organ or tissue other than the lens of the eye, bone marrow, and the gonads of 2500 mSv (250 rem) or more will be considered for reporting as an AO. In addition, Appendix A (see Criterion I.D.3,"Othwr Events") of this report states that l a serious deficiency in management or procedural controls in major areas will be considered for reporting as an AO.
Date and Place July 1,1996; Wolf Creek Mine, Walker County, Alabama Nature and Probable Consequences - A rrfiographer, employed by Certified Testing and Inspection of Cottondale, Alabama, and a technician, employed by Ultron, Inc., of Mt. Vemon, Illinois, were performing industrial adiography at the Wolf Creek Mine in Walker County, Alabama, when they became so distracted by problems with excessively exposed film that they forgot they had an exposure in progress and entered the high radiation area without mcking a survey and changed the film with the sourcs in the unshielded exposed position. The radiographer had received prior radiation safety training, however, the technician, an employee of Ultron, Inc., had not received prior radiation safety training. The radiography film and the device used to support the source and the film during exposums were being supplied to the radiographer by Ultron, Inc.
Consequently, both individuals received unintended radiation exposure. The State Agency estimated that the radiographer received a dose of 530 millislevert (mSv) (b3 rem) to his head and 48 mSV (4.8 rem) to the center of his body and the Ultron, Inc., technician received a dose of 110 mSv (11 rem) to his head and 28 mSv (2.8 rem) to the center of his body. Neither individual reported any acub radiation symptoms.
The radiography film supplied by Ultron, Inc., had faster and different exposure c.baracteristics than the film usually used by Certified Testing and thus was being overexposed during processing in the darkroom. The darkroom, which was supplied by Certified Testing, utilized a homemade ' safe light," which had been made a safe light by the application of red spray paint.
The radiographer did not realize beforehand that the light would not be ' safe' for the film vupplied by Ultron, Inc.
Cause or ' ' dia The indtographer entered a designated high radiation area with his alarm ratemeter tumed off and without following his normal practice of cranking in the source and surveying the guide tube and e7mera. The radiographer interpreted the silence from the alarm ratemeter as an indication of safe conditions. Unfortunate when tumed e alarm
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l ratemeter gives the same indication as it does when indicating safe conditions, in addition, the redographer did not utilize a collimator to reduce the exposure to himself and the Ultron, Inc.,
tochtweien.
Adiana Talpn to Prevent Raourrence LlGADast The liconese stated that the radiographer did not develop any symptom of acute redation exposure and that its personnel were reinstructed in the importance of performing surveys and using a collimator. The licensee committed to the State Agency to verify the training of all technicians, inclueng those of the company that hires the licenste to perform radiography.
State Agency The State A0ency cited the Licensee for the following four violations: (1) excessive exposure to a re&stion worker, (2) exoossive exposure to a member of the public (the Ultron, Inc. technleian i+:::ree), (3) failure to prevent unauthortred entry into the High Radiauon Area, and (4) failure to exercise ALARA by using a collimator. A civil penalty was considered but not imposed. The State Agency recommended that both individuals contact the State and seek medical attention if any symptoms of acute exposure should appear.
This event is closed for the purpose of this report.
AS 97-3 Radionharmaceutical Minadministration at Mad River Community Hosphal in Arcata. Catfornia Appendx A (see Criterion IV, "For Medical Licensees") of tnis report states that a medical misadministration that results in a dcas that is equal to or greater than 10 gray (Gy) (1000 rad) to any organ (other than a makr portion of the bone marrow, to the lens of the eye, or to the . '
gonads) and represents a does or dosage that is at least 50 percent greater than that prescribed in a written directive will be considered for esporting as an AO,
'/. Data and Place February 8, kgg6; Mad River Community Ho Califomia. N I; Arcata, buh kk% &pJCnDwk G.
N Mure ble Conamquences A patient was prescribed a dosage of 3.7 megabecquerel '
(MBq) (0.1 millicurie (mci]) of iodme 131 (1 131) for a thyroid scan anu uptake procedure.
However, the petiant was administered a dosage of 262,7 MBq (7,1 mCl) of 1131. As a result, the patient's thyroid received a does of about 9100 contigray (cGy) (9100 red), instead of the rie 1 d dose of 130 cGy (D0 rad).
