ML20237H753
| ML20237H753 | |
| Person / Time | |
|---|---|
| Issue date: | 10/16/1986 |
| From: | Cunningham R NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | Jonathan Evans NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| Shared Package | |
| ML20237H486 | List: |
| References | |
| FOIA-87-402 NMSS-86-960, NUDOCS 8708170341 | |
| Download: ML20237H753 (3) | |
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... 9 OCT l e 1980 l l
i MEMORANDUM FOR: John D. Evans, Director Planning and Program Analysis Staff 1 FROM: Richard E. Cunningham, Director Division of Fuel Cycle and Material Safety i l
SUBJECT:
NRC SENIOR MANAGEMENT MEETING (NMSS #86-960) ? Below is a list of questions posed in your October 9, 1986, memorandum along ! with the Division of Fuel Cycle and Material Safety's responses: Question 1 How many requirements did NMSS impose upon licensees during l l the past year (FY-86)? l l Answer: New conditions are imposed upon Fuel Cycle licensees j almost every time a license is amended. Enclosed are three examples with the appropriate sections high lighted (Encicsures 1 thru 3). ; i In addition, we circulated a letter dated July 17, 1986 I (Enclosure 4), along with NUREG-1198, the Lessons Lecrned Group (LLG) Report of the Sequoyah Release to thirty-one i licensees. The LLG Report contained 10 recommendations , that affect 12 licensed facilities and 14 recommendations j that affect 31 facilities. The other LLS recommendations l stand to impact licensees in the future. Although no new requirements arose during FY 86, licensees were urged to give early consideration to the LLG recommendations. , Question 2 How many of the requirements have been implemented by the j licensees? puestion3 For how many of the items has implementation been verified by NRC7 Answer 2 and 3: For specific license conditions, our assurance of license l l compliance is derived in the following ways: l
- We communicate with the Regional inspectors notifying l
t them of the new conditions we intend to impose so that the inspectors can verify compliance.
- We emphasize the new conditions verbally and in writing with licensees before issuing the license amendments.
4 p~ information in this record was deleted t c .
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t 02 '" eccere8,ce tt" the rrees m et imre<mu>e# Act, exem tions 5 F0IA. - 402 B708170341 070812 I PDR FOIA 1 POTTERB7-402 PDR
l . - [ ( John D. Evans 2 0C716 1986 i We document the new conditions, both in the license l l itself and/or in the accompanying Safety Evaluation l Reports. With respect to the LLG recommendations, we do not yet know what actions are being taken by' licensees as a result of our urging them to consider the LLG recommendations. However, special team inspections see being conducted at the 12 licensed fuel facilities to review their status with respect to the applicable LLG recommendations and other , operational safety areas. These have been completed for l four facilities during FY-86. (Inspection reports are J available for Sequoyah and Allied, but are not yet available for UNC Naval Products or C. E. Windsor.) q On a closely related subject, Mr. Davis sent a memorandum to Mr. Mausshardt dated October 10, 1986. We think we should provide certain infonnation on some of Mr. Davis' topics. l
- 2. Status of Staff Efforts on Licensee Reporting Issue i The incident involving the recovered gauge formerly licensed with CE Glass has prompted the following NRC actions:
- a. IE developed a manual chapter (which is nearly ready in final form).
, It specifies that all licensees should be contacted annually (on a resource available basis) by telephone if they are not inspected.
In these calls, the Regional staff would check the status of the i programs by administering a short telephone questionnaire. If problems are identified, inspections would he scheduled.
- b. HMSS staff (FCML) is still coordinating with RES and IE regarding initiation of rulemaking to require licensees to report periodically the status of their programs to NRC and/or respond to the questionnaires.
- 3. Tracking of License Implementation of NMSS Requireme'Itl How is it done now? See answers 2 and 3 above.
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l l John D. Evans 3 l OCT 1 S .1986 i
- Population of these items and our knowledge of status of completion -
see Enclosure 6.
- Plans and status of doing this on computer - Already underway, for details see previous responses: NMSS #86 765 and HMSS #86 786 (Enclosure 7).
( OrH ' t aibi Ralph M.Yliid8 0 Richard E. Cunningham, Director Division of Fuel Cycle and Material Safety cc: Mr. Davis Mr. Mausshardt
Enclosures:
As stated i DISTRIBUTION: (NMSS86960) l NMSS R/F FC Central File FC Files RECunningham
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l AE00/f601 l . l l l 1 l l REPORT OH 1985 NONREACTOR EVENTS AND FIVE-YEAR ASSESSMENT FOR 1981-1985 l - by the a Nonreactor Assessment Staff - ( Office for Analysis and Evaluation . ' of Operational Data ) l l l I l Prepared by: Kathleen M. Black This report characterizes the Honreactor Event Report (NRER) database main-tained by the Office for Analysis and Evaluation of Operational Data. This
; report does not contain detailed analyses of individual events, but focuses
. on an attempt to identify potential and actual problem areas, and ad, dress the status of NRC activities in,those areas.
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TABLE OF CONTENTS Page 1
- 1. -INTR 000CTION..................................................
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- 2. THE NONREACTOR EVENT REPORT DATABASE..........................
2
- 3. REVIEW OF 1985 NONREACTOR EVENTS..............................
2 3.1 Ca tegoriza tion of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3.1.1 Radiati on Exposure Events . . . . . . . . . . . . . . . . . . . . . . . . - 9 3.1.2 Lost, Abandoned, and Stolen Material............. 13 3.1.3 Leaki ng or Contami nated Sou rces . . . . . . . . . . . . . . . . . . 15 3.1.4 Release of Materials. ......................'..... 16 3.1.5 Consumer Products................................ 17 3.1.6 Fuel Cycle Facility Event Reports . . . . . . . . . . . . . . . . 18 3.1.7 Radiography...................................... 18 3.1.8 Manufacturing and Distribution................... 20 3.1.9 Gauges / Measuring Systems......................... 22 3.2 Abno rmal Occu rrence s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
- 4. FIVE-YEAR ASSESSMENT FOR NONREACTOR EVENTS FROM 1981-1985.....
24 4.1 Discussion............................................... 24 l 4.2 Nonreactor 0'atabase...................................... ! 27 4.3 Abnormal Occurrences..................................... 33
- 5. AEOD STUDIES OF NONREACTOR " VENTS FROM 1981-1985..............
34
- 6. FINDINGS......................................................
List of Tables: 3 l Table 1 - Type of Licensees that Submitted Reports During 1985 . 4 Table 2 - Categoriza tion of Nonreactor Events. . . . . . . . . . . . . . . . . . . Table 3 - Personnel Radiation Exposure, 1985.................... 7 Table 4 - (Part 1) Lost or Stolen Sources, 1985................ 10 11 (Part 2) Irretrievable Well-Logging Sources, 1985.... 14 Table 5 - Reports of Leaking Sources, 1985..................... 19 Table 6 - Radiography Events, 1985............................. Table 7 - Manufacturing and Distribution Events, 1985.......... 21 Table 8 - Gauges / Measuring Systems Event Reports,19S5......... 23 Table 9 - Frequency of Reports Associated with Particular Areas. 25 Table 10 - Abnormal Occurrences. 1981-1985, Nonreactor Licensees. 28 1 l l W 1e 's
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. f REPORT ON 1985 NONREACTOR EVENTS AND FIVE-YEAR ASSESSMENT FOR 1981-1985 l
- 1. INTRODUCTION The responsibilities of the.0ffice for Analysis and Evaluation of Operational f
Data (AE00) include the maintenance of data bases for the storage and retrieval of operational experience data and the systematic review of. operational' safety l ! data. The Nonreactor Assessment Staff (NAS) prepares periodic reviews J , , current nonreactor data reports to provide an overview of these reports. -'This report contains a review of the 1985 nonreactor events, as w' ell as an assess-ment of the events reported in the five year period from 1981-1985.
- 2. THE NCNREACTOR EVEhT REPORT DATABASE j The AE00 Nonreactor Event Report (NRER) database contains information on licensed nuclear materials and fuel cycle operational events and on personnel.
radiation exposure events. -The NRER database management system
- provides for input, ctorage, retrieval, and computer-assisted analyses of operational event l
l data, and may be used to identify trends in operational safety events which may signal a need for remedial actions by the NRC and/or licensees. j j AE00 generally does not incorporate information on transportation events into the NRER database since the Department of Energy funds a transportation ) l l incident file at Sandia. Their report on Radioactive Material (RAM) Transportation Accident / Incident Analysis (SAND-85-1016) contains information about this database, and summarizes data for the period 1971-1985. l i i
*The NRER database utilizes the System 1022 database management system which operates on the Oak Ridge National Laboratory (ORNL) DEC System-10 computer.
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.l In the past, the NRC's Office of State Programs (SP) collected reports of
.l events at Agreement State licensees and published semiannual reviews of these
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events. The OSP publication was suspended after the review of 1984 events. Agreement States cooperate with the NRC in reporting Abnormal Occurren and OSP is in communication with Agreement States concerning significant events. Beginning in 1985, AEOD began a more extensive effort to enter into the database information forwarded by OSP on significant events at Agreement' State licensees.
