ML20217N824
| ML20217N824 | |
| Person / Time | |
|---|---|
| Issue date: | 12/31/1997 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| References | |
| NUREG-1272, NUREG-1272-V10-N02, NUREG-1272-V10-N2, NUDOCS 9805050445 | |
| Download: ML20217N824 (136) | |
Text
{{#Wiki_filter:o s # sihti. 3 s( ); a N( )
! ANALYSIS and l
- EVALUATION of 1
~
LOPERATIONAL L :;n i
~, pJ'T.
- DATAL 1
rg , p , 4 t 1l l
, -{ : -
, a.. ,
v
.i vi i ANNUAL REPORT,1996 'J NUCLEAR MATERIALS l 9-L
.f
' 7, .
0
. y, , "r'
)
+ +jp
~
. !t c ', ;}: oi c '
7 r ' ' s i
,-. 4 t
+ >
' , 9805050445 971231 -
PDR NUREC 1272 R PDR
AVAILABILITY NOTICE Availability of Reference Materials Cited in NRC Publications Most documents cited in NRC publications will be available from one of the fo!!owing sources:
- 1. The NRC Public Document Room, 2120 L Street, NW., Lower Level, Washington, DC 20555-0001
- 2. The Superintendent of Documents, U.S. Government Printing Office, P. O. Box 37082 Washington, DC 20402-9328
- 3. The National Technical Information Service, Springfield. VA 22161-0002 Although the listing that follows represents the majority of documents cited in NRC publica-tions, it is not intended to be exhaustive.
Referenced documents available for inspection and copying for a fee from the NRC Public Document Room include NRC correspondence and internal NRC memoranda; NRC bulletins, circulars, information notices, inspection and investigation notices; licensee event reports; vendor reports and correspondence; Commission papers; and applicant and licensee docu-ments and correspondence. The following documents in the NUREG series are available for purchase from the Government Printing Office: formal NRC staff and contractor reports, NRC-sponsored conference pro-coedings, international agreement reports, grantee reports, and NRC booklets and bro-chures. Also available are regulatory guides, NRC regulations in the Code of Federal Regula-tions, and Nuclear Regulatory Commission issuances. Documents available from the National Technical Information Service include NUREG-series reports and technical reports prepared by other Federal agencies and reports prepared by the Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission. Documents available from public and special technical libraries include all open literature items, such as books, journal articles, and transactions. Federal Register notices, Federal and State legislation, and congressional reports can usually be obtained from these libraries. Documents such as theses, dissertations, foreign reports and translations, and non-NRC con-ference proceedings are available for purchase from the organization sponsoring the publica-tion cited. Single copies of NRC draft reports are available free, to the extent of supply, upon written request to the Office of Administration, Distribution and Mail Services Section, U.S. Nuclear Regulatory Commission, Washington DC 20555-0001. Copies of industry codes ar'd standards used in a substantive manner in the NRC regulatory process are maintained at the NRC Library, Two White Flint North 11545 Rockville Pike, Rock-ville, MD 20852-2738, for use by the public. Codes and standards are usually copyrighted and may be purchased from the originating organization or, if they are American National Standards, from the American National Standards Institute,1430 Broadway, New York, NY 10018-3308.
n .. ANALYSIS and EVALUATION of OPERATIONAL DATA A J h$4 y a ce {jj'l8Ai!"'"',
AVAILABILITY NOTICE Availability of Reference Materials Cited in NRC Publications Most documents cited in NRC publications will be available from one of the following sources:
- 1. The NRC Public Document Room, 2120 L Street, NW., Lower Level, Washington, DC 20555-0001
- 2. The Superintendent of Documents, U.S. Government Printing Office, F O. Box 37082, Washington, DC 20402-9328
- 3. The National Technical Information Service, Springfield, VA 22161-0002 Although the listing that folices represents the majority of documents cited in NRC publica-tions, it is not intended to be exhaustive.
Referenced documents available for inspection and copying for a fee from the NRC Public Document Room include NRC correspondence and internal NRC memoranda: NRC bulletins, circulars, information notices, inspection and investigation notices; licensee event reports; vendor reports and correspondence; Commission papers; and applicant and licensee docu-ments and correspondence. The following documents in the NUREG series are available for purchase from the Government Printing Office: formal NRC staff and contractor reports, NRC-sponsored conference pro-ceedings, international agreement reports, grantee reports, and NRC booklets and bro-chures. Also available are regulatory guides, NRC regulations in the Code of Federal Regula-tions, and Nuclear Regulatory Commission Issuances. Documents available from the National Technical information Service include NUREG-series reports and technical reports prepared by other Federal agencies and reports prepared by the Atomic Energy Commission, forerunner agency to the Nuclear Regulatory Commission. Documents available from public and special technical libraries include all open literature items, such as books, journal articles, and transactions. Federal Register notices, Federal and State legislation, and congressional reports can usually be obtained from these libraries. Documents such as theses, dissertations, foreign reports and translations, and non-NRC con-ference proceedings are available for purchase from the organization sponsoring the publica-tion cited. Single copies of NRC draft reports are available free, to the extent of supply, upon written request to the Office of Administration, Distribution and Mail Services Section, U.S. Nuclear Regulatory Commission, Washington DC 20555-0001. Copies of industry codes and standards used in a substantive manner in the NRC regulatory process are maintained at the NRC Library, Two White Flint North 11545 Rockville Pike, Rock-ville, MD 20852-2738, for use by the public. Codes and standards are usually copyrighted and may be purchased from the originating organization or, if they are American National Standarris, from the American National Standards Institute,1430 Broadway, New York, NY 10018-3308.
OFFICE FOR vm : u,. m s, . ANALYSIS and EVALUATION of OPERATIONAL DATA ,, 4 7 f 3:
.n jgx , .
p
++
q. m e.; u
~: ;
i im .
...s W .
,j...
40 ANNUAL REPORT,1996 jg j. . b %., - 4N ; ;;F ' ,~'
&g &
y3
&p 7
s
,;Q- r,;
E N . ad N G . u r G .]y
- n. -
./ I'l[ '
y3d2[
.sv. . .
1 ep a g: 9,'$h
~ ;g .
-4.17 3
- 5) r 9 i .'d kN .l4 . 4g {g- ,
'ff.
s s.
< <,l
.;. #. .:o - n o ,
f
.-l !
'A.'
y ii - p s,- ng v ' y., y&=, j;;. .,w m a;y a m% .g w
. pp
}
~
M* ; . if "Q g ( e [ ]} 'f[19 & j glf. 1 ew y',g ,El " u ,- W, o r o ,.. e il. l lg 4 . " ,5 00
, fi m, [ ,, ..
L , (y g . ., . G sw L 4
;y m n . .
vye wm c ,. o 4) b '
- S, J p,
?g y
+ + + + + + + ++++ $~gjjk'Tl ,x M"l/[fW g k,,,o / k U.S. NUCLEAR REGULATORY MSSION DECEMB ER 1997 wm kasws, wan w m'ymmmmyym, xn -w .q . m - c E E E E E E E EE E E E E M I
Previous Reports in Series The following semiannual or annual reports have been prepared by the Office for Analysis and Evaluation of Operational Data (AEOD).
- Semiannual Repon, January - June 1984, AEOD/S405, September 1984 e Semiannual Report, July - December 1984, AEOD/S502, April 1985 e Annual Report 1985, AEOD/S601, April 1986 e Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational Data 1986, NUREG-1272, AEOD/S701, May 1987 ,
l e Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational Data l 1987,NUREG-1272, AEOD/S804 l Vol. 2, No.1, Power Reactors, October 1988 ) Vol. 2, No. 2, Nonreactors, October 1988 l e Officefor Analysis and Evaluation of Operational Data 1988 Annual Report, NUREG-1272 l Vol. 3, No.1, Power Reactors, June 1989 f Vol. 3, No. 2, Nonreactors, June 1989 e Officefor Analysis and Evaluation ofOperational Data 1989 Annual Report, NUREG-1272 Vol. 4, No.1, Power Reactors, July 1990 Vol. 4, No. 2, Nonreactors, July 1990 e Officefor Analysis and Evaluation of Operational Data 1990 Annual Report, NUREG-1272 Vol. 5, No.1, Power Reactors, July 1991 Vol. 5, No. 2, Nonreactors, July 1991
- Officefor Analysis and Evaluation of Operational Data 1991 Annual Report, NUREG-1272 Vol. 6, No.1, Power Reactors, July 1992, Vol. 6, No. 2, Nonreactors, August 1992 e Officefor Analysis and Evaluation of Operational Data 1992 Annual Report, NUREG-1272 Vol. 7, No.1, Power Reactors, July 1993 Vol. 7, No. 2, Nonreactors, October 1993
- Officefor Analysis and Evaluation of Operational Data 1993 Annual Report, NUREG-1272 Vol. 8, No.1, Power Reactors, November 1994 Vol. 8, No. 2, Nuclear Materials, May 1995 e Officefor Analysis and Evaluation of Operational Data 1994-FY95 Annual Report, NUREG-1272 l Vol. 9. No.1, Power Reactors, July 1996 !
I Vol. 9, No. 2, Nuclear Materials, September 1996 Vol. 9, No. 3, Technical Training, September 1996 I l i i
ABSTRACT The United States (U.S.) Nuclear Regulatory and fiscal year 1995, NUREG-1272, Vol. 9, Commission's Office for Analysis and Nos.1-3. Evaluation of Operational Data (AEOD) has published repons ofits activities since 1984. This report, NUREG-1272, Vol.10, No. 2, The first report covered January through June of covers nuclear materials and presents a review 1984, and the second repon covered July of the events and concerns associated with the through December of 1984. After those first two use oflicensed material in applications other semiannual repons, AEOD published annual than power reactors. NUREG-1272, Vol.10, reports ofits activities from 1985 through 1993. No. 1, covers power reactors and presents an Beginning with the repon for 1986, AEOD overview of the fiscal year 1996 operating Annual Reports have been published as experience of the nuclear power industry from NUREG-1272. Beginning with the report for the NRC perspective. NUREG-1272, Vol.10, 1987, NUREG-1272 has been published in two No. 3, covers technical training and presents the pans, No. I covering power reactors and No. 2 activities of the Technical Training Center in covering nonreactors (changed to " nuclear support of the NRC's mission. Throughout these materials" with the 1993 report). AEOD reports, whenever information is presented for a changed its annual report from a calendar year calendar year, it is so designated. Fiscal year (CY) to a fiscal year report, and added part information is designated by the four digits of No. 3 covering technical training, beginning the fiscal year. with the combined Annual Repon for CY 1994 i l I I i NUREG-1272, Vol.10, No. 2 iii
CONTENTS Page A bstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i i i Abbrev iat ions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v ii Executive Summary ...............................................................ix 1 Introd uct ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... ........ I 2 Operating Experience Feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2.1 Nuclear Material Events Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2.2 Medical Misadministrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2.3 Radiation Overexposures ............................................... 7 2.4 Loss of Control of Licensed Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.5 Leaking Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2.6 Release of Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2.7 Transportation Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 I 2.8 Equipment Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 1 2.9 Fuel Cycle Facility Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.10 Test, Research, and Training Reactors .............................. . .. 13 2.11 Annual Radiation Exposure Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... 13 3 Abnormal Occurrences ................................................ ..... 17 3.1 Abnormal Occurrence Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.2 Abnormal Occurrence Report for 1996 ............................... ... 17 4 Other AEOD Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.1 Agreement State Operational Experience Data .......................... .. 19 4.2 Nuclear Material Events Database Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.3 Medical Misadministration Abnor tal Occurrence Criteria . . . . . . . . . . . . . . . . . . . . 19 5 Incident Response .......................................................... 21 5.1 NRC Operations Center ............................................... 21 5.2 Emergency Response ....... ......................................... 21 5.3 Operations Center Data for 1996 ........................ ............... 23 5.4 Emergency Exercises ................................................. 23 5.5 State Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 5.6 Coordination With Other Federal Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 5.7 Gaseous Diffusion Process Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 6 Incident Investigation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 6.1 Incident Investigation Team Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 6.2 Augmented Inspection Team Events ..................................... 29 7 Committee to Review Generic Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 NUREG-1272, Vol.10, No. 2 v
f ( Appendices A Nuclear Materials Data by Event Type B Summary of 1996 Abnormal Occurrences C Repons and Videotapes issued Frorn 1981 Through 1996 D Status of AEOD Recommendations E Status of NRC Staff Actions for Events Investigated by incident investigations Teams Tables 2.1 Reportable Nuclear Materials Events in 1996 by Event Type Submitted to the NRC and to Agreement States ..... ...... . ......... . .. . ... .. 5 2.2 Medical Misadministrations in 1996 Reported to the NRC and to Agreement States . . . . . . ... .. ... .. . ... ....... . ... . . .7 2.3 Radiation Overexposures in 1996 Reported to the NRC and to l Agreement States . . . ...... ... ....... . ... .. .. . . . .. . 8 l 2.4 Loss of Control of Material Events in 1996 Reported to the NRC and to Agreement States .. .. . ... . . . ..... . . ... . ... ...... ... 9 l 2.5 Equipruent Problems in 1996 Reported to the NRC and to Agreement States . .. .. .. . ... . ..... . .... . 12 l 2.6 Annual Exposure Data for NRC Industrial Radiography Licensees, Calendar Years 1989 to 1995 . .. . . . . . ... .. ... .... ....... ... 14 2.7 Annual Exposure Data for NRC Manufacturing and Distribution Licensees, l Calendar Years 1989 to 1995 . . ...... . ... .... .... . .. ....... ....... 14 l 2.8 Annual Exposure Data for NRC Low-Level Waste Disposal Licensees, i Calendar Years 1989 to 1995 . . . . .. ... . . . ..... ... .... . 14 l 2.9 Annual Exposure Data for NRC Independent Spent Fuel Storage Licensees, l Calendar Yean 1989 to 1995 . . .. ... .. . . .. . ... ....... . 15 2.10 Annual Exp0 'e Data fm NRC Fuel Fabrication and Processing Licensees, Calendar Yeats 1989 to l@S . . . . . . . . . . . . . ... . . ............... .. 15 l 3.1 Abnormal Occurrences at Nuclear Materials Licensees Reported in 1996 . . .... .. .. .... ... .. .... ...... . . . . 18 5.1 Events Reported to the NRC Operations Center in 1996 . .. ....... ... . . 24 5.2 Classification of Events Under Licensee Emergency Plans, Calendar Year l989 to Fiscal Year l996 .. . .. . . . . ....... ... . . 24 5.3 Alerts and Site Area Emergencies Reported at NRC-Licensed Facilities ! Other Than Power Reactors in 1996 . . . . . ... .... . . . ... . ... .. . 25 i l l I NUREG-1272, Vol.10, No. 2 vi
ABBREVIATIONS , ACMUI Advisory Committee on Medical Uses FR Federal Rerister ofIsotopes FRERP Federal Radiological Emergency AEOD Analysis and Evaluation of Response Plan Operational Data (NRC Office for) FRP Federal Response Plan AO abnormal occurrence ARG Accident Review Group gBq gigabecquerel GDP gaseous diffusion plant Bq becquerel GE General Electric Company BRC Bureau of Radiation Control (State of Texas) GL Generic Letter (NRC) Gy gray CAL Confirmatory Action Letter (NRC) cGy centigray llDR high-dose-rate CFR Code of Federal Regulations I iodine Ci curie IDNS lilinois Departmen of Nuclear Safety em centimeter IDOT lilinois Department of Transportation Co cobalt-60 IIP Incident Investigation Program CRGR Committee to Review Generic Requirements (NRC) IIT Incident Investigation Team cSv centisievert IN Information Notice CY calendar year in inches ISA integrated safety analysis DNA deoxyribonucleic acid MBq megabecquerel EDO Executive Director for Operations (NRC) mci millicuries MC Manual Chapter (NRC) FCSS Fuel Cycle Safety and Safeguards (NMSS Division of) NUREG-1272, Vol.10, No. 2 vii
ABBREVIATIONS (cont.) l MD Management Directive (NRC) REM radiation equivalent . nan MDI Many Diversified Interests, Inc. RES Nuclear Regulatory Research (NRC Omce of) MIT Massachusetts Institute of Technology RI Region I (NRC) mi milliliter RIl Region 11(NRC) mm millimeter Rlli Region 111(NRC) mrem millirem RIV Region IV (NRC) mSv millisievert RPC Radiation Protection Committee (MIT) Nal sodium iodide RPO Radiation Protection Omcer (MIT) NIST NationalInstitute of Standards and Technology RSO radiation safety officer NMED Nuclear Material Events Database RTM Response Technical Manual NMSS Nuclear Material Safety and Safeguards (NRC Office of) SF&CG standard format and content guidance NRC U.S. Nuclear Regulatory Commission SNM special nuclear material NRR Nuclear Reactor Regulation (NRC Sr strontium-90 Office of) l SRP Standard Review Plan l l OGC Office of the General Counsel (NRC) Sv sievert ORISE Oak ridge Institute for Science and Education TDH Texa Department of Health OSP Office of State Programs (NRC) TEDE total effective dose equivalent TRTR Test, Research, and Training Reactors P&GD policy and guidance directive U.S. Uniterd States QMP quality management program USEC United States Enrichment Corporation RCM Response Coordination Manual NUREG-1272, Vol.10, No. 2 viii
EXECUTIVE
SUMMARY
General Operating Experience Feedback The Office for Analysis and Evaluation of NRC and Agreement State nuclear materials Operational Data (AEOD) was created in 1979 licensees are required by Title 10 of the Code of to provide a strong, independent capability to FederalRegulations, comparable Agreement analyze and evaluate operational safety data State regulations, or license conditions, to associated with activities licensed by the United submit repons of events which meet established States (U.S.) Nuclear Regulatory Commission criteria. Reportable nuclear materials events (NRC). AEOD is also responsible for the NRC's include the following types: Incident Response Program, Incident Investigation Program, and Technical Training . medical misadministrations of radiation or Program. In addition AEOD provides radiopharmaceuticals to patients management direction and oversight of independent safety inspections, as well as . radiation overexposures administrative and technical support to the NRC's Committee to Review Generic . loss of control oflicensed material Requirements. AEOD also obtains industry feedback on these activities. . problems with equipment that uses licensed material or is otherwise associated with the The AEOD programs constitute the essential use oflicensed material independent review and assessment of power reactor and nuclear materials safety . releases of material or contamination performance, and complement the regional, the Office of Nuclear Reactor Regulation, and the . leaking radioactive sources Office of Nuclear Material Safety and Safeguards reviews of operating events. They . problems during the transportation of perform a quality verification function that licensed material provides assurance of feedback ofimponant operational safety lessons. AEOD findings and . problems occurring at fuel cycle facilities recommendations continue to be addressed through generic correspo. dence, in the . problems occurring in nonpower reactors resolution of generic issues, and in initiatives taken by industry. AEOD collects, reviews, and codes nuclear materials event information reported by NRC AEOD has published annual reports ofits licensees and Agreement States. In 1993 AEOD activities since 1985. AEOD changed its annual developed a new database, the Nuclear Material report from a calendar year (CY) to a fiscal year repon begmnm, g with the combmed Annual Events Database (NMED), that was designed to Report for CY 1994 and fiscal year 1995, allow multiple events m a single repon to be NUREG-1272, Vol. 9. This report, NUREG- appropriately recorded. For example, a report 1272, Vol.10, No. 2, presents a review of the may describe a loss of control of licensed events and concerns during 19% associated material and an overexposure. In such a case, with the use of licensed materials in applications both events would be recorded in the NMED other than power reactors. Throughout this and both would be identified by the same report report, whenever information is presented for a number. An interim, stand-alone version of the calendar year, it is so designated. Fiscal year NMED was distributed to the Agreement States information is designated by the four digits of in October 1994. Installation of the NMED the fiscal year. within NRC headquarters was completed in June 1996, and the NMED was distributed to NUREG-1272, Vol.10, No. 2 ix Executive Summary
AEOD Annut! Report,1996 Nuclear Materials June 1996, and the NMED was distributed to occupational overexposure events reponed by Agreement States in September 1996. both NRC and Agreement State licensees involved industrial radiography. Eighty-three Approximately 7,000 NRC licensees and 15,000 percent (29/35) of the overexposures were Agreement State licensees submit reports of whole-body doses ranging from 0.16 events. NRC licensees submit reports directly to centisievert (cSv)(0.16 rem) to 53 cSv (53 the NRC regional or headquarters offices. rem), with a median value less than 10 cSv (10 Agreement State licensees submit reports to the rem). The 53 cSv whole-body exposure was to a States, which in turn voluntarily transmit radiographer who forgot to retract the source summary reports to the NRC under an informal while replacing film for the next exposure. Two information sharing agreement. In 1996 the events caused multiple overexposures. One of NRC received 420 reposts describing 442 events these involved 22 members of the public when involving nuclear materials licensees and the source fnsm a stolen radiography camera nonpower reactors that were required to be became detac hed from the camera in a scrap reported under NRC or equivalent Agreement yard. The soure was handled by a worker who State regulations. Twenty of those events were received a 3000 cSv (3000 rem) extremity reported to Congress as Abnormal Occurrences exposure to his thumb and middle finger that (AOs). resulted in severe damage to the fingers. Twenty-one other people received whole-body There were 40 reportable medical overexposures in this event. The primary causes misadministrations that occurred in 1996, of the overexposures were failure to issue including 17 that were reported to Congress as adequate dosimetry, failure to conduct required AOs. In all but one of these events, there were radiation surveys, and failure to follow little or no adverse effects on the patient's procedures. In response to overexposure events, health and no follow-up medical care was the NRC issued two information notices. required. In the remaining case,25 patients treated with an eye applicator containing a 3.22 There were 389 other nuclear materials events, gigabecquerel (87 millicuries [ mci]) Sr-90 including loss ofcontrol oflicensed material, source received doses that were more than twice leaking sources, release of material, the intended dose. These patients are at transportation events, equipment problems, fuel increased risk of cataracts, eye infections, and cycle facility problems, and problems at test, blindness. The main factors contributing to research, and training reactors. Three of these these misadministrations included events were reported as AOs to Congress: communication problems (misunderstanding of the referring physician's request, not following a the theft of two radiography cameras the quality management plan, and not properly (reported as a loss of control of licensed documenting changes to the treatment plan), material, this is the same event that resulted errors in calculation of the treatment plan, errors in the overexposure of 22 people described in the operation of the equipment, and incorrect above) preparation and implantation of brachytherapy seeds. . a nuclear medicine generator containing a 666 megabecquerel(MBq)(18 mci)Mo-There were 13 events in 1996 that caused 35 99ffe-99 source fell from a moving delivery people to exceed their exposure limit. (The limit van, was struck by another vehicle and was is 0.05 sieverts (5 rem) per year whole-body destroyed, spreading contamination on both j dose for radiation workers, and 1 millisievert sides of the highway (a release of material (0.1 rem) per year whole-body dose for event) members of the public.) Most of'he Executive Summary x NUREG-1272, Vol.10, No. 2
Nuclear Mrteriils AEOD Annut! Report,1996 i'
. a 370 MBq (10 mci) Cs-137 source, part of a written directive, or either (1) the wrong a fixed density gauge mounted to a fly ash radiopharmaceutical,(2) delivered by the wrong chute, was lost when a vibrator was attached route, (3) delivered to the wrong treatment site, to the chute and apparently destroyed the (4) delivered by the wrong treatment mode, or source housing shutter mechanism (an (5)from a leaking source.
equipment problem event) Other AEOD Activities There was one nuclear materials event in 1996 To establish standards for collecting material that was judged to have a level of safety event data from Agreement States and to significance sufficiently high to warrant an encourage voluntary reporting of material Incident Investigation Team. 'Ihis occurred in events, a trial program for Agreement State August 1995 at the Massachusetts Institute of , Technology Center for Cancer Research. The ! reporting of events began in April 1995. Agreement States are encouraged to report team found that a researcher most likely significant events to the NRC Operations Center mgested P-32 as the result of a deliberate act by within I working day, and to report routine a knowledgeable person, but that the ingestion is events using the NMED software. The program not expected to result in any clinical symptoms l was evaluated after approximately 6 months and or acute effects. j i the results were provided to the Commission in late 1996. The Commission extended the trial There were two . Augmented Inspection Team y program to allow all Agreement States to inspections conducted in response to the implement the Nuclear Material Events following events: Database. In its final Policy Statement on Adequacy and Compatibility of Agreement
. A Site Area Emergency was declared at the State Programs, currently under review by the Nuclear Fuels Services facility in Erwin, Cena issie, the staff has proposed to require Tennessee, on April 2,1996, due to a fire in Agreement State event reporting as an element the ductwork on the roof of a complex of ofcompatibility. buildings.
Revised medical misadministration reporting
- An Alert was declared at the ABB criteria became effective in 1997. The most Combustion Engineering facility in significant change in the criteria is the new Hematite, Missouri, on August 22,1996, definition of a medical misadministration as an due to an unanticipated chemical reaction in event that results in a 1 gray (Gy)(100 rad) dose an evaporation tank, that ejected hot to a major portion of the bone marrow, lens of materials from the tank and caused a large the eye, or gonads, or a 10 Gy (1000 rad) dose column of reddish-brown vapor and steam to any other organ. In addition, the dose must be to extend offsite.
at least 50 percent greater than that prescribed in NUREG-1272, Vo!,10, No. 2 xi Executive Summary
1 INTRODUCTION The United States (U.S.) Nuclear Regulatory administrative and technical support to the Commission (NRC) licenses the use of reactor- NRC's Committee to Review Generic produced isotopes, the milling of uranium, and Requirements. AEOD also obtains industry the subsequent processing of both natural and feedback on these activities. enriched uranium, as well as other special nuclear material (SNM). In 1996 the NRC The AEOD programs, taken as a whole, directly regulated licensees in 21 States, the constitute the essential independent review and District of Columbia, and the U.S. territories. assessment of nuclear materials safety The remaining 29 states, known as Agreement performance, and complement the regional and States, have entered into agreements with the the Office of Nuclear Material Safety and NRC under Section 274 of the Atomic Energy Safeguards reviews of operating events. They Act, as amended, whereby the NRC relinquishes perform a quality verification function that and the States assume regulatory authority over provides assurance of feedback ofimportant the use of byproduct materials, source materials, operational safety lessons. AEOD findings and and other SNM in quantities not capable of recommendations continue to be addressed
. sustaining a chain reaction. (In 1997 the State of through generic correspondence, in the Massachusetts became the 30th Agreement resolution of generic issues, and in initiatives State.) taken by industry.
The NRC's Office for Analysis and Evaluation In 1996, as a consequence of the elimination of of Operational Data (AEOD) was created in its responsibility for oversight and 1979 to provide a strong, independent capability administration of the Diagnostic Evaluation to analyze operational data. AEOD implements Program, AEOD's Incident Response Division this role for nuclear materials applications by was reorganized. AEOD now consists of three collecting and maintaining nuclear materials divisions organized as follows: the Incident event data in the Nuclear Material Events Response Division, which includes the Database, analyzing and evaluating this Response Operations Section, the Response operating experience data, providing feedback Coordination Section, and the Operations on lessons learned and, as appropriate, Officer Section; the Safety Programs Division, recommending actions to reduce the probability which includes the Reactor Analysis Branch and that operational events will recur or will lead to the Reliability and Risk Assessment Branch; more serious events. and the Technical Training Division, comprised of the Reactor Technology Training Branch, the AEOD is also responsible for the NRC's Specialized Technical Training Branch, and the Incident Response Program, Incident Technical Training Support Branch. Investigation Program, and Technical Training Program. The Incident Response Program AEOD changed its annual report from a provides a coordinated NRC emergency calendar year (CY) to a fiscal year report response to ongoing events through the NRC beginning with the combined Annual Report for Operations Center. The Incident Investigation CY 1994 and fiscal year 1995, NUREG-1272, Program provides a structured NRC Volume 9. This report, NUREG-1272, Vol.10, No. 2, presents a review of the events and investigative response to significant operational concerns during 1996 associated with the use of events according to their safety significance. licensed materials in applications other than The Technical Training Program provides initial power reactors. Throughout this report, and continuing technical training for NRC staff whenever information is presented for a and contractors. In addition, AEOD provides calendar year, it is so designated. Fiscal year management direction and oversight of inf rmation is designated by the four digits of ind-aandant safety inspections, as well as scal year he report also meludes the r , followmg appendices: NUREG-1272, Vol.10. No. 2 1
AEOD Annuct Report,1996 Introduction e ' Appendix A summarizes the 1996 nuclear actions resulting from the findings of materials events by event type NRC IITs for nuclear materials events
- Appendix B summarizes the 1996 nuclear materials abnormal occurrences The report on power reactors, NUREG-1272, Vol.10,No.1, presents an overview of the 1996 e Appendix C lists nuclear materials reports operating experience of the nuclear power and videotapes issued by AEOD from industry from the NRC perspective. NUREG-1981 through 1996 ..
1272, Vol.10, No. 3, covers techm. cal trammg e . Appendix D presents the status of and presents the activities of the Technical recommendations included in AEOD Training Center in support of the NRC's nuclear materials studies mission.
