ML20217P107

Report to Congress on Abnormal Occurrences.Fiscal Year 1997

ML20217P107
Person / Time
Issue date:	04/30/1998
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V20, NUREG-90, NUREG-90-V20, NUDOCS 9805060097
Download: ML20217P107 (23)

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NUREG-0090 Vol. 20 Report to Congress on Abnormal Occurrences Fiscal Year 1997 U.S. Nuclear Regulatory Commission Omce for Analysis and Evaluation of Operational Data

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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, P. O. Box 37082 Washington, DC 20402-9328

3. The National Technical Information Service, Springfield, VA 22161-0002 Although the hsting 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 Pub!ic 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: Commisu.on papers; and applicant and licensee docu-ments and correspondence.

The following documents in the NUREG series are available for purchase from the Government Printing Offico: 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 Feders/ 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 Reg / ster notices, Federal and State legislation, and congressional reports can usually be obtr.ined 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 Standards, from the American National Standards Institute,1430 Broadway, New York, NY 10018-3308.

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NUREG-0090 Vol. 20 Report to Congress on Abnormal Occurrences Fiscal Year 1997 Date Published: April 1998 Ofrice for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555-0001

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Abnormal Occurrences, Fiscal Year 1997 Previous Reports in Series NUREG 75/090 (January-June 1975), published October 1975.

NUREG-0090-1 through 10 (July-September 1975 through October-December 1977), published March 1976 through March 1978.

.NUREG-0090, Vols.1 through 18, No. 3 (January-March 1978 through July-September 1995), published June 1978 through February 1996. No Vol.18, No. 4, was published because annual reportingon a fiscal-year basis started with publication of the report for fiscal year 1996.

NUREG-0090, Vol.19, Fiscal Year 1996, published April 1997.

NUREG-0090, Vol. 20 ii t

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Abnormal Occurrences, Fiscal Year 1997 ABSTRACT-Section 208 of the Energy Reorganization Act of The report addresses two AOs at facilities 1974 (PL 93-438) identifies an abnormal licensed by or otherwise regulated by NRC. One occurrence (AO) as an unscheduled incident or involved an event at a nuclear power plant, and event that the U.S. Nuclear Regulatory one involved an occupational overexposure. Four Commission (NRC) determines to be significant AOs submitted by the Agreement States are from the standpoint of public health or safety. The included. Two involved overexposures of workers Federal Reports Elimination and Sunset Act of or a member of the public, and two involved 1995 (PL 104-66) requires that AOs be reported radiopharmaceutical misadministrations. Recent to Congress annually. This report includes those information about a previously reported AO is events that NRC determined to be AOs during included in this report.

fiscal year 1997.

iii NUREG-0090, Vol. 20

Abnormal Occurrences, Fiscal Year 1997 CONTENTS Page Abstract................................................................................ iii Preface.................................................................................vii I n trod ucti on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii The Regulatory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Reportable Occurre nces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Agree me n t S t a te s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Foreign I nformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Reopening of Closed Abnormal Occurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Report to Congress on Abnormal Occurrences-Fiscal Year 1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Nucle a r Pbwe r Pl an ts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 97-1 Loss of Two of Three High Pressure Injection Pumps at Oconee Nuclear S t a tion Uni t 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Fuel Cycle Facilities (Other than Nuclear Power Plants) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Other NRC Licensees (Industrial Radiographers, Medical Institutions, Industrial Users, etc.) . . . . 2 97-2 Overexposure of a Worker at Mallinckrodt, Inc., in Maryland Heights, Missouri . . . . . . 2 Agreement S tate Licensees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 AS 97-I Multiple Transuranic Overexposures to a Worker at Isotope Products Laboratories in Burbank, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

- AS 97-2 Overexposure of a Radiographer and an Untrained Technician at Wolf Creek Mine in Walker County, Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 AS 97-3 Radiopharmaceutical Misadministration at Mad River Community Hospital in Arcata, California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 AS 97-4 Radiopharmaceutical Misadministration at 'Ibomey Regional Medical Center in Sumter, South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Appendix A-Abnormal Occurrence Criteria and Guidelines for Other Events of Interest . . . . . . . . . . 9 l . Appendix B-Update of Previously Reported Abnormal Occurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Othe r NRC Lice nsees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

%-3 Medical Brachytherapy Misadministration by Jose L Fern 5ndez, M.D.,

in Mayagnez, Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Appendix C-Other Events of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 v NUREG-0090, Vol. 20

Abnormal Occurrences, Fiscal ' Year 1997 i

PREFACE

. Introduction Document Room (PDR) and all Local Public Document Rooms (LPDRs). Potential AOs Section 208 of the Energy Reorganization Act of reported by NRC licensees are placed in the PDR 1974 (PL 93-438) identifies an abnormal before NRC prepares the AO report to Congress, occurrence (AO) as an unscheduled incident or Potential AOs identified by Agreement States are event that the Nuclear Regulatory Commission placed in the PDR upon receipt by NRC via (NRC) determines to be significant from the NRC's Regulatory Information Distribution standpoint of public health or safety. The Federal System.

Reports Elimination and Sunset Act of 1995 (PL . .

104-66) requires that AOs be reported to NRC has determined that of the m.eidents and Congress annually. This report includes those events reviewed for this reportm, g period, only events that NRC determined to be AOs during those that are described in this report meet the fiscal year 1997. critena for reporting as AOs. Information reported for each AO includes the date and place, NRC identifies an AO for the purpose of this nature and probable consequences, cause or report, using the criteria in Appendix A. The causes, and actions taken to prevent recurrence.

criteria were initially promulgated in an NRC pohey statement that was published in the Federal Appendix B presents recent information on previously reported AOs as it becomes available.

Register on February 24,1977 (Vol. 42, No. 37, Appendix C gives information on events that the pages 10950-10952). This pohey statement was Commission determines can be of interest to published before medical licensees were required to report medical misadmimstrations to NRC, and Congress and the public. These events are not few of the examples m, the policy statement were reportable as AOs but are provided as "Other Events of Interest."

applicable to these misadmimstrations. Therefore, in 1984, NRC adopted additional guidance for AO reporting of medical misadministrations.