- 3. REVIEW OF 1985 NONREACTOR EVENTS -
J l 3.1 Categorization of Events The NRER database includes 170 records of events that occurred during 1985, Information on these events was contained in reports submitted by nonreactor l licensees to the Regional Offices or in other documents, primarily inspection 4 reports. Table 1 provides information on the types of licensees for which The database does not include information was entered into the database. 3 information from certain fuel cycle licensee reports, such as those related to routine effluent releases, nor does it include information from reports of l l medical misadministration.* 1 j Table 2 provides information on how the event information was categorized 1 An NRER datrbase item may be associated with 9 and entered into the database. more than one category of event. For example, a report from a radiography licensee concerning a personnel radiation exposure would be counted in the total number of radiation exposure events as well as in the total number of ]
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events involving radiography. The 170 nonreactor licensee reports were Note that, because some cataloged as 318 entries in nine different areas. reports are associated with more than one event category, the total number l of events exceeds the total number of reports, l
-"The results of AE00 studies of medical misadministration are published elsewhere.
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l e 1 l TABLE 1 j TYPES OF LICENSEES THAT SUBMITTED REPORTS DURING 1985 NUMBER OF LICENSE TYPE REPORTS RECEIVFO* - ACADEMIC 1 !
)
MEDICAL 50 COMMERCIAL / INDUSTRIAL MEASURING SYSTEMS 38 j WEtt LOGGING (23) - OTHER MEASURING SYSTEMS (15) MANUFACTURING AND DISTRIBUTION (EXCLUDING MEDICAL) 17 l INDUSTRIAL RADIOGRAPHY 17 ) SINGLE LOCATION (IN PLANT) (2) { MULTIPLE LOCATIONS (FIELD) (15) l IRRADIATOR 3 R&D 9 SOURCE MATERIALS ** 1 MILLS (1) UF6 FACILITIES (0) OTHER (0) SPECIAL NUCLEAR MATERIAL (INCLUDING PLUTONIUM) 5 AGREEMENT STATE 16 OTHER*** y TOTAL 170 l
- MEDICAL MISADMINISTRATION REPORTS ARE NOT INCLUDED.
** ROUTINE ENVIRONMENTAL EFFLUENT RELEASE REPORTS, E.G. REPORT 3 REQUIRED BY 40.65 AND 70.59 WERE NOT INCLUDED IN THE TOTALS FOR SOURCE AND SPECIAL NUCLEAR MATERIALS LICENSEES.
*** NUMBER INCLUDES REPORTS RECEIVED FOR WHICH NO PROGRAM CODE WAS AVAILABLE.
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i TABLE 2 ] CATEGORIZATION OF NONREACTOR EVENT REPORTS CATEGORY
- NUMBER OF REPORTS ASSOCIATED PRIMARY CATEGORIES: I 34 FERSONNEL RADIATION EXPOSURES LOST, ABANDONED, AND STOLEN MATERIAL 54 29 LEAKING SOURCES
- RELEASE OF MATERIAL 8 l i
S CONSUMER PRODUCTS SECONDARY CATEGORIES: I FUEL CYCLE (E.G., MILLS, UF FACILITIES, 1 6 l SPECIAL NUCLEAR MATERIAL) 6 1
'17 ,
INDUSTRIAL RADIOGRAPHY J g MANUFACTURING AND DISTRIBUTION 36 (INCLUDING FEDICAL) COMMERCIAL / INDUSTRIAL MEASURING SYSTEMS (EXCLUDING WELL LOGGING) IS , OTHER** 115
- TOTAL 319 !
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*AN NRER DATABASE ITEM MAY BE ASSOCIATED WITH MORE THAN ONE CATEGORY O EVENT FOR EXAMPLE, A' REPORT P E 4 A RADIOGRAPHY LICENSEE CONCERNING A
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PERSONNEL RADIATION EXPOSURE WOULO BE COUNTED IN THE TOTAL NUMBER OF RADIATION EXPOSURE EVENTS AS WELL AS IN THE TOTAL NUMBER OF EVENTS INVOLVING RADIOGRAPHY.
**0THER INCLUDES CATEGORIES SUCH AS MEDICAL, TRANSPORTATION, MISCELLANEOUS,
,,.4 ETC.
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J t, certain categories in Table 2 are primary categories; that is, they contain events from all types of licensees. These primary categories are: exposures; lost, abandoned, or stolen material; leaking source's; releases of material; and consumer products. With few exceptions, most events are assigned to only one of the categories. The secondary categories.in Table 2 are designed to capture events by the type l of licensee involved in the event. Many of the events assigned to these categories are also assigned to primary event categories. Secondary categories l generally serve os a measure of the frequency with which certain types of , licensees make reports to the NRC. 3.1.1 Radiation Exposure Events The criteria that define overexposure are defined in 10 CFR 20.205 (a)(1). ! The limits are: Restricted areas: whole body 1-1/4 rem / calendar quarter, or 3 rem / calendar quarter, if the individual's prior occupational exposure is obtained in writing, and the accumulated exposure does not exceed 5 (N-18), where N is the individual's age I extremity 18-3/4 rem / calendar quarter skin 7-1/2 rem / calendar quarter l inhalation 40 MPC hours / week for 13 weeks, MFC (maximum permissible concentration) is given in 10 CFR Appendix B, Table I, Col 1) 10% of above limits minors s Unrestricted areas: individuals 0.5 rem / year, subject to rate limitations (
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9 1 The NRER database contains information from 34 reports of events that occurred ; during 1985 in which there was the potential for, or an actual . radiation overexposure. Of these 34 events, 21 involved actual radiation overexposure. Information on the 34 overexposure reports is provided in Table 3. The types ; of licensees associated with the actual overexposure 3 reported during 1985 were j as follows: ' 1 il Number of Total Number of Licensee Type Overexposure Events Individuals Exposed j Medical / Academic 7 7 . ] i Radiography 9 12 Commercial / Industrial 5 2 Totc1 21 33 1
.I Overexposure at riedicai or Academic Licensees - The seven i reported events at medical and academic licensees included: !
l l three whole body exposcre reports, with exposures of 1.75, 2.0E, and 3.9 rem / quarter; three skin exposures of 8, 23.73 ; and 32 rem / quarter; and an extremity exposure of 20.29 rem / quarter. All of these reports came from different licensees. i l l The extremity exposure of 20.29 rem was attributed to exposure from use of a fluoroscopy device, and was reportable because the ! individual'also worked with radioactive materials. -The 32 rem skin expbsure resulted when an experimenter was contaminated i from spray when a vial was being opened; the 23 rem skin exposure-
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resulted from a contamination accident at a hospital; and the
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3.9 rem whole body dose, although counted as an actual. exposure by the licensee, could not be explained. The other three overexposure represented comparatively small overexposure. None of the overexposure at medical or academic licensees was large. 4
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I TABLE 3 PERSONNEL RADIATION EXPOSURE, 1985 NO TYPE OTHER EVENT LICENSE ACTIVITY ** DATE_ EXP EXPOSURE _ NUMBER
- LOCATION LICENSEE MN 10/01/1985 1 EXTREMITY MAD 3M C0 220005706 ST PAUL WHOLE BODY RAD MIDLAND TX 11/09/1985 1 .