The licensee stated that such a does may induos a hypothyroid state requiring the patient to take thyroid hormone, C4Wat.orlauses The wrong dosage was administered on the assumption that the patient was prescribed a whole body thyroid scan for a cancer metastatic disease evaluation.
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limits of 10 CFR Part 100 or 5 times the dose limits of 10 CFR Part 50, Appendix A, General Design Cnterion (GDC) 19, could occur from a postulated transient or accident (e.g., loss of emergency core c.coling system, loss of control rod system),
B. Design or Safety Analysis Deficiency, Personnel Error, or Procedural or Administrative Inadequacy,
- 1. Discovery of a major condition not specifically considered in the safety analysis report (SAR) or TS that requires immediate remedial action.
- 2. Personnel error or procedural deficiencies that result in loss of plant capability to perform essential safety functions so that a release of radioactive materials, which could result in exceeding the dose limits of 10 CFR Part 100 or 5 times the dose limits of 10 CFR Part 50, Appendix A, GDC 19, could occur from a postulated transient or accident (e.g., loss of emergency core cooling system, loss of control rod system).
Ill. For Fuel Cycle Facilities A. A shutdown of the plant or portion of the plant resulting from a significant event and/or violation of a law, regulation, or a license / certificate condition.
B. A major condition or significant event not considered in the license / certificate that requires immediate remedial action.
C. A major condition or significant event that seriously compromises the ability of a safety system to perform !ts designated function that requires immediate remedial action to prevent a criticality, radiological or chemical process hazard.
IV. For Medical Licensees.
A medical misadministration that:
A. Results in a dose that is (1) equal to or preater than 1 gray (Gy) (100 rads) to a major portion of the bone marrow, to the 19ns of the eye, or to the pon*ds, g (2) equal to or greater than 10 Gy (1000 rads) to any other organ; and B. Represents either (1) a dose or dosage that is at least 50 percent greater tha JL-K that prescribed in a written directive g (2) a prescribed dose or dosage that (l) is ')
the wrong radiopharmaceutical,' or (ii) is delivered by the wrong route of administration, or (iii) is delivered to the wrong treatment site, or (iv) is delivered by the wrong treatment mode, or (v) is from a leaking source (s).
8 The wrong radopharmaceubcel as used in the O entenon for medical misadmnstratens refers to any tsdepharmaceubcal other than the one hated in the wnt.en directive or in the cincal procedures manual 14
I APPEilDIX B UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES During this reporting period, the following update of a previously reported abnormal occurrence (AO)is included in the report.
OTHER NRC LICENSEES 96-3 Medical Brachythernov Misadministration by Jose L Femindez. M D.. In Mavaa0ez.
Puerto Rico Thic AO was originally reported in fiscal year 1996, NUREG 0090, Vol.19, " Report to Congress on Abnormal Occurrences."
The AO criteria used for this event was based on the AO criteria that were effective in FY 1996, which stated that administering therapeutic radiation such that the actual dose is greater than 1.5 times the prescribed dose, or the event (regardless of any health effects) affects two or more patients at the same facility, should be considered an AO.
On January 14,1994, Dr. Fern &ndez acquired an eye app:ic Qr rievice, which contained a strontium 90 (Sr 90) source of approximately 3219 n,egabecquerel(87 millicurie) activity, from the estate of a deceased licensee in Mayaguez, Puerto Rico. (Eye applicator devices are used int the supplemental treatment of non-malignant growths on the nye after surgery is performed.) Because the eye applicator device was not calibrated properly, patients received unprescribed radiation dosos. The NRC medical consultant stated that the long term consequences of the misadministered radiation treatments to the 25 patients C.at received the highest dose could include: (1) increased risk of cataracts and (2) increased risk of infections, caused by severe thinning or ulceration of the sclera, which could cause blindness if not detected early and aggressively treated. No adverse health effects were reported during a Y. reexamination of seven of these 25 patients by Dr. Fem &ndez.gH owever, the NRC medical consultant indicated that the possible adverse consequences toJhese patients may not appear for a period of up to 10 years after irradiation, g .
W p b h c u ld W I
Dr. Femindez purchased the medical practice and the Sr 90 source from the estate of the deceased former licensee, Dr. Luis A. V&zquez of Mayag0ez, Puerto Rico. Consequently, Dr.