The Regulatory System In 1996, NRC revised the AO criteria, including The system of licensing and regulation by which criteria for medical misadministrations, and NRC carries out its responsibilities is published them in the FederalRegister implemented through the rules and regulations in (December 19,1996: 61 FR 67072). Again in . Title 10 of the Code ofFederalRegulations. Public 1997, NRC revised these criteria to include AO participation is an element of the regulatory criteria for gaseous diffusion plants and published process. To accomplish its objectives, NRC them in the FederalRegister (April 17,1997: 62 FR regularly conducts licensing proceedings, 18820). The events included in this report were inspection and enforcement activities, evaluation determined to be AOs based on the revised 1997 of operating experience, and confirmatory AO criteria that are summarized in Appendix A- research, while maintaining programs for establishing standards and issuing technical To provide wide dissemination of information to reviews and studies, the public, a Federal Register notice is issued on events reported by facilities licensed by or NRC follows the philosophy that the health and otherwise regulated by NRC or an Agreement safety of the public are best ensured by State that have been determined to be AOs. At a establishing multiple levels of protection. These minimum, each notice must contain the date and levels can be achieved and maintained through place of the occurrence and a description ofits regulations specifying requirements that will nature and probable consequences. Information ensure the safe use of nuclear materials. The on activities licensed by Agreement States is also regulations include design and quality assurance publicly available at the State level. Copies of the criteria appropriate for the various activities notice are distributed by the NRC Public regulated by NRC. An inspection and vii NUREO-0090, Vol. 20

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Abnormal Occurrences, Fiscal Year 1997 enforcement program assists in ensuring regulatory authority over byproduct, source, and compliance with the regulations, special nuclear materials (in quantities not capable of sustaining a chain reaction).

Agreement States must maintain programs that Reportable Occurrences are adequate to protect public health and safety and compatible with the Commission's program Operating experience is an essential input to the for such material. Currently there are thirty

. regulatory process for ensuring that licensed Agreement States.

activities are conducted safely. Licensees are required to report certain incidents or events to In early 1977, the Commission determined that events that meet the criteria for AOs occurring at NRC. This reporting helps to identify deficiencies and to ensure that corrective actions are taken to Agreement State licensed facilities should be prevent recurrence. included in the periodic report to Congress.

Agreement States report event information to NRC and the industry provide detailed review of NRC in accordance with compatibility criteria operating experience to help identify safety established by the Policy Statement on Adequacy concerns early; to improve dissemination of such and Compatibility of Agreement State Programs, information; and to feed back the experience into published in the Federal Register (September 3, licensing, regulations, and operations. In 1997): 62 FR 46517. Procedures have been addition, NRC and the industry are continuing to developed and implemented for the evaluation of improve the operational data systems, which material events to determine those that should be include not only the type and quality of reports reported as AOs. AOs reported by the Agreement required to be submitted, but also the methods States to NRC are included in the periodic report used to analyze data. To more effectively collect, to Congress and the Federal Register notice issued collate, store, retrieve, and evaluate operational to provide wide dissemination of information to j data, the information is maintained in the public. The AO criteria included in Appendix l computer-based data files. A are applied uniformly to events that occur at l facilities regulated by NRC and the Agreement Except for records exempt from public disclosure States.

by statute or regulation, information concerning reportable occurrences at facilities licensed by or otherwise regulated by NRC is routinely Foreign Information disseminated by NRC to the industry, the public, and other interested groups as these events occur. NRC participates in an exchange of information with various foreign governments that have Dissemination includes special notifications to nuclear facilities. This foreign information is licensees and other affected or interested groups reviewed and considered in the NRC's assessment and public announcements. In addition, of operating experience and in its research and information on reportable events is routinely sent regulatory activities. Reference to foreign to the NRC's LPDRs throughout the United information may occasionally be made in the AO States and to the NRC PDR in Washington, D.C. reports to Congress; however, only domestic AOs Congress is routinely informed of reportable are reported.

events occurring in facilities licensed or otherwise j regulated by NRC.

Reopening of Closed Abnormal Occurrences Agreement States NRC reopens previously closed AOs if significant Section 274 of the Atomic Energy Act, as new information abcut an AO becomes available, amended, authorizes the Commission to enter Similarly, previously reported "Other Events of l into agreements with States whereby the Interest" are updated if significant new Commission relinquishes and the States assume information becomes available.

NUREO-0(M), Vol. 20 viii

Abnormal Occurrences, Fiscal Year 1997 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FISCAL YEAR 1997 NUCLEAR POWER PLANTS Using the criteria and guidelines in Appendix A of Plant cool-down evolutions appeared to be normal this report, the following event, which occurred at until the "B" HPI pump started to cavitate and a nuclear power plant during this reporting makeup flow to the reactor coolant system was period, was determined to be significant enough to lost. A RCP seal water (which is also supplied by be reported as an abnormal occurrence (AO). the HPI pump) low-flow signal automatically started the "X HPI pump. However,it also began to cavitate. (The third HPI pump is not designed 97-1 Loss of Two of Three High to automatically start on this signal and remained Pressure Injection Pumps at in the standby condition.) The operators stopped Oconee Nuclear Station Unit 3 both pumps and began troubleshooting the problem. A Notification of Unusual Event was The following information pertaining to this event declared when it was recognized that the pumps is also being reported concurrently in the Federal w uld be moperable past the shift that was on Rmister. Appendix A (see Criterion I.D.2) of this duty. Unit 3 pressure and temperature were report notes that a major deficiency in design, stabilized and there was no immediate concern that conditions would worsen.