- Appendix E presents the status of staff l
Introduction 2 NUREG-1272, Vol.10, No. 2
2 OPERATING EXPERIENCE FEEDBACK The primary concem with the use of radioactive e a problem during the transportation of materials is the potential for overexposure, licensed material which can cause cancer or, in severe cases, death. Extremity or localized skin exposures e a problem in a fuel cycle facility from radioactively hot particles are a lesser health concern but are still important to the e a problem in a nonpower reactor NRC in assessing the effectiveness of byproduct materials control. AEOD collects, reviews, and codes information about nuclear materials events that NRC One measure of the effectiveness of a licensee's licensees and Agreement States report. control of regulated materials is the collective Approximately 7,000 NRC licensees and 15,000 dose received by all employees who work with, Agreement State licensees submit reports of or may be present in the vicinity of, nuclear events. Non-licensees also report events materials. Licensees are required to provide involving radioactive material to both NRC and appropriate monitoring equipment to, and to Agreement States. Those that are found to require the use of such equipment by, each involve radioactive material licensed under the individual who is likely to receive a dose in any Atomic Energy Act are ;ncluded in this report. calendar quarter exceeding 25 percent of the Licensees also voluntarily submit reports of allowable limits specified in Part 20 of Title 10 events that are not required to be reported. of the Code ofFederal Regulations (CFR). Voluntary reports are not considered when Licensees are also required to monitor and evaluating operating experience and are control activities that can lead to exposing their therefore not included in this annual report. employees or the general public to radiation. NRC licensees submit reports directly to the i NRC regional or headquarters offices. 2.1 Nuclear Material Events Agreement State licensees submit reports to the States, which, in turn, voluntarily transmit Database summary reports to the NRC under an informal l information sharing agreement. In addition, the NRC and Agreement State nuclear materials NRC obtains reports of events from other i licensees are required by 10 CFR, comparable sources, such as NRC inspection reports, and, Agreement State regulations, or license occasionally, from non-licensees, including ; conditions, to submit reports on any of the members of the public. following events: From 1981 through 1992 AEOD coded nuclear e a medical misadministration of radiation materials event data and maintained them in two or radiopharmaceuticals to a patient databases, one containing records of medical misadministration events and the other e a radiation overexposure containing records of other reported nuclear materials events. In 1993 AEOD developed a e a loss of control of licensed material new database, the Nuclear Material Events Database (NMED), that was designed to allow e a problem with equipment that uses multiple events in a single report to be licensed material or is otherwise appropriately recorded. For example, a report associated with the use oflicensed may describe a loss of control of licensed material and an overexposure. In such a case, material both events would be recorded in the NMED and both would be identified by the same report e a release of material or contamination number. In developing the database structure, AEOD solicited and received substantial input e a leaking radioactive source 3
I l AEOD Annual Report,1996 Operating Experience Feedback l from the NRC Headquarters Offices of Nuclear to effectively control licensed material or from Materials Safety and Safeguards, State other human errors, such as dispensing a Programs, and Nuclear Regulatory Research; the radiopharmaceutical that does not comply with the written directive. This can result in a patient l regional offices; and the Agreement States, receiving an unintended or excessive dose or a Most of this input was provided during AEOD- dose to the wrong treatment site. Occasionally a sponsored workshops in November 1993 and radiopharmaceutical is administered to the May 1994. An interim, stand-alone version of wrong patient. Excessive exposures to the NMED was distributed to the Agreement monitored employees and uncontrolled States in October 1994. Installation of the exposures to the general public are also a NMED within NRC headquarters was concern in the medical use of radioactive completed in June 1996, and the NMED was materials. However, such incidents are relatively distributed to Agreement States in September rare, considering the hundreds of thousands of 1996. procedures performed each year. The NMED contains about 13,310 detailed The misadministration rule, which became records of reported events, including voluntary effective on November 10,1980, required NRC reports, as well as information for identifying medical licensees to report medical associated repons, such as inspection reports. misadministrations to the NRC. This mle was NRC data since 1981 are available, as well as revised in 1987 to require Agreernent States to Agreement State data from 1991. The NMED have reporting requirements for medical contains records of material events for all misadministrations that are compatible with the categories of materials licensees, including NRC reporting requirements. Licensees in nonpower reactors. Radiation overexposure Agreement Sates would then report events since 1993 for commercial power misadministrations to the appropriate regulatory reactors are also maintained in the NMED. A agency in their state. Agreement State agencies new NMED data entry, search, and report had 3 years to promulgate such rules. Therefore, program was fully operational in the third Agreement State licensees were required to quaner of 1996. report medical misadministration events by 1991. The Agreement States have agreed to In 1996 there were 438 events involving nuclear voluntarily submit misadministration reports to materials licensees and nonpower reactors that the NRC. were required to be reported to the NRC. Twenty of those events were reported to The Quality Management Program and Congress as Abnormal Occurrences (AOs). Misadministration Rule, which became effective Table 2.1 shows the number of reportable events in 1992, requires a quality management program in 1996 by type submitted both to the NRC and and contains revised definitions of, and to Agreement States as of the date of reporting requirements for, medical preparation of this report. misadministrations. As part of this rule, the misadministration definitions were changed to 2.2 Medical Misadministrations include the following six types of procedures: The NRC and Agreement States regulate certain e administration of diagnostic aspects of reactor-produced radionuclides used radiopharmaceuticals, including less than in nuclear medicine and therapeutic radiology in 1.11 megabecquerels (MBq)(30 accordance with 10 CFR Part 35, " Medical Use microcuries [pCi]) sodium iodide-125 (Nal-of Byproduct Material." The major concerns 125) or Nal-131 with the use of radioactive materials in medical l applications arise from either a licensee's failure l l Operating Experience Feedback 4 NUREG-1272, Vol.10, No. 2 i
Operating Experience Feedback AEOD Annuil Report,1996
)
Table 2.1 Nuclear Materials Events in 1996 by Event Type Submitted to the NRC and to Agreement States Agreement Type of Event NRC States Total Misadministrations 26 14 40 Overexposures 5 8 13 Loss of Control of Material 88 76 164 Leaking Sources 11 11 22 Release of Material 22 14 36 Transportation 17 16 33 Equipment Problems 76 29 105 Fuel Cycle Operations 22 - 22 Research and Training Reactors 3 - 3 Totals 270 168 438 Note: Not all Agreement State swi. had been received at the time this table was prepared. e diagnostic administrations of NaI-125 or Part 35. Nal-131 radiopharmaceuticals in quantities greater than 1.11 MBq (30 pCi) The term " diagnostic misadministration," as used in NRC regulations, refers' to the e administration of therapeutic misadministration of radioisotopes in such radiopharmaceuticals (other than Nal-125 or nuclear medicine studies as renal, bone, and Nal-131) liver scans. " Therapeutic misadministration" refers to the misadministration of radiation in e gamma stereotactic radiosurgery the treatment of patients using Co-60 (the external use of radiation from a single Co-60 e teletherapy source for therapeutic treatment), gamma stereotactic radiosurgery (the external use of e brachytherapy radiation from about 200 small Co-60 sources for therapeutic treatment), brachytherapy (the The criteria for misadministrations vary and insertion or implantation of sealed sources include such things as treatment of the wrong containing radioactive material for therapeutic organ or patient, use of the wrong treatment), or radiopharmaceutical therapy (the radiopharmaceutical, administration of a dose ingestion or injection of radioactive materials that differs from the prescribed dose, or an for therapeutic treatment). incorrect administration route or treatment mode. The specific definitions are in 10 CFR i NUREG-1272, Vol.10, No. 2 5 Operating Experience Feedback
i AEOD Annual R: port,1996 Operating Experience Feedback l l The potential or actual effect of a therapeutic radiopharmaceutical or gamma stereotactic misadministration generally differs from that of radiosurgery misadministrations reported. ) a diagnostic misadministration. Therapeutic l misadministrations are associated with Misadministration events that demonstrate a procedures in which large doses of radiation are major failure of the radiation safety program or ! administered to patients to achieve a therapeutic result in adverse health effects to a patient are effect, while diagnostic misadministrations are reported to Congress as AOs. Seventeen of the l l associated with clinical or investigative misadministrations that occurred in 1996 were procedures requiring comparatively small doses reported as AOs. (The AO numbers for these of radiation. However, some misadministrations events are 96-3, -4, -5, -7, -8, -9, -10, -12, -13, - involving the use of NaI-125 or Nal-131 for 14, -16, -17, and -18; and AS 96-5, -6, -7, and - l diagnostic purposes may deliver unintended 8. Other AOs reported in 1996 occurred in l doses in the therapeutic range to the patient's previous years (see Section 3.2 of this volume).) thyroid. Not all therapeutic overdoses result in In all but one of these events, there were little or l significant radiation-induced clinical effects to no adverse effects on the patient's health and no patients. Some misadministrations occur follow-up medical care was required. In the because patients are administered a dose of remaining case,25 patients treated with an eye radiation that is less than that prescribed. In applicator containing a 3.22 gigabecquerel (87 these cases, if the error is found in time, the millicuries (mci]) Sr-90 source received doses total prescribed dose can still be achieved. that were more than twice the intended dose. These patients are at increased risk of cataracts, In 1996 the NRC regulated approximately 2000 eye infections, and blindness. licensees in 21 states, the District of Columbia, ; and the U.S. territories that use radionuclides in The causes for the reported misadministrations radiation therapy and nuclear medicine were reviewed and separated into three applications. These facilities submitted reports categories: communication problems, human of 26 misadministrations that occurred in 1996. errors, and equipment problems. The 29 Agreement States in 1996 regulated Communication problems were primarily due to about 5000 medical institutions, including misunderstanding the referring physician's hospitals, clinics, and physicians in private request, not following the quality management practice. Agreement States submitted reports of plan, and not properly documenting changes to 14 misadministrations that occurred in 1996. the treatment plan. Human error problems These events are listed in Tables A-1.1 and A- included incorrect calculation of the treatment 2.1 of Appendix A for NRC and Agreement plan; errors in the operation of treatment State licensees, respectively. Reported medical equipment; inattention to detail; and incorrect misadministrations are shown by type of preparation, loading, and implantation of procedure in Table 2.2. For both NRC and brachytherapy applicators and seeds. Equipment Agreement State licensees, the majority of the problems were primarily the result of source misadministrations involved brachytherapy migration. treatment (65 percent). Sodium iodide procedures resulted in the second highest Corrective actions reported by licensees number of misadministrations (25 percent), and included creating a new procedure, teletherapy treatments and therapeutic implementing a new training program, radiopharmaceutical procedures were each modifying an existing procedure, retraining, and responsible for 5 percent of the reported writing a new quality management plan. l misadministrations. There were no diagnostic Operating Experience Feedback 6 NUREG-1272, Vol.10, No. 2
Operating Experi:nce Feedback AEOD Annual Report,1996 l l l Table 2.2 Medical Misadministrations in 1996 Reported to the NRC and to Agreement States Agreement Procedure l NRC State Total ' Diagnostic Radiopharmaceutical 0 0 0 SodiumIodide 5 5 10 Therapeutic Radiopharmaceutical 2 0 2 Gamma Stereotactic Radiosurgery 0 0 0 Teletherapy 2 0 2 , 1 Brachytherapy 17 9 26 Totals 26 14 40 l 2.3 Radiation Overexposures 2.3). These events are listed in Tables A-1.2 and A-2.2 of Appendix A to this report. Most of the The occupational dose limits for radiation occupational overexposure events reported by i' workers are defined, in 10 CFR 20.1201, both NRC and Agreement States licensees ,
" Occupational dose limits for adults," to be involved industrial radiography. Eighty-three j equivalent to 0.05 sieverts (Sv) (5 rem) whole- Percent (29/35) of the overexposures were body dose per year. The dose limit for non. whole-body doses ranging from 0.16 radiation workers (members of the public)is I centisievert (cSv) (0.16 rem) to 53 cSv (53 rem),
millisievert (mSv) (0.1 rem) per year, in with a median value less than 10 cSv (10 rem). accordance with 10 CFR 20.1301, " Dose limits The 53 cSv whole-body exposure was to a for individual members of the public." In radiographer who forgot to retract the source addition, the occupational dose limits for minors while replacing film for the next exposure. Two are defined, in 10 CFR 20.1207, " Occupational events caused multiple overexposures. One of , dose limits for minors," to be 10 percent of the these involved 22 members of the public when annual limits for adult worker . (Mcdical the source from a stolen radiography camera l misadministrations resulting in doses to patients became detached from the camera in a scrap exceeding planned treatments are not yard. The source was handled by a worker who categorized as overexposures. Only doses to received a 3000 cSv (3000 rem) extremity patients not intended to be treated are included exposure to his thumb and middle finger that in this section.) resulted in severe damage to the fingers. Twenty-one other people received whole-body , There were 13 events in 1996 that caused 35 overexposures in this event. Nine percent (3/35) people to exceed their exposure limit. NRC of the overexposures were skin doses ranging l licensees reported 5 events that overexposed 5 from 53 cSv (53 rem) to 70.6 cSv (70.6 rem), l people and Agreement State licensees reported 8 with a median value of 60.05 cSv (60.05 rem). events that overexposed 30 people (see Table The two remaining overexposures were internal NUREG-1272, Vol.10, No. 2 7 Operating Experience Feedback
i AEOD Annual R: port,1996 Oper ting Experi:nce Feedback Table 2.3 Radiation Overexposures in 1996 Reported to the NRC and to Agreement States No.of Reports No. ofIndividuals Agreement Agreement Type of Licensee NRC State Total NRC l State Total < Medical / Academic 1 1 2 1 1 2 Research/ Commercial 1 2 3 1 2 3 Industrial Radiography 3 4 7 3 5 8 Other* 0 1 1 0 22 22 Totals 5 8 13 5 30 35
- Non-Licensee event involving a stolen source.
exposures in which the total effective dose or administrative control of a nuclear materials equivalent exceeded the annual limit of 5 cSv (5 licensee. This can be due to actual loss, rem). administrative loss, unauthorized abandonment or disposal, or theft. Discovery of licensed Medical / academic and research/ commercial material in the public domain is also considered overexposures were primarily caused by failure a loss-of-control event even if the licensee did to (1) ensure that adequate dosimetry was issued not recognize the loss. The prir.1ary safety and monitored, (2) wear adequate protective concem is that, while the material is out of the clothing, and (3) follow procedures. The licensee's control, it may adversely affect public primary causes of industrial radiography health and safety, whether or not it is later overexposures were failure to conduct the recovered. required radiation surveys and failure to follow established procedures. Part 20 of 10 CFR contains the reponing requirements for all loss-of-control events As part of its response to overexposure events, except well-logging sources that have been the NRC issued two Information Notices (ins) declared irretrievable. Well-logging sources to alert licensees to events associated with their may be abandoned (left in place) in accordance particular type of license. These notices are IN with the requirements of 10 CFR 39.77 and 96-004, " Incident Reporting Requirements for guidelines approved by the NRC and the Radiography Licensees" and IN %-057, Agreement States. " Incident Reporting Requirements Involving Intakes During a 24-Hour Period that May Licensed material can generally be lost in one of Cause a Total Effective Dose Equivalent in the following five ways: Excess of 0.05 Sv (5 rem)." Both notices were issued to clarify reporting requirements to all e inadvertently sent to commercial land-fills licensees. (mostly medical waste) 2.4 Loss of Control of Licensed e inadvertently shipped to metal scrap yards Material ("S""I'Y * "'^*i""'*d ****I ' I"d"S*'i^I measuring gauges) o st len(m st ften in portable moisture Loss of control of licensed material occurs when e ty gauges) licensed material is not under the direct physical Operating Experience Feedback 8 NUREG-1272, Vol.10, No. 2
Operating Experience Feedback AEOD Annual Report,19% e in well-logging sources that are abandoned radiography cameras, was reported to Congress downhole (usually Cs-137 and Am-241) as an AO (AS 96-01). (This is the same event that resulted in the overexposure of 22 people e missing from inventory of calibration and described in Section 2.3 of this volume.) medical marker sources (miscellaneous) Portable moisture density gauges, which contain There were 88 loss of control of material events an 8 to 10 mci cesium-137 source on a retract-in 1996 that were reported to the NRC and 76 able rod and an internal 40 mci americium-241 such events that were reported to Agreement source, are the most commonly stolen licensed States. These 164 events are listed in Tables device. They are used in highway and other A-1.3 and A-2.3 of Appendix A and are construction projects involving soil compaction summarized in Table 2.4. Radionuclide and paving. They are thought to be targeted for activities involved in these events ranged from theft because they are valuable and portable. undetermined trace amounts of Nal-131 in The NMED lists approximately 25 to 30 thefts municipal waste to a pair of irradiators, each of moisture density gauges each year, from both containing approximately 7.7 terrabecquerel NRC licensees and Agreement States. Some of (210 Ci) of Cs-137, located at two high schools the stolen gauges were left unsecured, but the with terminated licenses. One loss of control of typical report is of a properly stored and locked licensed material event, the theft of two gauge being stolen from a locked and seemingly Table 2.4 Loss of Control of Material Events in 1996 Reported to the NRC and to Agreement States Agreement Type of Loss Status NRC States Total Lost Material Recovered 14 6 20 Not Recovered 28 23 51 Total 42 29 71 Stolen Material Recovered 10 6 16 Not Recovered 7 15 22 Total 17 21 38 Abandoned Licensed Material Recovered 9 14 23 Not Recovered 11 7 18 Total 20 21 41 Material Recovered Total 33 26 59 Material Not Recovered Total 46 45 91 Abandoned Well-Logging Sources 9 5 14 Total Loss of Control Events Reponed 88 76 164 l NUREG-1272, Vol.10, No. 2 9 Operating Experience Feedback
AEOD Annuci Report,1996 Operating Experience Feedback secure facility. AEOD has undertaken a study to were reported to the NRC and 1I events with 15 identify the causes of the thefts oflicensed leaking sources that were reported to Agreement material, including portable moisture density States. These 22 events are listed in Tables A-gauges, the recovery rate for stolen gauges, and 1.4 and A-2.4 of Appendix A. The report for one the relative risk to public health and safety. event did not identify the radionuclide involved. Of the 27 leaking sources in which the Of the 164 lost material reports received by the radionuclide was reported, about 30 percent NRC,12 were reports of material found at scrap involved Am-241 used in various industrial metal facilities and 6 were reports of material gauges, one of which resulted in the internal found at sanitary landfills. The number of events overexposure of a worker. Thirteen percent of involving licensed material found in the public the leaking sources used Ni-63 in electron-domain was lower in 1995 and 1996 (about 20 capture detectors contained in gas per year) than in CY 1992 and CY 1993 (about chromatographs. These sources are covered with 30 per year), a thin film and are prone to show minor leakage with normal use. Another 13 percent of the The causes of the reported events generally leaking sources contained Fe-55. The remainder involved inadequate accounting procedures, of the reports involved industrial gauges using failure to follow procedures, and inadequate sources other than Am-241, including an Ir-192 security measures. Radiation monitors installed radiography source and a Co-60 irradiator at commercial landfills and scrap metal yards source. All licensees took prompt corrective can reduce the amount of licensed material action by removing the leaking sources from entering such facilities. Corrective actions that service. Most licensees returned the leaking were reported included retraining of personnel sources to the equipment manufacturer for on procedures for handling and oversight of source replacement. Several licensees elected to licensed material, new procedures for using dispose of the sources. devices containing licensed material, and improving the labeling and handling of licensed 2.6 Release of Material material. Release of licensed material events include 2.5 Leaking Sources spills and gaseous or effluent releases during which licensed material is either released to the Sealed sources are constructed oflicensed environment (air or water) or results in radioactive material welded in a metal capsule personnel or facility contamination exceeding or encapsulated within a sealing material such regulatory limits. Release of licensed material as metallic foil or a ceramic. Periodic leak tests events are required to be reported to the NRC or are required from quarterly to every 3 years, to Agreement States by 10 CFR 20.2202 and depending upon the source construction and the 20.2203 or comparable Agreement State method of encapsulation. Test results of more regulations. Certain contamination events that than 185 Bq (.005 Ci) of removable occur at facilities are also included in this contamination is considered evidence of category and are required to be reported to the leakage. Detecting leaking sources early is NRC or to Agreement States by 10 CFR 30.50, essential to preventing significant facility 40.60,50.72,50.73 and 70.50 or comparable contamination, personnel contamination, and Agreement State regulations. personnel exposures. Sources that are ruptured because of a physical impact or that are ground There were 22 events in 1996 involving the up in a recycling facility are not counted as release of licensed material that were reported to leaking sources. Events of this nature are the NRC and 14 such events that were reported captured in other event categories. In 1996 thc.e to Agreement States. These 36 events are listed were !I events with 13 leaking sources that in Tables A-1.5 and A-2.5 of Appendix A. Operating Experience Feedback 10 NUREG-1272, Vol.10, No. 2
1 1 Opercting Experience Feedback AEOD Annual Report,1996 There was one release of material event that was NRC or to the Agreement States as required by reported to Congress as an AO (AS 96-3): a 10 CFR Pan 71 and 10 CFR 20.19% or nuclear medicine generator containing a 666 comparable Agreement State regulations. MBq (l 8 mci) Mo-99ffc-99 source fell from a moving delivery van and was struck by another in 1996 there were 17 transportation events that vehicle and destroyed, spreading contamination were reponed to the NFC and 16 transportation on both sides of the highway. Two other events events that were reported to Agreement States. involved personnel overexposures and major These events are listed in Tables A-1.6 and A-contamination of two facilities as a result of 2.6 of Appendix A. Thirty-nine percent of the leaking sources. Overall,39 percent of these 36 33 events were accidents involving vehicles events involved minor contamination of transponing licensed material that did not result j facilities licensed to possess nuclear materials. in the loss of shielding or the release of material. Licensed material was released from a licensed However, material was released in one facility to the general environment in 28 percent transportation accident. The material released of the events. An additional 11 percent involved had very low activity and was decontaminated either shipment oflicensed material that was in a short period of time. This event was released from its shipping container to the reponed to Congress as an AO (AO AS 96-3). immediate environment or shipment of Twenty-one percent of the events involved equipment that was found to be contaminated damage to packages in which there was no when it reached its destination. Nuclear power release of material and the external radiation plants reported 14 percent of the events, four of limits were not exceeded. Another 18 percent of which resulted in transponation of a the events involved damage to packages which contaminated individual to an area hospital for resulted in external radiation levels that treatment ofinjuries. exceeded the limits. The other events involved radioactive surface contamination on packages Thirty-nine percent of the release of material shipped between licensees. events occurred at either medical or fuel facilities. The majority of the events at hospitals Because many of these events resulted from involved either Nal-131, Tc-99m, or P-32 and personnel errors, the NRC issued Generic Letter were primarily due to spills. Equipment failure (GL) 95-009, " Monitoring and Training of was the primary cause of the events at fuel Shippers and Carriers of Radioactive Material." facilities, but the causes of the equipment This GL was issued to clarify the requirements failures were not reported. Few of the reports for monitoring and training of shipping and indicated what corrective actions were taken to carrier personnel during pickup and delivery of prevent similar future events. Of the actions that packaged radioactive materials at NRC-licensed were reported, the principal ones were facilities. additional training, new equipment purchases, and design changes made to existing equipment. 2.8 Equipment Problems 2.7 Transportation Events There were 105 reportable equipment problems Transportation events involve shipments of that occurred in 1996,76 of them reported to the packages that have removable radioactive NRC and 29 reponed to Agreement States. surface contamination or radiation levels that These problems are listed in Tables A-1.7 and exceed NRC limits. Licensed material shipments A-2.7 of Appendix A and are summarized in that are involved in accidents or damaged during Table 2.5. One equipment problem event was shipment are also included as transportation reported to Congress as an AO (AS 96-4): a 370 events. Transportation events are reported to the MBq (10 mci) Cs-137 source, part of a fixed NUREG-1272, Vol.10, No. 2 11 Operating Experience Feedback
AEOD Annud R* port,1996 Opetting Experi:nca Feedback Table 2.5 Equipment Problems in 1996 Reported to the NRC and to Agreement States Agreement Type of Equipment NRC State Total l Industrial Gauges 19 13 32 l Industrial Radiography Devices 21 4 25 Fuel Processing 12 0 12 Irradiators 3 3 6 Electron Capture Devices 3 0 3 Medical Equipment 3 0 3 Radioluminescent Devices 2 0 2 HDR Units 0 2 2 Sealed Sources 0 2 2 Well Logging Equipment 0 2 2 Exhaust Hoods 1 0 1 Non-Power Reactors 1 - 1 Other 11 3 14 Totals 76 29 105 density gauge mounted to a fly ash chute, was Inconsistency in 10 CFR Part 34 Compatibility." lost when a vibrator was attached to the chute and apparently destroyed the source housing 2.9 Fuel Cycle Facility Events shutter mechanism. Twenty-four percent of the 105 problems involved industrial radiography Fuel cycle facility events include criticality, loss equipment, most of them caused by a failed or of a control that is required to prevent criticality, defective part. Seventeen percent of the or a release involving any of the non-radioactive equipment problems involved moisture density chemicals that are used in the fabrication of gauges, most of which sustained damage from uranium reactor fuel. The criteria for reporting vehicles at construction sites. Other significant fuel cycle facility events are found in 10 CFR equipment problems involved gauges other than Part 50,10 CFR Part 70, and NRC Bulletin 9141. moisture density gauges that failed because of defective parts, fire, or mechanical impact. The NRC regulates all commercial fuel cycle facilities involved in processing uranium ore Five equipment problems were associated with and fabricating reactor fuel. The nine major fuel locking devices on Amersham radiography cycle facilities include one uranium cameras. To address these problems, the NRC hexafluoride production facility and eight issued IN 96-53, " Retrofit to Amersham 660 uranium fuel fabrication facilities. In addition, Posilock Radiography Camera to Correct two gaseous diffusion uranium enrichment Operating Experience Feedback 12 NUREG-1272, Vol.10, No. 2
Operating Experiencs Feedback AEOD Annual Report,1996 plants, owned by the Department of Energy but leased to and operated by the U.S. Ennchment 2.11 Annual Radiation ExMsure Corporation, will come under NRC regulatory Data oversight in early 1997. There were 22 reponed fuel cycle facility events According to the National Council on Radiation that occurred in 1996. These events are listed in Protection and Measurements, the average total Table A-1.8 of Appendix A. Eleven of the effective dose equivalent (TEDE) to a person in twenty-two events involved the loss or the United States is approximately 0.36 degradation of criticality controls; the majority centiSievens (cSv) (360 millirem [ mrem]) per of them exceeded the administrative limits of year, mostly from natural sources of radiation. fissionable material in a given area as defined The average person in the United States receives by a license condition or a criticality safety a TEDE of about 0.05 cSv (50 mrem) per year analysis. Three events involved fires in fuel from medical applications. The entire fuel cycle, cycle facilities, for which no radiation including operation of reactors, contributes less overexposures, contaminations, or personnel than 0.001 cSv (1 mrem) per year. All other injuries were reponed. No fuel cycle facility human-controlled sources of radiation combined problems were reponed to Congress as add up to a TEDE of approximately 0.006 cSv Abnormal Occurrences. (6 mrem) per year. The NRC regulates both reactor and nonreactor 2.10 Test, Research. and Training applications of nuclear materials. All NRC , Reactors licensees are regiared to monitor employee exposure to radiation and radioactive materials The NRC regulates all reactor facilities, at levels sufficient to demonstrate compliance ! including power reactors and test, research, and with the occupational dose limits specified in 10 I training reactors (TRTR). NUREG-1272, Vol. CFR Pan 20.The performance of power ! 10, No.1, covers power reactors and presents an reactors is discussed in NUREG-1272, Vol.10, I' overview of the operating experience of the No.1.That repon also compares the nuclear power industry from the NRC performance of power reactors with the i perspective. The operating experience of TRTRs performance of nuclear materials licensees. is described here. The NRC regulates the TRTR facilities in accordance with 10 CFR Pan 50. Personnel exposure data from 1989 through 1995 (the latest year for which data are There are 58 TRTR facilities currently licensed available) are given in Tables 2.6 through 2.10 by the NRC,45 with operating licenses,8 with for the following five categories of material possession-only licenses, and 5 with dismantling licensees: (1) industrial radiography, (2) orders. The TRTR facilities are owned and manufacturing and distribution, (3) low-level operated by universities, the Federal waste disposal, (4) independent spent fuel Government, and commercial companies. stc; ge, and (5) fuel fabrication and processing. Exposure data for Agreement State licensees are Three TRTR events were reported in 1996, all n t included in these tables because the of them caused by equipment failures. On, Agreement States are not required to supply th,si inf rmati n to the NRC. Because licensees event resulted in the release of insoluble submit revisions, late repons, or retractions, radioactive material to a sewer. There were n data are updated as appropriate. This may cause adverse effects on public health and safety. The minor changes in the data published from year TRTR events are listed in Table A-1.9 of to year. The data are taken from the Radiation Appendix A. Exposure Information Reporting System funded by the NRC's Office of Nuclear Regulatory Research. NUREG-1272, Vol.10, No. 2 13 Operating Experience Feedback
AEOD Annual R: port,1996 Operating Experience Feedback Table 2.6 Annual Exposure Data for NRC Industrial Radiography Licensees Calendar Years 1989 to 1995 No. of Average Workers Collective Average Measurable No. of with TEDE Individual TEDE per No. of Monitored Measurable person-cSv TEDE-cSv Worker-Year Licensees Individuals TEDE (rem) (rem) cSv (rem) 1989 276 6745 4352 2%7 0.31 0.47 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 1993 176 4721 3007 15 % 0.34 0.53 1994 139 3230 2351 1415 0.44 0.60 1995 139 3530 2465 1338 0.38 0.54 Table 2.7 Annual Exposure Data for NRC Manufacturing and Distribution Licensees Calendar Years 1989 to 1995 No. of Average Werkers Collective Average Measurable No. of with TEDE Individual TEliE per No. of Monitored Measurable person.cSv TEDE-cSv Worker-Year Licensees Individuals TEDE (rem) (rem) cSv (rem) 1989 48 4554 2345 770 0.17 0.33 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 Table 2.8 Annual Exposure Data for NRC Low Level Waste Disposal Licensees Calendar Years 1989 to 1995 No. of Average Workers Collective Average Measurable No. of with TEDE Individual TEDE per No. of Monitored Measurable person.cSv TEDE-cSv Worker-Year Licensees Individuals TEDE (rem) (rem) cSv (rem) 1989 2 925 119 35 0.04 0.29 1990 2 784 115 2.6 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 I Operating Experience Feedback 14 NUREG-1272, Vol.10, No. 2 m
Opercting Experience Feedback AEOD Annual Report,1996 Table 2.9 Annual Exposure Data for NRC Independent Spent Fuel Storage Licensees Calendar Years 1989 to 1995 No. of Average Workers Collective Average Measurable No. of with TEDE Individual TEDE per No. of Monitored Measurable person-cSv TEDE-cSv Worker-Year Licensees Individuals TEDE (rem) (rem) cSv (rem) 1989 2 190 102 33 0.17 0.32 1990 2 56 22 6 0.11 0.27 1991 2 41 24 4 0.10 0.17 1992 2 290 85 11 0.04 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 1.04 Table 2.10 Annual Exposure Data for NRC Fuel Fabrication and Processing Licensees Calendar Years 1989 to 1995 No. of Average Workers Collective Average Measurable No. of with TEDE Individual TEDE per No. of Monitored Measurable person-cSv TEDE-cSv Worker-Year Licensees Individuals TEDE (rem) (rem) cSv (rem) 1989 8 11,583 2992 243 0.02 0.08 j 1990 11 14,505 3871 422 0.03 0.11 j I991 11 11,702 3929 378 0.03 0.10 i 1992 11 8439 5061 545 0.06 0.11 l 1993 8 9649 2611 339 0.04 0.13 I994 8 3596 2847 1147 0.32 0.40 1995 8 4106 2959 1217 0.31 0.41 l In 1995 NRC radiography licensees had the and the number of individuals who received a highest collective TEDE. Independent spent fuel measurable TEDE among most categories of storage licensees had the highest average licensees. Over this same period the average measurable TEDE per worker. Low-level waste measurable TEDE per worker has increased for ! disposal licensees and independent spent fuel most categories of licensees. In all cases. l storage licensees had relatively low collective however, the average measurable TEDE per l TEDE. worker is far below the allowable limits of 10 CFR Part 20 There has been a decreasing trend since at least 1992 in the number of individuals monitored l i NUREG-1272, Vol.10, No. 2 15 Operating Experience Feedback
3 ABNORMAL OCCURRENCES 3.1 Abnormal Occurrence examples in the policy statement are applicable to medical misadministrations. Therefore, in Reporting 1984 NRC adopted additional guidance for
. . . reporting medical misadministrations. This Section 208 of the Energy Reorganization Act guidance was still in effect in 1996 and was of 1974 identifies an abnormal occurrence (AO) used to select events to be included in the 1996 as an unscheduled mcident or event that the AO report to Congress.