BASIN INDUSTRIAL X-RAY INC AS. ND 3/30/1985 2 WHOLE BODY RAD AS WILLISTON BASIN TESTING LAB WI 4/01/1985 1 WHOLE BODY MDI BELOIT MEMORIAL HOSPITAL 481128102 BELOIT WHOLE BODY RAD MD 2/07/1985 1 BRAND EXAMINATION SERVICES 061715601 FREDERICK EXTREMITY RAD 131634701 BURNS HARBOR IN 6/14/1985 1 WHOLE BODY RAD ', CALUMET TESTING SERVICES 420845602 DALLAS TX 3/01/1985 1-CONSOLIDATED X-RAY -OH 3/30/1985 0 WHOLE BODY RAD , 0AYTON X-RAY C0 340694301 DAYTON BADGE GAU 290088601 DEEPWATER NJ 10/08/1985 0 .,
'E I DUPONT MA 11/18/1985 1 EXTREMITY MAD 200032009 NO BILLRICA E I DUPONT 351619101 LABARGE W 9/26/1985 2 WHOLE BODY RAD RAD ~
EXAM C0 OK 8/01/1985 0 BADGE HOUSTON INSPECTION LAB 352336201 TULSA 451483701 HOPEWELL VA 2/01/1985.1 WHOLE BODY GAU ICI AMERICAS INC CNYANNE WY 10/18/1005 10***WHOLE BODY GAU-JIM BRIDGF.R COAL STATION GL WHOLE BODY M01 521493101 T.,ntAMON PR 5/01/1985 1 JOSE T MEDINA MD EXTREMITY MAD , KAY RAY INC 121118401 .1RLINGTON HTS IL 5/13/1985 1 WHOLE BODY MD1 LUCY LEE HOSPITAL 241665202 POPLAR BLUFF MO 6/07/1985 1 GAU 211872401 FERNDALE HI 5/10/1985 0 BADGE MD1 MCDOWELL & ASSOC. DE 6/28/1985 0 OTHER NANTIC0KE MEMORIAL HOSP 071761801 SEAFORD MD1 071761801 SEAFORD DE 3/14/1985 0 OTHER NANTIC0KE MEMORIAL HOSP 6/21/85 0 EXTREMITY MD1 202122701 NUCLEAR PHARMACY INC 370027625 NEWELL W 4/04/1985 0 EXTREMITY RAD MSC' PITTSBURGH TESTING LAB NJ 5/07/1985 1 SKIN PRINCETON UNIVERSITY 290518524 PRINCETON WHOLE BODY RTR RAD GA 10/06/1985 1 PULLMAN POWER PRODUCTS CORP- 370804201 WAYNESBORO UT 5/12/1985 0 INTERNAL FCI MOA8 RIO ALGOM CORPORATION AR 6/01/1985 0 WHOLE BODY RAD SOUTHWEST X-RAY 032135401 LITTLE ROCK MD1 NJ 1/25/1985 0 RADGE , l ST BARNABAS MEDICAL CENT O 290160803 LIVINGSTON NJ 1/30/1985 1 SKIN M01 -
, ST BARNABAS MEDICAL CENTER 290160803 LIVINGSTON PA 10/08/1985 1 WHOLE BODY RAD TRANS-EASTERN INSPECTION IN 371485501 WASHINGTON NJ 2/01/1985 1 EXTREMITY MD1 VALLEY HOSPITAL 290384501 RIDGEWOOD MD1 CA 6/14/1985 1 SKIN VETERANS ADMINISTRATION 40091604 SEPULVEDA MDI 80360401 WASHINGTON DC 4/01/1985 0 BADGE WASHINGTON HOSPITAL CENTER WY 8/01/1985 2 WHOLE BODY RAD WESTERN STRESS C0 492349001 EVANSTON AS HOUSTON TX 2/11/1985 2 WHOLE BODY RAD l WORLD TECHNICAL SERVICES
^AS AGREEMENT STATE LICENSEE GL GENERAL LICENSEE
** ACTIVITY TO WHICH EXPOSURE VAS ATTRIBUTED FC1 MILLING GAU GAUGE USE MAD MANUFACTURING ~AND DISTRIBUTION MD1 MEDICAL MSC MISCELLAEE005 RAD RADIOGRAPHY
***HO ESTIMATE OF OVEREXPOSURE AVAILABLE.
o f 8-Overexposure at Radiography Licensees
- The nine overexposure events at radiography licensees included one extremity overexposure and eight whole body overexposure. The doses involved in these events were:
extremity exposure 98-288 rem to small part of palm whole body exposures 1.275 rem 2.510 rem 3.26 rem and 4.5 rem (2 individuals) 8 rem ! 15.59 rem
- 8-31 rem and 8 rem (2 individuals) 34 rem and 8 rem (2 individuals)
! 128 rem i Four of the nine radiography events resulted in small overexposure. In the remaining five, the overexposure ranged from moderate (5-25 rem whole body; <375 rem extremity) to large (>25 rem whole body). l The individual who received 128 rem whole body in the overexposure event at Basin Industrial Testing, Midland, TX, also showed evidence, 9 of high extremity dose (blister on hand). The Texas Department of Health, Bureau of Radiation Control, has characterized the activities of this liiEensee as showing a " pattern of violations [that] ultimately lead to an employee being seriously injured by over-exposure to radiation." The radiography events were reported by different licensees. ! However, eight of the nine events, and all of the events in which there were large ov,erexposures occurred during radiography at l remote sites (i.e., not fixed sites). See Section 3.2 below for a discussion of Abnormal Occurrences. Overexposure at Commercial / Industrial Licensees The five overexposure at commercial or industrial licensees consisted of:
- two extremity exposures (19.1 and 19.41 rem / quarter); an over-exposure of 1.76 rem whole body; and an event resulting in a skin exposure (thumb) of 93 , rem. Ten workers worked for 70 hours near an
-l unshielded'500 mci Cs-137 source in an event at the Jim Bridger Cot.1 Station, a general licensee.
The overexposure at these licensees were marginally above the regulatory limits. No data, however, are available on the estimated exposures. In general, with the exception of the overexposure at radiography licensees, .
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most of.the overexposure reported'during 1985 were small. Of the nine reported overexposure of radiographer, three _ resulted in whole body . j
, I overexposure to individuals in excess of 20 rem, with one e, vent resulting in serious injury from rac'iation. .
1 3.1.2 Lost, Abandoned, and Stolen Material Licensees are required to report the loss or theft of licensed material that i has occurred in such quantities and under such circumstances that it, appears to the licensee that a substantial hazard may result to persons in unrestricted l : areas (10 CFR 20.402(a)(1)). The proposed Part 20-specifies activity limits below which written reports need not be made. Irretrievable well-logging sources must be reported pursuant to 10 CFR 30.56 and 70.60. . Fif ty-four events occurred during 1985 that involved. lost, abandoned, or_ sto;en a licensed material. These events are summarized in Table 4. These events consist of 32 reports of lost or stolen material, plut 22 reports of abandoned, irretrievable well-logging sources. Nbne of the 54 events resulted in a known radiation overexposure.*
*An event, not involving U.S. licensed radioactive material, occurred in Morocco. A lost or stolen radiography source is reported to have caused gross overexposure of several members of the public.
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1 t TABLE 4 (Part 1) l LOST OR STOLEN SOURCES, 1985 LICENSE EVENT 150- NUMBER __ DATE DISPOSITION TOPE , LOCATION LICENSEE 31724301 7/15/1985 UNKNOWN AM241 LITTLE ROCK AR MCCLELLAN ENGINEERS INC 8/06/1985 FOUND c 121876001 I AM241 MUNDELEIN IL JOHN MATHES & ASSOC. 8/01/1985 FOUND GL AM241 PLYMOUTH IN DELMONTE CORP LA SCHLUMBERGER 420009003 10/18/1985 FOUND (LOST '79) AM241 GRAND ISLE . AM241 TROY MI TESTING ENGINEERS & CONSULT GL 211866801 2/28/1985 11/16/1985 UNK UNKNOWN AM241 NEENAH WI AMERICAN CAN CO 6/27/1985 FOUND WY CENTENNIAL ENGINEERING, INC 491971101 AM241 CASPER 341886801 7/15/1985 UNKNOWN C057 CINCINNATI OH OTTO C EPP MEM HOSPITAL 10286105 1/25/1985 FOUND C060 FT MCCLELLAN AL DEPT OF ARMY AS 5/01/1985 UNKNOWN CS137 OPELIKA AL UNIRnYAL TIRE CO 9/26/1985 UNKNOWN 240226103 CS137 ST LUUIS M0 MC00NNELL DOUGLAS 9/10/1985 UNKNOWN OH BOWSER-MORNER TESTING LAB 341739001 CS137 DAYTON AS 2/13/1985 FOUND , CS137 GRAHAM TX SCHLUMBERGER i 61302202 1/22/1985 UNKNOWN H3 FARMINGTON CT UNIV 0F CONN 7/22/1985 UNKNOWN i AS H3 CHAPEL HILL NC UNIV 0F NORTH CAROLINA 2/20/1985 FOUND 121283601 i 1125 ARLINGTON HTS IL AMERSHAM CORP 370338702 3/18/1985 UNKNOWN I125 ALTOONA PA MERCY HOSPITAL ! 370086510 4/12/1985 COMM. WASTE DISP. 1125 PITTS8URGH PA MONTEFIORE HOSPITAL 290013904 9/18/1985 UNKNOWN 1131 NEW BRUNSWICK NJ C R SQUIBB & SONS INC 370187301 8/28/1985 COMM. WASTE DISP. 1131 J3HNSTOWN PA CONEMAUGH VALLEY HOSPITAL 41503061 5/01/1985 UNKNOWN IR192 SAN DIEGO CA VETERANS ADMIN MED CTR. 340025506 1/03/1985 FOUND KR85 BRUSSELS ACCURAY CORP 290102211 1/07/1985 UNKNOWN KR85 FT S HOUSTON TX DEPT OF ARMY 80597002 8/17/1985 OTHER* PM147 LIT 1LE CREEK VA DEPT OF NAVY AS/GL 7/29/1985 UNK!!OWN P0210 WAHPETON ND 3M CO
, 6/17/1985 UNKNOWN PU239 LEXINGTON KY DEPT OF ARMY 340304303 4/02/1985 COMM. WASTE DISP.