construction, control, or operation having significant safety implications requiring immediate Later investigations revealed that the potential for remedial action can be considered an AO. a more serious situation existed if there had been a small break loss-of-coolant accident, which is the Date and Place-May 3,1997; Oconee Unit 3, a design basis for the HPI system, prior to this pressurized water nuclear reactor plant designed event. If such an accident had occurred, all three by Babcock and Wilcox Company, operated by the of the HPI pumps would have automatically, Duke Energy Corporation (formerly known as started and become moperable very quickly. In Duke Power Company), and located about 8 miles addition, the pumps may have become air bound north of Clemson, South Carolina. and unavailable when the pump suction was transferred to the Borated Water Storage Tank to Nature and Probable Consequences-On May 3, inject into the RCS. This would have significantly 1997, the Oconec Unit 3 reactor was shut down c mpli ated recovery from the accident, but would

.md the reactor coolant system (RCS) was being have been within the Emergency Operatmg Procedure guidance and tram, mg provided to the cooled down for inspection of the high pressure perators. It would, however, increase the injection (HPI) discharge piping. The need for probability of core damage. The length of time the inspection resulted from RCS leakage from a that Unit 3 was m this degraded status could not weld crack in the HPI makeup piping on Unit 2.

be accurately determined, but the condition may Reactor pressure was approximately 270 psig, RCS have existed since start-up m March 1997, when temperature was approximately 205 'F, one plant conditions required that the HPI system be reactor coolant pump (RCP) was running, and the perable.

Low Pressure Injection System was being used to cool down the RCS. Makeup water to the RCS to Cause or Causes-Loss of the HPI pumps compensate for the temperature decrease was occurred when all of the water was inadverantly being supplied from the letdown storage tank pumped from the LDST because of faulty lmel (LDST) by one of the three HPI pumps. Makeup indication. The erroneous level indication was to the LDST consisted of periodic batch additions caused by the loss of approximately one-half of as needed. These plant conditions were below the the water in the level detector reference leg point where the technical specifications required because of a slight leak in the instrument fitting.

that the HPI system must be operable; that is, This loss of the reference leg water caused the required to mitigate a small-break loss-of-coolant tank level instrument to indicate a water level accident. higher than the actual level, a condition that may 1 NUREG-0090, Vol. 20

Abnormal Occurrences, Fiscal Year 1997 have existed since February 1997, the last time the Actions Taken to Prevent Recurrence reference leg was verified to be full. It also caused the loss of the low-level alarm. As a result of Licensee-Corrective actions included (1) the these conditions, the operators did not provide addition of a second reference leg to the LDST to makeup water to the tank when it was needed, provide separate level indications, (2) enhanced resulting in the HPI pump continuing to run until operator training and procedures, and (3) the the tank was empty. The LDST level detection performance of an HPI System Reliability Study system consists of two level instruments connected that is to be completed by December 31,1997.

to a common reference leg. Thus, the condition affected both level detectors equally. NRC-Escalated enforcement, which incorporated this issue, resulted in the determination that a Severity Level II violation existed, and the licensee was assessed a $330,000 In addition, the control room operators did not civil penalty. Information Notice 97-38, properly monitor and detect the inaccurate LDST " Level-Sensing System Initiates Common-Mode level indications. They did not notice that for a Failure of High-Pressure-Injection Pumps,"was short period of time the indicated level stopped issued on June 24,1997, to alert other licensees to decreasing and continuously showed the tank to this event.

be approximately half-full at the same time water was being pumped from the tank. This event is closed for the purpose of this report.

FUEL CYCLE FACILITIES (Other than Nuclear Power Plants)

Using the criteria and guidelines in Appendix A of determined to be significant enough to be this report, no events that occurred at fuel cycle included in this report.

facilities during this reporting period were OTHER NRC LICENSEES (Industrial Radiographers, Medical Institutions, Industrial Users, etc.)

Using the criteria and guidelines in Appendix A of were determined to be significant enough to be this report, the following events that occurred at reported as AOs.

other NRC licensees during this reporting period 97-2 Overexposure of a Worker at extremities of 2500 mSv (250 rem) or more will bc )

Mallinckrodt, Inc., in Maryland considered for reporting as an AO.

Heights, Missouri Date and Place-May 14-15,1997; Mallinckrodt, '

The following information pertaining to this event is also being reported concurrently in the Federal Nature and Probable Consequences-On May 14, Register. Appendix A (see Criterion I.A.1,"For 1997, an employee was removing radioactive All Licensees") of this report states that any waste from the hot cell where rhenium-186 unintended radiation exposure to an adult (any (Re-186) was used. The employee was individual 18 years of age or older) resulting in an performing this task manually, using gloves, annual shallow-dose equivalent to the skin or instead of remotely. When he left the area, he NUREO-0090, Vol. 20 2 t

Abnormal Occurrences, Fiscal Year 1997 I 1

attempted to perform a personal contamination effects. However, according to a report from an survey but the survey meter immediately went off NRC consultant, a small possibility exists for skin the scale. He assumed that the high count rate cancer to develop in the exposed area of the was due to background radiation from an adjacent thumb.

radioactive material transport cart and, j subsequently, forgot to resurvey himself in a low Cause or Causes-The cause of the event was a i background area before he left the facility that procedural deficiency in handling waste from the evening. Upon arrival at work the next day, he Re-186 hot cell. Normally, radioactive waste in was told that his urine sample, which he had other hot cells at the facility was handled with submitted before going home the previous night, remote tools. However,in this case, procedural indicated iodine-131 (I-131) radiation controls did not require remote handling of the contamination and that he was restricted from waste. Once the employee completed the work, working with radioactive material. At that time, poor radiation work practices were exhibited as he he performed a personal contamination survey cross-contaminated his hands when he removed and detected significant levels of contamination his gloves. In addition, the worker did not on his left thumb which subsequently was imrestigate the detection of high count rates identified as Re-186. The I-131 contamination daring his first attempt to perform a level did not exceed the AO criteria for exposure contamination survey.

to radiatian from licensed material. )

Actions Taken to Prevent Recurrence l The licensee estimates that the individual reccived l a shallow-dose equivalent of 6090 millisievert (609 Licensee-The staff was instructed on the rem) to an area of about 0.75 square centimeters importance of conducting proper personal (0.12 square inches) on the palm side of the contamination surveys and the proper use of thumb cihis left hand. Lower levels of protective clothing. The use of Re-186 was contamination were found on the back of his right suspended until improvements to existing waste i hand and fingers. On May 15,1997, the employee disposal procedures could be evaluated and had undergone decontamination to the extent that implemented. Plans were made (1) to compile all only approximately 4 percent of the activity existing contamination protection procedures into i remained. one contamination protection procedure, (2) to l evaluate the use of a portal type monitoring  !