NRC determines to be significant from the standpoint of public health or safety. The On January 27,1992, new medical Federal Reports Elimmation and Sunset Act of misadministration requirements became 1995 requires that the NRC report AOs t effective. Consequently the NRC staff Congress annually. Consequently, AEOD now developed revised criteria for reporting prepares and publishes the annual NRC AO report on a fiscal year basis. incidents and events. The revised criteria became effective on January 9,1997, and relate AOs directly to the requirements in Title 10 of AEOD identifies AOs using criten.athat were the Code of Federal Regulations for protection initially promulgated in an NRC policy of public health and safety. The revised criteria statement that was published in the Federa,s will be used to select events to be included in Register on February 24,1977. Usmg these cnteria, an event will be considered an AO ifit the 1997 AO report to Congress. involves a major reduction in the degree of protection of public health and safety. Such an 3.2 Abnormal Occurrence Report event would involve a moderate or more severe for 1996 impact on public health and safety and could include, but need not be limited to, (1) moderate The AO report for 1996 (NUREG-0090, Vol. exposure to, or release of, radioactive material 19) describes 16 AOs for events at NRC nuclear licensed by or otherwise regulated by the materials licensees and 8 AOs for events at Commission; (2) a major degradation of Agreement State nuclear materials licensees. essential safety-related equipment; or (3) major These 24 AOs are summarized in Table 3.1 and deficiencies in design, consbetion, use of, or described in Appendix B to this report. (Twenty management controls for, licensed facilities or of the twenty-four AOs occurred in 1996 and are material. discussed briefly in Section 2 of this volume. Four of the AOs occurred before 1996 and are This policy statement was published before therefore not included in the discussion of 1996 medical licensees were required to report nuclear materials events in Section 2 of this misadministrations to the NRC, and few of the report.) Abnormal Occurrences 17 NUREG-1272, Vol.10, No. 2 m , . - - -
AEOD Annuct Report,1996 Abnormal Occurrences Table 3.1 Abnormal Occurrences at Nuclear Materials Licensees Reported in 1996 ; Agreement NRC State l Category Licensees Licensees Medical Institutions Brachytherapy misadministrations 11 2 Radiopharmaceutical misadministrations 5 2 Industrial Licensees Stolen radiography cameras 0 1 Ruptured source 0 1 Release of radioactive material 0 1 Lost source 0 1 Totals 16 8 Source: NUREG-0090. Vol.19 Abnormal Occurrences 18 NUREG-1272, Vol.10, No. 2
4 OTHER AEOD ACTIVITIES 4.1 Agreement State Operational 4.2 Nuclear Material Events Experience Data Database Training To establish standards for collecting material The Agreement States were given a final version event data from Agreement States and to of the NMED database in September 1996. encourage voluntary reporting of material AEOD staff trained personnel in Regions 11 and events, a trial program for Agreement State III and in the Agreement States of North reporting of events began in April 1995. The Carolina, South Carolina, Georgia, Mississippi, program was evaluated after approximately 6 Arkansas, and Louisiana on the installation and months and the results were provided to the use of the NMED. Commission in late 1996. The Commission extended the trial program to allow all 4.3 Medical Misadministration Agreement States to implement the Nuclear Material Events Database. In its final Pohey Abnormal Occurrence Criteria Statement on Adequacy and Compatibility of As explained in Chapter 3 of this volume, Agreement State Programs, currently under AEOD prepares the NRC annual report to review by the Commission, the staff has Congress on abnormal occurrences (AOs). Also proposed to require Agreement State event as explained in Chapter 3, revised medical reporting as an element of compatibility. mis dministration AO reporting criteria became As part of the trial program, Agreement States gffe tive in 1997. The most significant change are encouraged to report significant events to '".the cry,teria is the new definition of a medical misadmmistration as an event that results m a 1 the NRC Operations Center within one working gray (Gy) (100 rad) dose to a major portion of day. Agreement States are encouraged to report the bone marrow, lens of the eye, or gonads, or a routine events using the Nuclear Material 10 Gy (1000 rad) dose to any other organ. In Events Database (NMED) software and addition, the dose must be at least 50 percent procedures provided to the Agreement States. Agreement States not using the NMED can send gnater than that prescribed m a wntten directive, or either (1)the wrong hard copies of reports to the deputy director of the NRC Office of State Programs (OSP). In radiopharmaceutical, (2) delivered by the wrong either case, updated information such as r ute,(3) delivered to the wrong treatment site, (4) delivered by the wrong treatment mode, or inspection reports should be sent to the deputy (5) from a leaking source. director of OSP. At a future date, Agreement States will be encouraged to send all hard copy n ' approving the new AO criteria,the documents to the NRC Document Control Center. Commission directed the NRC staff to implement three new requirements. First, the staffis to file incident infonnation on potential Other important aspects of the program for AOs m, the NRC's Public Document Rooms Agreement State event reporting include the (PDRs) as soon as possible after the staff following: (1) the NRC operations center will determines that the me,i dent is a potential AO. promptly notify the appropriate regional duty Sec nd, the staffis to determme if modificatic ns oflicer, who will notify the regional state t the AO crhena for fuel cycle facilities are agreements program officer of a reported event, necessary to explicitly melude those facilities and (2) all events reponed to the NRC Operations Center will be entered into the that are not licensed by the NRC but are themse agulated by the NRC, such as the NRC's Event Notification System. gaseous diffus,on i plants. Finally, the staff was NUREG-1272, Vol.10, No. 2 19
l AEOD Annual Rtport,1996 Other AEOD Activities 4 l 1 directed to report to the Commission on how the In keeping with the changes to the AO criteria, j NRC will identify unintended medical radiation AEOD will finalize the draft revision of NRC exposures to an embryo / fetus or a nursing child; Management Directive 8.1, " Abnormal describe the staff's experience with voluntary Occurrence Reporting Procedure," which it reporting; and address whether, ifit does not previously prepared. The final revision will l recommend a mechanism to identify unintended include the new AO reporting criteria, the medical radiation exposures to an embryo / fetus requirement for publishing an annual AO report or a nursing child, the final AO criteria should on a fiscal-year basis, and the requirement for be revised to omit reference to these types of using the PDRs to quickly inform the public of l incidents. potential AOs. 1 l l l l l l l-l l Other AEOD Activities 20 NUREG-1272, Vol.10, No. 2
5 INCIDENT RESPONSE AEOD maintains and implements the NRC's gaseous diffusion plants are required to maintain Incident Response Program with the support of Emergency Plans. The requirements for other headquarters and regional ofSces. This independent spent fuel storage installations program includes the receipt of data and reports located on the sites of NRC-licensed nuclear for both emergency and non-emergency events power reactors are satis 0ed by the Emergency from licensees followed by an appropriate NRC Plans required for these sites. Other facilities or response. The response for the more serious activities that the NRC licenses to possess or emergencies is through an incident response utilize nuclear materials are not required by the organization that includes representatives from Code of Federal Regulations to maintain several headquarters ofSces and the afTected Emergency Plans; however, these facilities or regional of6ce. The NRC's response program activities may be required to maintain also includes coordination with other Federal Emergency Plans in accordance with their NRC agencies as well as State and local governments. licenses. 5.1 NRC Operations Center NRC-licensed facilities also have various classes of emergencies. Both power and The NRC Operations Center, located at Two nonpower reactor licensees utilize the following White Flint North in Rockville, Maryland, four emergency classes, in order ofincreasing provides the focal point for NRC severity: communications with Commission licensees, State agencies, and other Federal agencies about e Notification of Unusual Event - a condition events that occur in the commercial nuclear involving potential degradation of the level sector. It is continuously staffed by a of lant P safety that does not represent an Headquarters Operations Officer who is a immediate threat to public health and nuclear systems engineer trained to receive, safety. evaluate, and respond to all types of events. The Operations Center features a state-of-the-art e Alert - a condition involving actual or information management system that integrates Potential substantial degradation of the voice, video, and data subsystems to provide the level of plant safety where any offsite timely and effective now ofinformation during radiological releases are expected to be the NRC's response to an incident. limited to small fractions of the Environmental Protection Agency 5.2 Emergency Response Protective action guideline exposure levels.
.
- Site Area Emercency - a condition NRC-licensed facilities have a variety of Emergency Plan requirements. Both production
. involving actual or likely major failures of and utilization facilities (power and non-power one or more plant functions required for reactors) are required to maintam plans for protection of the public or involving responding to emergencies that could impact the conditions with potential for a signit'icant health and safety of the public. Facilities or offsite radiological release but where a core melt situation is not indicated, activities that are licensed for the possession and utilization of byproduct material, source e General Emercency - a condition involving matenal, or special nuclear material are required actual or imminent substantial core to maintam Emergency Plans for respondmg t a radiological release only if these licensees degradation or melting with potential for possess quantities of nuclear material that loss of containment.
exceed the amounts specified in 10 CFR Parts 30,40, and 70. In addition, all NRC-certified NUREG-1272, Vol.10, No. 2 21 L
1 AEOD Annual Report,1996 Incident Response Emergencies for nuclear materials licensees are licensed facilities: Normal, Standby, Initial classified into one of the following two levels in Activation, and Expanded Activation. order ofincreasing severity: For the Normal Mode, the lowest level of e Alert - for an NRC-licensed nuclear response, the NRC will not fully stafTthe materials facility, this indicates that events headquarters Operations Center or the regional may occur, are in progress, or have incident Response Center, but it may take some occurred that could lead to a release of other action such as sending oui a special radioactive material but that the release is inspection team or staffing the response centers not expected to require a response by with a few select experts to monitor the event. offsite response organizations to protect The latter is referred to as the Monitoring Phase individuals offsite. of the Normal Mode. s Site Area Emercency - for an NRC- Standby Mode, the next level of response, is licensed nuclear materials facility, this entered when an event isjudged to be indicates that events may occur, are in sufficiently uncertain or complex that the progress, or have occurred that could lead situation needs to be continuously monitored to a significant release of radioactive from the headquarters and regional response material and that could require a response centers by teams of experts. During Standby by offsite organizations to protect . Mode, the NRC response is led from the individuals offsite. headquarters Operations Center. Although not required by the Code of Federal if the event threatens public health and safety, Regulations, some nuclear materials licensees the NRC will enter the Initial Activation may also utilize the Notification of Unusual Mode. Upon entering this mode, the NRC will Event emergency class for events with lower promptly send a team from the regional office to safety significance. the site to lead the NRC response. Until the Site Team is in place, the NRC response will be led in the event of an emergency at an NRC- from the headquarters Operations Center. licensed facility (or associated with an NRC- Within this Operations Center, teams of licensed activity), the licensee places an specialists will evaluate the mtus of reactor emergency telephone call to the NRC critical safety functions and will independently i Operations Center immediately after notifying evaluate protective actions recommended by the l appropriate State and local agencies. For Alert licensee for implementation by State and local and higher declarations and for events for which authorities. All communications with the media, an NRC response may be appropriate, the State and Federal officials, Congress, and the l Regional Administrator and an Executive Team White House will also be coordinated from the member (typically the Director of the OfYice of NRC Operations Center. Nuclear Material Safety and Safeguards for a nuclear materials event) will be added to the Once the NRC site team arrives on the scene discussion of the event in a conference call with and is prepared to accept the authority and the licensee. responsibility for the Federal response, the NRC enters the Expanded Activation Mode. The The NRC's response to an event may range from Director of Site Operations, typically the routine follow-up to a complete activation of Regional Administrator, will report to the both the regional incident Response Center and licensee's Emergency Operations Facility near the NRC Operations Center located in the site or the Technical Support Center at the headquarters. The NRC utilizes the following site. The lead responsibility for performing j formal modes for responding to events at its assessments of reactor safety and protective l 1 Incident Response 22 NUREG-1272, Vol.10, No. 2
Incident Response AEOD Annual Report,1996 measures then shifts from headquarters to the Mode for the Site Area Emergency reported by NRC team at the site. The headquarters Nuclear Fuel Services and for Hurricane Bertha. Operations Center will th:n provide logistical and technical support to the NRC Site Team as 5.4 Emergency Exercises necessary. Emergency exercises are held periodically to 5.3 Operations Center Data for ensure that NRC, licensee, local, State, and 1996 other Federal response organizations are proficient in dealing with each type of In addition to emergency event notifications, the emergency. The NRC's primary role in NRC Operations Center receives many participatmg m these exercises is to provide an notifications of events that do not meet the independent assessment oflicensee actions, threshold for emergency classification. Actions assist the licensee when requested, review the taken by the IIeadquarters Operations Officer in protective action recommendations that response to such notifications range from licensees make to State and local authorities, computer and log entries followed by and facilitate communications between the appropriate notifications to establishing licensees and other response organizations. emergency conference calls between licensee Preparation for these exercises includes the representatives and senior NRC regional and development of a postulated accident scenario headquarters representatives. For very that usually goes well beyond the facility's significant events, conference calls may result in design basis and that results in the release of the activation of the agency's Incident Response s me radioactivity outside the facility's Plan. boundary. NRC experts in reactor safety and ) protective measures follow the progression of Table 5.1 shows the total number of events the simulated event; communicate with the reported to the NRC Operations Center during licensee, State, and Federal responders; and 1996. These notifications were primarily Provide recommendations to an NRC Executive received from nuclear power plant licensees. A Team in the NRC Operations Center. In 1996 small subset of these notifications involved the NRC conducted a tabletop emergency events classified by licensees into one of the planning exercise with the Siemens Nuclear four emergency classes. Power Corporation, a uranium fuel fabrication company, on October 25,1995. l Table 5.2 shows the number of each type of emergency event reported annually from CY 89 5.5 State Outreach through 1996. The number of Unusual Events reported to the Operations Center has decreased in 1996 AEOD continued an aggressive State by 66 percent since CY 89. This can be partially Outreach Program designed to increase and attributed to the fact that many licensees have improve the NRC's interaction with States implemented revised procedures for emergency during events and exercises. The program action levels that better reflect the severity of included briefings of State officials on the NRC events. and Federal Emergency Response Program, NRC/ State liaison during an emergency, and Table 5.3 lists the emergency events reported by financial assistance available to responders. NRC-licensed nuclear materials facilities to the This year, AEOD also expanded the program to NRC Operations Center during 1996 that were include training on the recently published categorized at the Alert level or higher. The NUREG/BR-0230, " Response Coordination NRC entered the Monitoring Phase of Normal NUREG-1272, Vol.10, No. 2 23 Incident Response
AEOD Annu:1 Rtport,1996 Incident Response Table 5.1 Events Reported to the NRC Operations Center in 1996 Event Power Fuel Non-Power Transport / Well/ Type Reactor Facility Reactor Hospital Materials Other Total Non-Emergency 1,345 10 2 60 100 82 1,599 Unusual Event 65 1 0 0 1 0 67 Alert 5 5 0 0 0 0 10 Site Area Emergency 0 1 0 0 0 0 1 General t Emergency 0 0 0 0 0 0 0 Totals 1,415 17 2 60 101 82 1,677 l I Table 5.2 Classification of Events Under Licensee Emergency Plans l Calendar Year 1989 to Fiscal Year 1996 CY 89 CY 90 CY 91 CY 92 CY 93 CY 94 CY 95 1996 Unusual Event 197 151 170 135 103 97 66 67 Alert 13 10 9 20 8 4 8 10 Site Area Emergency 0 1 2 1 1 0 0 1 General Emergency 0 0 0 0 0 0 0 0 Totals 210 162 181 156 112 101 74 78 Calendar year values are shown for 1985 through 1995. Fucal year values are used from 1996 on. Data for October I,1995, through December 31,1995, are included in both calendar year 1995 and fiscal year 1996 values. Incident Response 24 NUREG-1272, Vol.10, No. 2
1 Incid:nt Response AEOD Annut! Report,1996 Table 5.3 Alerts and Site Area Emergencies Reported at NRC-Licensed Facilities Other Than Power Reactors in 1996 Facility Event NRC Name Number Date Description Duration Response Nuclear Fuel 30220 04/02/96 SITE AREA 2 hrs 24 mins Monitoring l Services EMERGENCY- Fire exceeding 15 minutes, failure of ductwork, and potential for radioactive release ) Babcock and 30609 06/10/96 ALERT -Tornado sighted 50 mins N/A Wilcox 27 miles south / southwest j of Lynchburg, VA J i General Electric 30740 07/12/96 ALERT- Anticipated 9 hrs 10 mins Monitoring
]
Nuclear Energy hurricane-force winds i onsite from hurricane Bertha j Combustion 30910 08/22/96 ALERT - Chemical fire 49 mins N/A ) Engineering (alert downgraded to ' Unusual Event within 17 minutes.) General Electric 30964 09/05/96 ALERT - Sustained 6 hrs 13 mins N/A Nuclear Energy winds above 75 miles per hour due to Hurricane Fran Allied-Signal 30986 09/09/96 ALERT - Small uranium 45 mins N/A hexaflouride release in the materials building basement NUREG-1272, Vol.10, No. 2 25 Incident Response
AEOD Annual Report,1996 Incident Response Manual (RCM-96)," and the recently updated establish a new government corporation, the NUREG/BR-0150, " Response Technical United States Enrichment Corporation (USEC), Manual (RTM-96)." Outreach sessions were for the purpose of managing and operating the conducted with 15 states and numerous uranium enrichment plants owned and licensees. Rf WRTM training was sponsored by previously operated by the Department of Florida Power Corporation for the State of Energy. These enrichment plants are the l Florida and the utility; sponsored by the State of Portsmouth Gaseous Diffusion Plant located in Louisiana for Louisiana, Mississippi, Texas, and Piketon, Ohio, and the Paducah Gaseous Arkansas; and sponsored by Nebraska for Diffusion Plant located in bducah, Kentucky. Nebraska, Kansas, Iowa, and Missouri. The The Act further directed the NRC to establish a exercise mentioned in Section 5.4 was also certification process under which these two conducted under this program umbrella. plants will be certified annually by the NRC for compliance with NRC standards. These 5.6 Coordination With Other Federal standards require site-specific emergency Agencies response plans for the gaseous diffusion plants (GDP) to be submitted, reviewed, and approved During 1996 the NRC continued to participate p i r to certification, with other Federal agencies in the issuance of the Federal Radiological Emergency Response Tl ; NRC's oversight role has required many Plan (FRERP). The NRC also participated in additions to the NRC's incident Response drafting of the RadiologicalIncident Annex to Program, including the establishment of a Fuel the Federal Response Plan (FRP), which Cycle Safety Team. In conjunction with the describes how the FIU) and the FRERP are Office of Nuclear Material Safety and integrated when both plans are used during an Safeguards (NMSS) and Region 111, AEOD i emergency. In addition, the NRC participated in subsequently modified the NRC response an intensive activity to evaluate the adequacy of pr cedures to include the GDPs. As a result, the the Federal plans in response to nuclear, Protective Measures Team was modified to biological, and chemical terrorist events. The include GDP specialists from NMSS. NRC continued to train Regional Federal Emergency response planmng and training was agency representatives on the Federal role in also conducted between the USEC and all levels response to a radiological emergency using the f the NRC to include the GDP resident Concept of Operations described in the FRERP. inspectors and regional and headquarters j Regional Federal responders have also been materials / fuel cycle emergency response incorporated in the State Outreach Program rganizations. To enhance the understanding of . events to increase awareness of NRC response emer8ency response operations on site, NRC methods and to encourage integrated training and GDP personnel attended full-scale exercises and planning. In addition, the NRC provided t one another's facilities. A supplement to the training to selected Congressional staff RTM is also under development that will members on our role during a radiological pr vide tools and procedures for analysis of emergency. GDP events. To further aid in the response to an event, the computer model which is used by the GDPs during their response to an event has been 5.7 Gaseous Diffusion Process installed in the NRC Operations Center as a tool Activities for assessing plume dispersion. The NRC also installed Federal Telecommunications System The President signed H.R. 776, the " Energy telephone lines at these facilities. (Regulatory Policy Act of 1992" (the Act), into law on authority over GDP operations was transferred October 24,1992. Among other things, the Act from the Department of Energy to the NRC on amended the Atomic Energy Act of 1954 to March 3,1997.) Incident Response 26 NUREG-1272, Vol.10, No. 2
l l 6 INCIDENTINVESTIGATION PROGRAM The incident Investigation Program (llP) actions that the EDO assigned to various NRC ensures that NRC investigations of significant offices as a result of this and previous llT report events are timely, thorough, well coordinated, f'mdings. and formally administered. The scope of the llP includes investigations of significant operational The Center for Cancer Research (Center) at the ! I events involving reactor and materials activities Massachusetts Institute of Technology (MIT) licensed by the NRC. Under the llP, the NRC consists of several laboratories involved in responds to an operational event according to its various aspects of cancer research. ; safety significance. For an event of Radionuclides, including P-32, are used in these l extraordinary safety significance, the laboratories for the synthesis of components of Commission may establish an Accident Review deoxyribonucleic acid (DN A). Possession Group (ARG), led by an individual from outside limits, types of activities, and requirements for the NRC and composed of experts from within facilities and equipment in individual and outside the NRC. The ARG reports directly laboratories are reviewed and approved by the to the Commission and is independent of NRC MIT Radiation Protection Cornmittee (RPC). management. For an event of potentially major Each laboratory is periodically audited by the safety significance, the Executive Director for staff of the Radiation Protection Office to Operations (EDO) establishes an Incident determine that activities are being conducted in Investigation Team (llT) to investigate the accordance with the authorization issued by the event. For an event ofless safety significance, RPC and the requirements in NRC regulations the cognizant NRC Regional Administrator may and the NRC license issued to MIT. One establish an Augmented Inspection Team (AIT) particular laboratory typically receives 1 to 2 to investigate the event. Both IITs and AITs are millicuries (37 to 74 megabecquerel [MBq]) of assigned to determine the circumstances and P-32 each week. This laboratory has a Principal causes of an operational event and to assess the Investigator and a Laboratory Manager with safety significance of the event so that more than 30 postdoctoral research fellows, appropriate follow-up actions can be taken. The graduate students, and technical assistants EDO assigns staff follow-up actions arising working under their supervision. Because of the from llTs, while the Regional Administrators nature of the research, activities in the Principal identify needed actions based on AIT findings. Investigator's Laboratory frequently continue AEOD and other NRC offices, including NMSS, past midnight and 7 days a week. independently review AIT reports to provide additional assurance that potential generic On Saturday, August 19,1995, at 5:10 p.m., the lessons are learned and communicated to the Campus Police at MIT received a telephone call industry. As described in NUREG-1303, from a senior postdoctoral fellow (Researcher
' Incident Investigation Manual," AEOD has A) at the Principal Investigator's laboratory.
overall responsibility for administration of the Researcher A had noted detectable radioactivity llP, while NRR is responsible for maintaining during a routine survey of his hands about I the procedures for an AIT response, hour earlier and reported that his body and urine were contaminated. Before placing the call, 6.1 Incident Investigation Team Researcher A determined that the contamination
"' uld n t wash off his hands and appeared to be Events on his knees and head as well. The last time Researcher A had used P-32 before this date There was one nuclear materials event in 1996 was August 14. He had surveyed himself on that that was judged to have a level of safety date and had not found contamination.
sigmficance sufficiently high to warrant an IIT On Tuesday, September 12, the RPC met and mvestigation. This event is desenbed below. discussed the P-32 contamination incident. The Appendix E documents the status of the staff 27
AEOD Annual Report,1996 Incident Investigation Program l l Radiation Protection Officer (RPO) described and the NRC Region i Office regarding the intake as 500 microcuries (19 MBq) and the regulatory practices, procedures, and assessment dose as 4000 millirem (40 mSv) to the of similar events. individual. The RPC decided to have the Committee Chairman send a letter to Researcher The Team reached the following conclusions: A expressing regret and concern about the incident and a letter to the Campus Police o Researcher A most likely ingested P-32 as requesting their assistance to determine how it the result of a deliberate act by a occurred and how to prevent recurrence. On knowledgeable person. October 12, the RPO provided to Researcher A his final intake estimate of 579 microcuries (21
- The amount of radioactive material MBq),just under the 600 microcuries (22 MBq) ingested by Researcher A (500 to 750 Ci which would represent an overexposure. [19 to 28 MBq]) is not expected to result in any clinical symptoms or acute effects.
On Friday, October 13, the RPO learned that the Any symptoms that may have been magazine Nature planned to publish an article experienced were due to factors other than about the MIT contamination incident. On radiation exposure. Monday, October 16, the RPO notified the NRC Region I office of the planned article about the
- The security of radioactive materials in incident. Region I personnel began an initial storage and the control of radioactive onsite review of the incident aat day. materials in use in the Center were weak.
On October 17, in conformance with the IIP, the
- The Radiation Protection Office exercised NRC EDO requested that an IIT (the Team) be weak oversight with regard to storage and established to investigate the ingestion of P-32 control of radioactive material in at MIT. The Team was to find facts, determine unrestricted and controlled areas.
what happened, and make appropriate findings and conclusions. The Team included personnel e NRC regulatory standards and guidance for with a broad knowledge of health physics, security and control of byproduct material incident analysis, radiation dosimetry, were inconsistent. operations using radioactive materials for research, and criminal investigation. The Team
- While the Team found weaknesses in the included two observers from the Commonwealth actions taken by Radiation Protection of Massachusetts and one observer from the Office personnel, the licensee's overall NRC Office of the Inspector General. On response was good.