SNM ALLIANCE OH BABC0CK & WILCOX 422353901 9/23/1985 OTHER** CHUGACH AK OEPT OF ARMY SR90 MI SYNCOR INTERNATIONAL CORP 211921901 4/10/1985 *** TC99M GRAND RAPIOS 6/30/1985 UNKNOWN U235 SAN DIEGO CA G A TECHNOLOGIES INC 290811303 9/01/1985 COMM. WASTE DISP. t XE133 LONG BRANCH NJ MONMOUTH MEDICAL CTR 200074218 9/27/1985 COMM. WASTE DISP. Y BOSTON MA BETH ISRAEL HOSP
- LOST IN CHESAPEAKE BAY
** LOST IN EAGLE RIVER GLALIER, CHUGACH STATE PARK, AK
*** THEFT OF BRIEFCASE CONTAINING RADI0 PHARMACEUTICALS; SYRINGES CRltril BY TRAFFIC, CONTAMINATING ROAD
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l l TABLE 4 (Part 2) IRRETRIEVABLE WELL-LOGGING SOURCES, 1985 LICENSE EVENT _, ISO- DATE LICENSEE NUMBER __ TOPE LOCATION DRESSER INDUSTRIES 420296401. 2/14/1985 AM241* 420645803 10/18/1985 AM241* OFFSHORE GEARHART OWEN INDUSTRIES GEARHART OWEN INDUSTRIES 420645803 2/21/1985 .) AM241* 0FFSHORE 420009003 1/13/1985 i AM241* OFFSHORE SCHLUMBERGER SCHLUMBERGER 420009003 2/19/1985 - AM241* OFFSHORE 420009003 3/21/1985-AM241* OFFSNORE SCHLUMBERGER . LA GEARHART OWEN INDUSTRIES . 420645803 10/06/1985 AM241* 0FFSHORE 420009003 7/17/1985 i AM241* OFFSHORE AM241* CUSTER CTY LA SCHLUMBERGER OK DRESSER INDUSTRIES- 420296401 8/16/1985 l OK GEARHART OWEN INDUSTRIES- 420645803 2/26/1985 l AM241* MCCLAIN CTY OK GEARHART OWEN INDUSTRIES 420645803- 5/18/1985 AM241* -CUSTER CTY 6/02/1985 OK GEARHART OWEN INDUSTRIES 420645803 . l AM241* TEXAS CNTY 3/11/1985 l TX DRESSER INDUSTRIES 420296401 AM241* OFFSHORE i TX SCHLUMBERGER 420009003 11/12/1985 , AM241* OFFSHORE ( i AM241* CAMPBELL CTY WY GEARHART OWEN INDUSTRIES 420645803 1/29/1985 l 0FFSHORE CONOC0 INC 420296401 4/27/1985 I CS137 SCHLUMBERGER 420009003 6/20/1985 CS137 LA DRESSER INDRUSTRIES 420296401 6/26/1985 l'
- CS137 420296401 8/03/1985 CS137 0FFSHORE LA DRESSER INDUSTRIES PITTSBURG OK DRESSER INDUSTRIES 420296401 8/07/1985 CS137 CS137 CIMMARON CTY- OK GEARHART OWEN INDUSTRIES 420645803 11/09/1985 WIRT CTY WV YOUNG WIRELINE 472535101 5/05/1985 CS137 I
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*IN MOST CASES, A CS137 SOURCE WAS LOST WITH THE AM241 SOURCE.
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1 12 - Of the 32 reports of lost or stolen material, 9 corr.e.ned nuclear gauges,. oneconcernedstaticeliminatorbars,and22mateEialinotherforms. Of the nine missing gauges, five were portable gauges stolen from vehicles or construction trailers;'of the five, two were found undamaged. Of the remaining, ! four events involving lost gauges, one involved the loss by the U.S. Navy'of a gauge in the Chesapeake Bay; and three, the loss of fixed gauges. In one of the latter event <s, a generally licensed gauge' containing 200 mci of Am-241, was found at' a scrap yard (Delinonte Corp.). In another event, four gauges. I containing Cs-137 sources licensed by Alabama were reported missing by Uniroyal . [ Tire Co; One was recovered. During an attempt to find the other three' gauges .
]
an overflight to monitor the area identified Cs-137 contamination at a pipe.and . j j !- founcry company, however, no positive evidence' traces the' lost gauges to.the foundry. No information is available on the third event. The event involving f j static elia.inator bars covered three bars that were gencrally licensed l materi al . .I ' l The remainir.g 22 events concerned material that was not in the form of a l l pauge source. Six involved very small amounts of radioactivity. (If the
' criteria the proposed 10 CFR Part 10 were applied to the six, they would not hav* m n reportable.) In five, the material was found;-in four, the
?
materie. ss probably sent to commercial waste disposal; in one,' stolen ) syringes containing radiopharmaceutical doses were run over by a vehicle,- ; resulting in local contamination of a road by technetium-99m; and in one,.a j
< helicopter crash resulted in the loss of strontium-90 sources (five sources of 100 mci each) on the Eagle River glacier in Alaska, where recovery was not possible.
.l Of the other five events involving lost material, three of the five involved iodine or iridium-192 seeds that were lost by hospitals; one involved the improper disposal, over a 30-year period of a.very large number of metal-bars,-
each one of which contained a small; amount (about 100 uCI) of Cs-137; and in one. event, tne Department of Army r6orted that a calibration set containing ., 23 ug (approxine.tely 1.5 uCi) Pu-239' was lost between Korea and Kentucky.' t f f i 9 a e g.
r I l' l Abandoned Well-Logging Sources - NRC licensees are required to report the location of abandoned well-logging sources to NRC.' The 22 events shown in Table 4 (Part 2) did not result in any known releases. 3.1. 3 Leaking or Contaminated Sources Certain licensees are required to lea'k test sources and to-report leaking
~
l sources under 10 CFR 34.25; others are required to leak test sources and to l report leaking sources as a license condition. In both cases, a removable. , contamination exceeding the most common test limit for removable' contamination . (0.005 uCi) is considered evidence of leakage, and must' be reported to NRC. Twenty-nine events of leaking or contaminated sources occurred during 1985. Information from the reports is included in Table 5. None of the events resulted in a radiation overexposure. The isotopic sources found to be leaking or contaminated contained americium, cesium, iodine, or nickel. About half of the 29 events were reports of small, individual sources found to f i l be leaking or contaminated. Two source leakage events were attributed.to-damage to the source during use. In an additional 13, there was some evidence of a manufacturing or use problem. l l
-- Five reports, four from Beta Diagnostics, and one fron. AECL
- concerned the leakage of I-125 sources used in medical procedures.
-- Two events concerned leaking Ir-192 radiography sources shipped from Gamma Industries occurred in 1985. Following one event, Gamma Industries committed to bubble testing all sources. .
-- Two reports of leak tests of ion chambers containing Am-241 were received from the Air Force. AE00 had performed an engineering evaluation of similar sources found to be leaking in prior years. These sources were installed in missile silos and may have been exposed to corrosive atmospheres. In addition, the specific manufacturing process used to hold the source in
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TABLE 5 REPORTS OF LEAKING SOURCES, 1985 l LICENSE EVENT ! 150- NUMBER DATE MANUFACTURER i TOPE LOCATION LICENSEE ! 151381201 1/08/1985 l AM241 LITTLE ROCK AR DEPT OF AIR FORCE I KS DEPT OF AIR FORCE 151381201 11/14/1985 1 ! AM241 MCCONNELL 1/27/1985 AMERSHAM TRC AM241 ST LOUIS M0 WASHINGTON UNIV SCH OF MED 240016711 ) PA SUN C0 370827503 11/13/1985 AM241 MARCUS HOOK 5/01/1985 AM241 FT WORTH TX PENGO INDUSTRIES 421967101 ] OUACHITA BAPTIST UNIVERSITY AS 5/14/1985 CS137 6/05/1985 AR AGREEMENT STATE LICENSEE AS CS137 2/28/1985 121118401 l CS137 ARLINGTON HTS IL KAY RAY 1/17/1985 3M j IL UNIVERSITY OF ILLIN0IS 120008806 CS137 CHICAGO 8/29/1985 j M0 DEPT OF AGRICULTURE 190091506 CS137 BELTSVILLE 9/01/1985 i NC TROXLER ELECTRONIC LAB AS CS137 OH PERFECTION SERVICES INC 341630501 5/01/1985 GULF NUCLEAR CSV-898 I ' CS137 STONE CREEK 6/06/1985 ANDOVER MA ANALYTIC MARKETING, INC. 201984202 FESS C0 UNIV 0F COLORADO 62080402 10/07/1985 BRANDHURST [ H3 j ON ATOMIC ENERGY OF CANADA LTD 482439501 4/15/1985 I125 KANATA 4/15/1985 WI BETA DIAGNOSTICS 482439501 i I125 FT ATKINSON 4/24/1985 AECL C-235 l WI BETA DIAGNOSTICS 482439501 I125 FT ATKINSON S/06/1985 j FT ATKINSON WI BETA DIAGNOSTICS 482439501 1125 WI NORLAND CORP 481340302 4/16/1985 I125 FT ATKINSON 2/21/1985 GAMMA IND l e IR192 CT STONE & WEBSTER 600560002 WA DEPT OF NAVY 460307801 3/06/1985 GAMMA IND IR192 BREMERTON CINCINNATI OH OHMART 340063903 4/03/1985 3M 3E40 KR85 j PA HEWLETT PACKARD 370700202 5/23/1985 NI63 AVONDALE ' NI63 DALLAS TX DEPT OF HEALTH & HUMAN SERV 420976402 8/22/1985 NV U S ENVIRONMENTAL PROT AGEN 70586101 2/14/1985 4 NI63 LAS VEGAS i PM147 CHICAGO IL MAGNAFLUX 120062209 4/13/1985 IL MAGNAFLUX 120062209 4/11/1985 TL204 CHICAGO 7* ST PAUL MN MINNESOTA MINING & MANUFACT 220005706 4/08/1985 CINCINNATI OH CHRIST HOSPITAL 340383102 5/31/1985 Z
*Z = UNSPECIFIED l
s. l e-
n 1 . 1 place in the ion chamber may have contributed to the failure, The use of the sources is to be phased out by 1987, f so that no action by the NRC appears necessary. l Two reports in Table 5 concern the same event. Ohmart l discovered two leaking Kr-85 sources manufactured by 3M; the same event was discussed in an Inspection Report of 3M. The cause of the leakage was attributed to failure of a brazed seal; 3M has replaced the brazing process with laser welding. I l Ohmart committed to recclling all gauges (12) containing the - 3M krypton source. . Perfection Services reported that a large (2 Ci) Cs-137 i source was found leaking. The leakage was attributed to I a bubble on the inner weld. 1 Kay Ray reported that it found that a number of small,10 uCi Cs-137 sources were leaking. The type of source purchased was going to be changed, in an attempt to eliminate the problem. l The brief overview of-the leaking or contaminated source reports presented above shows that generic (or potentially generic) problems that have arisen to l date have been corrected by the manufacturer to eliminate or detect the leakage before distribution. Thus, no additional action by the NRC appears to be warranted. 3.1.4 Release of Materials [ Eight events occurred in 1985 that involved the release of materials: l I I I l p l Tr-99m generat' ors were accidentally incinerated in two events. j Neither event resulted in contamination outside of the licensee facility. Contaminated waste was accidentally incinerated.