The licensee surveyed the offsite locations where system, and (3) to post personal-monitoring the employee had been after leaving work on reminder signs at alllaboratory exits. .

May 14,1997. Low levels of Re-186 l I

contamination were found on three locations NRC-NRC conducted a special safety inspection, inside the employee's vehicle and on various items proposed a $55,000 civil penalty on December 17, i I

in the bathroom and kitchen of his horro. The 1997, and the licensee paid the civil penalty on employee's vehicle and home were January 20,1998.

decontaminated. The empicyee was examined by a physician who identified no immediate health This event is closed for the purpose of this report.

l 3 NUREO-0090, Vol. 20

Abnormal Occurrences, Fiscal Year 1997 AGREEMENT STATE LICENSEES Using the criteria and guidelines in Appendix A of the bioassay data by these consultants, which this report, the following events, which occurred at included dose summation and retrospective time Agreement State licensees during this reporting correction for various intakes, suggested that period, were determined to be significant enough during 1995 the radiochemist received a TEDE of to be reported as AOs. 383.20 mSv (38.32 rem) and a CDE of 6900 mSv (690 em) to the bone surfaces. The specific exposures were as follows: (1) committed effective AS 97-1 Multiple 'IYansuranic Over- dose equivalent (CEDE) of 271.8 mSv (27.18 rem) exposures to a Worker at from Cm-244, (2) CEDE of 80 mSv (8 rem) from  !

Isotope Products Labora. Am-241, (3) CEDE of 4.4 mSv (0.44 rem) from j Pu-238, Pu-239, and Pu-240, and (4) DDE of tories in Burbank, California 27.0 mSv (2.70 rem) from external radiation.

Appendix A (see Criterio9 I.A.1,"For All Licensees") of this report states that any The State Agency discovered this incident during unintended radiation exposure to an adult (any a routine inspection on December 5,1995, and individual 18 years of age or older) resulting in an was initially reported to NRC in January 1996, annual total effective dose equivalent (TEDE) of During a follow-up inspection, the State Agency 250 millisievert (mSv) (25 rem) or more; or an learned that another Cm-244 incident took place annual sum of the deep dose equivalent (DDE) and was significant. The State Agency also learned (external dose) and committed dose equivalent of other exposure incidents that indicated the (CDE) (intake of radioactive material) to any licensee had a deficient contamination control individual organ or tissue other than the lens of program, an inability to conduct internal dose the eye, bone marrow, and the gonads of 2500 assessnients, and inadequate management mSv (250 rem) or more will be considered for oversight. The State provided additional reporting as an AO. In addition, Appendix A (see information on these events to NRC n 1997.

Criterion I.D.3,"Other Events") of this report states that a serious deficiency in management or Cause or Causes-The liccusee's radiation procedural controls in major areas will be protection program was inadequate and lacked considered for reporting as an AO. importte elements needed to ensure the radiation safety ofits workers. Some of these Date and Place-Between January 1 and inadequacies were the lack of (1) work permits, December 31,1995; Isotope Products (2) glove boxes for certain types of work, and Laboratories; Burbank, California. (3) radiation procedural controls.

Nature and Probable Consequences-A Actions Taken to Prevent Recurrence radiochemist was assigned to make transuranic and other types of sources. The transuranics Licensee-After the licensee's consultants utilized included the isotopes of plutonium-238 conducted their review and comprehensive audit (Pu-238), Pu-239, Pu-240, americium-241 of the existing radiation protection program, they (Am-241), and curium-244 (Cm-244). During made recommendations to ensure future January 1995, while making a Cm-244 source, it compliance with the license and regulations. The was discovered that the exhaust fan of the fume licensee hired a competent radiation safety hood where the source was being fabricated was officer, and the radiochemist was assigned duties  !

not working. An analysis of room air samples that did not involve the handling or processing of confirmed the loss of Cm-244 into the working radioactive materials.

area.

State Agency-The State Agency completed its Bioassay results disclosed that the fecal and urine investigation and is committed to closely tracking samples provided by the radiochemist contained the licensee's radiation protection program to Cm-244 and Am-241. The licensee hired ensure continued compliance.

dosimetry and radiation protection consultants as directed by the State Agency. Careful ana!ysis of This event is closed for the purpose of this report.

NUREG-0090, Vol. 20 4

Abnormal Occurrences, Fiscal Year 1997 AS 97-2 Overexposure of a Radi. mSv (11 rem) to his head and 28 mSv (2.8 rem) to ographer and an Untrained the center of his body. Neither individual reported any acute radiation symptoms.

Technician at Wolf Creek Mine in Walker County, The radiography film supplied by Ultron, Inc., had Alabama faster and different exposure characteristics than Appendix A (see Criterion I.A.1,"For All the film usually used by Certified Testing and thus Licensees") of this report states that any was bemg overexposed durmg processing m the darkroom. The darkroom, which was supplied by unintended radiation exposure to an adult (any Certified Testmg, utilized a homemade " safe individual 18 years of age or older) resulting in an light,', which had been made a safe light by the annual total effective dose equivalent (TEDE) of ,

application of red spray paint. The radiographer 250 millisievert (mSv) (25 rem) or more; or an did not rcalize beforehand that the light would not annual sum of the deep dose equivalent (DDE)

(external dose) and committed dose equivalent be " safe, for the film supplied by Ultron,Inc.