October 20, the Team charter was modified to remove references to assessing possible o Management oversight of the Radiation wrongdoing, and the representative of the NRC Protection Program was weak. MIT staff Office ofInvestigations was taken off the Team. did not use a process of management On the same day, the NRC Office of review and self-assessment to find investigations began an independent weaknesses in their program and to take { investigation. appropriate remedial actions. j On October 25, the Team finished gathering e NRC reporting requirements were not ; information at the site and held an exit interview specific regarding intentional i at MIT that was open for public attendance and contamination. NP.C reporting observation. After returning to NRC requirements for intake were unclear. headquarters, the Team interviewed NRC staff liowever, sufficient data was available in NMSS, AEOD, the Office of State Programs, Incident Investigation Program 28 NUREG-1272, Vol.10, No. 2
Incid:nt Investigrtion Progrr.m AEOD Annuil Report,1996 within the first week to indicate the event air cleaning systems for the complex. The threatened to cause an overexposure. licensee established a team to review the causes of the fire and to recommend The Team concluded that the ingestion of P-32 corrective actions. ! at MIT was most likely the result of a deliberate act by a knowledgeable individual. However, The AIT concluded that the cause of the the Team could not determine how the ingestion fire was inadequate cooling of the hot occurred. Consequently, the Team could not exhaust from the incinerator. This resulted determine a root cause. However, the Team ; from inadequate water flow to the pre- 4 found sufficient information to identify the quench tank caused by operating the following contributing causes to the event: equipment in an altered configuration from the original design. Contributing to this e MITs program for the control, security, were inadequate maintenance and and accounting of radioactive materials surveillance of incinerator equipment, was not effective for deterring or detecting inadequate procedures, and inadequate deliberate diversion of radioactive implementation of procedures. , materials. I The team reviewed the corrective actions e The NRC did not have reporting for a previous fire in incinerator ducting requirements in place to collect that occurred on June 13,1963. Several of information about deliberate acts in order the licensee's corrective actions for that to assess their frequency.' fire were not effectively implemented, in addition, the team reviewed indications e The NRC did not disseminate information from the weeks prior to April 2 that the about known precursor events and did not incinerator was not being operated as inform licensees of the circumstances of a designed. This was evidenced by increased similar incident at the National Institutes of quantities of soot-like material in the Health until 4 months after the incident scrubbers in early 1996. The team was reported. determined that the ducting and air cleaning systems for the building complex 6.2 Augmented Inspection Team had suffered extensive damage as a result f the fire but found no indication of Events structural damage to the buildings. The
"*"" "** 8" " *****"
in 1996 two AITs were conducted in response to the following nuclear material events: 'E"" "" ""* * *'I '" "88 *"" comprehensive. (1) On April 2,1996, at approximately 12:00 (2) On August 22,19%, an unanticipated noon, the licensee, Nuclear Fuel Services
, chemical reaction occurred in a large m Erwm, Tennessee, discovered a fire in evaporation tank at the ABB Combustion ductwork on the roof of a buildmg Engineering facility in Hematite, Missouri. l cornplex. The hcensee's Emergency
. The reaction caused the ejection of hot :
Brigade, with suppoit from the Erwm. Fire l materials and liquids from the tank that Department, brought the fire under control landed on the other tanks in the by approximately 12:30 p.m. The licensee evaporation complex, the surrounding dike declared a Site Area Emergency, notified and asphalt, and the adjacent sides and roof offsite agencies of the fire, and performed of the building. These materials initiated a offsite radiat,oni dose projections. The i.r' fire in the mop water boildown tank which was in the exhaust ductwork from the was located next to the large evaporation mcmerator, and the exhaust ductwork ar2d NUREG-1272, Vol.10, No. 2 29 Incident Investigation Program i
AEOD Annual Report,1996 Incident Investigation Program tank. The reaction also caused a large Although the event initiator could not be column of reddish-brown vapor and steam definitively identified by the licensee or the to rise from the tank to a height of AIT, it was most likely due to an approximately 15 to 20 feet. A steady wind interaction between an organic material took the vapor plume over the oxide and and ammonium nitrate that occurred at an pelletizing plant roofs and out over the elevated temperature. The ammonium restricted area fence. The plume extended nitrate accumulated in the large evaporator in the east-northeasterly direction along a for a period of about six weeks. During this valley that extends from the plant. The time, an organic material may have been licensee declared an Alert. introduced into the large evaporator, probably by way of the mop water The licensee's actions during the event boildown tank. Samples of residual were appropriate and in accordance with chemical material were obtained for the Emergency Plan Implementing analysis. The results of these analyses were Procedures. Decisions by the Emergency not available at the conclusion of the Director were conservative and interfaces inspection. with the offsite emergency responders and agencies were generally smooth. Ilowever, Notwithstanding the lack of a definitive the AIT noted weaknesles in the licensee's resolution of the initiating reaction, the sampling program for identifying potential root cause of the event appeared to be offsite consequences during the event, insufficient managerial control over the including the lack of procedural guidance process, involving both design and for performing and assessing radiological operational control issues. The design of and chemical sampling, inadequate air the outside hold and evaporator tank sampling, and the lack of records system did not meet standard chemical documenting sample locations and results. safety practices for isolating acids and bases, and there were no positive controls From the liniited air sampling during the over what material was placed in the event and additional sampling after the system. The system was open, unmarked, event, the AIT concluded that there were and unposted. no indications of adverse chemical or radiological consequences to plant staff, Inadequate operating procedures, out of members of the public, or the environment date piping and instrument diagrams as a result of the event. One employee inadequate labeling and component strained his back while evacuating the site identification, inadequate operator training, and was taken to the hospital for treatment. inadequate communications, and a lack of Results of air samples taken from the maintenance were contributing causes. In licensee's fixed environmental samplers, a particular, the system was operated in a hipel air sample taken during the event, and manner that was not consistent with the vegetation and soil samples taken after the approved operating procediares. Although event were all at normal background. In many of the issues identified by the AIT particular, an independent analysis were known by the operating staff, the i conducted by the Oak Ridge Institute of licensee operated the system without taking Science and Engineering of soil and appropriate and timely corrective actions to vegetation samples found no uranium address the problems. activity above normal background. Ammonia samples taken along the public The AIT concluded that the licensee had road and nearest residence downwind were opportunities to identify the problems in ! also negative. system design and control. Two precursor Incident Investigation Program 30 NUREG-1272, Vol.10, No. 2
Incid:nt Investigation Program AEOD Annut! Report,1996 events occurred over the past eight years investigation for this event was thorough involving unanticipated vigorous reactions and identified the same basic causes and in the storage and evaporation tanks. No issues as the AIT. After reviewing the investigation or corrective action records licensee's corrective action plan, the AIT could be located for either event. No root concluded that the licensee had taken wises were identified and no corrective appropriate actions to preclude the j actions were taken. The AIT also occurrence of a similar event. concluded that the licensee's root cause i i l l 1 I 1 I i i i i l NUREG-1272, Vol.10, No. 2 31 incident Investigation Program
7 COMMITTEE TO REVIEW GENERIC REQUIREMENTS The Committee to Review Generic Joseph Murphy, Executive Assistant to the Requirements (CRGR) reviews all generic Director, RES requirements proposed by the NRC staff that involve one or more classes of power reactors. Charles W. Hehl, Director, Division of On March 22,1996, the Commission approved a Nuclear Materials Safety, RI-revision to the CRGR Charter which expanded the scope of CRGR reviews, on a 1 year trial Dennis Dambly, Assistant General Counsel basis, to include selected nuclear materials for Materials, Antitrust and Special issues that are requested by the Director of the Proceedings, OGC Omce of Nuclear Material Safety and l Safeguards or the Executive Director for While performing the CRGR review function, a , Operations. The CRGR consists of senior CRGR member expresses an individual managers from various headquarters program professional opinion about each item I offices and, on a rotational basis, from one of considered, rather than representing the view of the NRC regional offices. The AEOD Director his or her respective omce. The members of the serves as the CRGR Chairman, and the AEOD CRGR determine whether proposed new generic staff provides support for all of the Committee's requirements have sufficient merit in terms of activities. The AEOD Director also oversees safety and are justified in terms of cost (where plant-specific backfit activities of the NRC staff appropriate) before reac'.ing a consensus in the headquarters program omces and the recommendation about each issue considered. regional offices. The membership of the CRGR Each independent CRGR recommendation is as of Se- mber 30,1996, was as follows:. given to the EDO for consideration. l Edward L. Jordan, Director, AEOD In 1996 the CRGR held 15 meetings during (Chairman) which it discussed 23 issues, all related to power l reactors. The Committee, in its reviews of Frank J. Miraglia, Deputy Director, NRR proposed new generic requirements, continued I to place emphasis on less prescriptive, more Malcolm Knapp, Deputy Director, NMSS performance-based and risk-informed j regulations. 1 i l l NUREG-1272, Vol.10, No. 2 33 (
APPENDIX A Nuclear Materials Data by Event Type A-1 NRC Licensee Events A-2 Agreement State Licensee Events
)
1
APPENDIX A-1 NRC Licensee Events I
CONTENTS Tables A-1.1 Medical Misadministrations Reported to the NRC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1-1 A-1.2 Overexposures Reported to the NRC ...........................................A-1-2 A-1.3 Loss of Control of Material Events Reported to the NRC . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1-3 A-l .4 Leaking Sources Reponed to the NRC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1-7 A-l .5 Material Release Events Reported to the NRC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1-8 l A-l .6 Transponation Events Reponed to the NRC . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1-9 p A-1.7 Equipment Problems Reponed to the NRC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1-10 i A-1.8 Fuel Cycle Events Reported to the NRC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-1-13 l A-1.9 Research and Training Reactor Events Reponed to the NRC . . . . . . . . . . . . . . . . . . . . . . . . A-1-14 i l l l l t l l l NUREG-1272, Vol.10, No. 2 A 1-iii
Nuclear Mit: rials AEOD Annu:1 R: port,1996 Table A-1.1 Medical Misadministrations Reported to the NRC Item License Event Type of No. Licensee No. City State Date Misadministration % 0352 Berkshire Medical 20-12009-03 httsfield MA 05/09/96 Teletherapy l Cent r i 960349 Brigham & Women's llospital 20-17131-01 Boston MA 04/27/96 Brachytherapy 960040 Clara Maass Medical Center 29 43163-03 Belleville' NJ 01/16/96 Brachytherapy 960478 Community llospitals 13-06009 4 1 Indianapolis IN 08/16 S 6 Brachytherapy ofIndiana 960356 Connecticut llealth Center, University 06-13022-05 Farmington CT 08/0786 Teletherapy of 951198 Danbury llospital 06-08544-01 Danbury CT 10/20/V5 Brachytherapy 960334 Deaconess llospital 24-00752 01 Saint Louis MO 05/01/96 Brachytherapy 960165 Detroit-Macomb liospital Corp. 21-01190-05 Warren M1 03/11/96 Brachytherapy 960060 Fernandez, Jose, M.D. 52 25114 1 San Juan PR 10/10/95 Brachytherapy 96022i Good Samaritan Ilospital 34-00991-02 Cincinnati OH 12/2185 Radiopharmaceutical 951291 Harper llospital Division 21-04127-06 Detroit MI 11/24/95 Brschytherapy % 0483 Ilealth One Unity liospital 22-12614-01 Fridley MN OU19/96 Brachytherapy % 0096 Lee, Phillip J. W., M.D. 53-04935-01 lionolulu lil 11/16/95 Brachytherapy 960313 Mahoning Valley Cancer Center 37-30086-01 Lehigh PA 12/31/95 Brachytherapy 960212 Minnesota, University of 22-00187-46 Minneapolis MN 03/27/96 Brachytherapy 951311 Queen's Medical Center 53-16533-02 lionolulu HI 12/08/95 Radiopharmaceutical l % 0218 Saint Francis Hospital & Medical 06-00854-03 Ilartford CT 03/12/96 Brachytherapy Center 960280 Saint Joseph Mercy Hospital 21-00943-03 Ann Arbor MI 04/09J5 Sodium lodide 960294 Universal Imaging, Inc. 21-26532-01 Taylor M1 03/18/96 Sodium lodide % 0010 V.A. Medical Center 39-12130-02 Charleston SC 01/09/96 Sodium lodide 951123 Walter Reed Army Medical Center 08-01738 02 Washington DC 10/20/95 Sodium lodide 960057 William Beaumont Hospital 21-01333-01 Royal Oak M1 01/30/96 Brachytherapy 960097 William Beaumont Hospital 21-01333-01 Royal Oak M1 02/24/96 Brachytherapy 960177 William Beaumont Hospital 21-01333-01 Royal Oak MI 03/19/96 Brachytherapy 951242 Winchester Medical Center 45-01589-01 Winchester VA 10/31/95 Sodium lodide 951186 Wisconsin, University of, at Madison 48-09843-18 Madison WI 10/19/95 Brachytherapy NUREG-1272, Vol.10, No. 2 A-1 -1 Nuclear Materials by Event Type
l AEOD Annual R: port,1996 Nucle:r Mzterisis l l l l Table A-1.2 Overexposures Reported to the NRC It:m License Event Type of No. Dose Nr. Licensee No. City State Date Exposure Exposed (Rem) 960235 Braidwood, Unit 2 NPF-0077 Braidwood IL 04/08/96 Skin 1 70.60 i 960210 Conam lnspection, 12-16559 4 1 Itasca IL 02/27/96 Whole Body I 36 00 , inc. l l 960479 E.1. Du Pont Merck 20-28598 4 1 Nonh Billerica MA 07/29/96 Whole Body 1 5.71 Pharmaceutical Co. 960205 Globe X-Ray 35-15194 4 1 Tulsa OK 12/31/95 Whole Body I 5.10 l Senice, Inc. 960160 Ohio State 34-00293 42 Columbus Oil 03/06/96 Skin 1 53.00 University I Nuclear Materials Data by Event Type A-1-2 NUREG-1272, Vol.10, No. 2
Nuclear Materials AEOD Annual Report,1996 i l Table A 1.3 Loss of Control of Material Events Reported to the NRC Item License Event Radio- Activity No. Licensee No. City State Date Nuclide , (mCl) 960164 21st Century Technologies, Inc. 30-23697-ole Albuquerque NM 12/22/95 H3 6630 960176 A. E. Staley Manufacturing Co. 12-01457-01 Decatur IL 01/10/96 Cs-137 20 960535 AB!laboratones 37-30215-01 Philadelphia PA 09/11/96 Am-Be 50 Cs 137 11 960339 Abington Memorial Hospital 37 00432-02 Abington PA 05/13/96 Cs-137 16 i 960532 Air Force, Department of the 42-23539-01 AF Brooks AFB TX 09/16/96 Sr 90 1.5 960488 Air Force, Department of the 42-23539-01 AF Brooks AFB TX 08/20/96 U-dep NR l 960039 Air Force Department of the 42-23539-01 AF Brooks AFB TX 01/24/96 H-3 NR 960002 Air Force. Department of the General Brooks AFB TX 01/03/96 H-3 200 960428 Air Force. Department of the 42-23539-01 AF Brooks AFB TX 08/05/96 Am-241 .008 960282 Airborne Express Non-Ucensee Bristol PA 06/01/96 Cd-109 5 Fe-55 40 951317 Alaska industrial X-ray 50-16084 01 Anchorage AK 12/08/95 Ir 192 9000 960190 Allegheny General Hospital 37 01317-04 Pittsburgh PA 03/08/96 1-125 .32 960299 Alt & Witzig Engineering, Inc. 13-18685-01 Indianapobs IN 06/25/96 AnvBe 40 Cs 137 8 96G891 Alt & Witzig Engineenng, Inc. 13-18685-01 Indianapolis IN 08/29/96 Am-Be 50 Cs-137 10 960492 Alt & Witzig Engineering, Inc. 13 18685-01 Indianapolis LN 08/29/96 Am-Be 40 Cs-137 8 960065 Amersham Corp. 20-12836-01 Burlington MA 02/05/96 Ir 192 107000 951240 Applied Construction Technologies 34-25834-01 Cleveland OH I1/02/95 Am Be 50 Cs-137 8.5 951328 Army, Department of the Rock Island 12 00722-07 Rock Island IL 11/01/95 Pm-147 16 Arsenal 960354 Army, Department of the . Rock Island 12-00722-13 Rock Island IL 02/09/96 Am-241 4.5 Arsenal 9604 % Ashland Petroleum .'4-15998-01 Canton OH 08/29/96 Fe-55 50 Co. 951233 Ashland Petroleum 34-15998-01 Canton OH 11/01/95 Sr-90 .002 Co. 951280 Atlantic Geotechnical Services, Inc 45-25191-01 Ashland VA 11/28/95 Am-Be 50 Cs-137 10 960330 Bayley-Ellard High School 29-13030-01 Madison NJ 05/16/96 Cs-137 400000 Cs-137 400000 960318 Bethesda Hospital 34-10921-03 Cincinnati OH 04/11/96 1 131 .29 951214 Boone Hospital Center 24-01565-01 Columbia MO 10/05/95 Ir 192 6 88 City and State for licensees are as listed on the license; for non-licensees, they are where the event was reported. NR means not seported. NUREG-1272, Vol.10, No. 2 A-1-3 Nuclear Materials by Event Type
l AEOD Annual R: port,19% Nuclear Mat: rials Table A-1.3 Loss of Control of Material Events Reported to the NRC Item License Event Radio- Activity No. Licensee No. City State Date Nuclide (MCI) l 960237 Broce Construction 35-27481 01 Norman OK 04/27/96 Cs-137 8 Co., Inc. 960197 Centro De Medicina Nuclear 52 25127-01 Santurce PR 03/24/96 Mo-99 48 Tc-99m NR 951302 CTI& Associates,Inc. 21 17007 01 Farmington MI 12/05/95 Am-Be 40 Hills Cs-137 8 960054' Dande Plastics General Dunallen NJ 12/30/95 Po-210 1.5 Po-210 1.5 960620 Duquesne University 37-02451.o4 Pittsburgh PA 03/14/96 P-32 10 960019 E. L Du Pont De Nernours & Co., Inc. 07-13441-02 Newark DE 12/22/95 Ni 63 15 l 960027 E. L Du Pont Merck Pharmaceutical Co. 20-28598-01 North MA 01/20/96 P-32 10 Billerica 960627 EMR Photoelectric 29-08636-02 Princeton NJ 09/17/96 H-3 1300 960604 Evart Pmdacts General Evart MI 01/21/96 Po-210 10 Po-210 10 Po-210 10 960311 Fairfax Manor Condominiums General Mentor OH 06/23/96 H-3 16000 960538 Federal Express Non-Ucensee Indianapolis IN 08/02/96 P-32 .72 951235 FMC Wyoming Corp. 49-04295-01 Green River WY 10/31/95 Cs-137 150 960811 Gentex Corp. General Zeeland MI 04/04/96 Po-210 10.2 960470 George Washington University Medical SNM-1499 Washington DC 06/27/96 Pu-238 NR Center Pu-238 NR 960072 Good Samaritan Hospital 13-01787-01 Vincennes IN 02/09/96 P-32 20 960435 H. C. Nut:ing Co. 34-18882-01 Cincinnati OH 08/06/96 Am-Be 40 960312 Pawmaaa University 37 00467-34 Philadelphia PA 04/24/96 I-125 2.1 951290 Hall-Houston Co. NR NR NR 11/22/95 Am-Be 50000 960275 Halliburton Co. 42-01068 07 Houston TX 04/07/96 Am-Be 20000 960704 Hiram Walker & Sons, Inc. 21 20408-01 Uvonia M1 08/23/96 H-3 200 Ni-63 NR 960795 Hnu Systems,Inc. 20-279384 30 Newton MA 02/27/96 Fe 55 6 Highlands 951197 Kidde Consultants, Inc. 45-19018-01 Manassas VA 10/28/95 Am-Be 407.8 Cs-137 960158 Ime Construction Corp. 06-06284 4 2 Meriden CT 03/08/96 Am-Be 40 Cs-137 8 City and State for licensees are as listed on the license; for non-licensees, they are where the event was reported. NR means not reported. Nuclear Materials Data by Event Type A-1-4 NUREG-1272, Vol.10, No. 2
Nuclear Mit: rids AEOD Annual Repon,1996 l 1 1 Table A 1.3 Loss of Control of Material Events Reported to the NRC Item License Event Radio. Activity No. Licensee No. City State Date Nuclide (mCl) 960593 12e Markquart Auto and Truck Center General Eau Claire WI 01/01/96 Po-210 10 l 960274 Imngview Inspection Service 45-25279-01 Richmond VA 04/10/96 Ir-192 40000 960208 Mallinckrodt Medical,Inc. 24-04206-01 Maryland MO 02/24/96 Tc-99m NR Heights Mo-99 2500 951250 Mallinckrodt Medical, Inc. 24-04206-04MD Maryland MO I1/I1/95 Mo-99 3000 lleights Mo-99 1000 960540 Mallinckrodt Medical,Inc. 24-17450-03 Saint louis MO 07/l1/96 Tc-99m 1900 960216 Miami University 34-01329-07 Oxford OH 02/21/96 P-32 .578 960430 Michigan, University 21-00215-04 Ann Arbor M1 06/11/96 Am-241 .0002 , of l % 0557 Miller Associates 24-25950-02 Columbia MO 09/19/96 Am-Be 80 Cs-137 16 Am-Be 80 Cs-137 16 . l 960063 Miller Engineering 28-23457-01 Manchester NH 02/06/96 Am-Be 40 and Testing Cs 137 80 951188 Minnesota Mining & Manufactunng Co. 22-00057-03 Saint Paul MN 10/20/95 H-3 114 951229 Monsanto Chemicals Co. II-27361-01 Soda Springs ID 10/26/95 Cs-137 50 960586 National Naval 45-23645-0INA Bethesda MD 09/10/96 Pd-103 1.35 Medical Center 960499 Navy, Department of 4523645-0INA Portmouth VA 08/09/96 Am-241 .005 Am-24I .005 96006I Navy, Department of the 45-23645-01NA Portsmouth VA 02/08/96 U-dep 75 951175 Nth Consultants, Ltd. 21 14894-01 Farmington MI 10/09/95 Am-Be 40 Hills Cs-137 8.5 951320 Professional Servicc industries. Inc. 45-25085 01 Fairfax VA 12/07/95 Am-Be 50 Cs-137 10 960755 S.C. Johnson & Son, Inc. 48-06453-01 Rac:re W1 08/26/96 Am-241 300 960004 Saint Joseph's Hospital 48-00537 03 Milwaukee WI 01/02/96 I-125 .35 1-125 .35 960495 Saint-Gobain/Norton 34-06558 45 Solon OH 07/31/96 Am-241 .00001 960178 Salem, Unit I DPR-0070 Salem NJ 03/18/96 U-2.s5 .00004 960248 Schlumberger Anaddll NR NR TX 04/30/96 Am-24i NR 960289 Schlumberger Technology Corp. 42-00090-03 liouston TX 06/14/96 Cs-137 1700 951189 Schlumberger Technology Corp. NR New Orleans IA 10/20/95 Am-Be 16000 Cs-137 1700 City and State for hcensees are as listed on the license; for non-licensees, they are where the event was reported. NR means not reported. NUREG-1272, Vol.10, No. 2 A-1 -5 Nuclear Materials by Event Type
AEOD Annual Repolt,19% Nuclear Miterials 1 l Table A-1.3 Loss of Control of Material Events Reported to the NRC l Item License Event Radio- Activity No. Licensee No. City State Date Nuclide (mCl) l
%0113 Sctdumberger Technology Corp. 42-00090-03 Houston TX 10/23/95 Am-Be 16000 Cs-137 1700 960094 Schlumberger Technology Corp. 42-00090-03 Houston TX 02/17/96 Am-241 .005 Am-24 8 .05 960201 Sperry Sun Drilling Services,Inc. 42-268444)1 Houston TX 03/18/96 3000 t 2000 960102 Stocker & Yale, Inc. 20-16532-01 Beverly MA 10/01/95 NL NR 960486 Technicut Co. General Prospect CT 08/22/96 Po-210 10 960111 Teledyne lsotopes. Inc- 29-00055-02 Westwood NJ 10/06/95 H-3 28000 960605 Thierica General Grand Rapids MI 04/01/96 ! -210 .25 960812 United Medical Manufacturing Co. General Indianapolis IN 03/22/96 Po-210 20 %0592 V.A. Edward Hines, 12 01087-07 Hines IL 06/26/96 Tc-99m NR Jr., Medical Center 960481 V.A MedicalCenter 13 00694-03 Indianapolis IN 07/29/96 P-32 .6 951239 V.A. Medical Center 45-09413-06 Richmond VA 10/05/95 I-125 .5 960614 V.A. Medical Center 42-00084-06 Houston TX O'Al/96 Am-241 .13 960829 Western Atlas International,Inc. 42-02964-01 Houston TX 06/14/96 H-3 10000 960056 Xitec General Labelle PA 01/30/96 Cs-137 100 960140 X-Ray inspection NR Sulfur LA 03/04/96 Ir-192 25000 960480 Yale University 06-00183-03 New Haven CT 08/16/96 Th-228 .00007 960422 Yale-New Haven Hospital 06-00819 03 New Haven CT 03/06/96 1-125 15 City and State for licensees are as listed on the bcense; for non-licensus, they are where the event was reported, NR means not reported.
t l l l 1 Nuclear Materials Data by Event Type A-1-6 NUREG-1272, Vol.10, No. 2
Nuclear M terills AEOD Annual Report,1996 l Table A-1.4 Leaking Sources Reported to the NRC Item License Event Radio-No. Licensee No. City State Date Nuclide 960697 Anheuser-Busch, Inc. General St. louis MO 02/26/96 Ni-63 960698 Anheuser-Busch, inc. General St. Louis MO 08/26/96 Ni-63 i 960300 Army, Department of the - White 30-02405-10 White Sands NM 04/23/96 Co-60 Sands Missile Range i i 960309 Battelle Columbus Laboratories SNM-0007 Columbus Oil 04/24/96 Ni-63 960638 Cominco Alaska,Inc. General Kotzebue AK 07/26/96 Fe-55 960643 Ita!!iburton Co. 42-01068 07 11ouston TX 02/13/96 Gd-153 951187 Metorex, Inc. 37-28461-01 Langhorne PA 10/20/95 Fe-55 951245 Metorex, Inc. 37-28461-01 Langhorne PA 11/07/95 Fe-55 Cd-109 960346 Ohio State University 34 00293 4 2 Columbus OH 02/29/96 NR 960797 PCC Airfoils,Inc. 34-2II09-02 Mentor Oil 07/22/96 NR 960429 Perfection Services,Inc. 34 16305 01 Stone Creek 0 11 07/31/96 Am-Be Am-Be NR means not reported. I l i i NUREG-1272, Vol.10, No. 2 A-1-7 Nuclear Materials by Event Type
AEOD Annu:1 Report,1996 Nuclear Mrterials i l Table A-1.5 Material Release Events Reported to the NRC Item License Event Release Radio-No. Licensee No. City State Date Type Nuclide i
%0355 Army, Department of the . 12-00722-10 Rock Island IL 07/09 S 6 Surface H-3 Rock Island Arsenal l
951185 Army, Department of the - 12-00722-06 Rock Island IL 10/18/95 Air Am-241 Rock Island Arsenal 11-3 960100 Brandeis Lniversity 20-01958-05 Waltham MA 10/06/95 Surface P-32 i 960238 Calvert Cliffs, DPR-0053 Lusby MD 04/23/96 Person NR l Unit i 960457 Cleveland Clinic 34-00466-01 Cleveland Oli 08/27/96 Surface 1-131 Foundation 1-131 960801 Cooper llospital/ 29-08285-01 Camden NJ 07/08/96 Surface P-32 University Medical Center 960276 Itatch, Unit i DPR-0057 Baxley GA 04/20 S 6 Person NR 960297 Illinois, University of R Oll5 Urbana IL 04/11/96 Water NR I 960215 Nuclear Fuel Servic.s, Inc. $NM-0124 Erwin TN 04/02/96 Surface U-235 960319 Nuclear Metals, Inc. SMB-0179 Concord MA 05/13/96 Surface U-238 960553 Oyster Creek DPR-0016 Toms River NJ 09/17/96 Water 11-3 960533 Saint Louis University 24-00196-07 Saint Louis MO 09/12/96 Surface P-32 P-32 951176 Sequoyah, Unit I DPR-0077 Soddy-Daisy TN 10/14/95 Person NR 960790 Syncor international Corp. 04-26507 OlMD Chatsworth CA 08/12/96 Surface 1-131 960273 Total Minerals Corp. SUA 1341 Casper WY 05/17/96 Surface U-Nat 951190 U.S. Enrichment Corp. USEC-O Piketon Oli 10/20/95 Surface UF6 960135 V.A. Medical Center 09-15294-01 Tampa FL 02/29/96 Surface P-32
% 0756 Y.A. Medical Center 09-15294-01 Tampa FL 03/01/96 Surface P-32 P-32 960539 V.A. Medical Center 04-17862 1 tema Linda CA 08/01/96 Surface Tc-99m 951262 V.A. Medical 04-00421-05 San Francisco CA 11/23/95 Surface P-32 Center 960304 Washington Nuclear, Unit 2 NPF-0021 Richland WA 06/02/96 Person NR 960200 WillowRun Airport Non-Licensee Ypsilanti MI 03/I7/96 Surface Sr-90 Y-90 NR means not reported.
Nuclear Materials Data by Event Type ' A-1-8 NUREG-1272, Vot 10, No. 2 iiI. -
Nucl:er M;t2 rials AEOD Annn:1 Report,1996 Table A-1.6 Transportation Events Reported to the NRC Item License Event Type of Trans-No. Licensee No. City State Date portation Event 960538 Amersham Corp. 1212836-02E Arlington lleights IL 08/02/96 Transport Vehicle Involved in Accident 960005 Army, Department of the . 12 00722 06 Rock Island IL 12'26/95 Surface Contamination Rock Island Arsenal Levels Exceeded Limits For Package 960240 Edlow International Non-Licensee Washington DC 04/15/96 Failure To Brace and Block Shipment 96005) Mallinckrodt Medical,Inc. 24-04206-04MD Maryland licights ivio 01/23/96 Radiation levels Exceeded Limits For Package 960336 Mallinckrodt Medical,Inc. NR West llaven CT 05/20/96 Surface Contamination levels Exceede1 Limits For Package 960242 Malhnckroot Medical,inc. NR NR NR 05/16/96 Surface Contamination levels Exceeded Limits For Package 960340 Mallmckroot Medical, Inc. NR Pinebrook NJ 05/16/96 Surface Contamination Levels Exceeded Limits For Package 960277 Medi+ Physics, Inc. 20-30176-01MD Woburn MA 06/20/96 Surface Contamination ! levels Exceeded Limits ) For Package 951322 Meritus llealth Systems, lac. 45-25194 4 1 Roanoke VA 12/13/95 Transport Vehicle l Involvedin Accident ! 960271 Monticello DPR 0022 Monticello MN 05/05/96 Failure To Brace and Block Shipment 960568 New England Medical Center NR NR NR 09/2396 Radiation levels Exceeded Limits For Package 960084 Nordion Europe Non-Licensee Brussels BE 02/15/96 Radiation levels Exceeded Limits For Package 960337 Pharmalogic 37-30219-OlMD Sayre PA 04/18/96 Radiation Levels Exceeded Limits For Package
% 0073 Syncor International Corp. 22-19174-01MD St. Paul MN 02/12/96 Transport Vehicle involved in Accident 960548 Syncor International Corp. 04 26507-01MD St. Paul MN 09/16/96 Surface Contamination Levels Exceeded Limits For Package 960537 Syncor International Corp. 04-26507-01MD St. Paul MN 09/10/96 Transport Vehicle involved in Accident 960153 Westinghouse Electric Corp. SNM-Il07 Pittsburgh PA 12/22/95 Improperly Packaged Material NR mean not reported.