. l l
- l
l l I
-- A fire at a facility that possessed material under a general license resulted in the destruction of two Po-210 static eliminator sources and damage to an Am-241 source.
I
-- A fire at an Army base in Korea resulted in contamination of ;
1 a building and the area around it by Pm-147 microspheres (3 mci). Three laboratories were contaminated when Os-185 and 191 l (2 mci) vaporized.
-- A small amount of UF was released when a valve -on an empty 6
l l cylinder was opened. Concentrations of uranium were less than 10 CFR Part 20 limits; calculated exposures at the site boune'.ry were less than 0.5 mrem. (NFS Erwin)
-- Cs-137 contamination was founo in fly-ash in a steel company j baghouse. A gauge containing 200-500 mci Cs-137 may have been melted with scrip steel. The licensee was unaware of the event r until a toxic waste shipment from the mill was found to be
~
contaminated. This event resulted in substantial cleanJp costs. (See Secton 3.1.5 also.) No data are available on the extent of contamination resulting from the two S events involving fires. The contamination resulting from the other events was limited. 3.1.5 Consumer Products An additional category, " consumer products," was defined for the database in 1985. These reports describe events in which radioactive material was found j in, or had a reasonable probability for being introduced into, nonlicensed consumer products. Five reports of this nature were received in 1985: A gauge originally owned by Del Monte Corporation was discovered at a scrap yard. No contaminav.icn resulted from this event. L
_ 17 3
-- Steel originating in Brazil was found (by Florida) to be contam--
inated by Co-60. Calculations showed co'ntamination levels of no l l more than 0.03% of.MPC could result if the contaminated steel lf4 pipe is used in drinking water systems. . Toxic waste .from a California . steel' manufacturer was discovered - to be contaminated with Cs-137. Investigation showed that< , l fly-ash in the baghouse was also contaminated. It is probable d L- that a gauge containing 200-500 mci Cs-137 was melted with lI i scrap steel. . 1 l 1 A Cs-137 gauge licensed by' Alabama was found at a scrap yard j j -(three others were still missing). 1 1 i I
-- In an overflight made in an attempt to find the above three 1 1 missing gauges, low level Cs-137 contamination was discovered at U.S. Pipe and Foundry in Bessemer, AL. ]
l All of the above events concerned the possibility of introducing radioactivity into a steel process. This is a frequent source of contaminating consumer products, but is not-the only source. Other consumer products have been known to become contaminated by leaking sources used as process monitors. In two l cases, gauges were found before they were melted. In the case of the Co'60 - l l contaminated steel, the contamination level was so low that overexposure 5 l would not result from its use. The State of California is conducting an l investigation of the Cs-137 gauge melting event. No information is available: j
' on the Alabama' events from which to assess their significance.
- I 3.1. 6 Fuel Cycle Facility Event Reports
- l l^
Reports on six events were received from fuel cycle licensees during 1985: .;
*NRER database does not include information from fuel. cyc1c licensee reports. i of routine effluant releases. .
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-- Two events occurred at NFS Erwin. In the.first, the top of an 11-liter cylinder containing concentrated uranium solution blew q off, permitting six to eight liters to escape. To avoid the 'l problem .in the future, NFS is adding instrumentation to the process y that generates the solution. In the second, uranium hexafluoride was released from'an " empty" cylinder when a valve was opened. .l The releases did not exceed regulatory limits, and the calculated- l J
exposure at the site boundary was 0.5 mrem.
-- One event invol'ved a worker at a uranium mill being exposed to 1 108 MPC-hours in one week.
-- Three events involved waste shipments. Two involved one shipment each from different fuel fabricators, where the shipping drums had holes in them. The other involved a waste shipment from a third licensee which contained partially solidified waste.
None of these events appeared to be significant, given the corrective actions taken, the potential for public health and safety consequences; and the-generic concerns. .. 3.1.7 Radiography Seventeen 1985 events involved radiograpF/. Two (2) of the events occur _edr at a fixed radiography site'and 15 occurred at remote (field) radiography sites. Information on the reported events is included in Table 6. Thirteen of the reports concerned overexposure or potential overexposure events tand have been listed in Table 3. The number of radiography events (17) does not differ substantially from the number of events reported during prior years. 3.1.8 Manufacturing and Distribution Those 1985 events were identified as being associated with manufacturing and distribution from the program code of the licensee. These licensees have no unique reporting requirements for events involving health and safety, unless the requirements are incorporated into af license condition or an order w E&
i l l
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TABLE 6 RADIOGRAPHY EVENTS, 1985 l EVENT TYPE 150- EVENT
- LICENSEE DATE l TOPE LOCATION C060 PHILLIPSBERG NJ INGERSOLL-RAND C0 4/15/1985 TRS IR192 CT STONE & VEBSTER 2/21/1985 LKS i
IR192 WAYNESBOR0 GA PULLMAN POWER PRODUCTS CORP 10/06/1985 EXP RTR l IR192 BURNS HARBOR IN CALUMET TESTING SERVICES 6/14/1985 EXP IR192 FREDERICK MD BRAND EXAMINATION SERVICES 2/07/1985 EXP IR192 WILLISTON ND BASIN TESTING LAB 3/30/1985 EXP IR192 TULSA OK HOUSTON INSPECTION LAB 8/01/1985 ** IR192 WASHINGTON PA TRANS-EASTERN INSPECTION 10/08/1985 EXP . TX BASIN INDUSTRIAL X-RAY INC 11/09/1985 EXP IR192 MIDLAND l IR192 BREMERTON WA DEPT OF NAVY 3/06/1985 LKS ' IR192 NEWELL WV PITTSBURGH TESTING LAB 4/04/1985 EXP IR192 LABARGE WY EXAM CO 9/26/1985 EX? IR192 EVANSTON WY WESTERN STRESS CO 8/01/1985 EXP Z LITTLE ROCK AR SOUTHWEST X-RAY 6/01/1985 l Z DAYTON OH DAYTON X-RAY C0 3/30/1985 Z TULSA OK UNITFD INSPECTION 1/16/1985 MSC ! Z DALLAS TX CONSOLIDATED X-RAY 3/01/1985 EXP l
-
- TYPE EVENT: ..