(CDE) (intake of radioactive material) to any individual organ or tissue other than the lens of Cause or Causes-The radiographer entered a the eye, bone marrow, and the gonads of 2500 designated high radiation area with his alarm ratemeter turned off and without following his mSv (250 rem) or more will be considered for n rma1 practice of crankmg m the source and reporting as an AO. In addition. Appendix A (see ,

surveymg the gmde tube and camera. The Criterion I.D.3,"Other Events") of this report radiographer interpreted the silence from the states that a serious deficiency in management or alarm ratemeter as an indication of safe procedural controls in major areas will be conditions. Unfortunately, when turned off, the considered for reporting as an AO. ,

alarm ratemeter gives the same indication as it Date and Place-July 1,1996; Wolf Creek Mine, does when indicating safe conditions. In addition, Walker County, Alabama the radiographer did not utilize a colhmator to reduce the exposure to himself and the Ultron, Nature and Probable Consequences-A Inc., technician, radiographer, employed by Certified Testing and Inspection of Cottondale, Alabama, and a Actions Taken to Prevent Recurrence technician, employed by Ultron, Inc., of Mt.

Vernon, Illinois, were performing industrial Licensee-The licensee stated that the radiography at the Wolf Creek Mine in Walker radiographer did not develop any symptom of County, Alabama, when they became so distracted acute radiation exposure and that its personnel by problems with excessively exposed film that were reinstructed in the importance of performing they forgot they had an exposure in progress and surveys and using a collimator. , licensee entered the high radiation area without making a committed to the State Agency to verify the survey and changed the film with the source in the training of all technicians, including those of the unshielded exposed position. The radiographer company that hires the licensee to perform had received prior radiation saftty training, radiography.

however, the technician, an employee of Ultron, Inc., had not received prior radiation safety State Agency-The State Agency cited the training. The radio"raphy film and the device

~

Licensee for the fo!!owing four violations:

used to support the source and the film during (1) excessive exposure to a radiation worker, exposures were being supplied to the radiographer (2) excessive exposure to a member of the public by Ultron, Inc. (the Ultron, Inc., technician representative),

(3) failure to prevent unauthorized entry into the Consequently, both individuals received High Radiation Area, and (4) failure to exercise unintended radiation exposure. The State Agency ALARA by using a collimator. A civil penalty was estimated that the radiographer received a dose of considered but not imposed. The State Agency 530 millisievert (mSv) (53 rem) to his head and 48 recommended that both individuals contact the mSv (4.8 rem) to the center of his body and the State and seek medical attention if any symptoms Ultron, Inc., technician received a dose of 110 of acute exposure should appear.

5 NUREG-0090, Vol. 20 I

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Abnormal Occurrences, Fiscal Year 1997 This event is closed for the purpose of this report. Hospital, which included a segment on the effects of studies involving therapy dosages.

State Agency-The State Agency conducted numer us f 11 W-UP inspections to ensure that the AS 97-3 Radiopharmaceutical licensee's actions taken to prevent recurrence had Misadministration at Mad been implemented.

River Community Hospital in Arcata, California This event is closed for the purpose of this report.

Appendix A (see Criterion IV,"For Medical Licensees") of this report states that a medical misadministration that results in a dose that is ]

AS 97-4 Radiopharmaceutical i equal to or greater than 10 gray (Gy) (1000 rad) t any organ (other than a major portion of the bon Misadministration at 'Ibomey marrow, to the lens of the eye, or to the gonads) R'E l onal Medical Center in and represents a dose or dosage that is at least 50 Sumter, South Carol,ma percent greater than that prescribed in a written Appendix A (see Criterion IV,"For Medical directive will be considered for reportmg as an AO. Licensees") of this report states that a medical I misadministration that results in a dose that is Date and Place-February 28,1996; Mad River equal to or greater than 10 gray (Gy) (1000 rad) to Community Hospital; Arcata, California. The any rgan ( ther than a major portion of the bone State initially reported this event to NRC in marr w, to the lens of the eye, or to the gonads)

December 1996, and represents a dose or dosage that is at least 50 percent greater than that prescribed m, a written Nature and Probable Consequences-A patient directive will be considered for reporting as an was prescribed a dosage of 3.7 megabecquerel AO.

(MBq) (0.1 millicurie [ mci]) of iodine-131 (I-131) for a thyroid scan and uptake procedure. Date and Place-December 11,1996; Tuomey Regional Medical Center; Sumter, South However, the patient was admm, istered a dosage of 262.7 MBq (7.1 mci) of I-131. As a result, the Carolina' patient's thyroid received a dose of about 9100 Nature and Probable Consequences-A patient centigray (cGy) (9100 rad), instead of the was prescribed a dosage of 74 megabecquerel prescribed dose of 130 cGy (130 rad). (MBq) (2.0 millicurie [ mci]) of iodine-131 The licensee stated that such a dose may induce a (I-131) for a treatment of Graves disease.

However, the patient was administered a 388.5 hypothyroid state requiring the patient to take thyroid hormone. MBq (10.5 mci) dosage of I-131. As a result, the patient's thyroid received a dose of 40,400 Cause or Causes-The wrong dosage was centigray (cGy) (40,400 rad) instead of the administered on the assumption that the patient prescribed dose of 7700 cGy (7700 rad).

was prescribed a whole body thyroid scan for a The licensee stated that the administered dose of cancer metastatic disease evaluation.

1-131 to the patient's thyroid is not expected to Actions Taken to Prevent Recurrence aw maj r hea% ekts.

Cause or Causes-The wrong dosage was Licensee-Procedures for scheduling a whole body scan for thyroid cancer metastases were administered to the patient because the written order for the 1-131 procedure was misread by the revised to include a detailed patient preparation administering technologist.

and history. The revised proceduies required that the approving radiologist sign the I-131 Actions Taken to Prevent Recurrence administration policy before ordering a radiopharmaceutical. In addition, the nuclear Licensee-The licensee will have the written order medicine technologist attended a continuing on hand before ordering radiopharmaceuticals education program at San Francisco General from the pharmacy and will have a second person NUREG-0090, Vol. 20 6

Abnormal Occurrences, Fiscal Year 1997 '

I verify the dosage before administration to the licensee's report and corrective action as patient. appropriate. No further action was requested.

l This event is closed for the purpose of this report.