Femindez had the records of all of the administrations that were made, using the Sr-90 source, while it was licensed to Dr. V4zquez. In a letter to Dr. Femindez dated Ociober 28,1996, NRC confirmed with Dr. Femindez that he would preserve the patient records of the former licensee and perfomi a computer search to identify the patients who nere treated with the eye applicator.
The AO report is updated as follows:
The consultant hired by Dr. Femindez identified that 202 of the patients treated were involved in misadministratio 16
[M /nf & hM A in addition, NRC reviewed the records of administrations done by Dr. Luis A. Vizquez after September 1990 and identified 559 dose administrations in which 41 resulted in overdosM k misadministration. Dr. Fem 6ndez and the clinic, in possession of Dr. Vizquez' patient records, made all reasonable efforts to notify the patients involved in these misadministrations according to the requirements of 10 CFR 35.33 however,24 patients were not notified because of inaccurate information on the record, such as a wrong address or telephone number.
NRC compiled information on patients I eceived :/ dbb, misadministratio i y .
X Femindez and Dr. V&zquez and sent the information to the Commonwealth of Puerto Rico, Department of Health, which is considering follow up actions, including reminding the patients annually about the need to receive periodic eye exams by specialized physicians. On June 11, 1997, NRC issued a Notice of Violation and Proposed imposition of a Civil Penalty to Dr.
Feminder for the violations identified during NRC inspections that represented a significant lack of program oversight and careless disregard of regulatory requirements. Dr. Femindez paid the $8000 Civil Penalty, and on July 17,1997, filed an NRC Form 314, " Certificate of Disposition of Materials" requesting the termination of his license. Since Dr. Femendez disposed of the licensed materialin his possession, the NRC terminated his license on September 5,1997.
This event is closed for the purpose of this report.
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[pa ctow%, UNITED STATES ]1 8' "i j
NUCLE AR REGULATORY COMMISSION
.g t W ASHING 10N D C 205th 0001 6,* o ,,,, February 6. 1998 OFFICE OF THE stCatTAMV MEMORANDUM TO. L. Joseph Callan E c tive irector for Operations k- }h)(/
FROM: hn le, Secretary
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SUBJECT:
STAFF REQUIREMENTS - SECY 97 288 REPORT TO ,
CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 1997 The Commission has not approved the draft Report to Congress on Abnormal Occurrences for Fiscal Year 1997. As such, and based upon discussion with the staff, the staff should consider the following comments and resubmit the draft report for Commission approval.
The staff should clanfy the reasoning for listing event AO 97 2 and explain how the lens of the left eye received a dose of 100 rads greater than it would have received under a successful treatment when the displacement caused the source to move away from, rather than towards the left eye, The staff should provide clarification of its interpretation regarding criteria IV(a)(1).
That is, is the staff's interpretation of the enteria regarding the 100 rads delivered to the bone marrow, the lens of the eye, or to the gonads, a dose that is in addition to the dose these sites would have received in a successful treatment, or is this an absolute dose, regardless of the dose the site would have received in a successful treatment, if after review of the enteria and the facts reta;od to this event, the staff determines that this event does not meet the AO cnteria, this event should be removed from the revised AO report.
The staff should insert the following under Appendix C:
'During FY 1997, a number of events occurred involving the loss of control of licensed materials resulting in the materials entering the public domain in an uncontrolled manner, in some cases causing radioactive contamination or radiation exposures. Some of these events received media coverage, and in the case of at least one event, the NRC's oversight of the licensed material was the subject of correnondence exchanged between the NRC and a State health agency. Although not raeeting the AO criteria, the frequency of these types of events and the increased public interest and concem has caused the NRC to increase its attention on the issue of the loss of control of licensed materials. Therefore, this issue merits recognition in the report to Congress under Appendix C, 'Other Events of Interest,*
SECY NOTE: THIS SRM, SECY 97 288, AND THE COMMISSION VOTING RECORD CONTAINING THE VOTE SHEETS OF ALL COMMISSIONERS WILL BE MADE PUBLICLY AVAILABLE 5 WORKING DAYS FROM THE DATE OF THIS SRM.