EXP EXPOSURE LKS LEAKING SOURCE MSC MISCELLANEOUS RTR REACTOR S TRS TRANSPORTATION
**NO OVEREXPOSURE e
o
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I l ! Thirty-six events occurring during 1985 involved the manufacturing and d!stri- ! bution of byproduct material. Information from the. reports is included in Table 7. 4 One event in Table 7 was significant from the point of view of presenting a l possible threat to public safety. The John C. Haynes Company, holding a ; i manufacturing and distribution license, sas the focus of extensive NRC 1 activities in March 1985. Mr. John C. Haynes, doing business as John C. Haynes Company, was arrested by FBI agents for illegal possession and ese of l radioactive material and for making material false statements to the NRC. Ten j to 14 curies of americium were seized. In April, NRC ordered Mr. Haynes to l provide access to his laboratory for cleanup and removal of contaminated j equipment. NRC and EPA initiated a cleanup of areas of significant contami- ? nation in the laboratory and surrounding areas using moneys (up to $150,000) from the EPA Superfund. l 1 As early as 1981, NRC modified the John C. Haynes Company license to limit l I activities to storage or.ly, and in 1984, a Show Cause Order was issued l requiring-Mr. Haynes to submit a decontamination plan for his facility. (He l responded that he was financially unable to undertake the cleanup.) A February l 1 j 1985 allegation that Mr. Haynes possessed significant amounts of americium and was continuing to use radioactive materials led to the March and April l interventions by NRC and other Government agencies. l l 3.1.9 Gauges / Measuring Systems I Holders of specific licenses to possess gauges are required to report failures of, or dartage to, shielding, on/off mechanisms, or indicators of the gauge, or ! detection of removable contamination on the gauge. In addition, these : licensees must make reports required pursuant to 10 CFR Part 20 (lost, or . stolen materials, releases of material, etc.). Gauge licensees that submitted f reports of events occurring in 1985 were identified by the program codes of the i licensee. l i l
i 1 i TABLE 7 MANUFACTURING AND DISTRIBUTION EVENTS, 1985 EVENT TYPE < 150- LICENSE TOPE LOCATION LICENSEE NUMBER DATE _ EVENT
- AM241 NEWARK OH JOHN C HAYNES COMPANY 341377401 4/05/1985 MSC
! C14 NO BILLRICA MA E I DUPONT 200032009 11/16/1985 EXP i CS137 ARLINGTON HTS IL KAY RAY, INC 121118401 2/28/1985 LKS l I CS137 ARLINGTCN HTS IL KAY RAY, INC 121118401 5/13/1985 EXP
'CS137 ST PAUL MN 3M CD 220005706 10/01/1985 EXP H3 C0 UNIV 0F COLORADO 062080402 10/07/1985 LK$ '
1125 ARLINTON HTS IL AMERSHAM CORP 121283601 2/20/1985 LAS I125 KANATA ON AT014IC ENERGY OF CAN LTD 482439501 4/15/1985 L%S . 1125 G ATKINSON WI BETA DIAGNOSTICS 482433501 4/15/1985 LKS 1125 tT ATKINSON WI BETA DIAGNOSTICS 482439501 4/24/2985 LKS l 1125 FT ATKINSON WI BETA DIAGNOSTICS 482439501 5/06/1985 LKS 1131 NEW BRUNSWICK NJ E R 50VIBB & SON INC 290013904 9/18/1985 LAS KR81M PHILADELPHIA PA NUCLEAR PHARMACY INC 371846106 1/14/1985 TRS KR85 BRUSSELS ACCURAY CORP 340025506 1/03/1985 TRS LAS KR85 CINCINNATI OH OHMART 340063903 4/03/1985 LKS i XR85 FT 5. HOUSTON TX .0EPT OF ARMY !?90102211 1/07/1985 LAS l NI63 AVONDALE PA HEWLETT PACKAk0 370700202 5/23/1985 LES PM147 CHICAGO IL MAGNAFLUX 120062209 4/13/1985 LKS TC99M WOBURN MA NUCLEAR PHARMACY INC 202122701 9/13/1985 MD1 TC99M GRAND RAPIDS MI SYNCDR INTERNATIONAL CORP 211921901 4/10/1985 LAS
, TC99H HARRISBURG PA NUCLEAR PHARMACY INC 371846101 1/07/1985 TRE TL UsNCASTER PA NUCLEAR PHARMACY INC 371958601 4/10/1985 MSC l
TL201 PHILADELPHIA PA NUCLEAR PHARMACY INC 371846101 1/25/1985 MSC TC99M PHILADELPHIA EA NUCLEAR PHARMACY INC 371846101 1/07/1985 MSC TC99M PHILADELPHIA PA NUCLEAR PHARMACY INC 371758601 3/21/1985 MSC TC99M PHILADELPHIA PA NUCLEAR PHARMACY INC 371846101 4/03/1985 MDI TL204 CHICAGO IL MAGNAFLUX 120062209 4/11/1985 LKS Y BOSTON MA NUCLEAR PHARMACY INC 202122701 5/18/1985 M01 i Y LEBANON PA NUCLEAR PHARMACY INC 371958601 1/29/1985 TRS 2 ARLINGTON HTS IL KAY RAY INC 121118401 6/01/1985 EXP Z WOBURN MA NUCLEAR PHARMACY INC 290013902 5/03/1985 MSC Z BOSTON MA NUCLEAR PHARMACY INC 202122701 7/02/1985 MSC Z BOSTON MA NUCLEAR PHARMACY INC 202122701 10/07/1985 MSC Z BOSTON MA NUCLEAR PHARMACY INC 202122701 10/18/1965 MSC Z ORANGE NJ NUCLEAR PHARMACY INC 29196U801 10/14/1985 MSC Z PHILADELPHIA PA NUCLEAR PHARMACY INC 371846101 6/14/1985 M01
- TYPE OF EVENT EXP EXPOSURE LKS LEAKING SOURCE 3 LAS LOST, ABANDONED, STOLLN MATERIAL M01 MEDICAL MSC MISCELLANEOUS TRS TRANSPORTATION
- - - - ----s--------. - - ---J
t i 22 - I - Fifteen events during 1985 were received from gauge licensees. Information L from the reports is included in Table 8. Most of the 15 reports of 1985 gauge events also represent events reviewed in other sec'tions of this report: exposures (3.1.1), lost or stolen sources (3.1.2), leaking sources (3.1.3), and release of materials (3.1.4). Only one event in the table has not been listed in prior tables--an event ! l (Herbert Rimby, Inc.) in which a portable gauge manufactured by Troxler was run ! over by a paving roller. Although the gauge was damaged, the source was not (i.e., no radioactive material was released). There were no reports of failure of, or damage to, shielding; on/off mechanisms of gauge indicators during 1985. .
. i l
3.2 Abnormal Occurrences Abnormal Occurrences (A0s) are unscheduled incidents or events which the ! Commission determines are significant from the standpoint of public health or j safety. They may be individual incidents, recurring events, generic concerns, l or a series of incidents involving: )l I Moderate exposure to, or release of, radioactive material ) l licensed by or otherwise regulated by the Commission; Major degradation of essential safety-related equipment; or Major deficiencies in design, construction, use of, or management controls for licensed facilities or materisl. In the first three quarters of 1985, there were eight nonreactor events classified as A0s: Four events involved overexposure of radiographer or radiographer' assistants; One event involved the overexposure of an employee at a manufacturer, Gulf Nuclear; e6 e-u--_ ~ . --- --_ n----- - -a - - - - - - - - - - . - - - . -- .c
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23 - TABLE 8-1 GAUGES / MEASURING SYSTEMS EVENT REPORTS, 1985 . l i-
' LICENSE . EVENT TYPE' 150- DATE EVENT
- TOPE LOCATION LICENSEE NUMBER _
AM241 LITTLE ROCK- AR MCCLELLAN ENGINEERS INC 31724301 7/15/1985 (AS
-AM241 LITTLE ROCK- AR.. DEPT 0F AIR FORCE: 151381201 '1/08/1985 LKS:
AM241 MCCONNELL -KS ' DEPT OF AIR' FORCE 151381201 11/14/1985 LKS AM241 TROY- MI TESTING ENGINEERS & CONSET 211866801. 11/16/1985 LAS
~AM241 . PIKE CTY . PA HEP 8ERT RIMBY,'INC :371846301 10/22/1985 MSC AM241 MARCUS HOOK PA SUN CO 370827503 11/13/1985 LKS
'AM241 CASPER .W CENTENNIAL ENGINEERING, INC 491971101 6/27/1985 LAS CS137 -MUNDELEIN It iJOHN MATHES & ASSOC. . 121876001 8/06/1985 LAS- . . '
CS137 DAYTON OH BOWSER-MORNER TESTING LAB 341739001 i NI63 DALLAS- TX DEPT OF HEALTH & HUMAN SERV ' 420976402' :9/10/1985 LAS 8/22/1985'LKS' PH147' . DEPT OF ARMY, 120072207 6/21/1985 MSC RLM PM147 LITTLE CREEK VA DEPT OF NAVY . .80597002 8/17/1985.LAS Z FERNDALE MI MCDOWELL & ASSOC. .211872401 5/10/1985 EXP Z BAYAMON PR JOSE T MEDINA MD 521493101- 5/01/1985 EXP-l Z HOPEWELL VA ICI AMERICAS INC 451483701' 2/01/1985 EXP l
- TYPE EVENT-EXP EXPOS'JRE LAS LOST, ABANDONED,-STOLEN MATERIAL LKS LEAKING SOURCE' MSC MISCELLANEOUS ~
RLM RELEASE OF MATERIAL d 88 6 6 w e
1
-- bae event involved unlawful possession of radioactive material by John C. Haynes Co.;
-- One event involved the breakdown of management controls'at j
i Pittsburgh Testing Laboratory, a-radiography licensee; and
-- One event involved the loss of a large (1.5 Ci Cs-137) well-logging ;
source from a Schlumberger Well Services facility. The source sas recovered atiut two months after it was lost. Of the eight events, six were reported by the licensees. The A0s at Pittsburgh . Testing at.d John C. Haynes resulted from NRC inspections of the facilities. l I t ! Because A06 are sometimes found months after they have occurred, two of the ; 1985 A0s involving radiography overe.xposures actually occurred during 1984. ] 4 The four radiography A0s resulted in estimated exposures of 2000 rem to the palm; 1320 rem to the hand; 8 and 34 rem whole body to two individuals; and 8-31 rad and 15 rad whole body to two individuals. j
' The majority of nonreactor A0s for 1985, in terms of numbers as well as potential health effects, resulted from radiography operations.