State Agency-The State Agency accepted the l

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7 NUREG-0090, Vol. 20

Abnormal Occurrences, Fiscal Year 1997 APPENDIX A 1

ABNORMAL OCCURRENCE CRITERIA AND GUIDELINES FOR OTHER

EVENTS OFINTEREST i

An event will be considered an abnormal 1. Any unintended radiation exposure i occurrence (AO) if it involves a major reduction to an adult (any individual 18 years l in the degree of protection of the public health or of age or oldcr) resultingin an l safety. This type ofincident or event would have a ar.nual total effective dose moderate or more severe impact on the public equivalent (TEDE) of 250 milli.

health or safety and could include, but need not be sievert (mSv)(25 rem)or more; or limited to the following: an annual sum of the deep dose equivalent (external dose) and (1) Moderate exposure to, or release of, committed dose equivalent (intake 4 radioactive materiallicensed by or otherwise of radioactive material) to any I regulated by the Commission; individual organ or tissue other than j the lens of the eye, bone marow, (2) Major degradation of essential safety-related and the gonads of 2500 mSv (250 equipment; or rem) or more; or an annual dose equivalent to the lens of the eye of 1 (3) Major deficiencies in design, construction. Sv (100 rem) or more; or an annual use of, or management controls for facilities sum f the deep dose equivalent and or radioactive material licensed by or comnutted dose equivalent to the otherwise regulated by the Commission, bone marrow. and the gonads of 1 Sv (100 rem) or more; or an annual The following criteria for determining an AO and shallow 4!cse equivalent to the skin the guidelines for "Other Events of Interest" were or extremities of 2500 mSv (250 rem) or more, set forth in an NRC pohey statement published in the FederalRegister on December 19,1996 (61 FR 2. Any unintended radiation exposure 67072). The policy statement was revised to to any minor (an individualless than include criteria for gaseous diffusion plants and 18 years of age) resultingin an was published in the FederalRegister on April 17, annual TEDE of 50 mSv (5 rem) or 1997 (62 FR 18820). more, or to an embryo / fetus resultingin a dose equivalent of 50 Note that in addition to the criteria for fuel cycle mSv (5 rem) or more.

facilities (Section III of the AO criteria) that are applicable to licensees and certificate holders, J. Any radiation exposure that has such as the gaseous diffusion plants, other criteria resulted in unintended permanent that reference " licensees,"" licensed facility," or functional damage to an organ or a

" licensed material" also may be applied to events physiological system as determined at facilities of certified holders. by a physician.

)

Ahnormal Occurrence Criteria B. Discharge or Dispersal of Radioactive Material from lts Intended Place of

. . Confinement.

Criteria by types of events used to determine which events will be considered for reporting as 1. The release of radioactive material AOs are as follows: to an unrestricted area in concentrations which,if averaged I. For All Licensees. over a period of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, exceeds 5000 times the values specified in A. Human Exposure to Radiation from Table 2 of Appendix 13 to 10 CFR Licensed Mat: rial. Part 20, unless the licensee has 9 NUREG-0090, WI. 20

Abnormal Occurrences, Fiscal Year 1997 demonstrated compliance with such conditions that doses in excess 5 20.1301 using s 20.1302 (b) (1) or of the reporting thresholds specified 20.1302 (b) (2) (ii). in AO criteria I.A.1 and I.A.2 were not known to have occurred.

2. Radiation levels in excess of the design values for a package or the 2. A substantiated case of actual or loss of confinement of radioactive 8ttempted theft or diversion of material resulting in one or more of licensed material or sabotage of a the following:(a) a radiation dose f cility, rate of 10 mSv (1 rem) per hour or

3. Any substantiated loss of special more at 1 meter (3.28 feet) from the accessible external surface of a nuclear material or any package containing radioactive substantiated inventory discrepancy material; (b) a radiation dose rate of that is judged to be significant 50 mSv (5 rem) per hour or more on rel tive to normally ext,)ected the accessible external surface of a performance, and that is judged to package containing radioactive be caused by theft or diversion or by material and that meet the substantial breakdown of the requirements for " exclusive use" as ccountability system.

defined in 10 CFR 71.47; or (c) release of radioactive material from 4. Any substantial breakdown of ,

a package in amounts greater than P.hysical security or material control the regulatory limits in 10 CFR (i.e., access control containment or accountability systems) that 71.51(a)(2). , ,,

significantly weakened the protection against theft, diversion, C. Theft. Diversion, or Loss of Licensed or sabotage.

Material, or Sabotage or Security Breach.

D. Other Events (i.e., those concerning design, analysis, construction, testing,

1. Any lost, stolen, or abandoned operation, use, or disposal of licensed sources that exceed 0.01 times the facilities or regulated materials).

Alvalues, as listed in 10 CFR Part 71, Appendix A, Table A-1, for 1. An accidental criticality [10 CFR special form (scaled /nondispersible) 70.52(a)].

sources, or the smaller of the A2 or 0.01 times the Al values, as listed in 2. A major deficiency in design, Table A-1, for normal form construction, control, or operation (unsealed /dispersible) sources or for having significant safety implications sources for which the form is not requiring immediate remedial known. Excluded from reporting action.

under this criterion are those events involving sources that are lost, 3. A serious deficiency in management 3 stolen, or abandoned under the or procedural controls in major i following conditions: sources areas. '

abandoned in accordance with the -

requirements of 10 CFR 39.77(c); 4. Series of events (where individual scaled sources contained in labeled, events are not of major importance),

rugged source housings; recovered recurring incidents, and incidents sources with sufficient indication with implications for similar that doses in er. cess of ibe reporting facilities (generic incidents) that thresholds specified in AC criteria create a major safety concern.

I.A.1 and I.A.2 did not occur duriry the time the source was missing, sd II. For Commercial Nuclear Power Plant unrecoverable sources lost under Licensces.

NUREG-0090, Vol. 20 19

Abnormal Occurrences, Fiscal Year 1997 l

A. Malfunction of Facility, Structures, or B. A major condition or significant event Equipment. not considered in the license / certificate that requires immediate remedial action.