NUREG-1272, Vol.10, No. 2 A-1-9 Nuclear Materials by Event Type
AEOD Annu 1 Rrport,1996 Nucl=r Mtt: rills Table A-1.7 Equipment Problems Reported to the NRC Item License Event No. Licensee No. City State Date Equipment 960335 Air Force, Department of the General Brooks AFB TX 06/07/96 RsJioluminescent Exit Sign 95134i Amersham Corp. SUB I485 Burimston MA 12/21/95 Camera, Radiography 451232 ANS Consultants, Inc. 29-30183-01 Edison NJ 10'31/95 Gauge, Moisture / Density 951?!8 Applied Geoscience & 37 27835 01 Readmg PA 10/26/95 Gauge, Moisture / Engineermg, Inc. Density 960012 Applied Radiant Energy 45-11496-01 Lpchburg VA 01/10/96 Irradiator Corp. 960317 Army, Department of the General Fort Sill OK 06/28/96 Radioluminescent Exit Sign 960694 Army, Department of the - 13-18235-01 Crane IN 07/09/96 Camera, Radiography Crane Navel Weapons 951185 Army, Department of the - 12-00722-06 Rock Island IL 10/18/95 Detector, Chemical Agent Rock Island Arsenal Collimator, infimty Alignment Device 960005 Army, Department of the - 12-00722 06 Rock Island IL 12/26 S 5 Collimator Rock Island Arsenal 960283 Babcock & Wilcox Co. SNM-0042 Lynchburg VA 06/19/96 Alarm, Criticality 960579 Babcock & Wilcox SNM-0042 Lynchburg VA 09/19/96 Vacuum, IIEPA- Filtered Co. 960767 Baker Hughes Oilfield 17 27437-01 Broussard LA 03/25/96 Gauge Operations, Inc. 960062 Bethlehem Steel Corp. 37-01861-05 Bethlehem PA 01/23/96 Electron Capture Detector 960038 Champion Target Co. 13 16598-01 Richmond IN 01/14/96 Gauge, Level 951241 Civil & Environmental 37-28465-01 Pittsburgh PA 11/04/95 Gauge, Moisture / Consults Inc. Density % 0228 Combustion Engineering, Inc. SNM-0033 llematite MO 04/05/96 Furnace 960308 Combustion Engineering,Inc. SNM-0033 llematite MO 05/08/96 Chute, Feed 960301 Combustion Engineering. Inc. SNM-0033 llematite MO 06/04/96 Ilood, Exhaust 9601 % CTI Alaska,Inc. 50-19202-01 Anchorage AK Oi/09/96 Camera, Radiography 960055 CTI Alaska,Inc. 50 19202-01 Anchorage AK 12/23/95 Camera, Radiographj 960706 CTI Alaska,Inc. 50-19202-01 Anchorage AK 01/09/96 Camera, Radiography 960705 CTI Alaska,Inc. 50-19202-01 Anchorage AK 02/05/96 Camera, Radiography 960323 CTI Alaska,Inc. 50-19202-01 Anchorage AK 03/04/96 Camera, Radiography 960324 CTI Alaska,Inc. 50-19202-01 Anchorage AK 03/26/96 Camera, Radiography 960689 CTI Alaska,Inc. 50-19202-01 Anchorage AK 06/23/96 Camera, Ra,Jiography Nuclear Materials Data by Event Type A-1-10 NUREG-1272, Vol.10, No. 2
Nuclear M:teri:Is AEOD Annual Report,1996 Table A-1.7 Equipment Problems Reported to the NRC Item License Event No. Licensee No. City State Date Equipment 960500 E.1. Du Pont Merck NR NR MA 09/0566 Camera, Radiography 951253 EDP Consultants, Inc. 34-21301-01 Willoughby llills Oli 11/16/95 Gauge, Moisture / Density 960231 Edwards Pipeline Testing, 35-23193-01 Tulsa OK 11/12/95 Camera, Radiography Inc. 960241 Exxon Co. 25-03375-01 Dillmgs MT 04/l5S6 Gauge, tevel 960351 General Dynamics Corp. 06-01781 08 Groton CT 03/22/96 Camera, Radiography 960693 General Dynamics Corp. 06-01781 08 Groton CT 06/04/96 Camera, Radiography 960207 General Electric Co. SNM-1097 Wilmington NC 03/27/96 incinerator 960209 General Electric Co. SNM-1097 Wilmington NC 03/28/96 Blender,Iligh Enriched Rotary 960285 General Electric Co. SNM 1097 Wilmington NC 06/17/96 Line, Transfer % 0433 General Electric Co. SNM-1097 Wilmington NC 08/08S6 Criticality Alarm 951289 Gene 11 Electric Co. SNM-1097 Wilmington NC 11/26/95 Furnace MufDer 960195 Globe X-Ray Service,Inc. 35-15194-01 Tulsa OK 12/21/95 Camera, Radiography 960221 Good Samaritan llospital 34 00991 02 Cincinnati OH 12/21/95 Tubing, Intravenous 960202 llealth & lluman Services, NR Bethesda MD 03/22 S 6 Irradiator Department of 960222 Knight Consulting Engineers, 44-19115-02 Williston VT 04/03/96 Gauge, Moisture / I inc. Density 960028 Law Engineering,Inc. 45-18377-01 Chesapeake VA 01/23/96 Gauge, Moisture / Density 960288 Mackin Engineering Co. 37-20533-01 Pittsburgh PA 06/2496 Gauge, Moisture / Density 951342 Malden Mills industries,Inc. General Lawrence MA 12/11/95 Gauge, Thickness Gauge, , Density l 960267 Michigan South Central NR Litchfield M1 04/26/96 Gauge, Density Power Agency 960174 Minnesota Valley 22 24393-01 New Prague MN 02/05/96 Camera, Radiography Engineering 960226 Missouri, University of R-0103 Columbia MO 01/23/96 Research Reactor Regulating Blade 960552 Navy, Department of 45-23645-0INA Portsmouth GA 03/20/96 Camera, Radiography the 960175 Navy, Department of the 45-23645-0INA Portsmouth VA 02/01/96 Camera, Radiography 951300 Nine Mile Point, DPR-0063 Scriba NY I1/29/95 Cask Lifting Device Liner, Cask Unit i NR means not reported. NUREG-1272, Vol,10, No. 2 A-1-11 Nuclear Materials by Event Type
AEOD Annuil R: port,1996 Nuclzr Miteriils Table A-1.7 Equipment Problems Reported to the NRC Item License Event No. Licensee No. City State Date Equipment 960497 NJS Engineering 40-26894-01 Spearfish SD 08/2986 Gauge, Moisture / Density 960157 Nuclear Containers. Inc. NR Elizabethton TN 10/11/95 Container,0verpack j 960199 Nuclear Fuel Services,Inc. SNM-0124 Erwin 1H 03/22 S 6 Alarm, Criticality
% 0215 Nuclear Fuel Services,Inc. SNM-0124 Erwin TN 04/0266 heincrator 960472 Nuclear Fuel Services,Inc. SNM4124 Erwin TN 08/07/96 Alarm, Criticality 960095 Nuclear Metals,Inc. SMB-0179 Concord MA 02/21/96 Ra&oactive Waste System 960319 Nuclear Metals, Inc. SMB-0179 Concord MA 05/13/96 Pipeline, Waste 960345 Olin Brass Corp. 13-26078-01 Indianapolis IN 05/04/96 Gauge Thickness 960338 Permagrain Products,Inc. 37 17860-02 Media PA 05/20/96 Fan, Exhaust 960122 Permagrain Products, Inc. 37-17860 01 Media PA 12/07/95 trradiator 960211 Power Resources,Inc. SUA-15 tl Glenrock WY 01/20 S6 Coupling, Pipe 960189 Precision Components Corp. 37-16280-01 York PA 01/12/96 Camera, Radiography 960120 Precision Components Corp. 37-16280-01 York PA 10/09/95 Camera, Radiography 960188 Precision Components Corp. 37-16280-01 York PA 12/11/95 Camera, Radiography 960204 Quahty Controllaboratories 29 18171-02 Audubon NJ 01/23/96 Electron Capture Detector 951247 Saint Joseph's Hospital a 29-10191 02 Paterson NJ 11/06 S 5 Syringe Mc6 cal Center 960434 Shell Chemical Co. 34 13012-01 Belpre OH 08/25 S 6 Gauge, Level 951249 Shilts, Graves & Associates, 13-18528 4 1 South Bend IN 11/09/95 Gauge, Moisture /
Inc. Density 960498 Terracon 15-20070-01 Boise ID 08/29/96 Gauge, Moisture / Density 960645 Transportation, Department 09-25011-01 Galveston TX 03/14S6 Gauge AsphaltContent of 960332 United Technologies Corp. 06-02269-03 Stratford CT 05/09/96 Helicopter Inflight Blade Indicator 960305 U.S. Engineering 1.aboratory, 29-30107-01 Rahway NJ 06/27/96 Gauge, Moisture / Inc. Density 960194 Western Stress,Inc. 42-26900 4 1 Houston TX 02/07/96 Camera, Radiography 960066 Westinghouse Electric Corp. SNM Il07 Pittsburgh PA 01/31/96 Fuel Assembly 960293 William Beaumont Hospital 21-01333-01 Royal Oak M1 04/29/96 Shield, Vial 960200 Willow Run Airport Non-Licensee Ypsilanti MI 03/17/96 Detector, ke 960052 Yankee Atomic Electric Co. 20-14597-01 Bolton MA 01/26/96 Electron Capture Detector NR means not reported Nuclear Materials Data by Event Type A-1-12 NUREG-1272, Vol.10, No. 2 l l
Nuclear Miteritis AEOD Annual Report,1996 l Table A-1.8 Fuel Cycle Events Reported to the NRC Item License Event Type of' Fuel No. Licensee No. City State Date Cycle Event 9603 % Babcock & Wilcox Co. SNM 0042 Lynchburg VA 03/14S6 Other 960796 Babcock & Wilcox Co. SNM-0412 Lynchburg VA 05/24/96 Other 960283 Babcock & Wilcox Co. SNM 0042 Lynchburg VA 06/19/96 Equipment Failure 960494 Babcock & Wilcox Co. SNM-0042 Lyr.chburg VA 08/25S6 Other 960579 Babcock & Wilcox Co. SNM 0042 Lynchburg VA 09/1986 Other 960582 Babcock & Wilcox Co. SNM-0042 Lynchburg VA 09/24 S 6 Equipment Failure 960308 Combustion Engineenng. Inc. SNM-0033 llematite MO 05/0886 Potential Criticality 960301 Combustion Engineering,Inc. SNM-0033 itematite MO 06/0486 Equipment Failure 960487 Combustion Engineering,Inc. SNM4033 itematite MO 08/2266 Other 960826 Combustion Engineering, lac. SNM 0033 itematite MO 09/18S 6 Potential Criticality 960209 General Electric Co. SNM-1097 Wilmington NC 03/2886 Potential Criticality 960185 General Electric Co. SNM-1097 Wilmington NC 06/1766 Equipment Failure, Potential Criticality 960433 General Electric Co. SNM-1097 Wdmington NC 08/08 S 6 Equipment Failure 951289 General Electric Co. SNM-1097 Wilmington NC i1/2685 Equipment Failure, Potential Cnticality 951326 General Electric Co. SNM 1097 Wilmington NC 12/12S5 Potential Criticality 951340 General Electric Co. SNM 109'l Wilmington NC 12/1985 Potential Criticality 960472 Nuclear Frel Services,Inc. SNM 0124 Erwin TN 08/07 S 6 Equipment Failure 960292 Siemens Power Corp. SNM-1227 Richland WA 01/05 S 6 Potential Criticality 960526 Siemens Power Corp. SNM-1227 Richland WA 09/12 S 6 Potential Criticality 960764 U.S. Enrichment Corp. USEC-O Piketon Oil 04/30 S 6 Potential Criticalsty 951190 U.S. Enrichment Corp. USEC-O Piketon 0 11 10/20S5 Equipment Failure
% 0153 Westinghouse Electric Corp. SNM-Il07 Pittsburgh FA 12/22/95 Potential Criticality NUREG-1272, Vol.10, No. 2 A-1-13 Nuclear Materials by Event Type
AEOD Annu 1 R: port,1996 Nuctrar Mat: rials Table A-1.9 Research and Training Reactor Events Reported to the NRC Item License Event No. Licensee No. City State Date Type of Reactor Event 960297 II'mois, University of R 0115 Urbana IL 04/11/96 Equipment Problem 960003 Interior, Department of the R4113 NR CO 01/04/96 Equipment Problem 960226 Missouri, University of R4103 Columbia MO 01/23/96 Equipment Problem NR means not reported. l Nuclear Materials Data by Event Type A-1-14 NUREG-1272, Vol.10, No. 2 1
l 1 APPENDIX A-2 l i l t 1 Agreement State Licensee Events ' l i l l t l l , 1 I l l I 1 t i I l l l l l I i i I ' l I i 1 l
CONTENTS Tables A.2.1 Medical Misadministrations Reported to Agreement States . . . . . . . . . . . . . . . . . . . . . . . . . . A-2-1 A-2.2 Overexposures Reported to Agreement States ....................................A-2-2 A-2.3 Loss of Control of Material Events Reported to Agreement States . . . . . . . . . . . . . . . . . . . . A-2-3 A-2.4 Leaking Sources Reported to Agreement States ..................................A-2-7 A-2.5 Material Release Events Reported to Agreement States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-2-8 A-2.6 Transportation Events Reported to Agreement States ..............................A-2-9 A-2.7 Equipment Problems Reported to Agreement States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A 10 I NUREG-1272, Vol.10, No. 2 A-2-lii
Nuclear Materials AEOD Annual Report,1996 l Table A-2.1 Medical Misadministrations Reported to Agreement States Item License Event Type of l No. Licensee No. City State Date Misadministration 960295 Adventist Ilealth System I'L-0069-1 NR FL 04/22 S 6 Sodium lodide 960149 Baptist Medical Center, Princeton NR Birmingham AL Ol/08S6 Sodium lodide 960416 Bellaire llospital NR flouston TX 10/10/95 Brachytherapy 960417 Bc!! aire llospital NR liouston TX 10/11/95 Brachytherapy 960265 Bluegrass Radiological Physics, KY 202 061-25 texington KY 02/13/96 Sodium lodide Inc. 960171 Duke University Medical Center NC-032-0347-4 Durham NC 03/12 S 6 Brachytherapy 960744 11. lee Moffitt Cancer Center & FL-1739-01 Tampa FL 05/02 S 6 Brachytherapy Research Institute 960244 Johns Hopkins University llospital MD-05-007 03 Baltimore MD 06/03S6 Brachytherapy 960266 Kentucky, University of KY 202-049-22 Lexington KY 11/13/95 Sodium lodide 960011 Memorial Medical Center IL 01343-01 Springfield IL 01/09/96 Brachytherapy 951301 Methodist Medical Center IL-01204-01 Peoria IL i1/27S5 Sodium Iodide 960264 Mississippi, University of MS-MBL-01 Jackson MS 05/23 S 6 Brachytherapy 951312 North Carolina, University of, NC-068-0565-1 Chapel flill NC 12/08/95 Brachytherapy llospital 960772 Southern California, University of CA-1949-70 les Angeles CA 03/18S 6 Brachytherapy NR means not reported-NUREG-1272, Vol.10, No. 2 A-2-1 Agreement State Licensee Events
AEOD Annual Report,1996 Nuclzr Mat ri:Is Table A-2.2 Overexposures Reported to Agreement States It:m License Event Type of No. Dose N:. Licensee No. City State Date Exposure Exposed (Rem) 960441 Ana Tec, Inc. NR Nederland TX 12/12/95 Whole Body 1 6.3 960327 Certified Testing, AL-1174 Cottondale AL 07/01/96 Whole Body 2 53.00 Inc. I1.00 960546 Duke University NC-032 0247- Durham NC 09/16/96 Skin 1 60.05 Mcdical Center 4 960353 Isotope Products CA 1509-70 Burbank CA 07/17/96 Internal 1 8.3 Laboratories (TEDE) 960445 Kooney X-Ray, Inc. NR liouston TX 10/15/95 Whole Body 1 14.8 960163 Larpen of Texas TX LOOO74 liouston TX 03/05/96 Extremity 22 3000.00 Whole Body <10.00
<10.00
<10.00
<10.00
<10.00
<10.00
<10.00
<10.00
<10.00
<10.00
<10.00
.50
.50
.50
.50
.50
.16
+
.16
.!6
.16
.16 960152 Liberty Technologies, NR North SC 10/01/95 Whole Body I 8.00 Inc. Charleston 960070 NDC Systems CA 145170 Monrovia CA 02/01/96 Internal I >$.00 (TEDE)
NR means not iemkd. TEDE = Total Effective Dose Equivalent i l l Agreement State Licensee Events A-2-2 NUREG-1272, Vol.10, No. 2 l L
Nuclear Materials AEOD Annual Report,1996 Table A-2.3 Loss of Control of Material Events Reported to Agreement States Item License Event Radio- Activity No Licensee No. City State Date Nuclide (MCI) 960286 Abbott laboratories NR North Chicago IL 06/12/96 I-125 .2 960058 Agra Earth & Environmental, Inc. AZ 7-95 Phoenix AZ 02/05M6 Am-Be 50 Cs-137 10 960781 Amgen Incorporated CA 3768-56 Thousand Oaks CA 05/23/96 I125 .1 960423 Anderson Engineering Consuhants AR 519 Uttle Rock AR 07/30/96 Am-Be 40 960314 Anheuser-Busch General Van Nuys CA 06/20/96 H-3 30000 960646 Apphed Geotechnical Engineering UTI800298 Midvale UT 09/04/96 Am-Be NR Cs-137 NR 960774 Beckman Instruments, Inc. CA-044130 Fullerton CA 03/27/96 P-32 1 960715 C.Q C. Testing & Inspection Services CA-5952-70 lancaster CA 09/21/v6 Am-Be NR Cs-137 NR 960776 Cahfornia State University General Sacramento CA 04/11/96 H3 90000 960572 Califomia. University of, Medical Center CA-0278-30 Irvine CA 02/29/96 l 125 19.8 960722 California, University of CA 1339-80 San Diego CA 07/04/96 Cs-137 NR 951323 Cheeseborough Ponds Co. General Racford NC 12/05 S 5 Po-210 22 5 960105 Collins Engineering TN-R 19152 Nashville TN 02r26/96 Am-Be 44 E8 Cs-137 9 960542 Country Couch, Inc. General Junction City OR 03/05/96 Po-210 NR 960462 Dallas Transplant Institute NR Dallas TX 01/02/96 I-125 1.1 960298 Del Med Corp. Non-Ucensee New York NY 04/23/96 Mo-99 28 960069 Deseret Generation /Trans. UT-24000-37 Sandy UT 01/31/96 Cs-137 10 960459 Digital Surveys. Inc. NR Alvin TX 11/19/95 Co-60 22 960227 Duke University Medical Center NC-032-0247-4 Durham NC 03/29/96 I-125 7.6 960343 ECC International General Sylacauga AL 07/15/96 Cs-137 100 960444 Ellergee-Walzac, Inc. NR Fort Worth TX 12/27/95 Am-241 40 960250 Engeo, Inc tVR San Ramon CA 05/27/96 Am-Be NR Cs-137 NR Am-Be NR Cs-137 NR 951213 Engtneenng IVR Research NC 10/31/95 Am-Be 40 Consultant Services IJd- Triangle Pk Cs 137 8 951181 Federal Express Non-Ucensee Memphis TN 10/18/95 Xe-133 60 960162 Florida Department ILO109-01 Gainesville FL 02/22/ % Am-Be 40 ofTransportation Cs-137 8 960425 Gallet & Associates,Inc. NR Birmingham AL 08/06/96 Am-Be 44 Ciry and State for licensees we as listed on the license; for non-licensees, they are where the event was reported. NR raeans not reported. NUREG-1272, Vol.10, No. 2 A-2-3 Agreement State Licensee Events
AEOD Annual Report,1996 Nuclear Mit2 rills 4 Table A-2.3 Loss of Control of Material Events Reported to Agreement States l Item License Event Radio- Activity No Licensee No. City State Date Nuclide (MCI) 960724 Geocon Environrnental Consultants CA-3924-80 San Diego CA 03/3166 Am-Be NR Cs-137 NR 960742 Group Technology Cornoration General Tampa FL 05/23/96 Po-210 10 Po-210 10 Po-210 10 Po-210 10 Po-210 10 960270 llalliburton LA-2353-L01 Bossier City LA 06/23/96 Cs-137 50 Engineering Services 960575 Italliburton Energy Services CA-0782-15 Bakersfield CA 10/24S 5 Am-Be 18500 Cs-137 1500 1 960001 Harding /Larson Co. CA-1639 Concord CA 01/02/96 Cs-137 82 960172 Illinois, University IL-01883 01 Chicago IL 02/06/96 Ni43 NR l of, at Chicago 960753 L J. Nodarse & Associates,Inc. FL-2429-01 Winter Park FL 01/1066 Am-Be 40 Cs-137 8 l l 960044 Lafayette Police Department Non-Licensee Lafayette LA 12/18/95 Kr-85 2.5 960163 Larpen of Texas TX-LOOO74 llouston TX 03/05/96 Co 60 43000 Co-60 9000 Ir-192 NR 960571 Long Beach Memorial Medical Center CA-0165-70 long Beach CA 12/30S 5 Ir192 2 960173 Loyola University Medical Center IL 01131-02 Maywood IL 01/25/96 I-125 .01 960465 M.D. Anderson NR liouston TX 02/05/96 I-131 NR Cancer Center, Uninversity ofTexas 960415 Methodist llospital NR Baytown TX 10/13 S 5 Au-198 140 960609 Mobile Lab LA 1888-L01 Narrero LA 09/11/96 Ir-192 13000 t 960475 Mohawk Industries General Cartersville GA 08/15/96 Sr-90 40 l 960093 National Metals Non-Licensee Phoenix AZ 02/1766 Cs-137 NR 960262 Niton Corp. RI 3A-105-01 North RI 01/17 S 6 Fe 55 10 Kingstown 951312 North Carolina, University of. NC-068-0565-1 Chapel Hill NC 12/08 S 5 Cs-137 40 11ospital Cs-137 40 Cs 137 50 Cs-137 50 960750 Delray Beach Transfer Station NR Delray Beach FL 01/02/96 I-13I .31 951172 Private Individual General Greenville SC 10/04/95 11-3 NR 960651 Optex Biomedical NR The Woodlands TX 02/29/96 Am-Be 150 City and State for licensees are as listed on the license; for non-licensecs, they are where the event was reported. NR means not reported. Agreement State Licensee Events A-2-4 NUREG-1272, Vol.10, No. 2
Nucl: r Miterials AEOD Annual Report,1996 l l Table A-2.3 Loss of Control of Material Events Reported to Agreement States Item License Event Radio- Activity No Licensee No. City State Date Nuclide (mCl) 960047 Oregon, University of OR-90220-01 NR OR 10/27/95 1l-3 NR 960018 Palm Beach County Solid Waste Authority Non-Licensee West Palm FL 12/29/95 1 131 .25 Beach 960016 Palm Beach County Solid Wast: Authonty Non-Licensee West Palm FL 12/27 S 5 1-131 .2 Beach 960015 Palm Beach County Solid Waste Authority Non-Licensee West Palm FL 12/23 S 5 1-131 3 Beach 960725 Paul Young's Agricultural Service CA 3205-15 Wasco CA 05/07/96 Am-Be NR Cs-137 NR 960655 Pro Metals Processing Non-Licensee llouston TX 03/15 S 6 Co-60 NR Co. 960453 PSI NR llouston TX 01/07/96 Ir-192 3800 Ir-192 26000 fr-192 1000 Ir192 1000 tr 192 2500 Ir-192 22000 960650 Rodriques Engmeeting Laboratories NR Austin TX 04/25/96 Am-Be 50 Cs-137 10 960022 Scapa Press Fabrics OR-90717 NR OR 11/08/95 Am-241 100 t t 960612 Schlumberger Technology Corp. LA 2783-L01 Houston TX 09/14/96 Am Be 16000 Cs137 7000 960647 Schlumberger Technology Corp. NR Houston TX 01/27/96 Cs-137 1700 960414 Schlumberger Technology Corp. NR Houston TX 10/1065 Am-241 .05 960712 Schlumberger Technology Corp. CA-0144-15 Ventura CA 06/28 S 6 NR NR 960607 Southern Diagnostic LA-6629-L01 Lafayette LA 05/13/96 Cs-137 1 960269 Southern Earth Sciences,Inc AL-647 Mobile AL 04/29/96 Am-Be 50 Cs 137 10 960752 Southern Earth Sciences,Inc. FL-1957-01 Tallahassee FL 12/04/95 Am-Be 50 Cs13. 10 960161 Stottler 5tarmer Associates,Inc. FL-825 02 Cape Canaveral FL 03/04/96 Am-Be 40 Cs-137 8 Am-Be 40 Cs-137 8 Am Be 40 Cs-137 8 Av c 40 ts-137 8 960257 Sunrise Engineering, Inc. UT 14003-13 Fillmore UT 05/30/96 Am-Be 40 Cs-137 8 960139 Tektronix, Inc. General Beaverton OR 11/01/95 Po-210 NR City and State for licensees are as listed on the license; for non-licensees, they are where the event was reported. NR means not reported. NUREG-1272, Vol.10, No. 2 A 5 Agreement State Licensee Events
AEOD Annu 1 R port,1996 Nuclear Materials l ! Table A-2.3 Loss of Control of Material Events Reported to Agreement States Item License Event Radio. Activity No Licensee No. City State Date Nuclide (mCl) 960232 Tektronix, Inc. General Beaverton OR 05/15/96 Po-210 10 Po-210 20 Po-210 20 960258 Thomson Electric UT-03003-46 logan UT 03/19/96 H-3 7500 Sales 1 960251 Treasure Coast F1 235341 Port Saint Lucie FL 04/21/96 Cs-137 .22 I imaging Center,Inc. Cs-137 .21 960476 U.S. Pipe and Non-Ucensee Birmingham AL 08/13/96 NR NR Foundry 960779 UCI Medical Center CA-0278-30 Oninge CA 03/29/96 Ir-192 3.68 960460 Unitor, Inc. NR Houston TX 01/09/96 Co-60 .5 960017 Waste Management Non-Ucensee Boynton Beach FL 12/26/95 1-131 .35 of Palm Beach 960477 Western AZ-07-080 Pheonix AZ 08/15/96 Am-Be 50 Technologies Cs-137 10 l l 960561 Westlake Medical Center CA-2460-70 Westlake CA 12/09/95 Cs-137 NR i Village l 960611 X Ray !nspection inc. IA-2918-IAI Sulfur IA 03/02/96 Ir-192 25000 i City and State for licensees are as listed on the license; for non-licensees, they are where the event was reported. NR means not reponed. l Agreement State Licensee Events A-2-6 NUREG-1272, Vol.10, No. 2
Nuclzr Mit ri:Is AEOD Annual Report,1996 Table A-2.4 Lealdng Sources Reported to Agreement States l Item License Event Radio-No. Licensee No. City State Date Nuclide 960782 3M Company General Camarillo CA 04/26/96 Po-210 960714 Beckman Instrument, Inc. CA 0441-30 Fullerton CA 07/08/96 NR 960770 Deckman Instruments, Inc. CA-0441-30 Fullerton CA 02/05M6 NR l 96077i Beckman Instruments, Inc. CA-0441-30 Fullerton CA 01/19S 6 NR 960768 Generao Nucleonics, Inc. CA-1288-70 Pomona CA 02/28/96 Sr-90 960437 Industrial Nuclear Corp. CA-2229-60 San 12 andro CA 07/23N6 it192 960574 J. L. Shepherd and Associater CA-1777-70 San Fernando CA 01/25S 6 Am-241 960070 NDC Systems CA 1451-70 Monrovia CA 02/0lN6 Am-241 l Am-241 Am-241 Am-241 960033 Niton Corp. RI-3A 105-01 North RI 11/2165 Cd-109 Kingston 960451 North Texas, University of NR Denton TX 12/08/95 Cm-244 Cm-244 960150 Owens-Illinois, Inc. KY-401 126-30 Bardstown KY 12/0$M5 Pm-147 l NR means not reponed. l i l l l l l NUREG-1272, Vol.10, No. 2 A-2-7 Agreement State Licensee Events
AEOD Annuil Report,1996 Nuclear Materials Table A-2.5 Material Release Events Reported to Agreement States Item License Event Type of Radio-No. Licensee No. City State Date Release Nuclide 951169 Associated Couriers Non- Lemont IL 10/03 S 5 Surface Mo-99 Licensee Tc-99m 960249 Dramnaer Engmeering NR Shreveport LA 05/02/96 Surface 1-125 I-125 951244 Cardir.nl Surveys Co. TX-L00065 Midland TX 10/31M5 Surface Sb-124 960668 Isotag, Inc. NR Midland TX 05/13N6 Surface Sc-46 960353 Isotope Products Laboratories CA-1509-70 Burbank CA 07/17/96 Air Am-241 960070 NDC Systems CA-1451-70 Monrovia CA 02/0lM6 Air Am-241 960653 Saint Paul Medical Center NR Dallas TX 02/27M6 Surface Tc-99m 960434 Scientific Ecology Group,Inc. TN-R 73016 Oak Ridge TN 08/08/96 Surface NR 960458 St. Joseph flospital and Health NR Paris TX 12/29/95 Surface 1-131 Center 960464 St. Paul Medical Center NR Dallas TX 02/16/96 Surface Tc-99m 960159 Syncor Internanonal Corp. IL-01721-01 Des IL 10/1985 Surface Tc-99m Plaines 951338 Troxler Electronics NC-032 0182-1 Research NC 12/18/95 Surface Cs-137 Laboratories, Inc. Triangle Park 960328 Union Pacific Railroad Non-Licensee NR IL 07/03/96 Surface Th-232 960247 USX Corp. NR George TX 05/19/96 Surface U-Nat West NR means not reported. l l 1 Agreement State Licensee Events A-2-8 NUREG-1272, Vol.10, No. 2 1
Nucinr Materiils AEOD Annual Report,1996 Table A-2.6 Transportation Events Reported to Agreement States Item License Event Type of Trans-No. Licensee No. City State Date portation Event 960009 Alpha Omega CA 264170 los Angeles CA 01/10/96 Transport Vehicle involved in Accident 951169 Associated Couriers Non- lemont IL 10/03 S 5 Failure to Brace and Licensee Block Shipment 960234 Bmghamton General NR Binghamton NY 04/18/96 Radiation Ixvels llospital Exceeded Limits tor Package 960331 Federal Express Non-Licensee NR LA 07/0986 Transport Vehicle involved in Accident 960749 Florida Department of F1-0109-01 Gainesville FL 03/18/96 Transport Vehicle Transportation involved in Accident 960745 Florida Department of FL-0109-01 Gainesville FL 04/18/96 Improperly Packaged Transportation Material. Failure to Brace and Block Shipment 960746 Florida Department of FL-0109-01 Gainesville FL 04/1986 Improperly Packaged I Transportation Material; Failure to l Brace and Block Shipment 960743 Florida Department of FL-0109-01 Gainesville FL 05/23 S 6 Transport Vehicle Transportation involved in Accident 960740 Florida Department of FL-0109-01 Gainesville FL 05/29/96 Transport Vehicle Transportation involved in Accident 960026 Florida Department of FL-0109-01 Gainesville FL 11/30/95 Transport Vehicle Transportation involved in Accident 960020 Florida Department of FL-0109-01 Gainesville FL 12/14S$ Transport Vehicle Transportation involved in Accident 960753 L. I Nodarse & Associates, FL-2429-01 Winter Park FL 01/10/96 Failure to Brace and Inc. Block Shipment 96074i Syncor International Corp. FL-1264-08 Sarasota FL 05/25/96 Transport Vehicle Involvedin Accident 960198 Syncor Intemational Corp. NR Des Moines IA 03/22/96 Radiation Levels Exceeded Limits for Package 960263 Syncor Intemational Corp. NC-060-0794-1 Charlotte NC 05/01/96 Transport Vehicle involved in Accident 960328 Union Pacific Railroad Non-Licensee NR IL 07/03/96 Transport Vehicle involved in Accident NR means not reported. NUREG-1272, Vol.10, No. 2 A-2-9 Agreement State Licensee Events
AEOD Annuil Rtport,1996 Nuclear Materials j 4 1 Table A-2.7 Equipment Problems Reported to Agreement States Item License Event c J No. Licensee No. City State Date Equipment 960315 Amersham Corp. NR Arlingtec Heights IL 04/11/96 Irradiator ; 1 951169 Associated Courier Non- Le.nont IL 10/03S$ Container, Shipping Licensee Generator, Tc-99m 960565 Biomass Power Plant CA 5523-10 Mendota CA 01/30/96 Gauge, Level Ltd. 960249 Brammer Engineering NR Shreveport LA 05/02/96 Wellhead 960411 Cameron NR Richmond TX 11/16/95 Camera, Radiography 960224 CP&L NR NR NC 02/09/96 Camera, Radiography 960069 Deseret Generation / UT-24000-37 Sandy UT 01/31/96 Gauge, Density Transmission Cooperative 960654 Ethicon. Inc. NR San Angelo TX 04/08/96 Irradiator 960745 Florida Department of FL-0109-01 Gainesv!!!c FL 04/18/96 Gauge, Moisture / Transportation Density Gauge, Moisture / Density 960746 Florida Department of FL-0109-01 Gainesville FL 04/19/96 Gauge, Moisture / Transportation Density Gauge, Moisture / Density 960353 Isotope Products CA-1509-70 Durbank CA 07/1786 Scaled Source Laboratories 960146 Lebelle-Marvin, Inc. CA-4955 30 Santa Ana CA 10/06/95 Gauge, Moisture / Density 960011 Memorial Medical IL-01343-01 Springfield IL 01/09/96 IIDR Unit Center 960804 MQS Inspection, Inc. IL-01136-01 Elk Grove Village IL 05/20/96 Cameta, Radiography 960045 NR NR lictmiston OR 10/3185 Gauge 960452 Presbyterian Hospital NR Dallas TX 01/05/96 Gamma Knife Unit 960454 Price Construction NR Big Spring TX 12/08/95 Gauge, Moistare/ Density 960665 Quantum Chemical NR Deer Park TX 04/10/96 Gauge, Density 960773 Riverside County Flood CA 3252-33 Riverside CA 03/25 S 6 Gauge, Moisture / Control Density 951252 RTI Process Technology NC-001-0701 1 Haw River NC 11/13/95 trradiator 960434 Scientific Ecology TN-R-73016 Oak Ridge TN 08/08/96 Furnace Group, Inc. 960413 Southern Technical NR Lake Jackson TX 10/03/95 Camera, Radiography Services NR means not reported. Agreement State Licensee Events A-2-10 NUREG-1272, Vol.10, No. 2
l l Nuclear Materiils AEOD Annual Report,1996 l Table A-2.7 Equipment Problems Reported to Agreement States Item License Event No. Licensee No. City State Date Equipment l 951338 Troxler Electronics NC-032-0182 1 Research Triangle NC 12/18/95 Gauge, Moisture / Laboratories, Inc. Park Density 960779 UCI Medical Center CA-0278-30 Orange CA 03/29 S 6 Scaled Source, Seed 960247 USX Corp. NR George West TX 05/19/90 Wellhead 960709 Varian Associates,Inc. CA-1025-43 Palo Alto CA 03/08/96 IIDR Unit 96N85 4'estern Atlas 42-02964-1 11ouston TX 08/23/96 Gauge International, Inc. 960167 Wilhamette Industries OR-90141 Albany OR 12/29/95 Gauge 951255 Wiregrass Construction NR Dothan AL 11/20/95 Gauge, Moisture / i Co. Density I NR means not reported. l l l l l l l l NUREG-1272, Vol.10, No. 2 A-2-11 Agreement State Licensee Events
APPENDIX B Summary of 1996 Abnormal Occurrences B-1 NRC Licensees B-2 Agreement State Licensees l i
APPENDIX B-1 NRC Licensees i 1
-CONTENTS l NUREG-0090, Vol.19 Appendix B-1 NRC Licensees l 96-3 Medical Brachytherapy Misadministrations by Jos6 L. Fern 6ndez, M.D., in Mayaguez, Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B 1 96-4 Medical Brachytherapy Misadministrations by Phillip J. W. Lee, M.D., in Honol u lu, H awaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B- 1 -3 %-5 Medical Brachytherapy Misadministration at Harper Hospital in Detroit, M ic h igan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B- 1 -4 96-6 Medical Brachytherapy Misadministration at New England Medical Center in Boston, Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1 -4 96-7 Medical Brachytherapy Misadministration at William Beaumont Hospital in Royal Oak, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B- 1 -5 96-8 Medical Brachytherapy Misadministrations at Community Hospitals ofIndiana in Indianapolis, Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B- 1 -6 96-9 Medical Brachytherapy Misadministrations at EquiMed,Inc.,
in Lehighton, Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B- 1 -6 96-10 Medical Brachytherapy Misadministration at the University of Wisconsin in Madison, Wisconsin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1-7 96-11 Medical Brachytherapy Misadministration at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1 -8 96-12 Medical Brachytherapy Misadministration at Macombe Hospital Center in Warren, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B- 1 -9 96-13 Medical Brachytherapy Misadministration at Unity Hospital in Fridley, Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B 10 96-14 Radiopharmaceutical Misadministration at Universal Imaging ; in Taylor, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B 1 1 ! 96-15 Radiopharmaceutical Misadministration at Miami Valley Hospital in Dayton, Oh io . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B 12 96-16 Radiopharmaceutical Misadministration at St. Joseph Mercy Hospital in Ann Arbor, Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B- 1 -12 NUREG-1272, Vol.10, No. 2 B-1-iii
CONTENTS (cont.) 96-17 Radiopharmaceutical Misadministration at the Veteran Affairs Medical Center in Charleston, South Carolina . . . . . . . . . . . . . . . . . . . . . . . ........ . . . . . B 13 96-18 Radiopharmaceutical Misadministration at Queen's Medical Center in Honolulu,11awaii . . . . . . . . . . . . . . . . . . . . . . . . . . ..... . . . . B-1-14 NUREG-1272, Vol.10, No. 2 B-1-iv