- 4. FIVE-YEAR ASSESSMENT FOR NONREACTOR EVENTS FROM 1981-1985
- 4.1 Discussion AECD began accumulating information on nonreactor events in 1980, and has a (computer retrievable database of nonreactor events that occurred in 1981 and l
iater. An overview of the nonreactor events that occurred over the past five years is presented below. 4.2 Nonreactor Database , F l The reports in the nonreactor database were reviewed to determine whether any trends in the number or type of events were apparent. Table 9 shows informa-9e l , . . _ . . _..
i s <*e f *>i NQ'p%.pheog N;%pDdN* Ped ***t***st ? * %*l* %EN. - Maw * ***b a* * **
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TABLE 9 FREQUENCY OF REPORTS ASSOCIATED WITH. PARTICULAR AREAS (1981-1985) 1985 i 1981 1982 1983 1984 ITEM ! NUMBER OF REPORTS: 191 217 193 184 170 TOTAL 20 38 44 19 8 FUEL CYCLE 162 l OTHER 171 179 149 165
*b TYPE OF REPORTS:
EXPOSURE - 66 53 42 39 34 j l :l 25 21 13 29 24 ACTUAL BADGE 41 32 29 10 10 { , i 18 40 27 39 31 LOST / STOLEN MATERIAL 1 17 22 26 22 ABANDONED (W/L) SOURCES LEAKING SOURCES 15 17 9 15 29 i RADIOGRAPHY 24 31 24 18 17 MANUFACTURING & DISTRIBUTION 11 28 13 37 36 GAUGES 24 33 25 24 16
.,4 4
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1 . y,.. .
~
i tion on the total number of reports by year, as well as a. breakdown by type of I report by year. . Total Number of Reports - Although the total number of reports appears to show a downward trend from 217 in 1982 to 170 in 1985, a ! breakdown of reports by the type of licensee shows this decrease . could be due to the number. V reports from fuel cycle facilities (mills SNM licensees) beine; entered into the system, since there .l were fewer mills operating in 1985 than in 1981. The number of reports from licensees other than fuel cycle licensees ranged between 149 and 179, with no apparent secular trend. - Exposure Reports - The total number of reports' of actual over-exposures (those exceeding-regulatory limits) does not show any I secular trend. The number of real exposures annually varied from 13 to 29, with an average of 22. . Badge exposure or events in which there was no overexposure ranged from 41 to 10, with fewer eveits. being entered into the database in recent years.
- Radiography Reports - The number of radiography reports per year was comparatively constant, ranging from 17 to 24, except during 1982 when the number of reports / rose to 31. u Other Reports - The numerical distribution of other categories ,
of reports is also given in the table. Lost or stolen material reports varied annually, generally totaling 30 to 40; reports of i I abandoned well-logging. sources also showed some annual variation, L ranging from 17 to 26. The low number of abandoned well-logging sources. reported in 1981 probably resulted from' incomplete records for 1981. I A statistical analysis of the data in Table 9 did not reveal any trend in the number of events with time.
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l ~ 27 - < l i 4.3 Abnormal Occurrences, Over the period from 1981 to the third quarter of' 1985, there were 37 non-reactor events that were classified as A0s. Table 10 lists information on each of the A0s. It can be seen that exposure events'(19).were the most numerous of
'the events, with most of the exposure events occurring at radiography licensees.
Overexposure Events - As noted above, the largest category of abnormal events at nonreactor licensees over the time period from 1981-1985 was that of overexposure events. A total of ten events . occurred at NRC ifcensees and nine at Agreement St, ate licensees over the five year period. These events'have involved radiographer, other licensees, and members of the public. NRC Licensee Radiography Overexposure - There were three over-exposures to radiography personnel over the five year time period that were classified as A0s: 4
-- The employee of a consultant hired to assist in t'le recovery of a disconnected radiography source received en extremity expe,sure of 650-1100 rem. The direct cause of the overexposure was failure to perform an adequate survey.
-- A radiographer received an extremity exposure of 3400 rem from an X-ray unit at a site. (Although HRC does not regulate X-ray equipment, the. radiographer worked with NRC licensed material during the quarter and received 3.1 rem whole body from the X-ray' device-and the licensed material.) The principal causes were failure to install the required radiation alarm and the absence of an interlock on the door to the room containing the X-ray unit and radiography.
equipment. m E' -.
I . \ TABLE 10 i ! ABNORMAL OCCURRENCES, 198.1-1985 NONREACTOR LICENSEES YEAR AONO LICENSEE NAME TYPE OF EVENT TYPE OF LICENSEE ! 811 8102 AUTOMATION IND EXP MAD 813 8105 EVELETH EXPANSION C0' EXP GAU , l RAD I 813 8106 MUSTANG SERVICES EXP ANALYTIC INSP EXP RAD 813 AS8102 823 8206 CONSOLIDATION C0AL RLM WLO 831 AS8306 AUBURN STEEL CO CON GAU 831 AS8301 BROWN UNIV CTM ACA' , 831 AS8302 GEAR-TEX WELL SERV LAS WLO . l l 831 AS8303 HUYTECH CORP LAS- GAU 831 AS8304 DRESSER ATLAS CORP LAS WLO 831 AS8305 MAGNAFLUX CORP LAS RAD 832 AS8307 BAYOU TESTERS EXP RAD 832 AS8308 GEARHART IND LAS WLO 832 AS8309 GULF NUCLEAR INC RLM MAD EXP RAD l 833 8310 AUTOMATION IND 833 8308 NUCLEAR METALS INC EXP FC1 833 8311 KAY RAY INC EXP MAD 833 8309 AM TESTING LABS MFS GAU , MAD i f 833 8313 SHELLWELL SERV RLM J 834 8316 PITTSBURGH TESTING EXP RAD
, 834 AS8310 X-RAY INSPECTION C0 EXP RAD 841 8404 UNIV CINCINNATI HOSP EXP MED 841 AS8401 NDT INC EXP RAD 843 8415 VA BRONX- EXP MED 843 AS8402 RHODE ISLAND HOSP MD1 MED l l 843 8413 TWO RADI0 PHARMACIES MD1 HAD
- 843 8412 NUCLEAR FUEL SERV SGD FC3 844 ASB403 ULTRASONICS SPEC EXP RAD e44 8419 NUCLEAR FUEL SERV MSC FC3 851 AS8501 GULF NUCLEAR INC EXF MAD 851 AS8502 QA SPECIAL SERVICES EXP RAD 851 ASE503 MAGNAFLUX IND RAD EXP RAD 851 AS8503 SCHLUMBERGER LAS WLO 851 8504 JOHN C HAYNES CO LMC 852 AS8505 WORLD TECH SERV EXP RAD l 852 8510 PITTSBURGH TESTING LMC RAD l
853 8517 WESTERN STRESS EXP RAD l 7l
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1 KEY: YEAR = DATE OF FIRST TWO DIGITS ARE YEAR, THIRD, DIGIT IS QUARTER l AONO = A0 NUMBER 1 4 TYPE OF EVENT: i CON CONSUMER PRODUCT CTM CONTAMINATION j EXP EXPOSURE LAS LOST, ABANDONED, OR STOLEN MATERIAL LMC LOSS OF MANAGEMENT CONTROL MED' MEDICAL LICENSEE MFS MATERIAL FALSE STATEMENT j i MSC MISCELLANE0US RLM RELEASE OF MATERIAL l SGD SAFEGUARDS TYPE OF LICENSEE: ) ACA ACADEMIC j FCI URANIUM MILL FC3 FUEL FABRICATION l GAU GAUGE MAD MANUFACTURING AND DISTRIBUTION MED MEDICAL RAD RADIOGRAPHER WLO VELL LOGGING I j i l
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-- A radiographer and his helper received whole body exposures of 8-31 rad and <15 rad, respectively, as the result of a feilure to co'nnect a 29 Ci Ir-192 source pigtail to the drive cable. The radiographer did not make a survey when their work was completed.
The source pigtail remained in the source guide tube-for a day, and was transported in the guide tube from one job site to another. This exposure event was f ascribed to management and procedural control difficulties.
-- A fourth A0 event resulted in calculatect overexposure in an unrestricted area. A member of the general public.
may have received a whole body dose that exceeded 0.5 rem in one calendar year. A mounted radiography gauge was being removed from a trailer by an individual who did not have any personnel dosimetry and who did not use survey meters. The source became dislodged and fell into the bottom of the trailer. The trailer was F moved by its new owner, and, during the move, the source fell out. The source was recovered three days
-later. Calculations show that the only probable overexposure was to the new owner of the trailer.
He could have received 1.4 rem. . l ! Agreement State Licensees - There were eight overexposure at Agreement State radiography licensees over the five year period.
-- An exposure device broke loose due to barge motion and ,
rolled under some equipment and broke. The CaptMn of , the barge handed the source to the radiographer who l received approximately 3000-5000 rad extremity dose. Two members of the barge crew (public).were also I overexposed. The State agency cited the radiographer ! for failing to follow prescribed emergency procedures. l l
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m,.2 mo-., ., ~ , . . w , aw. ~ - 1 31 - l l l -- Two radiographer were overexposed (53 rem and 6 rem). l i Investigation showed that the exposure device lock plunger would close and lock even though the source i was unshielded. i A Radiation Safety Officer received an extremity { exposure of 4000-8000 rad when he picked up a guide tube knowing it contained a stuck source. A radiographer and his assistant received both whole body , . (9 and 63 rem) and extremity exposure (3000 and 5000 rad) l when they touched the end of a guidetube,that contained a { l radiography source. ) I A radiography trainee received an extremity exposure of between 2500-3000 rad. l A radiographer received an extremity exposure of possibly
- 2000 rem.