1. Exceeding a safety limit oflicense technical specification (TS) C. A major condition or significant event

[# 50.36(c)]. that seriously compromises the ability of  !

a safety system to perform its designated

2. Serious degradation of fuel integrity, function that requires immediate primary coolant pressure boundary, remedial action to prevent a criticality, or primary containment boundary. radiological, or chemical process hazard.

3. Loss of plant capability to perform IV. For Medical Licensees.

essential safety f unctions so that a release of radioactive materials, A medical misadministration that:

which could result m exceeding the dose limits of 10 CFR Part 100 or 5 A. Results in a dose that is (1) equal to or times the dose limits of 10 CFR greater than 1 gray (Gy) (100 rads) to a Part 50, Appendix A, General major portion of the bone marrow, to the Design Criterion (GDC) 19, could lens of the eye, or to the gonads, or l occur from a postulated transient or (2) equal to or greater than 10 Gy (1000 accident (e.g., loss of emergency rads) to any other orgart and core cooling system, loss of control rod system). B. Represents either (1) a dose or dosage B.

. .. that is at least 50 percent greater than Design or Safety Analysis Deficiency, Personnel Error, or Procedural or that prescribed in a written directive or Admimstrative Inadequacy. (2) a prescribed dose or dosage that (i) is the wrong radiopharmaceutical, or (ii) is

1. Discovery of a major condition not delivered by the wrong route of specifically considered in the safety admimstration, or (iii) is deh,vered to the analysis report (SAR) or TS that wr ng treatment site, or (iv) is dehvered requires immediate remedial act ion. by the wrong treatment mode, or (v) is from a leakmg source (s).

2. Personnel error or procedural deficiencies that result in loss of Guidelines for "Other Events of Interest" plant capability to perform essential safety functions so that a release of The Commission may determine that events other radioactive materials, which could than AOs may be ofinterest to C(mgress and the result in exceeding the dose limits of public and be included in an App;ndix to the AO 10 CFR Part 100 or 5 times the dose report as "Other Events of Interest." Guidelines limits of 10 CFR Part 50, Appendix for events to be included in the AO report for this A, GDC 19, could occur from a purpose are items that may possibly be perceived postulated transient or accident by the public to be of health or safety significance.

(e.g., loss of emergency core cooling Such items would not involve a major reduction in system, loss of control rod system). the level of protection provided for public health or safety; therefore, they would not be reported as III. For Fuel Cycle Facilitics abnormal occurrences. An example is an event where upon final evaluation by an NRC Incident A. A shutdown of the plant or portion of the Investigation Team, or an Agreement State plant resulting from a significant event equivalent response, a determination is made that and/or violation of a law, regulation, or a the event does not meet the criteria for an license / certificate co'ndition. abnormal occurrence.

I1 NUREG-0090, Vol. 20

i' Abnormal Occurrences, Fiscal Year 1997 i

APPENDIX B UPDATE OF PREVIOUSLY REPORTED ABNORhlAL OCCUR.RENCES During this reporting period, the following update i of a previously reported abnormal occurrence (AO) is included in the report. j

.I OTHER NRC LICENSEES 96-3 h1edical Brachytherapy patients may not appear for a period of up to 10 hiisadministration by Jose L. years after iriadiation.

Fernsndez, hf.D., in h1ayagnez, Dr. Ferndadez purchased the medical practice and  !

Puerto Rico the Sr-90 source from the estate of the deceased former licensee, Dr. Luis A. Vdzquez of This AO was originally reported in fiscal year Mayagnez, Puerto Rico. Consequently, 1996, NUREG-0090, Vol.19, " Report to Dr. Ferndndez had the records of all of the Congress on Abnormal Occurrences." administrations that were made, using the Sr-90 source, while it was licensed to Dr. Vszquez. In a The AO criteria used for this event was based on letter to Dr. Ferndndez dated October 28,1996, the AO criteria that were effective in FY 1996, NRC confirmed with Dr. Fern 5ndez that he would which stated that administering therapeutic preserve ine patient records of the former licensee radiation such that the actual dose is greater than and perform a computer search to identify the 1.5 times the prescribed dose, or the event patients who were treated with the eye applicator. ]

(regardless of any health effects) affects two or (

more patients at the same facility, should be The AO report is updated as follows:

considered an AO. The consultant h.

ired by Dr. Ferndndez identified that 202 of the patients treated were involved in On January 14,1994, Dr. Ferndndez acquired an the misadministrations.

eye applicator device, which contained a strontium-90 (Sr-90) source of approximately In addition, NRC reviewed the records of 3219 megabecquerel (87 millieurie) activity, from administrations done by Dr. Luis A. Vdzquez after the estate of a deceased licensee in Mayagnez, September 1990 and identified 559 dose Puerto Rico. (Eye applicator devices are used for administrations in which 41 re'.ulted in overdoses the supplemental treatment of non-malignant that met the definition of a misadministration.

growths on the eye after surgery is performed.) Dr. Fernnndez and the clinic,in possession of Because the eye applicator device was not Dr. Vszquez' patient records, made all reasonable calibrated properly, patients received radiation efforts to notify the patients involved in these doses in excess of the prescribed doses. The NRC misadministrations according to the requirements medical consultant stated that the long-term of 10 CFR 35.33; however,24 patients were not consequences of the misadministered radiation notified because of inaccurate information on the treatments to the 25 patients that received the record, such as a wrong address or telephone highest dose cou.d include (1) increased risk of number.

cataracts and (2) increased risk of infections, caused by severe thinning or ulceration of the NRC compiled information on patients who sclera, which could cause blindness if not detected received a misadministration (overdoses) by early and aggressively treated. No adverse health Dr. Fern 5ncez and Dr. Vszquez and sent the effects were reported during a reexamination of information to the Commonwealth of Puerto seven of these 25 patients by Dr. Fern 5ndez. The Rico, Department of Health, which is considering remaining 18 patients could not be located. follow-up actions, including reminding the However, the NRC medical consultant indicated patients annually about the need to receive that the possible adverse consequences to these periodic eye exams by specialized physicians. On 13 NUREG-0090, Vol. 20

Abnormal Occurrences, Fiscal Year 1997 June 11,1997, NRC issued a Notice of Violation an NRC Form 314," Certificate of Disposition of and Proposed Imposition of a Civil Penalty to Materials" requesting the termination of his Dr. Fernandez for the violations identified during license. Since Dr. Fern 6ndez disposed of the NRC inspections that represented a significant licensed material in his possession, the NRC lack of program oversight and careless disregard terminated his license on September 5,1997.

of regulatory requirements. Dr. Fernandez paid the $8000 Civil Penalty, and on July 17,1997, filed This event is closed for the purpose of this report.