Nuclear Materials AEOD Annual Report,1996 NUREG-0090, Volume 19 Report No. 96-3 Medical Brachytherapy Misadministrations by Jos6 L. Fernandez, M.D., in Mayagnez, Puerto Rico Detween January 14,1994, and October 10,1995, medical brachytherapy misadministrations were performed by Jose L. Fernsndez M.D. in Mayaguez, Puerto Rico. On January 14,1994, Dr. Fernsndez acquired an eye applicator device, which contained a strontium-90 (Sr-90) source of approximately 3219 megabecquerel (87 millicurie) activity, from the estate of a deceased licensee in Mayaguez, Puerto Rico. (Eye applicator devices are used for the supplemental treatment of non-malignant growths on the eye after surgery is performed.) The NRC knew that Dr. Tern 6ndez acquired the Sr-90 source because the estate was acting under a Confirmatory Action Letter (CAL) to maintain control of the Sr-90 source and to either dispose ofit or transfer control ofit to an authorized recipient. Since Dr. Fernsndez was already an NRC licensee for another Sr-90 source in San Juan, Puerto Rico, his license was amended so that he was an authorized recipient when the transfer took place. (After the transfer took place, Dr. Fern 6ndez was licensed to have two sources.) The NRC did not require Dr. Fern 6ndez to receive additional training in the use of the Sr-90 source after he acquired it from the estate because he was already an authorized user for a Sr-90 eye applicator as defined by 10 CFR 35. When Dr. Fernsndez took possession of the eye applicator device, it was in the manufacturer's carrying case. A label attached to the carrying case contained the following hand written information: (1) the dose rate for the device, which was calibrated as 24 centigray (cGy) per second (24 rad per second);(2) the instrument used to calibrate the dose rate; (3) the date when the dose rate was calibrated; and (4) the name of the individual who performed the calibration. Dr. Fernsndez assumed that the hand written information on the label attached to the manufacturer's carrying case was correct and proceeded to treat patients. On October 18,1995, during a routine inspection, an NRC inspector questioned the labeled dose rate on the eye applicator device and the resultant administered doses. Dr. Fernsndez was unable to provide documentation to answer the questions. He then voluntarily ceased the administration of radiation doses and requested a calibration cf the device by the manufacturer. The actual dose rate was found by the manufacturer to be 53 cGy per second (53 rad per second); i.e., more than twice the assumed dose rate. Dr. Fernsndez and the NRC reviewed the computer sorted records of all administrations using the eye applicator device and determined that between October 24,1994, and October 10,1995,87 patients had received radiation doses which were approximately twice the prescribed dose. However, the computer sort was not complete, since Dr. Fernsndez later discovered an additional 17 cases which occurred between January 1994 and October 1995. Dr. Fernsndez notified the patients about the misadministrations. The NRC contracted a medical consultant to review the medical aspects of the misadministrations. The NRC medical consultant, who reviewed patient records for the 87 patients initially identified, determined that 25 of the patients were at higher risk for complications. These 25 patients were initially NUREG-1272, Vol.10, No. 2 B-1-1 Summary of 1996 Abnormal Occurrences
AEOD Annu21 Report,1996 Nuclear Mrteritis prescribed treatment doses of 1500 to 2880 cGy (1500 to 2880 rad), but received doses of 3312 to 6360 cGy (3312 to 6360 rad) instead. Of these 25 patients,12 were then prescribed second treatment doses of 1000 to 2160 cGy (1000 to 2160 rad), but received doses of 2208 to 4770 cGy (2208 to 4770 rad) instead. Additionally, two of these 25 patients were prescribed third treatment doses of 1500 to 3000 cGy (1500 to 3000 red), but received doses of 3313 to 6625 cGy (3313 to 6625 rad) instead. The highest total dose received by a patient was 13,603 cGy (13,603 rad) to the surface of the eye, with an estimated 544 cGy (544 rad) to the lens of the eye. The NRC medical consultant believes that the long-term consequences of the misadministrations to the 25 highest dose patients could include: (1) increased risk of cataracts; and (2) increased risk of infections, due to 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 reexamination of seven of these 25 patients by Dr. Fern &ndez. However, the NRC medical consultant indicated that the possible adverse consequences to these patients may not appear for a period of up to 10 years after irradiation. The misadministrations occurred because Dr. Fern &ndez used an incorrect dose rate for the Sr-90 source, as calibrated by a medical physics consultant employed by the deceased former licensee, to develop treatment plans. The incorrect dose rate calibration occurred when the former licensee had a medical physics consultant calibrate the Sr-90 source, after the original calibration certificate was lost. The medical physics consultant used an inappropriate measurement instrument for the calibration, which gave an erroneous dose rate calibration of 24 cGy per second (24 rad per second). (The label attached to the carrying case of the eye applicator device indicated that the medical physics consultant calibrated the Sr-90 source in September 1990.) Also, Dr. Fern &ndez had no Quality Management Program (QMP) as required by 10 CFR 35.32, which could have helped in detecting the calibration error. Medical use licensees, as required under 10 CFR 35.32, must establish a QMP to provide high confidence that radiation will be administered as directed by the authorized user. l l To prevent recurrence, Dr. Fern &ndez initially ceased operations until the eye applicator device was properly calibrated; reliable dosimetric data was available to perform the dose administrations; and a QMP was developed and submitted to the NRC for review. Dr. Fern &ndez subsequently decided to cease using the Sr-90 source and to terminate his license. (The QMP was never implemented.) The NRC issued a CAL to confirm that Dr. Fern &ndez would submit a QMP for use of the eye applicator device, and that he would cease operations until approval was received from the NRC to resume operations. A second CAL was issued confirming that Dr. Fern &ndez would perform an in-depth review of his records to identify the misadministrations and to notify the patients. I After Dr. Fern &ndez requested termination of his license, the NRC issued an order which required him to maintain the Sr-90 sources in locked, safe storage until the sources were transferred to an authorized recipient, to transfer the Sr-90 source within 90 days, to identify and notify any additional patients who may have received misadministrations, to obtain the services of an independent medical physics consultant with expertise in therapy dosimetry calculations, and to perform several other tasks specified in the order. Dr. Fern &ndez currently has a possession only license until his sources are properly trrnsferred and his request for termination has been granted by the NRC. In addition, the NRC is requesting that the Puerto Rico Health Department perform a long-term follow-up of these patients. NUREG-1272, Vol.10, No. 2 B-1-2
Nucle:r Mit:ritis AEOD Annual Report,1996 The NRC also issued Information Notice 96-66, "Recent Misadministrations Caused by Incorrect Calibrations of Strontium-90 Eye Applicators," on December 13,1996, to alert all medical use licensees authorized to use Sr-90 cye applicators of misadministrations caused by incorrect source strength determinations of Sr-90 eye applicators. Dr. Fern 6ndez purchased the medical practice and the Sr-90 source from the estate of the deceased former licensee, Dr. Luis A. V4zquez of Mayaguez, Puerto Rico. Consequently, Dr. Fernandez has the records of all of the administrations that were made using the Sr-90 source while it was licensed to Dr. Vszquez. In a letter to Dr. FernAndez dated October 28,1996, the NRC confirmed with Dr. FernAndez that he would pre erve the patient records of the former licensee and perform a computer search to identify the patients who were treated with the eye applicator. The NRC is considering options for the review of these records to determine how many additional misadministrations occurred when the incorrectly calibrated Sr-90 source was in the possession of the former licensee. Report No. 96-4 Medical Brachytherapy Misadministrations by Phillip J. W. Lee, M.D., in Honolulu, Hawaii From May 6,1995, through November 16,1995, medical brachytherapy misadministrations were performed by Phillip J. W. Lee M.D. in Honolulu, Hawaii. During an NRC inspection, it was determined that the licensee had incorrectly performed calculations for the decayed activity of a strontium-90 (Sr-90) source in an eye applicator. Consequently, the licensee had the Sr-90 eye applicator calibrated by the National Institute of Standards and Technology (NIST). Based on calibration data provided by NIST, the NRC and the licensee determined that 17 misadministrations involving 16 patients had occurred between May 6 and November 16,1995. (Two of the misadministrations involved one patient who was treated on both eyes.) The delivered doses were from 21.1 to 22.7 percent greater than the prescribed total dose of 4000 centigray (cGy)(4000 rad). (The total dose was to be delivered in four fractions of 1000 cGy [1000 rad] each.) The licensee and referring physicians did not observe any adverse consequences to the patients. The licensee noted that the misadministered doses were within the ranges recommended for this type of treatment. The NRC contracted a medical consultant to review the cases and make an independent assessment of the potential health effects to the patients. As of the date of this report, the reviews of the NRC and its consultant were ongoing. The licensee notified the patients of the misadministration. The misadministrations occurred because the licensee did not know how to calculate the decay of the Sr-90 source, and used a linear function rather than a logarithmic function. In addition, the licensee used an incorrect half-life for Sr-90; hcwever, this error was less significant. To prevent recurrence, the licensee had the Sr-90 eye applicator calibrated at NIST and learned how to calculate the decay of the Sr-90 source. The NRC requested that the licensee have the Sr 90 eye applicator calibrated at NIST and taught the licensee how to calculate the decay of the Sr-90 source. The NRC is conducting an inspection, which NUREG-1272, Vol.10, No. 2 B-1-3 Summary of 1996 Abnormal Occurrences
I ; AEOD Annu:1 Report,1996 Nucle:r Materi:Is ] will remain open until the NRC medical consultant finishes reviewing the cases and provides an assessment of the potential health effects to the patients. Enforcement action may be taken in the future if j necessary. j i j ' Medical Brachytherapy Misadministrations by Phillip J. W. Lee, M.D., in Honolulu, Hawaii l i I l Report No. 96-5 Medical Brachytherapy Misadministration at Harper Hospital in Detroit, Michigan l On November 24,1995, a medical brachytherapy misadministration occurred at Harper Hospital in Denoit, Michigan. ! A patient was being treated with a strontium-90 eye applicator for pterygium (a growth over the eye l which causes gradual blindness). The patient was prescribed three 800-centigray (800 rad) treatments lasting 30 seconds each. Each of the treatments was to be administered to the medial side of the left eye. However, the second treatment was mistakenly administered to the lateral side of the left eye. The physician realized the error and immediately treated the correct side with the prescribed dose. The patient was notified of the misadministration and given a written report. The patient's referring l physician was notified. An NRC medical consultant evaluated the effects of the misadministration and concurred with the licensee that the patient was not expected to suffer any adverse health effects. The misadministration oceurred because the patient's chart was upside down and the treating physician
- incorrectly interpreted the sketch of the left eye on the diagram that specified the treatment site. (The Cagram was part of the written directive for treatment using the strontium-90 eye applicator; however, it did not show the nose, top of the page, or bottom of the page.) Also, the second treatment was
- administered by a different physician and physicist than the first treatment.
l To prevent recurrence, the licensee revised the diagram so that it Lhows the nose, thereby making it obvious which is the left eye and which is the right eye. The NRC conducitd a special safety inspection. A Notice of Violation was issued for failing to ensure that the adminisw. tion was in accordance with the written directive. Since the inspection showed that actions had been taken to correct the violation and to prevent recurrence, no reply to the violation was required. _ s._. _ Report No. 96-6 Med c d Ar ' .nytherapy Misadministration at New England , Me(.c. center in Boston, Massachusetts
]
]
l On November 10,1993, a medical brachytherapy misadministration occurred at New England Medical l Center in Boston, Massachusetts. NUREG-1272, Vol.10, No. 2 B-1-4
Nuclear M teriils AEOD Annut! Report,1996 A patient with carcinoma of the cervix metastatic to the brain was being treated with an intercavity implant using cesium-137 sourc-s in a gynecological applicator. During treatment a source became dislodged and delivered radiatioa to the patient's thigh, which was an unprescribed treatment site. The licensee subsequently calculated that the consequent dose to the patient's thigh was 71 centigray (cGy) (71 rad), as compared to 65 cGy (65 rad) which would have been delivered to the thigh at 20 centimeters (7.87 inches) distance from the applicator during the total procedure if perfvrmed as prescribed. l During a routine NRC inspection conducted on April 10-12,1995, the NRC inspector noted the incident l report and brought it to the attention of NRC management. The NRC subsequently determined that the event was a misadministration and notified the licensee. The licensee consequently submitted the required notifications to the NRC, and notified the patient in writing of the misadministration. The misadministration occurred because of a malfunction of the aging gynecological applicator, and a j possible lack of attention to details by the personnel involved in loading the applicator. l l To prevent recurrence, the licensee replaced the malfunctioning gynecological applicator. In addition, the ! licensee now requires that two persons perform loading of the gynecological applicator to insure that the l sources are in and that the ovoids are taped to insure that the sources do not come out inadvertently. l The NRC again reviewed the information provided by the licensee and determined that a violation of the licensee's Quality Management Plan had occurred. An NRC medical consultant reviewed the circumstances of the misadministration and determined that the patient received a dose of 864 cGy (864 l rad) to the thigh. The medical consultant stated that the patient experienced no ill effects. Report No. 96-7 Medical Brachytherapy Misadministration at William Beaumont Hospital in Royal Oak, Michigan On March 19,1996, a medical brachytherapy misadministration occurred at William Beau nont Hospital in Royal Oak, Michigan. A patient with cance t of the vagina ns prescribed treatment with a high-dose-rate (HDR) remote afterloader br;ehytherspy unit having an iridium-192 source. The treatment plan specified a step size of 2.5 millimeters (mm)(0.093 inches). A wrong step size of 5.0 mm (0.197 inches) was entered into the l HDR unit's computer control program. Therefore, a part of the body not scheduled to receive radiation l I was exposed. The licensee calculated that the skin of the patient's thighs, which was the wrong treatment site, received a maximum unintended dose of 500 centigray (500 rad) because of the misadministration. An NRC medical consultant determined that the patient should have no side effects as a consequence of the misadministration. The patient and the referring physician were notified of the misadministration. I The misadministration occurred because the wrong step size was entered into the HDR remote rdierloader brachytherapy unit's computer control program. i NUREG-1272, Vol.10, No. 2 B-15 Summary of 1996 Abnormal Occurrences
AEOD Annual R: port,1996 Nucinr Miterials To prevent recurrence, the licensee revised its " physics worksheet" to include the step length as an additional entry; developed a checklist for the physicist /dosimetrist to verify the treatment plan parameters, and posted it on the treatment console; and instituted a policy that all treatment plan parameters must be verified, and the verification recorded, prior to each treatment. The NRC conducted a special safety inspection, where one apparent violation was noted. This was the failure of the lice isee's Quality Management Program to provide assurance of correct administration of the prescribed dose in compliance with the physician's written directive. Report No. 96-8 Medical Brachytherapy Misadministration at Community Hospitals of Indiana in Indianapolis, Indiana On August 16,1996, a medical brachytherapy misadministration occurred at Community Hospitals of Indiana in Indianapolis, Indiana. A patient was prescribed a 500 centigray (cGy)(500 rad) treatment for an esophageal tumor using a high dose rate remote afterloader unit having an iridium-192 source. Because of a treatment planning error, a non-prescribed treatment area approximately 27 millimeters (mm)(1.06 inches [in]) below the tumor volume received a maximum dose of 465 cGy (465 rad) instead of the estimated dose of 50 to 100 cGy (50 to 100 rad). The patient was notified of the misadministration. The licensee expects no adverse health effects to the patient. An NRC medical consultant was retained to review the case. The misadministration occurred because of a treatment planning error; the source was placed approximately 27 mm (1.05 in) below the tumor volume. To prevent recurrence, the licensee placed a table of offset distances, for the various sources and catteter lengths used, in its quality control manual. The NRC conducted a special safety inspection. ! Report No. 96-9 Medical Brachytherapy Misadministrations at EqulMed, Inc., in Lehighton, Pennsylvania On December 31,1995, medical brachytherapy misadministrations occurred at EquiMed, Inc., in Lehighton, Pennsylvania. Two patients were prescribed vaginal treatment with a high-dose-rate (HDR) remote afterloader brachytherapy unit having an iridium-192 source. The prescribed total dose for each patient was between 2000 and 2200 centigray (cGy)(2000 and 2200 rad), and was to be delivered in five fractional doses over a period of several weeks. Each fractional dose was to be between 400 and 500 cGy (400 and 500 rad). NUREG-1272, Vol.10, No. 2 B-1-6 l
Nuclzr Mit:ri:Is AEOD AnnuIl Report,1996 For one of the treatment fractions,500 cGy (500 rad) was to be delivered to each patient over a treatment length of 5 centimeters (cm)(1.97 inches [in]) using a step size of 5 millimeters (mm)(0.197 in). . However, a wrong step size of 10 mm (0.394 in) was entered into the HDR unit's control console, and a ) length of 10 cm (3.94 in) was treated instead of the prescribed length of 5 cm (1.97 in). Therefore, l radiation was delivered to the wrong treatment site for each patient. The licensee concluded that each patient received 312 cGy (312 rad) instead of the prescribed dose of 500 cGy (500 rad)(an underdose of 37.6 percent), and an additional length of 5 cm (1.97 in) received an unintended dose of 312 cGy (312 rad). The licensee did inform the patients of the misadministrations, and does not expect the patients to have any adverse effects from the misadministrations. The misadministrations occurred because a wrong step size was entered into the HDR unit's control console because the licensee did not follow its Quality Management Procedures (QMP). The QMP ; requires that treatment planning information be checked by the person entering the data in the control ) console, and then verified by the authorized user. l To prevent recurrence, the licensee's authorized user and the HDR physicist will extract the pre-treatment printout of the input parameters from the HDR treatment console, review the input data for accuracy, and compare it with the written directise. Both the authorized user and the HDR physicist will then initial the printout before the HDR treatment is initiated. The NRC determined that the incidents occurred because the licensee did not follow its QMP. The NRC contracted a medical consultant to evaluate the health effects on the patients from the misadministrations. Subsequently, the consultant detennined no probable deterministic effects of the radiation exposure to the unintended site were expected. Report No. 96-10 Medical Brachytherapy Misadministration at the University of Wisconsin in Madison, Wisconsin On October 19,1995, a medical brachytherapy misadministration occurred at the University of Wisconsin in Madison, Wisconsin. A patient had two separate lung tumors, one in the lower section of the right lung and one in the middle section of the left lung. The patir nt was prescribed a total treatment dose of 1600 centigray (cGy)(1600 rad), with each tumor to receive a total dose of 800 cGy (800 rad). The total treatment dose was to be administered in four fractions of 400 cGy (400 rad) each over 2 days using a high-dose-rate (HDR) remote afterloader unit having an iridium-192 source. Each fraction was to be administered in two parts; a 200 cGy (200 rad) dose to the lower section of the right lung followed by a 200 cGy (200 rad) dose to the middle section of the left lung. Catheters of appropriate length were inserted into each lung to guide the source during treatment; i.e., a long catheter was inserted into the right lung and a short catheter was inserted into the left lung. While the HDR controller was inserting the source into the left lung during the first treatment fraction, the source stopped moving when it touched the bottom of the short catheter in the left lung even though NUREG-1272, Vol.10, No. 2 B-1-7 Summary of 1996 Abnormal Occurrences
AEOD Annual Report,1996 Nuclear Materials the HDR controller was attempting to move it further into the left lung. Because the intended treatment sites had been reversed during treatment planning and were subsequently programmed into the HDR controller, the controller had positioned the source in the middle of the right lung during the first part of the first treatment fraction and was attempting to position the source in the lower part of the left lung during the second part of the first treatment fraction. Consequently, the middle of the right lung had received an unintended dose of 200 cGy (200 rad) during the first part of the first treatment fraction. After the error was discovered, the correct treatments were delivered. The patient was notified of the misadministration both verbally and in writing. The referring physician was also notified. An NRC medical consultant evaluated the misadministration and concluded that the patient would not have organ damage or long term biological efTects. l The misadministration occurred because the treating physicist deviated from standard protocol, when planning the treatment, and used different dummy sources to obtain clearer opaque x-ray markers for source location. Upon recording the data, the planned source locations for each treatment fraction were reversed. An independent verification of the treatment plan by a second physicist did not include a review of the x-rays for proper source location, so the error was not immediately discovered. To prevent recurrence, the licensee revised its Quality Management Program to include an independent review of the x-rays for somce location by a second physicist. Also, when there is a deviation from the protocol, the results must be documented and reviewed by a second physicist. The NRC conducted a special safety inspection in conjunction with a routine inspection. A Notice of Violation was issued for failing to establish adequate procedures to ensure that final treatment plans were in accordance with the written directive, The licensee responded in writing and no additional actions , were required. { l Report No. 96-11 Medical Brachytherapy Misadministration at Thomas Jefferson University Hospitalin Philadelphia, Pennsylvania On August 14,1995, a medical brachytherapy misadministration occurred at Thomas Jefferson University llospital in Philadelphia, Pennsylvania. , A patient was undergoing brachytherapy treatment of the palate; i.e., the roof of the mouth. A total of 64 l iridium-192 seeds, having a total activity of 1102.6 megabecquerel (29.8 millicurie), were inserted into six catheters. Four of the catheters were sutured inside the mouth, and two were placed in the nostrils. While making a routine visit to the patient, the prescribing physician noticed that two catheters were outside of the patient's mauth and had been taped to the patient's right cheek. Also, one of the two catheters remaining in the mouth was loose and its sutures were removed. Because the catheters were not properly positioned, the physician terminated the treatment. The radioactive seeds were subsequently removed. The patient was informed both verbally and in writmg that the sources had become dislodged and had consequently delivered radiation to the wrong treatment site. it was determined that the patient's cheek received a dose of 70 centigray (70 rad). NUREG-1272, Vol.10, No. 2 B-1-8
, a ! ) Nuclect Matcrials AEOD Annual Report,1996 ) 1 The misadministration occurred because a nurse noticed that two of the catheters were loose, while responding to a call from the patient, and subsequently taped them to the patient's cheek. The nurse had l not been trained to recognize that the radioactive seeds were moved from their intended positions. To prevent recurrence, the licensee gave refresher in-service training to the nurses who care for brachytherapy patients. Emphasis was placed on identifying radioactive sources cad handling them i properly under normal and emergency conditions. Also, the nurses will be briefed on the details of a planned treatment at the time the sources are implanted with emphasis on radiation safety issues. Finally, l physicians will visit implant patients at least twic e daily during treatment. j After conducting an investigation, the NRC determined that the event was a misadministration. An NRC medical consultant concluded that no significant injury would be expected. A Notice of Violation was issued with one Severity Level IV violation. Report No. 96-12 Medical Brachytherapy Misadministration at Macombe Hospital Center in Warren, Michigan On March 11,1996, a medical brachytherapy misadministration occurred at Macombe Hospital Center in Warren, Michigan. A patient was undergoing a cervical boost brachytherapy treatment with a manually afterloaded standard gynecological applicator using cesium-137 sources. Approximately 100 minutes after the treatment was started, a nurse found one of the sources from the applicator lying on the sheet between the patient's legs. The dislodged source contained 1.29 gigabecquerel (34.8 millicurie) of cesium-137 and was intended for the right ovoid of the applicator. The nurse placed the source into the portable shielding that was available in the room and notified the radiation safety officer. The radiation safety officer immediatcly returned to the patient's room with the physician, who inserted the source into the right ovoid for the remainder of the prescribed 48 hours of treatment. The licensee calculated that the unintended skin dose to the patient's upper inner thighs was 5 centigray (cGy)(5 rad). The NRC concurred with the licensee's calculation and did not obtain a no dical consultant. The dose of 5 cGy (5 rad) is within the occupational exposure limit and is not expected to restJt in deleterious effects to the patient. The patient and physician were notified of the misadministration. The misadministration occurred beccuse when the radiation oncologist manually afterloaded the sources from the right and left carriers into the ovoids, difficulty was encountered in identifying the correct carrier for the right ovoid. Also, the hinge on the correct carrier for the right ovoid was tight. The radiation oncologist believed that the scaled source dislodged from the carrier bucket when the problem with the hinge was encountered. To prevent recurrence, the licensee will: (1) ensure that the carrier bucket hinges are working properly prior to loading the source into the bucket; (2) inscribe the handles of the ovoid carriers, with R" for right ovoid and "L" for lett ovoid, so that they can be readily identified without difficulty; (3) require the physicist to observe the radiation oncologist during the afterloading procedure in order to detect a dislodged source; and (4) require that the radiation oncolot;ist complete a visual check of the bed sheets and immediate art,a before leaving the room. NUREG-1272, Vol.10, No. 2 B-1-9 Summary of 1996 Abnormal Occurrences
AEOD Annual Report,1996 Nucle:r Materitis The NRC conducted a special safety inspection. The NRC issued a Notice of Violation for failing to meet the objective that each administration is in accordance with a written directive. The inspection showed that actions had been taken to correct the violation and to prevent recurrence. Report No. 96-13 Medical Brachytherapy Misadministration at Unity Hospitalin Fridley, Minnesota On August 19-20,1996, a medical brachytherapy misadministration occurred at Unity Hospital in Fridley, Minnesota. A patient was prescribed a dose of 2500 centigray (cGy)(2500 rad) for a gynecological brachytherapy procedure, using a gynecological applicator containing cesium-137 sources in two ovoids. Because 3-centimeter (cm) diameter caps had been used on the ovoids of the gynecological applicator, instead of the intended 2-cm diameter caps, the patient received a dose of 1186 cGy (1186 rad) to the vaginal surface. With the addition of the external beam therapy that the patient had received prior to this treatment, the total administered dose was 5680 cGy (5680 rad). The treating physician determined that the total administered dose was within the medically accepted range of treatment, and that no negative effects to the patient were expected. The treating physician did not plan to administer any further radiation treatments to the patient to compensate for the underdose. The patient was notified of the misadministration both verbally and in writing. The referring physician was also notified. The misadministration occurred because there was poor communicatica between the treating physician and the dosimetrist who prepared the treatment plan regarding the size of the ovoid caps to be used for the treatment. (The treating physician may select 2-cm diameter caps,3-cm diameter caps, or no caps at all from an applicator kit, depending on the anatomy of the patient.)ln addition, licensee personnel may have become desensitized to the possibility that an ovoid cap size different than 2-cm in diameter could be used; the treating physician failed to follow-up on earlier instructions to the dosimetrist to verify the correct cap size used; and the applicator kit was not returned immediately to the radiation oncology department following the implant of the applicator device. To prevent recurrence, the licensee revised its written-directive form to require the treating physician to enter the cap size when ovoids are used, and for a second person to verify that the information was entered. If the entry on the form is not made, the person confirming the information must independently verify which size ovoid caps were used. l The NRC conducted a special safety inspection on September 9,1996. No violations of NRC requirements were identified during the course of this inspection. NUREG-1272, Vol.10, No. 2 B-1-10
~