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2 For illustration purposes, the following list includes some of the events involving loss of control l of licensed materials that occurred in FY 1997. This list is not allinclusive nor is there any intention to f outinely provide examples of these events in the future.
- 1. January 1997 - Melting of Am 241 source at White Salvage, Riply, TN. This event was responded to by the TN RCP.
- 2. March 1997 Co 60 contaminated steel plate found in PA ano traced to WCl, Inc steel millin OH. See PNO Ill 97 029 and EN 32021. Additional Co-60 contaminated steel plate was found in WV in September 1997 (see PNO-97 047) and traced to the same wholesale distnbuter that distobuted the steel in PA.
- 4. May 1997 Tntium exit signs at a demolition site removed to a private home.
One sign was disassembled resulting in contamination and personnel exposure (see PNO l 97-028).
- 5. August 1997 Contamination of Royal Green metal recycling plant in PA as a result of damage to Am-241 source in a shredder (see EN 3/d59 & PNO l 97-056).
In FY 1997, the Comrnission directed the staff to develop recommendations to address this problem. The staffs recommendations have been received by the Commission (SECY 97 273) and the Commission will provide direction to the staff on this matter in FY 1998." -
The following changes should be made to both letters provided in attachment 1 to the SECY paper.
- 1. In paragraph 1, line 4, capitalize the 'A' in 'Act '
- 2. In paragraph 2, line 3, insert 'of a worker' after ' overexposure' at the end of the c second sentence.
- 3. In paragraph 2,line 3, replace Four AOs submitted by the Agreement States are include:' with the following:
The report also addresses four AOs at facilities licensed by the Agreement States. Agreement States are those States that have entered into a formal agreement with NRC pursuant to Section 274 of the Atomic Energy Act (AEA) to regulate certain quantities of AEA material at facilities located within their borders. Currently, there are thirty Agreement States. Regarding the Agreement State AOs,
- 4. In paragraph 2, line 4, insert 'of workers or a member of the public' after
_ _ _ _ _ _ _ _ _ _ _ _ . J
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3 The following changes should be incorporated in the draft AO report.
- 1. On page viii. paragraph 4, line 2, insert 'or an Agreement State' after 'NRC.' In line 5, insert 'also' after 'is.'
- 2. On trae x, paragraph 1, add ' Currently there are thirty Agreement States ' at the end Li .he paragraph. In paragraph 2, line 8, insert 'and the Federal Reoisitt notice issued to provide wide tiissemination of information to the public' after
' Congress.'
- 3. On page 5, paragraph 2, last line, replace 'that localized skin cancer may develop' with 'for skin cancer to develop in the exposed area of the thumb.'
- 4. On page 6, paragraph 5, insert at the end of the first sentence 'and was initially reported to NRC in January 1996,' At tne end of the paragraph, ado 'The State provided additional information on these events to NRC in 1997.'
- 5. On page 7, last line, insert commas after 'unfortunately' and 'off.'
- 6. On page 8, in the Date and Place section of AO 97 3, add at the end 'The State initially reported this event to NRC in December 1996.'
- 7. On page 14, in item IV.B., change the roman numeral in parentheses near the end of the line to lower case.
- 8. On page 16, paragraph 3 under AO 96-3, line 6, delete 'unpresenbed' and insert
'in excess of the prescribed doses' at the end of the sentence after ' doses.' In line 11, ir ert a new sentence before 'However' which states 'The remaining 18 patients uH not be located.' Also on page 16 last line, insert 'the' after 'in' and put an 's' on 'misadministrations,'
- 9. On page 17 ?aragraph 1, line 2, replace ' overdosing' with ' overdoses that met the definition of a.' In paragraph 2, line 1, replace 'that' with 'who' and replace
' overdosing' with 'a.' Also, in line 1, insert '(overdoses)' after ' misadministration.'
(EDO) (SECY Suspense: 3/6/98)
The staff should provide a clearly defined set of enteria for events to be inciuded in Appendix C to be used in next year's report.
(EDO) (SECY Suspense: 6/1/98)
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l cc: Chairman Jackson Commissioner Dieus Commissioner Diaz Commissioner McGaffigan OGC CIO CFO OCA OlG Office Directors, Regions, ACRS, ACNW, ASLBP (via E* Mail)
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