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NUREG-0090, Vol. 20 14 L _ _ - .. - - _ - _ - - _ _

Abnormal Occurrence:,, Fiscal Year 1997 l

l

-APPENDIX C l OTHER EVENTS OF INTEREST l

l "Other Events of Interest" are reported because Tennessee (TN). This event was responded to they may possibly be perceived by the public to be by the TN Radiation Control Program.

of health or safety significance. Such items would not involve a major reduction in the level of 2. March 1997-Cobalt-60 (_Co-60) contami.

l protection provided for public health or safety; nated steel plate found in Pennsylvania (PA)

therefore, they would not be reported as abnormal and traced to WCI Steel, Inc., steel mill in occurrences. Ohio (see Preliminary Notification of Event or Unusual Occurrence, (PNO)-III-97-029 During FY 1997, a number of events occurred and Event Notification, (EN) 32021).

involving the loss of control of licensed materials Additional Co-60 contaminated steel plate resulting in the materials entering the public was found in West Virginia in September 1997 l domain in an uncontrolled manner, in some cases (see PNO-II-97-047) and traced to the

! causing iadioactive contamination or radiation same wholesale distributer that distributed exposures. Some of these events received media the steelin PA.

! coverage, and in the case of at least one event, the l NRC's oversight of the licensed material was the 3. May 1997-Melting of cesium-137 source at

! subject of correspondence exchanged between the Kentucky Electric Steel plant (see Morning l NRC and a State health agency. Although not Report, (MR) 2-97-0032).

I meeting the AO criteria, the frequency of these

( types of events and the increased public interest 4. May 1997-Tritium exit signs at a demolition and concern has caused the NRC to increase its site removed to a private home. One sign was attention on the issue of the loss of control of disassembled resulting in contamination and licensed materials. Therefore, this issue merits personnel exposure (see PNO-I-97-028).

recognition in the report to Congress under Appendix C,"Other Events of Interest." 5. August 1997-Contamination of Royal Green metal recycling plant in PA as a result of l For illustration purposes, the following list damage to Am-241 source in a shredder (see includes some of the events involving loss of EN 32859 & PNO-I-97-056).

control of licensed materials that occurred in FY 1997. This list is not all inclusive, nor is there any In FY 1997, the Commission directed the staff to intention to routinely provide eramples of the e develop recommendations to address this events in the future, problem. The staff's recommendations have been received by the Commission (SECY-97-273),

1. January 1997-Melting of americium-241 and the Commission will provide direction to the (Am-241) source at White Salvage, Riply, staff on this matter in FY 1998.

1 15 NUREO-0090, Vo!. 20

1 NRC FORM s3g U.s. NUCLEAR RE!ULATORY CoMMisslON 1. 0EPORT NUMBE11 449) (Assegned by NRC, Add Yel., supp.,1:ev EE BIBUOGRAPHIC DATA SHEET *"'****""""""*"*"d (See metuchane on he reveree)

2. TITLE AND SU8 TITLE NUREG-0090, Vol. 20 Report to Congrees on Abnormal Occurrences Fiscal Year 1997

3. DATE REPORT PUBUSHED MONTH YEAR l

April 1998

4. FIN OR GRANT NUMBER l

S. AUTHOR (S) 6. TYPE OF REPORT Annual

7. PERIOD COVE 9ED ('ncoseve osau)

Fiscal Year 1997

8. PERFORheNG ORGANIZATION . NAAE AND ADDRESS (rNRc. provee Ovann. Orme or Regon u s Nucher Regure.kry commesamn. and medeng edckens, acontecsar.

p,ove name one meene mus >

Offic3 for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commi sion Washington, DC 20555-0001

9. SPONSORING ORGANIZATION NN4 AND ADORESS (r NRC. fype seme as e6 ave

• scont csar, prove NRC Dvuon, once er been, u s Nucher Ragusekry comm,non.

end momeo eseau1 Sims as 8., above

10. SUPPLEMENTARY NOTES

11. ADSTRACT 000 mrde or hee.)

Section 208 of the Energy Reorganization Act of 1974 identifies an abnormal occcurrence (AO) as an unscheduled incident or evInt that the Nuclear Regulatory Commission (NRC) determines to be significant from the standpint of public health or safety.

Thz Federal Reports Elimir ation and Sunset Act of 1995 requires that AOs be reported to Congress on an anuual basis. This r: port includes those events that NRC has determined to be AOs during fiscal year 1997.

Thh report addresses two AOs at NRC-licensed facilities. One involved an event at a nuclear power plant, and one involved mattrials overexposure. The report also addresses four Agreement State AOs. Two of these AOs involved overexposures and two involved radiopharma::eutical misadministratons. In adc'ition, Appendix C of the report includes five events of loss of control of lictnsed materials.

L i

l 13 AVALAsurY STATEMENT l 12. M !Y WORDS/DESCRIPTORS (tat urds ar psroese met ad esser reees,chers c hce6ng mo repart) unlimded Nuclear Power Plants; Oconee; Medical; Misadministration; Radiopharmaceutical; Overexposure 14 sECURIrY CEAsSWICATION (Tks Page) unclassified crha Repay unclassified

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16. PRICE NRC FORM 335 Q41il) TNs foem was e.ectronically produced by Elae Federei Forms ins

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