I 1 \ l A radiographer received an extremity exposure of 1300 rem ' at a plant. Two radiographer received 8 and 30 rem whole body when one of the individuals failed to connect the source. A Radiography Steering Committee, chaired by the Deputy Director of the NRC's Division of Fuel Cycle and Material Safety, Office of Nuclear Material Safety and Safeguards, has been working on ways to improve radiographer safety. A subgroup chaired by a representative of HRC's Office of Nuclear Regulatory Research (RES) developed a program for improved radiography equipment design. These design improvements, if mandated by regulations, might have eliminated some
. of the very high overexposure at radiography licensees.
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I In addition, a second subgroup of the Committee has been evaluating the characteristics of alarming dosimeters to determine whether or not their use would tend to elimirata o'verexposures such as those i discussed above.
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Other Exposure Events - There were-seven exposure events that did not involve radiography licensees. These events had few common 8 characteristics, and tent'ed to result in lower exposures than the radiography exposure events.
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A0s Involvino Release of Materials - Over the five-year period, . , there were four A0s that involved the release of radioactive materials: l
-- The rupture during recovery optrations, of a sealed ]
americium-241 well-logging source that had become wedged in the well during operations.
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-- The rupture of a sealed americium-241'well-logging
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source during attempts to remove the source from a source I holder in a workshop. The rupture of a sealed americium-241 well-logging source during attempts to remove the outer encapsulation f in an Agreement State laboratory. l
-- Melting of a cob' alt-60 source at a steel manufacturing plant in an Agreement State.
Three of the four events involved well-logging sources, and two of these three involved the rupture of a source during attempts to { open the source with sharp tools. Tt.e fourth event concerns the j melting of a source that was. unknowingly received as part of a j scrap steel shipment used~as feed to the steel process. l
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. I All of these events resulted in extensive contamination, with the second event above resulting in contamination of offsite. areas, and the overexposure of an individual.
Other A0 Events - There were 14 other nonreactor events classified l l as Abnormal Occurrences: l
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Six lost or stolen sources i
-- Three events involving management control or material i
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-- Two events involving molybdenum breakthrough of l l
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-- Twa fuel cycle events ;
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-- One event involving contamination of an individual l l
! l l None of these fifteen events appeared to show any generic problems. ] l
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- 5. AEOD STUDIES OF-NONREACTOR EVENTS FROM 1981-1985 AE00 undertook a number of studies of nonreactor events in 1981-1985. Most of the studies looked at leaking source events because of the' possibility of a generic problem with encapsulation of sources. One of the studies, contami-nation of sources at missile sites, appeared to point to problems stemming free.
the enviroment to which the sources were exposed in use or to problems associated with the manufacturing process. Since the.use of these sources.was being phased out with the particulai* allitary program, no action by NRC ! appeared necessary. 4 Other studies made over the period included three studies u
*of events at mills, one event at a fuel cycle plant, two events concerning lost sources, and nine studies that cuuld be categorized as . miscellaneous. .
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AE00 undertook one case study during the five year period: a study of the q breaching of well-logging sources. The study was occasioned by five events, 1 three of which were also ACs. In the case study,'AE00 niade recommendations to RES concerning the proposed 10 CFR Part 39. The response to our recommenda-tions was satisfactory, with the exception of one concerning a requirement that licensees have available a survey instrument capable of reading dose rate I levels of at least 100 mr/hr. The current version of the proposed Part 39 r requires that survey meters be capable of reading levels up to 50 mr/hr. j Although the proposed Part 39 does specify that licensees have access to a l survey meter reading to 100 mr/br, we note that Part 20 contains a requirement that licensees post and control access to high radiation areas, with a high . l radiation area being defined as an area in which an individual could receive l 100 mr in any 1 hour. Our recommendation stems in part from our reading of the regulations.
- 6. FINDINGS A raview of the 1985 nonreactor database showed that the number and type of
! events that were reported did not differ substantially from those received in other years. When the events from-1981-1985 were reviewed, the number and categories of events reported (i.e., exposures, lost or stolen materials, etc.) did not vary appreciably from year to year. No secular trend in event occurrence was apparent from a statistical standpoint. ! A review of the Abnormal Occurrence reports from 1981 through the third l quarter of 1985 indicated that 31 nonreactor events were determined to be i 1 Abnormal Occurrences.* Of these, 19 were overexposure events. Of the 19, j 12 were overexposure received in conjunction with radiography operations. i i
"To put thic number into perspective there were a total of 97 A0s over the j time period: 4 reactor events; 37 nonreactor events; and 12 misadministra- :
tion events. l t ! ! 2
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a 4 s . , ., - 35 - A Radiography Steering Committee chaired by NRC's Office of Nuciere Natcrial Safety and Safeguards has been Icoking at ways to reduce the overexposure to radiographer. Activities include development of proposed eqLipment standards for radiography devices, as well as evaluation of the use of different kinds of dosimetry,- These interoffice and Agreement State Steering Connittee activities support the Commission's Strategic Goal 3.2, Reduce Overexposure of Radio-graphers. To supplement the work already accomplished by the Steering Committee, AE00 has undertaken a study of " source disconnect" or " failure to connect" events, The study will attempt to determine whether there are any additional lessons to be learned from these events. There have been several events that occurred over the past (ive years that resulted from the accidental contamination of steel. The most notable of these events was the Mexican steel event of early 1984. These events sensi-tired the NRC staff to the need to collect information on events in which radioactive material was found in, or had a reasonable probability of being introduced into, consumer products. Five reports of this category occurred in 1985. Continuing collection of the category of reports should permit an' analysis and evaluation of their significance. u i Careful review and evaluation of nonreactor events is an essential activity i that supports the Commission's Strategic Goal 3.4, Ensure that Handling of Radioactivity is Conducted Safely. AE00 will continue its careful review of l [ events reported by NRC licensees, and will work with the NRC's Office of State l n Programs to assure that significant events in Agreement States are reported and reviewed. Lessons learned will be fed bac'k through Information Notices. Specific problems will be addressed through formal case study reports. l i s l l
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l' 1 l l i REPORTS.' ISSUED PRIOR TO 1985 - BY YEAR ; 1981- ! Subject No. j
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Interim Report on Brown Boveri Betatron- ') Calibration Check Source N101 Irradiator Incident at an Agreement State ! Licensee's Facility (Becton-Dickinson, BrokenBow, Nebraska) N102 Interim Report on the October 1980 Fire' at the Sweetwater Uranium Mill N103 .j 1 Interim Report on the January 2,1981 Fire
)
at the Atlas Uranium Mill .N104 a 1 Interim Report on Tailings Impoundment Liner i Failure at the Sweetwater Uranium Mill N105
.]
Review of Reports of Leaking Radioactive Sources- N106 Engineering Evaluation of Fire Protection at Nonreactor Facilities N107 Notes on AE00 Review of Emissions from Tritium i Manufacturing and Distribution Licensees N108 l 9 try Cc
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t . j 1982 Subject No. Report on Medical Misadministration for the Period November 10, 1980 - September 30s 1981 N201 Buildup of Uranium-Bearing Sludge in Waste Retention Tanks N202 Lost Plutonium - 238 Source N203 Report on Medical Misadministration for the Year 1981 N204 Preliminary AE0D Review of Iodine-125 Sealed Source Leakage Incidents N205 Eberline Instrument Corporatioit - Part 21 Report N206 AE0D Review of Iodine-125. Sealed Source Leakage Incidents N207-potentially Leaking Plutonium-Beryllium Neutron Sources N208 A Summary of the Nonreactor Event Report Database for 1981 N209 l Leaking) Hoses on Self Contained Breathing Apparatus (SCBA Manufactured by MSA N210 i i l i i , l j
1 1983 ,; l Subject No. l Nonreactor Event Repcrt Database for the' i
-Period January - June 1982 N209A I125/1131 Effluent Releases by Material Licensees N301 Mound Laboratory Fabricated PuBe Sources N302 Americium Contamination Resulting from Rupture of Well-Logging Sources N303 Nonreactor Event Report Database for the Period July - December 1982 N209B l Americium-241 Sources N304 , .1 1
l i Report on Medical Misadminstrations'for January 1981 - Deceraber 1982 N204C: I
.l Human Factors. Contributions.to Accident Sequence Precursor Events N305 Potentially Leaking Americium-241 Sources Manufactur A by Amersham Corporation .N306 Nonreactor Event Report Database for the Period January - June 1983 N307
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i i [ 1984 , l
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Subject No. Report on Medical Misadministration for l January 1983 through June 1983 N204D l Nonreactor Event Report Database for the
- Period July - December 1983 N401 Events Involving Undetected Unavailability i i
of the Turbine-Driven AFW Train N402
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Report on Medical Misadministration for July 1983 - December 198's N403 l
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