Nuclair Materials AEOD Annu:1 Report,1996 l 1 l Report No. 96-14 Radiopharmaceutical Misadministration at Universal Imaging in Taylor, Michigan On March 18,1996, a radiopharmaceutical misadministration occurred at Universal Imaging, Inc. in Taylor, Michigan. 1 i A patient was prescribed a 7.4 megabecquerel(MBq)(200 microcurie [pCi]) dosage ofiodide-123 (I-l 123) for a thyroid scan, but was administered 7.4 MBq (200 pCi) ofiodide-131 (1 131) instead. l The referring physician's directive stated that 1-123 was to be used. (This is the only isotope ofiodine used at the facility.) A technologist then accidently ordered the I-131 from the nuclear pharmacy. A second technologist recognized that the 1-131 was different from the 1-123 routinely used, but assumed j that it was prescribed and administered it anyway. The licensee estimated that the dose to the patient's thyroid was 104 centigray (104 rad). The referring physician was notified of the misadministration. The referring physician decided not to notify the patient because the information would be harmful to the patient. l An NRC medical consultant reviewed the event and determined that the impact of the misadministration on the status of the patient's health was very low, and that no specific medical follow-up care was necessary. The misadministration occurred because of a lack of sufficient oversight oflicensed activities, inadequate training, and failure to establish a written protocol for ordering and verifying radiopharmaceuticals. To prevent recurrence, the licensee implemented the following corrective actions: (1) all technologists were informed not to use any radiopharmaceutical that was not listed in the licensee's " Prescribed Dosage List"; (2) orders must be sent to the nuclear pharmacy via facsimile, rather than over the telephone; (3) the nuclear pharmacy was instructed not to deliver 1-131,1-125, or any other therapeutic radiopharmaceutical to the licensee; (4) all technologists were informed in writing not to proceed if they were un.eure of any procedure; and (5) copies of radiopharmaceutical orders and their activities were to be checked against receipts. The licensee is not required to have written directives to follow. This is because it does not perform therapy of any kind, does not use I-125 or 1-131 in quantities greater than 1.11 MBq (30 pCi), and has no Quality Management Program. The NRC conducted an inspection. Based on the results of the inspection, eight apparent violations were identified and are being considered for escalated enforcement action. A predecisional enforcement conference was held to discuss the apparent violations and any potential enforcement action is pending. NUREG-1272, Vol.10, No. 2 B-!-11 Summary of 196 Abnormal Occurrences
AEOD Annual R: port,1996 Nucimr Materials Report No. 96-15 Radiopharmaceutical Misadministration at Miami Valley Hospitalin Dayton, Ohio i On September 21,1995, a radiopharmaceutical misadministration occurred at Miami Valley Hospital in Dayton, Ohio. A patient was administered a 2.8 megabecquerel (MBq)(77 microcurie [pCi]) dosage ofiodine-131 (I-l 131) for a thyroid uptake study, rather than the prescribed dosage range of 0.19 to 0.37 MBq (5 to 10 pCi) ofI-131. The licensee determined that the dose to the patient's thyroid was 80.85 centigray (80.85 rad). The patient was informed of the misadministration in writing. The patient's referring physician was also notified. An NRC medical consultant determined that no adverse health effects are expected from the additional dosage. The misadministration occurred because a nuclear medicine technologist inadvertently pielved-up the i wrong capsule, and in accordance with the licensee's practice did not calibrate the dosage in the dose calibrator prior to administration. The licensee's staff did not believe there was a requirement to assay dosages below 1.11 MBq (30 pCi). To prevent recurrence, the licensee implemented procedures to require that all dosages must be assayed i regardless of their activity, and to review the assay of dosages on a quarterly basis. j The NRC conducted a special safety inspection. The NRC issued a Notice of Violation for failing to l measure dosages containing less than 1.11 MBq (30 pCi) before they were administered to patients for j medical use. The licensee responded in writing and no additional actions are required. Report No. 96-16 Radiopharmaceutical Misadministration at St. Joseph Mercy Hospitalin Ann Arbor, Michigan On April 9,1996, a radiopharmaceutical misadministration occurred at St. Joseph Mercy Hospital in Ann Arbor, Michigan. A patient was administered a 596 megabecquerel (MBq)(16.1 millicurie [ mci]) dosage ofiodine-131 rather than the prescribed 122 MBq (3.3 mci) dosage ofI-131 for a diagnostic study of the neck and chest. ne misadministration was discovered after a vial, intended for another patient, was assayed and found to contain 122 MBq (3.3 mci) instead of the expected 633 MBq (17.1 mci). The patient was notified of the misadministration. The patient's referring physician was also notified. ) NUREG-1272, Vol.10, No. 2 B-1-12
I Nucirr Mittri:Is AEOD Annual Report,1996 The patient's thyroid gland had been removed previously and therefore the licensee anticipated minimal medical consequences. The NRC contracted with the Oak Ridge Institute for Science and Education to conduct an assessment of the 1 131 dose to the patient. The assessment concluded that since the patient had no thyroid, the maximum dose was misadministered to the patient's bladder wall and was equal to 48.3 centigray (48.3 rad). The misadministration occurred because the technologist, when administering the dosage, mistakenly _ picked up a wrong radiopharmaceutical vial. To prevent recurrence, licensee personnel were instructed to completely follow the written Quality Management Program. The NRC conducted a special safety inspection. The NRC issued a Notice of Violation for failure of the supervised user (technologist) to follow instructions in accordance with the written directive. i Report No. 96-17 Radiopharmaceutical Misadministration at the Veteran Affairs Medical Centet in Charleston, South Carolina On January 9,1906, a radiophannaceutical misadministration occurred at Veteran Affairs Medical l Center in Charleston, South Carolina. An outpatient was administered 277.5 megabecquerel(MBq)(7.5 millicurie [ mci]) of a prescribed 573.5 MBq (15.5 mci) dosage of iodine-131 (1-131) in liquid form. The error was discovered when the licensee recnecked the prescription vial with a dose calibrator after the administration to verify that the patient had received all of the prescribed dose. The licensee discovered that approximately 296 MBq (8 mci) of the prescribed dosage had been retained in the vial cap, and consequently was not admiaistered to the patient. The patient was informed of the event and was subsequently administered an additional 296 MBq (8 mci) to make up for the underdosage. The licensee also notified the referring physician of the misadministration. The licensee expects no adverse effects to the patient from the misadministration. The misadministration occurred because there was a pronounced reaction of the 1-131 with the vial cap, thereby allowing a significant portion of the radioactive material to bind itself to the cap. To prevent recurrence, the licensee's Radiation Safety Officer investigated the incident. Bioassays were conducted on the individuals who handled and administered the 1-131 dose, and all were found to be negative. The licenm also revised its policy and procedures to require that only 1-131 in capsule form be used in the future. The NRC conducted a special inspection to review the circumstances surrounding the misadministration, and identified no vialations of NRC requirements. The State Agency is working with the nuclear pharmacy that filled the prescription and the intennediate processor of the I-131, both South Carolina state licensees, to determine the cause of event. The nuclear pharmacy informed its customers of the event. NUREG-1272, Vol.10, No. 2 B-1-13 Summary of 1996 Abnormal Occurrences
AEOD Annual R:; port,1996 Nucleu Mat: rials Report No. 96-18 Radiopharmaceutical Misadministration at Queen's Medical Center in Honolulu, Hawaii On December 8,1995, a radiopharmaceutical misadministration occurred at Queen's Medical Center in Honolulu, Hawaii. A patient was prescribed a dosage of 18.5 megabecquerel (MBq)(0.5 millicurie (mci]) of phosphorus-32 ! (P-32) to be administered to the wrist for treatment of symptoms related to rheumatoid arthritis, but was administered 6.179 MBq (0.167 mci) instead. The dosage was administered via a saline solution. Prior to treatment, the volume of the patient's wrist-joint space was to be determined using fluoroscopy so that the proper volume ofliquid would be injected. Also, two syringes were to be prepared. One was to contain 18.5 MBq (0.5 mci) of P-32 in a 0.25 milliliter (ml) volume, and the other was to contain 18.5 MBq (0.5 mci) of P-32 in a 0.5 ml volume. The appropriate syringe was to be chosen based upon the results of the fluoroscopy. Because of poor communication, a technologist erroneously prepared one syringe containing 6.179 MBq (0.167 mci) in a 0.25 mi volume and another syringe containing 12.32 MBq (0.333 mci) in a 0.5 ml volume. The syringes were not labeled. Based upon the results of the fluoroscopy, the administering physician chose the syringe with the 0.25 mi volume, believing that it contained 18.5 MBq (0.5 mci) of P-32. However, the 0.25 ml volume contained only 6.179 MBq (0.167 mci), which was one-third of the intended dosage. After the administration, the technologist who prepared the dosages asked why both syringes had not been used and explained how they were prepared. The patient was notified of the misadministration in writing. The two physicians involved with the misadministration have not observed any adverse health effects to the patient, and do not expect any. The NRC determined that a me dical consultant would not be required to review the case. The misadministration occurred because the details of the prescribed dosages were not properly communicated to the technologist who prepared the two syringes, the details were not independently confirmed by other licensee personnel, and the written procedure for preparing the dosages did not specify muhiple syringe volumes. To prevent recurrence, the licensee now requires the prescribing physician to establish a standard activity and volume for each treatment site, and the injecting physician to verbally repeat this information and ask the technologist to verbally confirm it prior to the administration. The NRC conducted a special inspection and issued a Notice of Violation for deficiencies in the Quality Management Program. NUREG-1272, Vol.10, No. 2 B-1-14
APPENDIX B-2 Agreement State Licensees t I 1 l h i i r f I
l CONTENTS NUREG-0090, Vol.19 Appendix B-2 Agreement State Licensees AS %1 Stolen Cobalt-60 Radiography Cameras . . . . . . . . . . . . . . . . . . . . . . . . . . . . B 1 AS 96-2 Rupture of a Source Owned by Little Bit Wireline at an Oil Well near Winnie, Texas .... .. .. ........ . ..... . .... B-2-2 AS %3 Release of Radioactive Material in Lemont. Illinois, From a Package That Was Accidentally Destroyed While Being Transported by Associated Couriers of Maryland Heights, Missouri . . . . . . . . . . . . . . . . B 3 AS 96-4 Lost Source at Deseret Generation and Transmission Cooperative's Bonanza Power Plant in Vernal, Utah ... ............................B-2-4 AS %-5 Medical Brachytherapy Misadministration at Duke University Medical Center in Durham, North Carolina . . . . . . . . . . .... ....... ... ............ B-2-5 AS %,6 Medical Brachytherapy Misadt.dnistrations at the University of Mississippi Medical Center in Jackson, Mississippi . . . . . . . . . . . . . . . . . ..... . ..... B-2-6 AS 96-7 Radiopharmaceutical Misadministration at Baptist Medical Center Princeton in Birmingham, Alabama ..... . .. ........ ...... ... . ........ .. B-2-6 AS 96-8 Radiopharmaceutical Misadministration at Methodist Medical Center in Peoria, Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B 7 i i B-2-iii
Nucirr Mit:rir.ls AEOD Annuil Rtport,1996 l NUREG-0090, Volume 19 Report No. AS 96-1 Stolen Cobalt-60 Radiography Cameras From February 27 to March 5,1996, stolen cobalt-60 radiography cameras were unconfined in Houston, Texas. Larpen of Texas (Larpen) was a radiography company that owned two cobalt-60 (Co-60) radiography cameras. The Co-60 sources in the cameras had activities of 1.31 terabecquerel(TBq) (35.3 curie (Ci]) and 0.32 TBq (8.6 Ci) respectively. Larpen provided radiography services to a steel-manufacturing company at the company's 37-acre site. When the steel-manufacturing company went bankrupt, the Texas Department of Health Bureau of Radiation Control (TDH/BRC) issued orders to Larpen in October 1992 to stop operating, and ordered all I ofits radioactive sources to be impounded in place. Larpen subsequently filed for bankruptcy and its ] name was cor,sequently changed to Many Diversified Interests, Inc. (MDI), in compliance with the law. I Upon learning of the MDI bankruptcy, TDH/BRC verified that the Co-60 radiography cameras were secured in a building on the site. TDIFBRC wrote to the bankruptcy court on June 24,1994, and to the trustee for bankrupt MDI on July 11,1994, to request that the Co-60 radiography cameras be properly disposed of, but no actions were taken. On July 29,1994, TDIUBRC formally notified the bankruptcy court, through the Texas Attorney General's Office, that it was a creditor and party cf interest in the bankruptcy of MDI. TDH/BRC then ensured that the Co-60 radiography cameras were secure in an on-site building and that the metal door to the building was welded shut. During the period of March 1995 to January 1996, all structures on the site were demolished and all salvageable equipment was sold, with the exception of the building containing the Co-60 radiography cameras. When the salvage company vacated the site, the site had no security and people removed , anything of value that could be sold as scrap. TDH/BRC consequently notified the bankruptcy court ofits l concern about the security of the Co-60 radiography cameras. On February 27,1996, three thieves broke into the building containing the Co-60 radiography cameras by removing the metal door that had been wCed shut, stole the cameras, and sold them to a scrap yard. The scrap yard then sold them to an intermediary dealer who sent them to a recycling facility. The recycling facility refused to accept the cameras because they were radioactive, and the intermediary dealer consequently returned them to the scrap yard by truck. When the cameras arrived at the scrap yard, the 1.31 TBq (35.3 Ci) Co-60 source, which was accidentally unshielded while in transit, was thrown to the l ground by the delivery man and forgotten. The scrap yard resold the cameras to other scrap yards. However, no one at the scrap yard knew that the unshielded Co-60 source was laying on the ground. The unshielded source lay on the ground for 100.5 hours until it was located by TDH/BRC on March 5,1996. l TDH/BRC also located the other camera on the same day. Both cameras and their Co-60 sources were then secured at an authorized disposal company. After the sources were recovered and secured, the NUREG-1272, Vol.10, No. 2 B-2-1 Summary of 1996 Abnormal Occurrences
AEOD Annual Report,1996 Nucl=r Miterials TDH/BRC also located the other camera on the same day. Both cameras and their Co-60 sources were then secured at an authorized disposal company. After the sources were recovered and secured, the trustee for bankrupt MDI had to obtain permission from the bankruptcy court for the disposal company to dispose of the cameras. The unshielded Co-60 source irradiated scrap yard workers and the scrap-yard manager's two small children. The delivery man who touched the source received radiation burns to the thumb and middle finger of his right hand. Five police officers who investigated the theft of the cameras were also ) irradiated by the source. Two TDH/BRC personnel who located and secured the source received doses of l 1.5 millisievert (mSv)(150 millirem [ mrem]) and 5.2 mSv (520 mrem) respectively. TDH/BRC estimated the possible radiation doses that were received by the individuals who were exposed to the unshielded Co-60 source. Since the estimates indicated that the doses may have been as high as 600 mSv (60 rem), the scrap yard workers, the children, the policemen, and the thieves had their blood tested to determine their doses. Cytogenetic studies by the Department of Energy's Radiation Emergency Assistance Center / Training Site in Oak Ridge, Tennessee, determined that their doses were less than 100 mSv (10 rem). Also, the doses to the general public conducting business at the scrap yard were determined to be less than 5.0 mSv (500 mrem). The three thieves were arrested for stealing the cameras and the owner, manager, and manager's wife of the scrap yard were arrested for receiving stolen goods. The theft occurred because TDil/BRC was forced to store the devices at a facility that did not have suitable seurity after a licensee went bankrupt. TDIFBRC has severely limited jurisdiction over radiography sources in cases where a licensee declares bankruptcy and any action must be taken through the bankruptcy court. The licensee could not take actions to prevent recurrence because the licensee is in bankruptcy and is no longer a viable company. All assets of the company are handled by a trustee appointed by the bankruptcy court. The cameras and sources are being disposed of by the trustee. TDH/BRC is trying to determine if there are requirements and controls that can be placed on the trustees of bankrupt companies possessing radioactive materials. TDH/BRC is also participating in a working group composed of represer.tatives from the Nuclear Regulatory Commission and other Agreement States to review the loss of control of radioactive sources, with emphasis on bankruptcy situations. I Report No. AS 96-2 Rupture of a Source Owned by Little Bit Wireline at an Oil , Well near Winnie, Texas i On September 15,1995, there was a rupture of a source owned by Little Bit Wireline at an Oil Well near Winnie. " us. An 111,000 megabecquerel (MBq)(3 curie [Ci]) americium-2*1/ beryllium source owned by Little Bit Wireline was found to be leaking after it was recovered from an oil well near Winnie, Texas, where it had been stuck. The Texas Department ofIIcalth, Bureau of Radiation Control (BRC), was notified of Summary of 1996 Abnormal Occurrences B-2-2 NUREG-1272, Vol.10, No. 2
1 Nucl=r Miteriils AEOD Annu:1 Report,1996 the event. BRC subsequently found that the radiation level of the leakir g source was 10 microdvert per hour (1 millirem per hour), and that the well site and associated equipment were contaminated. BRC reported the event to The NRC, and asked for assistance from the Department of Energy (DOE). DOE subsequently transported the leaking source to Los Alamos National Laboratory where it was determined that the remaining source activity was approxhnately 37,000 MBq (1 Ci). ! DOE was also asked to evaluate 10 individuals, including the licensee, for internal contamination. The individuals were sent to the Oak Ridge Institute for Science and Education (ORISE) for whole body scans and urinalysis. ORISE determined that the whole body scans and urinalysis for the individuals were negative, and that there was no reason to believe that anyone had received a significant internal exposure. It is believed that there are two ways in which the source may have been ruptured. The first is that it was i ruptured by a milling tool which was used to recover it. The second is that it was lodged between the oil well casing and another assembly known as a " screen and liner" which had also become stuck, and was I ruptured during operations to recover the " screen and liner." To prevent recurrence, access to the licensee's facility which was contaminated by the ruptured source has been restricted. The licensee is no longer performing well logging. BRC ordered the licensee and affected companies to restrict access to the contaminated equipment and lInd, to characterize the contamination, and to decontaminate the equipment and land. Further enforcement action is pending. Report No. AS 96-3 Release of Radioactive Material in Lemont, Illinois, From a Package That Was Accidently Destroyed While Being i Transported by Associated Couriers of Maryland Heights, Missouri On October 3,1995, there was a release of radioactive material in Lemont, Illinois, from a package that was accidently destroyed while being transported by Associated Couriers of Maryland Heights, Missouri. A spent nuclear medicine generator containing approximately 666 megabecquerel (18 millicurie) of molybdenum-99/ technetium-99m fell from a moving delivery van operated by Associated Couriers of Maryland Heights, Missouri. It was then struck by an unidentified vehicle and destroyed. The contamination that was released was spread on both lanes of the roadway by a sudden rain and the spray from moving vehicles. A Radiological Assessment Team from Argonne National L boratory was the first to arrive at the scene cf the accident. The team transferred control of the scene to <epresentatives of the Illinois Department of N iclear Safety (IDNS) when they arrived, but remained at the scene to assist the IDNS representatives. TI.e roadway was decontaminated to a near surface dose rete of 3 microsievert per hour (0.3 millirem per hour), at which time it was reopened. Since no contamination migrated from the roadway, doses to mec.bers of the public were negligible. Doses to emergency workers were significantly below regulatory limi,s. (It should be noted that even though the licensee [Medi-Physics, Inc.) was not responsible for the NUREG-1272, Vol.10, No. 2 B-2-3 Summary of 1996 Abnormal Occurrences
AEOD Annux! Report,1996 Nuclear Materials event, its personnel were at the scene to collect all debris and decontamination materials for transport to its facility.) The event was caused by the failure of the driver of the delivery van to secure the rear door of the van. The package fell out of the van when the door opened. The licensee for the spent nuclear medicine generator was not responsible for the accident, and consequently was not required to take corrective action. It is not known if the carrier, Associated Couriers, took any corrective action. Since this was a violation by a moving vehicle on a public roadway, enforcement action was brought against the carrier by the Illinois Department of Transportation (IDOT), based on information supplied by IDNS. IDOT assessed a civil penalty of $2,700 and received full payment of the penalty on December 14,1995. Since this was the first violation on record by this carrier, no further action was taken. An order may be issued in the future for recovery of response costs, but no further punitive penalty is anticipated. Report No. AS 96-4 Lost Source at Deseret Generation and Transmission Cooperative's Bonanza Power Plant in Vernal, Utah On January 31,1996, a source was lost at Deseret Generation and Transmission Cooperative's Bonanza Power Plant in Vernal, Utah. A 370 megabecquerel (10 millicurie) cesium-137 source was found to be missing from its housing. The source was part of a KayRay/Sensall Model 7062 BP fixed density gauge which was mounted to a fly ash chute. The gauge had been in service since October 18,1984. False signals from the gauge started to appear on January 9,1996, the day after a vibrator was attached to the fly ash chute. Several attempts were made to identify and correct the problem from January 9 until January 31,1996, when it was discovered that the source-housing shutter mechanism was broken and the source was missing. Several people tried unsuccessfully to find the source by systematically searching the plant site using radiation detection survey instruments. Consequently, five persons may have received an exposure to radiation. However, it is highly improbable that anyone received a measurable level of exposure. The licensee believes that the vibrator which was attached to the fly ash chute on January 8,1996, was probably responsible for destroying the source-housing shutter mechanism and precipitating the loss of the source. To prevent recurrence, the licensee modified its radiation protection program to require that a semi- j annual check be made to verify that the source is in its housing; that vibration isolators be used to mount the source housing; and that the source housing be positioned so that the opened shutter block lays on the bottom of the housing. Summary of 1996 Abnormal Occurrences B-2-4 NUREG-1272, Vol.10, No. 2
1 1 Nuclzt Mr.teri11s AEOD Annual Report,1996 s The Utah Division of Radiation Control notified the Illinois Radiation Control Program of the event involving KayRay/Sensall, a gauge manufacturer, licensed in the State ofIllinois. The Illinois Radiation Control Program is taking action with its licensee (KayRay/Sensall) regarding the possibility of any generic issues. The State of Utah is continuing its investigation and plans to follow-up at the next inspection ofits licensee (Deseret Generation and Transmission Cooperative's Bonanza Power Plant), which was advanced because of this event. Report No. AS 96-5 Medical Brachytherapy Misadministration at Duke University Medical Center in Durham, North Carolina On March 12,1996, a medical brachytherapy misadministration occurred at Duke University Medical Center in Durham, North Carolina. A patient was prescribed a dose of 650 centigray (cGy)(650 rad) to the bronchus using an Omnitres. 2000 high-dose-rate (HDR) remote afterloading brachytherapy unit having an iridium-192 source. The HDR unit was to be used with a catheter that was 150.25 centimeter (cm)(59.15 inch) long. However, during patient setup, the wrong catheter-length value of 125.25 cm (49.31 inch) was entered into the HDR's computer treatment planning software. Upon completion of the treatment, the attending physician recognized the misadministration and notified the radiation oncologist of the error. The patient and the referring physician were then notified by the radiation oncologist. Since the catheter length entered into the HDR's computer treatment planning software was 125.25 cm (49.31 inch), and a 150.25 cm (59.15 inch) long catheter was attached to the HDR, the source did not completely traverse the length necessary to treat the bronchus with 650 cGy (650 rad). As a result, the wrong treatment sites received unplanned exposure; the right cheek received 90 to 130 cGy (90 to 130 rad) and the right eye received 35 to 50 cGy (35 to 50 rr.d). The radiation oncologist anticipates no short or long term health effects from die misadministration. The misadministration occurred because of human error. The wrong catheter length was entered into the HDR's computer treatment planning software. To prevent recurrence, the licensee added redundancy to its internal checklists to verify that the correct catheter length is entered in the HDR's computer treatment software. The State Agency agrees with the licensee's action to prevent recurrence. t t 1 NUREG-1272, Vol.10, No. 2 B-2-5 Summary of 1996 Abnormal Occurrences s (
AEOD Annual Rsport,1996 Nuclear Materials l l Report No. AS 96-6 Medical Brachytherapy Misadministrations at the i University of Mississippi Medical Center in Jackson, Mississippi From May 21,1996, through May 23,1996, medical brachytherapy misadministrations occurred at the University of Mississippi Medical Center in Jackson, Mississippi. Two patients were prescribed manual gynecological brachytherapy procedures using cesium-137 (Cs-137) sealed sources loaded in a gynecological applicator. Patient A was prescribed a total dose of 4000 centigray (cGy)(4000 rad) in two fractional treatments of 2000 cGy (2000 rad) each. Patient B was prescribed a total dose of 2275 cGy (2275 rad) in one treatment. However, the medical physicist noticed while removing the sources from Patient A that the Cs-137 sources for the two patients were switched. The medical physicist immediately went to Patient B's room and removed the sources from Patient B. As a result of the error, the administered second fractional treatment dose for Patient A was 1342 cGy (1342 rad), for an underdose of 33 percent. Also, Patient B was administered a treatment dose of 2698 cGy (2698 rad), for an overdose of 19 percent. The licensee notified the referring physician and the patient's relatives of the misadministrations. The misadministrations occurred because of human error. The medical physicist prepared three source configurations for three patients at the same time. The loads were color-coded for each patient to prevent mix-ups. On removal of the sources, the medical physicist discovered that Patient A's and Patient B's loads were switched, even thougu the color-codes were correct for the patients. Patient C was not affected. The medical physicist stated that he must have switched the loads prior to color-coding the loads for the patients. To prevent recurrence, the licensee immediately implemented new procedures for loading brachytherapy sources into patients, which require the medical physicist to only prepare and load sources for one patient at a time. The State Agency conducted an investigation. The State Agency concurred with the licensee's evaluation of the event and the corrective action implemented by the licensee. No violations were cited. Report No, AS 96-7 Radiopharmaceutical Misadmir.istration at Baptist Medical Center Princeton in Birmingham, Alabama l On January 8,1996, a radiopharmaceutical misadministration occurred at Baptist Medical Center ! Princeton in Birmingham, Alabama. Summary of 1996 Abnormal Occurrences B-2-6 NUREG-1272, Vol.10, No. 2 i
Nucirr Mrteriils AEOD Annuil Report,1996 A 67-year-old male patient suspected of having Graves disease was prescribed 0.37 megabecquerel (MBq)(10 microcurie [pCi]) ofiodine-131 (I-J 31) for a thyroid uptake study. The nuclear pharmacy delivered 3.7 MBq (100 Ci) by mistake, and a nuclear medicine technician subsequently administered the 3.7 MBq (100 pCi) to the patient. The administered diagnostic dose exceeded the prescribed diagnostic dose by a factor of 10; i.e., the diagnostic dose to the thyroid was approximately 350 centigray (cGy)(350 rad) instead of 35 cGy (35 rad). The results of the thyroid uptake test confirmed that the patient had Graves disease and the patient was therapeutically treated with 555 MBq (15 millicurie) ofI 131 the next day. Because the patient was treated with a therapeutic dose of f-131, there was no consequence or adverse health effect to the patient as a result of the diagnostic misadministration. The patient's attending physician decided that there was no need to notify the patient of the diagnostic misadministration. The misadministration was caused by two errors. The first occurred at the nuclear pharmacy, Syncor of Birmingham, Alabama, where the wrong date was entered into a computer. As a result, a 3.7 MBq (100 pCi) I-131 capsule was incorrectly identified as being the lowest activity capsule in inventory. Consequently, a 3.7 MBq (100 Ci)I-131 capsule was sent to Baptist Medical Center Princeton instead of the prescribed 0.37 MBq (10 pCi)I-131 capsule. The second error occurred at Baptist Medical Center Princeton, where a technician failed to recognize that the activity of the capsule received from the nuclear pharmacy did not match the written directive for the prescribed activity. To prevent recurrence, Baptist Medical Center Princeton posted a copy ofits written directives for each routine diagnostic procedure in the nuclear medicine department and confirmed that the nuclear pharmacy had a copy on file. - The State Agency discussed the misadministration with both the nuclear pharmacy and Baptist Medical Center Princeton and determined that a special inspection was not warranted. The State Agency sent an information notice to the State nuclear medicine licensees and nuclear pharmacies requesting that each verify with the other the values of activity utilized on any written directives that they may use in ordering or dispensing radiopharmaceuticals. Report No. AS 96-8 Radiopharmaceutical Misadministration at Methodist Medical Center in Peoria, Illinois On November 27,1995, a radiopharmaceutical misadministration occurred at Methodist Medical Center in Peoria, Illinois. An outpatient received 177.6 megabecquel (MBq)(4.8 millicurie [ mci]) of a prescribed 444.0 MBq (12 mci) dosage ofiodine-131. The error wac later discovered w hen the rmclear pharmacy received two of the three capsules in a return shipment. The referring physician and the patient were informed of the misadministration. The patient was then administered an additional dosage of 370 MBq (10 mci) to make up for the underdose. The radiologist reported no harmful effects to the patient from the misadministration. ' NUREG-1272, Vol.10, No. 2 B-2-7 Smmary of 1996 Abnormal Occurrences
AEOD Annu:.1 R: port,1996 Nuclear Miterials The misadministration occurred because the technologist failed to verify the number of capsules delivered by the pharmacy. This was the first dosage sent by the pharmacy in multiple capsules, so the technologist was unaware of the need to check. To prevent recurrence, the licensee's staff was made aware of the error in order to prevent recurrence. Also, the pharmacy was requested to cease the practice of distributing multiple capsules for a single prescription. ; The State Agency accepted the licensee's report and corrective action as appropriate. No further action was requested. Summary of 1996 Abnormal Occurrences B-2-8 NUREG-1272, Vol.10, No. 2 i
i l i APPENDIX C l I Reports and Videotapes Issued From 1981 Through 1996 l l l 1 t 1 t 1 1 1 I l l
Nucle r Mitrials AEOD Annual Report,1996 Reports and Videotapes Issued from 1981 Through 1996 Date Title No. Author Nuclear Materials Reports Issued in 1995 SpecialStudies 08/95 Human Performance Evaluation ofIndustrial INEL-95/0387 S. Pettijohn Radiography Exposure Events 07/95 Misadministrations and Other Medical Events Memorandum to H. Karagiannis Caused by Computer Errors D.A. Cool from C.E. Rossi Nuclear Materials Reports Issued in 1994 Videotapes 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 Nuclear Materials Reports Issued in 1992 Engineering Evaluations 08/92 Report on 1991 Nonreactor Events NUREG-1272, K. Black Vol. 6, No.2, App. A I NUREG-1272, Vol.10, No. 2 C-1 Reports and Videotapes
AEOD Annual Repert,1996 Nuctrar Miteriils 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, 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. Karagiannis 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 Reports and Videotapes C-2 NUREG-1272. Vol.10, No. 2
Nuclear Miteriils AEOD Annuil Report,1996 Date Title No. Author j Nuclear Materials Reports Issued in 1990 (cont.) Engineering Evaluations (cont.) 06/90 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 Engineering Evaluations 1 06/89 Use of Radioactive lodine 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, l No. 2, App. B 06/89 Medical Misadministration Report - Medical NUREG-1272 11. Karagiannis Misadministrations Reported to NRC From Vol. 3, January 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 Nuclear Materials Reports Issued in 1988 Engineering Evaluations 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 January Through December 1987 NUREG-1272, Vol.10, No. 2 C-3 Repons and Videotapes
AEOD Annual Report,1996 Nuclear Miterials l Date Title No. Author I 1 Nuclear Materials Reports Issued in 1987 l SpecialReports 10/87 Radiography Overexposure Events Involving S703 S. Pettijohn Industrial Field Radiography Engineering Evaluations 01/87 Diagnostic Misadministrations 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 TechnicalReview Reports 11/87 Puiew of Data on Teletherapy Misadministrations T711 S. Pettijohn Reponed to the State of New York That Were the Title of PNO-1-87-74A 12/87 Distribution ofInformation 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-125 Brachytherapy Source C601 S. Pettijohn at the University of Cincinnati Medical Center Engineering Evaluations 06/86 Repon of 1985 Nonreactor Reported and Five-Year N601 K. Black Assessment for 1981-1985 Reports Reports and Videotapes C-4 NUREG-1272. Vol.10, No. 2
Nuclear Mit:rirls AEOD Annu:1 Report,1996 1 Date Title N o. 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 Reported 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 l 06/85 Summary of the Nonreactor Event Data Base for N502 K. Black j the Period July Through December 1984 ! 07/85 Report on Medical Misadministrations for N503 S. Pettijohn January Through December 1984 Nuclear Materials Reports Issued in 1984 i Case Studies 09/84 Breaching of the Encapsulation of Scaled C405 S. Pettijohn Well Logging Sources 05/84 Repon on Medical Misadministrations for N204D S. Pettijohn January Through June 1983 06/84 Nonreactor Event Report Database for the Period N401 K. Black July Through December 1983 NUREG-1272, Vol.10, No. 2 C-5 Reports and Videotapes
AEOD Annu;l Report,1996 Nucle:s M:terirls Date Title No. Author Nuclear Materials Reports issued in 1984 (cont.) Case Studies (cont.) 06/84 Events involvir g Undetected Unavailability of the N402 E. Trager Turbine-Driven Auxiliary Feedwater Train 07/84 Report on Medical Misadministrations for N403 S. Pettijohn July Through December 1983 Nuclear Materials Reports Issued in 1983 Engineering Evaluations and Technical Reviews 01/83 Nonreactor Event Report Database for the N209A E. Trager Period January Through June 1982 03/83 1-125/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 January 1981 Through December 1982 12/83 Potentially Leaking Americium-241 Sources N306 S. Pettijohn Manufactured by Amersham Corporation 12/83 Nonreactor Event Report Database for the N307 K. Black Period January Through June 1983 03/83 Internal Exposure to Am-241 NT301 K. Black l Reports and Videotapes C-6 NUREG-1272. Vol.10, No. 2
Nucir r M ttrials AEOD Annuil Report,1996 ( Date Title No. Author Nuclear Materials Reports Issued in 1983 (cont.) l Engineering Evaluations and Technical Reviews (cont.) 1 04/83 KayRay, Inc. Reports of Suspected Leaking NT302 S. Pettijohn l Scaled Sources Manufactured by General Radioisotope Products 08/83 Possession of Unauthorized Sealed Source / Exposure NT303 S. Pettijohn l Device Combinations by MidCon Inspection Services, Inc. l Nuclear Materials Reparts Issued in 1982 Engineering Evaluations 02/82 Report on Medical Misadministrations for the N201 S. Pettijohn Period November 10,1980-September 30,1981 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 oflodine-125 Sealed N205 E. Trager Source Leakage incidents 05/82 Eberline Instrument Corporation Pan 21 Repon N206 K. Black 05/82 AEOD Review ofIodine-125 Sealed Source N207 E. Trager Leakage incidents 08/82 Potentially Leaking Plutonium-Beryllium N208 S. Pettijohn Neutron Sources 08/82 A Summary of the Nonreactor Event Report N209 K. Black j Data Base for 1981 11/82 Leaking Hoses on Self-Contained Breathing N210 K. Black Apparatus (SCBA) Manufactured by MSA t l NUREG-1272, Vol.10, No. 2 C-7 Reports and Videotapes
AEOD Annu:1 R: port,1996 Nuclear M teriils 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 NIOS E. Trager Failure at the Sweetwater Uranium Mill 08/81 Review of Reports of Leaking Radioactive Sources N106 E. Trager 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 I i Reports and Videotapes C-8 NUREG-1272. Vol.10, No. 2 1
APPENDIX D i Status of AEOD Recommendations l
Nucts:r Mxteritis AEOD Annual Report,1996 Status of AEOD Recommendations The Office for Analysis and Evaluation of issues involving AEOD recommendations ! Operational Data (AEOD) tracking system regarding nuclear materials activities are L ensures that all formal AEOD recommendations unresolved that warrant the attention of the tre tracked until resolution. At this time, no Executive Director for Operations. l l l l l l l NUREG-1272, Vol.10, No. 2 D-1 Status of AEOD Recommendations
r 1 i Appendix E Status of NRC Staff Actions for Events Investigated by Incident Investigation Teams l I I ? l i i l l
l' Nucin Miteriils AEOD Annurl Report,1996 Status of NRC Staff Actions for Events Investigated by Incident Investigation Teams (Nuclear Materials) In accordance with NRC Management Directive evaluating the adequacy of the actions taken by l 8.3, "NRC Incident Investigation Program," the responsible office (s), and documenting the dated August 12,1992, the Executive director resolution of all staff actions. for Operations (EDO) shall, upon receipt of an Incident investigation Team (IIT) report, This appendix provides the status or disposition, identify and assign NRC office responsibilities along with appropriate references, for each of for generic and plant-specific actions resulting the NRC staff action items that the EDO from the investigation that are safety significant assigned to the various NRC offices that were and warrant additional attention or action. not documented as resolved in previous AEOD Office Directors designated by the EDO as Annual Reports on Nuclear Materials. Included having responsibility for the resolution ofissues are actions associated with the IIT reports on the or concerns are responsible for providing 1991 event at General Electric Nuclear Fuels written status reports on the disposition of Component Manufacturing Facility and the assigned actions. AEOD is responsible for 1992 event at the Indiana Regional Cancer l monitoring the status of assigned staff actions, Center. Action Source: IIT Report on the " Potential Criticality Accident at the General Electric Nuclear j Fuel and Component Manufacturing Facility, May 29,1991," NUREG-1450, I dated August 1991 (Reference 1). l Item 1: Adequacy of Criticality Safety Reviews Action (a): Evaluate existing regulatory requirements, guidance, and review standards for criticality 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) Status: Ongoing 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 guidance for fuel facility licensing and developing a Standard Review Plan (SRP) for license reviews. As steted 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 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 the initial application and, as appropriate, reanalysis to support amendment of the application or a 10 CFR 50.59-type process. Criticality safety would be one part of an ISA. The activities, described above, supersede the recommendation to consider separate action on criticality safety. NUREG-1272, Vol.10, No. 2 E-1 Incident Investigation Teams
AEOD Annual Report,1996 Nuclear Mcterials Following the development of a draft revision to 10 CFR Part 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 I presented in SECY-96-079. The staffis currently awaiting additional guidance from the Commission before proceeding. l Action (b): Evaluate the use of safety operating speci6 cations for radiation and nuclear safety instruments and controls. (Responsible Of6ce: NMSS) Status: Ongoing The staff has evaluated the need for a requirement for licensees to include in their applications technical specifications for nuclear safety instrumentation and controls and concluded that it is not warranted. Instead, the staffintends 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 Part 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 Part 70 will require licensees to perfonn ISAs. These bas 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 identify equipment, personnel, and procedures needed to assure safety. The licensing project manager and the inspection staff will ensure that a licensee does not signincantly change its ISA process without NRC approval, and that the ISA is used on an ongoing basis to evaluate any changes to the 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 equipment and procedures, including assurance of reliability and availability, human factors aspects, and training regarding safety signiGcance 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 ofincorporating 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 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 difHcult to inspect or enforce. The revamping of the regulations and guidance for fuel facility licensing, discussed in action (a) above, will provide a better regulatory base for obtaining better commitments. l Incident Investigation Teams E-2 NUREG-1272, Vol.10, No. 2
l Nucle:r Mittrials AEOD Annual Report.1996 Presently, NMSS is 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 (Reference 23). This item is on hold pending further direction from the Commission. Action (d): Evaluate the existing NRC programs and develop new guidance for the inspection of 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 ofISA documents. These will provide an improved basis for inspection guidance in this area. 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 Pan 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 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. 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/RES) Status: 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 oflSA documents. These will provide a more specific basis for improved inspection guidance. NMSS is presently going through a review process with licensees in an efTort 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 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 (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 NUREG-1272, Vol.10, No. 2 E-3 Incident Investigation Teams
f' AEOD Annu 1 Repon,1996 Nuclear Materials guidance, requirements, and standards as appropriate. (Responsible Of6ce: NMSS/RES/NRR) Status: Ongoing in February 1992, the NMSS Materials Regulatory Task Force issued NUREG-1324, . l " Proposed Method for Regulating Major Materials Licensees," which set forth (l l recommendations concerning deficiencies and needed improvements in licensing and l regulation of major materials licensees. NUREG-1324 placed considerable emphasis l 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 { benents of performing safety analyses and preparing safety evaluation reports for l initial materials licensing, renewals, and major amendment actions for the large materials plants. The planned revision to 10 CFR Part 70, discussed in Action (a) above, will include I requirements 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 speciGc topics, such as nuclear criticality safety. The SF&CG, derived directly from the SRP, will convey the details to the licensees. 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. This l document 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 Radiation Safety Committee (RSC) and Radiation Safety Of6cer (RSO), to include immediate termination of any activity that is a threat to public health and safety. As part of the licensing process, licensees are requested to provide cenification that the RSO understands and accepts all the responsibilities of the position. In addition, NUREG-1516, " Management of Radioactive Material Safety Programs at Medical Facilities," was published in January 1995. This NUREG introduces the concept of the " management triangle" to emphasize that three panies (executive management, the RSC, and the RSO) are responsible for providing effective j oversight of the radiation safety program. l The staff expects that review of this issue will be conducted as part of the overall Business 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 (Refeience 23). However, because of recent incidents at the ! National Institutes of Health and Massachusetts Institute of Technology, the l responsible ofHee will keep this item open until a review and any needed revisions of , 1 existing regulations and guidance are completed. Action (c): Examine the overall inspection process for monitoring and collecting fuel facility safety performance information include in the evaluation the merits of(l) a resident inspector program; (2) more frequent inspections, including use of team inspections; (3) establishment of a systematic performance appraisal and feedback program Incident Investigation Teams E-4 NUREG-1272, Vol.10, No. 2
Nucl:ar M terials AEOD Annual Report,1996 l analogous to the Systems Assessment of Licensee Performance for 10 CFR Part 50 licensees. (Responsible Office: NMSS/NRR) Status: Ongoing The stt Edetermined that completion of this item was dependent on issuance of the j revised Part 70, the new SRP and associated SF&CG, and staff guidance documents i concerning management controls and content ofISA documents. Part 70 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, Manual Chapter 2604, and their associated inspection procedures (Reference 23). Once revised Part 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 and feedback program for fuel facilities. Revise the program as appropriate. (Responsible Office: NMSS) i 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. 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 reporting and reviews for fuel facilities. Issue new guidance as appropriate. (Responsible Office: NMSS/AEOD) Status: Ongoing 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 stafTguidance 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 uiated inspection procedures (Reference 23). I NUREG-1272, Vol.10, No. 2 E-5 Incident Investigation Teams I l
AEOD Annuil R port,1996 Nuclear Mit: rials 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. Referenees: 1. NUREG-1450, " Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility, May 29,1991," August 1991. 1
- 2. Memorandum from J. Taylor to NRC staff, " Staff Actions Resulting from the Investigation 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 Investigation of the Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility Findings" (NUREG-1450),
September 6,1991.
- 4. Memorandum from R. Bernero to J. Taylor, " Staff Action Plan Responding to the 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.
- 7. Letter from J. Stohr to W. Ogden, " Management Meeting Summary," October 2, 1991.
I 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.
I 1. 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.
Incident Investigation Teams E-6 NUREG-1272, Vol.10, No. 2
Nucirar Miteriils AEOD Annual Report,1996 I i
- 16. NUREG-1324, " Proposed Method for Regulating Major Materials Licensees," l dated February 1992.
I
- 17. Memorandum from R. Bernero to J. Taylor, " Staff Actions Resulting from the i 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 ofitem 1.F 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" (NUREG-1450), dated August 2,1993.
- 19. Memorandum from E. Jordan to R. Bernero, " Completion ofitems 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 ofItem 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 Manufacturing Facility" (NUREG-1450), dated December 2,1992.
l
- 21. Memorandum from R. Bernero through 11. Thompson to J. Taylor, " Staff Actions Resulting From the Investigation of the Incident at General Electric Wilmington,"
i dated October 6,1994. l
- 22. Memorandum from E. Jordan to J. Ta3 ior. " Staff Action Plan Responding to
. Investigation 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.
l l NUREG-1272, Vol.10, No. 2 E-7 incident Investigation Teams
AEOD Annu:1 Report,1996 Nuclear Materi:Is l l l Action Source: IIT Report on " Loss of an Iridium-192 Source and Therapy Misadministration 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 denne the functions and responsibilities of the radiation safety officer (RSO) and the authorized user. (Responsible Of6ce: 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 ofisotopes at the November 1993 and May 1994 meetings. The NUREG was published for public comment in January 1995. The stafT will evaluate the need to further denne and provide guidance on the responsibilities of the RSO and authorized user during a major revision of Part 35 tentatively scheduled for 1999 following review of the National Academy of Sciences report 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 the Public and Authorities of Radiation Exposures Resulting from Licensed Activities. Action (b): Evaluate the need to further denne 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 Parts 19 and 20 to licensees for assessing radiation exposure and notifying members of the public and authorities. A final rule, making minor clarifying modifications to Parts 19 and 20 regarding reports 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 oflicensed material into the public domain. The Responsible Office considers this item resolved (Reference 2). Item 3: Adequacy of Regulatory Oversight of Scaled Sources and Devices and Medical Licenses Incident Investigation Teams E-8 NUREG-1272, Vol.10, No. 2
Nuclear M;teriils AEOD Annual Report,1996 Action (a): Evaluate the need to update licensing and inspection guidance and requirement for high-dose-rate (IIDR) afterloaders. (Responsible Office: NMSS/RES) Status: Ongoing The staff has undertaken several efforts 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 86-4 was revised to incorporate the requirements of the bulletin. A Temporary Instruction was issued to provide guidance on routine inspection ofIIDR anerloaders. 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 being revised and will be included as a module to Regulatory Guide 10.8, Revision 2. Training was provided to 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 ilDR 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 perfonnance-based approach versus schooling or cenification 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 and experience criteria will include a determination regarding the relative merits of different training approaches to ensure that all users have adequate radiation safety knowledge. The staffplans 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, " Materials Inspection Program," to provide guidance on inspection of satellite facilities, field offices, and temporaryjob sites. Policy and Guidance Directive 94-04 was issued June 21,1994 to NUREG-1272, Vol.10, No. 2 E-9 Incident Investigation Teams
AEOD Annual Report,1996 Nuclear Materirls 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 staffis developing additional guidance to assist the staffin review of applications requesting authorization j 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.
- 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 Stewart D. Ebneter, Regional Administrator, to Edward L.
Jordan, Director, AEOD, " Status of Staff Actions," dated October 31,1995. Incident Investigation Teams E-10 NUREG-1272, Vol.10, No. 2
Nucint Miteriils AEOD Annu:1 Report,1996 l Action Source: IIT Report on the " Ingestion of Phosphorus-32 at Massachusetts Institute of Technology, Cambridge, Massachusetts, Identified on August 19,1995," NUREG-1535, dated December 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. (Responsible Omce: NMSS/RES) Status: Ongoing Item 2: Adequacy of NRC's Events Databases Action (a): Review current mechanisms for the collection, review, and dissemination of nuclear materials events and implement appropriate modifications. (Responsible Office: AEODINMSS) Status: Ongoing Action (b): Review the Agreement States Program with regard to the compatibility of event reporting 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 appropriate. (Responsible Office: AEOD/OlP) Status: Ongoing Item 3: Reporting Requirements Action (a): Evaluate current regulations and guidance regarding the reporting ofinternal contamination and modify, as appropriate. (Responsible Office: RES/NMSS) Status: Ongoing NUREG-1272, Vol.10, No. 2 E-11 Incident Investigation Teams
AEOD Annuil Report,1996 Nucleir Mat:riils item 4: Management Oversight i 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 omcer, 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. (Responsible Omce: NMSS/RES) 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 consistent application of the requirements is achieved and finalize the Regulatory Guide, as appropriate. (Responsible Omce: 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 Team. Issue, if appropriate, revised piecedures or modify the Management Directive to cover exit and entrance interviews, exchang of information with the individuals, use of transcribed interviews, media coverage and decisions to recommend that an AIT should be upgraded to an IIT. (responsible Omce: AEOD/NRR) Status: Ongoing Action (b): Evaluate the adequacy of guidance for chartering IITs and AITs for events involving deliberate acts. In particular evaluate the adequacy of guidance for interfacing with criminal investigations (Office ofInvestigations, State or Federal law enforcement, and local or private police). Issue, if appropriate, revised procedures and guidance for IITs and AITs. (Responsible Office: AEOD) ; i Status: Ongoing Item 6: Adequacy of NRC's Guidance and Procedures for Licensee Response to Intakes of Radioactive Material by Individuals Action (a): Evaluate the adequacy of regulatory guidance for collecting data to analyze intakes of radioactive materials, for analyzing fetal dose based upon maternal intake, for licensees seeking outside medical expertise, and for NRC staff who monitor the licensee's analysis of an intake. Issue revised guidance and procedures, as appropriate. (Responsible Omce: NMSS/RES) Status: Ongoing Incident investigation Teams E-12 NUREG-1272, Vol.10, No. 2
Nuclear Materirls AEOD Annu 1 R: port,1996 { l
References:
- 1. NUREG-1535, " Ingestion of Phosphorus-32 at Massachusetts Institute of Technology, Cambridge, Massachusetts, Identified on August 19,1995,"
December 1995. i I I l l i l 1 1 I i l NUREG-1272, Vol.10, No. 2 E-13 Incident Investigation Teams
NRC FORM 336 u.s. NUCLEAR REiulATORY COMMISslON 1. REPORT NUMBER (249) (Assigned by NRC, Add vol, supp., Ret, NRCM 1102. and 4.ddendum Numtsers,it anyJ 32oi. 32a2 CCLIOGRAPHIC DATA SHEET (s= narruevons mune mor=' NUREG-1272
- 2. TITLE AND SUBTITLE Vol.10 No. 2 Office for Analysis and Evaluation of Operational Data 1996 Annual Report 3 DATE REPORT PuBUSHED MONTH EAR
__Dece_mber 1997
- 4. FIN OR GRANT NUMBER 5 AUTHOR (S) 6. TYPE OF REPORT
- 7. PERIOD COVERED (inciustwo Dates)
FY 1996
- 8. PEnFORMING ORGANLZATION NAME AND ADDRESS (#NRC powde Dwson. omco or Repon. 6 72" , rieguwory Comnsson, and madng act#ess. # contractor, powde name and madng address)
Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Wrhington, D.C. 20555-0001
- 9. SPONSORING ORGANIZATION . NAME AND ADDRESS (# NRC. type *same as above"; # contractor prowde NRc Dwson. Omco or Regon u S NucAsar Regusatory commason.
and madne adc#ess } S:me as in item 8 10 SUPPLEMENTARY NOTES
- 11. ABSTRACT (200 woros or Aess)
This annual report of the U.S. Nuclear Regulatory Commission's Office for Analysis and Evaluation of Operational Data (AEOD) describes activities conducted dunng 1996. The report is published in three parts. NUREG-1272, Vol.10, 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 report 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 Operations Center, NUREG-1272, Vol.10, No. 2, covers nuclear materials and presents a review of the events and concerns during 1996 associated with the use of licensed material in nonreactor Epplications, such as personnel overexposures and medical misadministrations. Both reports also contain a discussion of the incident investigation Team program and summarize both the incident investigation Team and Augmented inspection Team reports. Each volume contains a list of the AEOD reports issued from CY 1980 through 1996. NUREG-1272, Vol.10, No. 3, covers technical training and presents the activities of the Technical Training Center in support of the NRC's mission in 1996.
- 12. KEY WORDS/DESCRIPTORS (Ost worcs or phrases iner ad asset researchers e Ascafmp the reporf) O AVAR, M STARMLNT nuclear materials nonreactors non-power reactors unlimited Nuclear Materials Events medical misadministration radiation exposure 54 secuRiry ctAssiricatioN Database radiation exposure loss of control of Trnm eng )
leaking sources release of material licensed material trcnsportation events equipment problems unclassified fuel cycle facility - tst, research, and training abnormal occurrences operating expenence trin Repari reactor incident response NRC staff actions unclassified incident Investigation AEOD recommendations AEOD _ reports 16. NUMBER OF PAGES Program AEOD studies Operating Center data Commrttee to Review emergency response gaseous diffusion Generic Requirements 16. PRICE NRC FORM 335 (2-09)
l l l l l i l l l l Printed l ' on recycled I paper I 1 Federal Recycling Program l
M Qu . fyf. &,y.,:/ Q3?p;' q.;.Mv g,';M
- g. '< %. /'"", " '. _ ,j W ,_ ,; Mu mju;pyffd hspk y. %m&.g g ,' '-'
v~h, gv.w;; v. n~t y n,"
'+n',~- W > Oc r
. w.mng 4
%9 /A nw M s.y tn mem"& p:w; n n 7,e y
, + a L
,:. u i
w x . %*:vinW m, \ ~gy@Qp2p;,q
+
.n gy WUM@MM:0 g '? ,p W' ;
<hp W k $n&g@3 SMkl ;& ~b p :t p aw ??M Ms i
*+ "4; s l y" ' % n:nu n- a %, C?: Q N"%,
Wh.:G-NQ
&n ;g&y
@9p$N &w;+bQen,n u %e&@B C '
W
- w. g%s? " . WC &I l a:a n
Q@e? 4 , s : . .
- ..(
m3~ e. n-
+
,. . pm ag- ,
a s : e o: _g 4 a smmmu up 4 e ?.h , y,- , r i m+ , - c N$ ' , -m.%sh% gh
@+? @s, m# >
.o-s'
',J (1, MW l l 2' vg %Wy ? > %yl
-D-qn v
mh , l- :QJ~s e g-w :
,i 6.&
e
< ?
ww a ,. m o. :,s .m. ~.f"w... , ,s : . n p.fa w'um+ w yR.m!
, A nH,Qh.%.p%mt g
..y ..f
?
l & &y&yy.fljm.&,
, i
?&
(a&p) {O W. *
? t A. ~ A . S' % a # &,% e i .u & . ',@,a.l L,, ,
i _n_ , ~ , ~ ---_n~+ui W1 V_: h_y ~M m s _h 4 p @ . pQ\ p s_JQMM MW? t
- a. we'(f(p ps t' % %c vl,27 r &< f, e X{,Wp, . ta(! :
y g,r.,. y;J :_' MW_~ % :x %p.mdy er m Qgf rW g:4.W w .yA,(y% .? $p y w@W W L @vg,Wwy gr
. y3p, pp;4 q%glg e t p g _n b
o e9lpyp.;Q:.:y: -w < %. w a , > ~
+ u .
y 4.h. . & v.Myg k,n,3 ,,a 4 m s m'Epp tvun /;,0@y a. ,W-ekt% 0 P./C~
'g~ > + .U m, $., g:n gy e g%my.
V&9Nj;fM & Q: & ? RR@;m 9 c ,< > a
&$y}lN&m"u 4.c ud' bjQ.W.. , Q. & ?lWh f w,,, . w~ . -c
, anmv (r y ,.s h- n )
. [
, ~u;.
. . , n-1 MEvu,b!' ,e, ;.+ mfwe . e sn. 1y4l,h;hfp0h .& s$
f m 2 ~ vee , y 8
' ' * ~4 :
t ,h hNm . ,,W ^ge { g, E, W ' w .-
^ ' "
b hky M & i f:a; h - 4. q4 V r
~
w@#dMV, V- w Qn$Q
~ *
-a;&%+ z. ~'am$ g 9> . , b J r ,8
' r*y w ,
%m$mg' T d%yw"Q3 's o - v &
9 ~ ^
- W y r .,
" Ma@mp@fmf DiMMf %fh
, iA g.c W ii m ,
- o. .f '
.,'.s f) 47 @ ;g o
. yy.I, e-w5
- m c:..,aa w o povsn s 3 ,
4 s. e s e ,e? A,a,exqq%
< Jn. xJ, v, ;- --s.m ra X . t rQw Lp e m >:w., 'un -. ( [.
, e s s.*:.
=
's v p q, .
q s e. , $ - N i uyTv
.Y a$ I .$.
. ll l f .fl 4 3 - f+? d If .
h ha m4 pN h} %bbh' . :Y f (
+;t;wlhf'f,h'q 4
~
^:h
- u, h'$!?'
- nwxydgw%wAe $ k % k'f ' k;!h *'h
> ;' ' q w a r w g a g ,y 3 '. f .t psM6(ddh.c.ww m-a pg % @ &. ' ' WWWWhd M,
u^ e-m
'N, 7
4 hf jk b':l h ?) ,L,! f, gg mjag&; &#-%% MMp % f & u,kmpeu hhhhh [ '~ w r #_ e~m
%w$a~lGhfkf ewm Lg% , ,
~ , .
v, w q M a ydNWAn;w%, WQ p v" ' M. ~ v v a .Ahn, + < yn~ <W> w~1 o , r
.,.'n:
vs ..g u: w % n ,?w 4 mw. s , m.m pRy% , /, u um .
- n,, s : e u . .
y, cy b; <, a
;gp;g%gf h&
,".~bm p. mQpa p w M.%g,+: r'i g Q a.(* g! w @fQ y r
Ws
, , '+t : v-se-p '. as' s -
w x a:,g y(,
, 2 :s py G:,e i n . v. .: f Qe nWy.4&.g.
q'y.pv&wATQ4,$7.. ym ya r c " m+ 4m% s dg)> b&g%@
+ s 5 , y.9 - -
iAf;ly r W A 'p: ' j p g&NMdk.k kh vem t Y i j n ny?!^n ) ew
- Q- 'w ar l& - O ' fug'?
*qw%m@&
43 a ,6 - - w-4 t s ;.;s; ., a i ;% q ,
.~
> .n d.@. a. m A ._%,w
%3 h %Q 4 ?
4
* ' : Q,. y s M.W '
;! o v r r. t. d~ VN, pip;,;t wCgpg WwV, p
.rm_Q:
s , s t o _x ; . i (- 1 fo s . (; 3 w#p-
.A . :t s y,dq t yu.w1y Gp.hth wdl ' .f 6 e
J s' '
- 9. epna pg*r t ,nQ' !i ! )q%<,
e, ,M' ld > ,~W ;L
. 57 .-- *;&y
- n .} t ouq>nQ.4@%,.
s ,p <r:
.;W bg 4 t
~
I. (.h2). ,I_ i .r, i
.4a~ "'r s .\
wh s s 3**< 3 v\pm.f.d' Y u.e h
'l i6 l+F f > i .-e o -
P- s ,( Y Q,N% h/M) < ]vu m, h' +
< ci n V. 4?
t -. [if[hi@@h
' fff 4 , . q , *, *-
a:qb s u?r ,?7 ' i ,. A m 1 'wq- _ imp -
&%m ggi ,1 7
tnm , 7 1 1 rung 34 ;g yg is, i y_ ab Q..(Y,i i
>m
'wh% g l~ ;
g_ lg ww ,g" J.
...,,r ( t
.} , ; g ,;
g-s q. # s,
-f , , y W r_,f Q-W c . i. '
,,,~-1 ,
., , .LH ;,9.e
?p t
p,3.e,.~. s s
.-. ;..,- .@g% ,
; g p 4 i's m
i f. f., m>g-
.m Q *,-ly
~
;I 'e s ,.y _
.lf, .W. ' y.&, , {&. '
e
~ .
c% ; .in .r:
'Fp , Me:).c a?@ rM -
r' pf .Q:x @
, % .o X .- , y 4y f
o ; W:- g -
.. M M& ib O; ,m% b . h$
pqNi ' 1qam QL .:: , 3' '. g;f W
;h@9 o A ;y .
o
,N -) , fv .
yr
-[
c D.
.,.r' , s -- i
[ E a.
.Q
, y '
;ite l
,3; A b
,'t
~ '
i.. fL. w
+,2j q.3 4 j ,rp..,,s
, V- .e
..T ,.
.<: q n, -_ , l ., , . -
;y r j
.s.'. /
, _.f'
,p
._$O
_m__&
_ k-b D ~; l I AA M Pf' 7 DS 6 - RETG. AE D FC ND R O ' AN N N TA ST S E UM t L A I AG lfR E 2 b s s CT4P 5 ES , o i [ P S.PO ' 0 ' i w
~
r v , _>
^
+
b g i.
. T , 7 w ~
7 ~ g
+ .g
- k [
-.! 6
.V 5 C 5 f cl 7
0 &,
-_q 2 7 x
"a e_
c; i e . n. E ' J r,-
^ -
C ! e
-1
+
4' - 4' 6 ,. e.
. 7 c; -;
^
$; - 7 T 1 -
5 c r s '4 5 na T 5N I
~
3 NH
;F3 2SrW A 1UT2h N
- O I ,
S 1 ;1 S0 I 0 M M0 0
-0 8
3 M-5 4 3 O5 SS
- E E C5 TY2 0 SU E
AR N TE I SA TOC UV STD, BfR DA EL N LP A I R TUO I CO I NE GG T FF F Y OT Uc RN I L _RH A N AS E EA P ~ LW C U' N}}